Occupational safety and health in public health emergencies: a manual for protecting health workers and responders

O ccupational safety and health in public health em ergencies X Occupational safety and health in public health emergencies A manual for protecting health workers and responders ILO |W HO Occupational safety and health in public health emergencies: A manual for protecting health workers and responders Geneva, 2018 Copyright © World Health Organization and International Labour Organization 2018 Reprinted in 2020 with a new cover design First published 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. 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ILO ISBN: 978-92-2-030795-3 (web PDF) WHO ISBN: 978-92-4-000543-3 (web PDF) WHO ISBN: 978-92-4-151434-7 (print) Also available in French: Sécurité et santé au travail durant les crises sanitaires: un manuel pour la protection des personnels de santé et des équipes d’intervention d’urgence, WHO ISBN 978-92-4-000546-4 (web PDF), ILO ISBN 978-92-2-030797-7 (web PDF), Geneva, 2020; and in Spanish: Seguridad y salud de los trabajadores en las crisis sanitarias: Manual sobre la protección del personal sanitario y de los equipos de emergencia, WHO ISBN 978-92-4-000544-0 (web PDF), ILO ISBN 978-92-2-032050-1 (web PDF), Geneva, 2020. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO or ILO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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In no event shall WHO or ILO be liable for damages arising from its use. iiiAcknowledgements This manual was developed by the World Health Organization (WHO) and the International Labour Office (ILO), with contributions from the WHO collaborating centres for occupational health at the University of British Columbia (Canada), University of Maryland and the Centers for Disease Control and Prevention (CDC)/National Institute for Occupational Safety and Health (NIOSH) (USA). The manual was produced under the direction of Ivan D. Ivanov from the WHO Department of Public Health, Environmental and Social Determinants of Health, and Francisco Santos- O’Connor from the ILO Labour Administration, Labour Inspection and Occupational Safety and Health Branch. Shubhendu Mudgal, WHO Consultant on Workers’ Health, developed the draft versions of the manuscript. Valuable contributions were provided by: Benedetta Allegranzi, Sebastian Bruno, Zhanat Carr, Kenneth Carswell, François Cognat, Rudy J.J.M Connix, Sergey Eremin, Ivan Ivanov, Erin Maura Kenny, Meleckidzedeck Khayesi, Kazunobu Kojima, Mark van Ommeren, Adrienne May Rashford, Joana Helena Tempowski and Ju Yang of WHO; Shengli Niu, Francisco Santos-O’Connor, Yuka Ujita and Christiane Wiskow of ILO; Joanna Gaitens, Melissa McDiarmid and G.M. Oliver of the University of Maryland, USA; Karen Lockhart, Stephanie N Parent and Annalee Yassi of the University of British Columbia, Canada; and Claire C. Caruso, Christopher Coffey, Lisa Delaney, Chad Dowell, Selcen Kilinc-Balci, Margaret Kitt, Leslie Nickels and Jill Shugart of CDC/National Institute of Occupational safety and Health of the USA. The publication was prepared with financial support from the WHO Regional Preparedness Programme funded by the Department for International Development of the United Kingdom of Great Britain and Northern Ireland and the WHO cooperative agreement with Centres for Disease Control and Prevention National Institute for Occupational Safety and Health of the United States of America on implementing Resolution WHA 60.26 “Workers’ Health: Global Plan of Action”. Acknowledgements viiContents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Purpose of the manual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv Chapter 1. Occupational safety and health during emergencies: management aspects . . . . . . . . . . 1 1.1 Management system approach to occupational safety and health hazards and risks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Rights, duties and responsibilities of employers and workers during outbreaks and emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.3 Overview of health and safety surveillance and monitoring system implemented during the Ebola virus disease response in West Africa . . . . . . . 7 1.4 Emergency Responders Health Monitoring and Surveillance . . . . . . . . . . . . . 11 Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.1 International Health Regulations, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.2 Incident Command System for managing outbreaks and emergencies . . . . . . 16 2.3 The World Health Organization Health Emergencies programme . . . . . . . . . . 21 2.4 Occupational safety and health controls . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 2.5 Strategies for infection prevention and control . . . . . . . . . . . . . . . . . . . . . . . 24 2.5.1 Standard precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 2.5.2 Prevention of occupational respiratory infections in health-care settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Chapter 3. Common risks for safety and health in emergencies . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.1 Vector-borne diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.2 Water and foodborne diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 3.3 Vaccine-preventable diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 3.4 Heat stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 3.5 Slips, trips and falls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 3.6 Road traffic injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 3.7 Ergonomic hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Contents viii OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 3.8 Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 3.9 Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 3.10 Psychosocial stress during outbreaks and emergencies . . . . . . . . . . . . . . . . 50 Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 4.1 Occupational safety and health in Ebola treatment and care units . . . . . . . . . 58 4.2 Occupational safety and health in the cholera treatment unit . . . . . . . . . . . . 59 4.3 Managing occupational safety and health in laboratories handling infectious agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.4 Management of exposure to blood, body fluids and other contaminants in health-care settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4.5 Occupational safety and health protection of health workers from acute respiratory diseases during respiratory disease outbreaks . . . . . . . 64 4.6 Occupational safety and health in outbreak response in community settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 4.6.1 Community work (e.g. social mobilization, contact-tracing, case-finding) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 4.6.2 Ambulances and vehicles for patients or dead bodies . . . . . . . . . . . . . 67 4.6.3 Post-mortem examinations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 4.6.4 Safe and dignified burials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 4.6.5 Points of entry and exit, land crossings, airports and sea ports . . . . . . 71 4.6.6 Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 4.6.7 Ships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 4.6.8 Taxis and public transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 4.6.9 Waste-water workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 4.6.10 Insecticidal spraying for vector control activities . . . . . . . . . . . . . . . . 76 Chapter 5. Occupational safety and health in chemical incidents . . . . . . . . . . . . . . . . . . . . . . . . 81 5.1 Emergencies caused by chemical incidents . . . . . . . . . . . . . . . . . . . . . . . . . 81 5.2 Occupational safety and health hazards and risks of chemicals . . . . . . . . . . . 81 5.3 Occupational safety and health management of emergency responders during chemical incidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 5.3.1 Incident Command System for managing chemical emergencies . . . . 83 5.3.2 Personal protective equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 5.3.3 Decontamination of emergency response personnel . . . . . . . . . . . . . . 88 5.3.4 Medical surveillance of emergency responders . . . . . . . . . . . . . . . . . 91 ixContents Chapter 6. Occupational safety and health in radiation incidents . . . . . . . . . . . . . . . . . . . . . . . . 93 6.1 Sources and scenarios of radiation incidents . . . . . . . . . . . . . . . . . . . . . . . . 93 6.2 Occupational safety and health management of emergency responders during radiation emergencies . . . . . . . . . . . . . . . . . . . . . . . . . 94 6.2.1 Guidance for protection of emergency responders during radiation emergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 6.2.2 Incident Command System for managing radiation emergencies . . . . 98 6.2.3 Personal protective equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 6.2.4 Decontamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 6.2.5 Occupational health surveillance of persons occupationally exposed to radiation in emergencies . . . . . . . . . . . . . . . . . . . . . . . . 101 Chapter 7. Occupational safety and health hazards in natural disasters . . . . . . . . . . . . . . . . . . 105 7.1 Occupational safety and health hazards and risks due to floods . . . . . . . . . 106 7.2 Tropical storms, hurricanes, cyclones and typhoons . . . . . . . . . . . . . . . . . . 107 7.3 Earthquakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 7.4 Common occupational safety and health hazards encountered during response activities following natural disasters . . . . . . . . . . . . . . . . . 109 7.4.1 Search and rescue team operations . . . . . . . . . . . . . . . . . . . . . . . . 109 7.4.2 Hazards and risks associated with the use of chainsaws and their control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 7.4.3 Hazards due to animal/insect bites and contact with poisonous plants during outdoor work . . . . . . . . . . . . . . . . . . . . . . . 113 Chapter 8. Managing the health and safety of health workers during humanitarian response in conflict situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 8.1 Management of occupational safety and health in health facilities during conflicts and emergencies . . . . . . . . . . . . . . . . . . . . . . . . 115 8.1.1 Measures for the safety of health facilities . . . . . . . . . . . . . . . . . . . 116 8.1.2 Measures for protection of people working in health facilities . . . . . . 117 8.1.3 Management of stress during conflicts . . . . . . . . . . . . . . . . . . . . . . 118 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Appendix Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 xiAbbreviations ARD Acute respiratory disease BSS Basic Safety Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources ERHMS Emergency Responders Health Monitoring and Surveillance ERW Ebola response worker EVD Ebola virus disease HBV Hepatitis B virus HCV Hepatitis C virus HIV Human immunodeficiency virus IAEA International Atomic Energy Agency IASC Inter-Agency Standing Committee IATA International Air Transport Association ICAO International Civil Aviation Organization ICS Incident Command System IFRC International Federation of Red Cross and Red Crescent Societies IHR International Health Regulations ILO International Labour Organization IPC Infection prevention and control MERS-CoV Middle East respiratory syndrome – coronavirus NGO Nongovernmental organization NIOSH (United States) National Institute for Occupational Safety and Health OSH Occupational safety and health PEP Post-exposure prophylaxis PPE Personal protective equipment PTSD Post-traumatic stress disorder SARS Severe acute respiratory syndrome SCBA Self-contained breathing apparatus UNCDF United Nations Capital Development Fund UNDP United Nations Development Programme Abbreviations xii OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES UNFPA United Nations Population Fund UNMEER United Nations Mission for Ebola Emergency Response USCDC United States Centers for Disease Control and Prevention WFP World Food Programme WHO World Health Organization xiiiIntroduction In its Emergency Response Framework, the World Health Organization (WHO) has defined an emergency as a situation that has an impact on the lives and well-being of a large number of people or a significant percentage of a population and requires substantial multisectoral assis- tance [1]. For a WHO response, there must be clear public health consequences. In addition, under the International Health Regulations (IHR), adopted by the World Health Assembly in 2005, a public health emergency of international concern is defined as “an extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease and (ii) to potentially require a coordi- nated international response” [2]. Such events may include, inter alia, outbreaks of infectious diseases, hazardous chemical spills or releases of radiation. During the last five decades, the world has witnessed a wide range of natural and man- made disasters and emergencies. These emergencies included outbreaks of infectious diseases – such as severe acute respiratory syndrome (SARS), H1N1 influenza, Ebola virus disease, cholera, Zika virus – that occurred from time to time in different parts of the world. Apart from infectious disease outbreaks, other key emergencies included radiation emergencies (e.g. Chernobyl, Fukushima), and chemical emergencies (e.g. the Bhopal toxic gas leak, Deepwater Horizon oil spill). In addition, a large number of natural disasters have occurred across the world, such as the Indian Ocean tsunami, and earthquakes, floods and cyclones in Haiti, Pakistan and Philippines [3]. Current environmental, economic and political developments and trends suggest an increase in the future severity and frequency of disasters. Phenomena that support this assumption include increased energy use, climate change and pollution, population growth, dispersal of industrialization around the globe, expansion of transportation facilities, and the growing spread of terrorism. Severe drought and associated food insecurity, flooding, rains and temperature rises due to El Niño in 2015-2016 caused a wide range of health threats, including disease outbreaks, malnutrition and disruption of health services [4]. The worldwide risk of chemical incidents is increasing with the global rise in the production, trade and use of chemicals (e.g. in agriculture). This is particularly the case in developing countries and those with economies in transition, where chemical production, extraction, pro- cessing and use are closely tied to economic development, and where production is projected to increase six-fold by 2050 [5]. Management of such outbreaks and emergencies involves close coordination and cooperation between a large number of diverse organizations. The emergency response personnel asso- ciated with such organizations comprise professional groups that include fire-fighters, police officers, emergency medical staff (paramedics, emergency medical technicians, doctors and nurses) and psychologists. In major disasters, rescue workers, technicians from large relief Introduction xiv OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES organizations, additional medical staff, military personnel, antiterrorist forces, corpse-handlers, clean-up workers, construction workers and numerous volunteers are also involved. Each of these categories of workers have specific roles in managing an emergency response that may expose them to various health and safety hazards while carrying out their duties. Many events in recent years have posed a high risk of injuries and infections, and in some cases have resulted in fatalities among emergency health and response workers. Incidence of infections among health workers were observed during outbreaks of SARS and Middle East Respiratory Syndrome – coronavirus (MERS-CoV). However, during Ebola virus disease outbreaks in West Africa, the high morbidity and mortality among health workers in the most affected countries led to serious negative impacts on the overall functioning of health services [6]. Further to these events, many countries are currently facing humanitarian crises and conflicts that increasingly involve the disturbing trend of attacks on health facilities. Such attacks not only affect the health and safety of health providers but also seriously affect the capacity of health systems to deal with humanitarian emergencies. According to a WHO report, during the two-year period from January 2014 to December 2015 there were 594 reported attacks on health-care workers that resulted in 959 deaths and 1561 injuries in 19 countries with emer- gencies [7]. In view of all these events, the need for better occupational safety and health (OSH) protection for emergency workers is increasingly being recognized as a major priority. xvPurpose of the manual Purpose of the manual This manual provides an overview of the main OSH risks faced by emergency responders during disease outbreaks and other emergencies, such as natural disasters, chemical incidents, radiological emergencies and emergencies involving conflicts. The intent is to assist organi- zations and workplaces to better prepare and respond to these events. The manual, which is particularly focused on needs in low-resource settings, provides technical guidance on good practices and procedures in establishing systems that can: 1) reduce occupational exposures, injury, illness and death among response workers; 2) decrease stress and reduce fears; and 3) promote the health and well-being of health-care and other response workers. The manual has three main parts. Chapters 1 to 3 cover managerial and technical tools and strategies for managing OSH in emergency situations. These tools include an OSH manage- ment systems approach for use in emergencies, an incident command system (ICS), OSH con- trols and standard precautions and their application during emergencies. Chapters 4 to 8 cover OSH hazards in different types of emergencies, such as outbreak situations covering clinical and community response settings, chemical incidents, radiation incidents and natural disas- ters, as well as conflict situations. The Appendix includes a collection of tools and resources compiled from various resources that are intended to provide practical support to users on different aspects of OSH in emergencies and outbreaks. The manual is intended for experts and officials in emergency response organizations who are responsible for workers’ OSH. This information is particularly important in countries with high risk of emergencies – such as those with high transmission of highly infectious agents (e.g. cholera, yellow fever, viral haemorrhagic fevers) and/or natural disasters, and chemical and radiological incidents. The key target audience includes personnel from agencies and organiza- tions responsible for implementing the International Health Regulations (IHR) within a country, government agencies in the health and labour sectors, international organizations, nongovern- mental organizations (NGOs), humanitarian and charitable bodies, faith-based organizations, hospitals and health-care facilities, public and private companies, security forces, employers and trade unions. 1Chapter 1. Occupational safety and health during emergencies: management aspects Managing the OSH of emergency health workers requires a systematic approach that includes various management functions such as planning, organizing, implementing, monitoring and evaluating actions in an orderly manner. This chapter covers various management aspects that are related to the OSH of emergency response workers during outbreaks and emergencies. 1.1 Management systems approach to occupational safety and health hazards and risks The management of OSH of emergency response workers should be implemented as an OSH management system that is compatible with or integrated into overall emergency response management, including the stages of preparedness, response and recovery [8]. Source: OSH Management System: tool for continual improvement, International Labour Organization [9]. Figure 1. The continual improvement cycle of the OSH management system Chapter 1. Occupational safety and health during emergencies: management aspects 2 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Key components of the OSH management system All managers, team leaders and workers’ representatives in emergency operations need to be trained in the development of the OSH management system in outbreaks and emergencies through the ICS. This includes coverage of (Figure 1): ● workplace policy on OSH; ● organizational structure and roles and responsibilities for OSH within the ICS; ● planning, including resource mobilization (e.g. human resources, personal protective equipment (PPE), monitoring equipment, medicines and vaccines, procedures and guidelines on OSH); ● monitoring and evaluation mechanism (e.g. indicators, checklists). The following are key requirements for the OSH management specific to emergency response workers during outbreaks and emergencies: ● Selection of the right persons with qualifications and skills for the required job. ● Training of selected professionals in health and safety risk assessment, risk man- agement and risk communication management. ● Assessment and management of OSH risks during deployment. ● Health surveillance covering monitoring for adverse impacts of deployment on the physical, mental and social health of responders, and management of these impacts, including through psychological support and counselling. Selection of the right persons with qualifications and skills for the required job This is an important step in organizing any response mechanism, whether for disease outbreaks or any other emergency. The process includes matching the requirements of the potential emer- gency with the qualifications, skills and physical and mental status of the persons to be selected. Training requirements for OSH management during outbreaks and emergency response Training is an integral element of the deployment process for response workers in an emer- gency response to outbreaks, chemical and radiation incidents and natural disasters in order to equip them with knowledge, attitudes and skills to ensure appropriate behaviour for protecting their personal health and safety – both so they can remain healthy and safe and so they can carry out their response activities effectively. All workers who are expected to be involved in the response to an outbreak or other public health emergency should be trained in the following: ● basic assessment and management of OSH hazards and risks in the field, covering physical, chemical, biological, mechanical and psychosocial hazards; ● hazards and risks associated with specific outbreak or emergency situations such as Infection Prevention and Control (IPC) and the basics of chemical and radiation safety; ● roles and responsibilities of emergency responders under the ICS; ● personal security in the field; ● incident reporting on diseases, injuries and incidents during the emergency operation. 3Chapter 1. Occupational safety and health during emergencies: management aspects Additionally, during the response, workers should receive daily briefings and instructions on safe working practices relating to specific hazards and risks to their health and safety. Also, such daily briefings would serve as a good opportunity for supervisors to check the health status of the workers Emergency responders (e.g. workers employed in medical treatment units, laboratories and burials, as well as chemical and radiation workers) may need, in addi- tion to the above, training in awareness and specific skills (e.g. use of PPE and chemical and radiation decontamination procedures). Communication with workers involved in outbreaks and emergencies Risk communication is a crucial part of the response plan and is required at all stages of deployment. Communication is the responsibility of all supervisors in the field. The key prin- ciples for risk communication with health and other emergency workers during outbreaks and emergencies include: ● Risk communication with workers should be personal, face-to-face, and should not rely solely on posters and health education materials; ● Workers’ representatives should be involved in risk communication; ● Workers should not learn from the media about risks and dangerous situations; all accidents should be discussed with workers and preventive measures should be taken immediately; ● Risk communication with workers should promote a no-blame culture; ● Risk communication should be fair and should address fears, rights and entitlements and the effectiveness of measures for protection. Psychological support and counselling The emergency response process is associated with high levels of stress which affect emer- gency responders through all stages of deployment. Therefore the aim of psychological sup- port is to prevent and manage stress and its impacts on physical, mental and social health throughout deployment and afterwards. The effects of stress encountered during an assignment do not magically disappear when emergency response personnel return home. Protection against the impact of stress requires psychological first aid as well as specialized counselling and psychological support from professionals. 1.2 Rights, duties and responsibilities of employers and workers during outbreaks and emergencies Protecting the health and safety of health-care workers and other emergency responders is crucial to maintaining an adequate and functional workforce and ensuring the continuity of the emergency response and essential health services. In an emergency situation such as an outbreak, chemical spill or radiation release, where workplace risk changes rapidly, employers need to be prepared to adapt their usual practice in consultation with workers, their represent- atives and technical experts in order to achieve a reasonable balance of safety versus obligation to work. Box 1 describes the risk allowance policy applied in Sierra Leone during the 2015 response to the Ebola outbreak there. 4 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES General rights and responsibilities of employers and workers In dealing with the OSH risks during management of outbreaks and emergencies, the following general rights, duties and responsibilities of employers are specified in the International Labour Organization (ILO) Occupational Safety and Health Convention of 1981 (No. 155) [10]: Employers have overall responsibility to ensure that all practicable preventive and protective measures are taken to minimize occupational risks: ● Employers are responsible for providing adequate information, comprehensive in- struction and necessary training on OSH, for consulting workers on OSH issues related to their work, and for notifying the competent authority (e.g. labour, medical inspectorate) of cases of occupational injuries and diseases; ● Employers are required to provide workers with adequate protective clothing and protective equipment and appropriate training on their use, to prevent, so far as is reasonably practicable, the risk of adverse effects on health; ● The following general rights, duties and responsibilities of workers apply: ● Workers are required to report immediately to their supervisor any situation that they have reasonable justification to believe presents an imminent and serious danger to their lives or health. Until the employer has taken remedial action, if necessary, the employer cannot require workers to return to a work situation where there is a continuing imminent and serious danger to life or health; ● Workers have the right to remove themselves from a work situation that they have reasonable justification to believe presents an imminent and serious danger to their lives or health. When a worker exercises this right, he or she shall be protected from any undue consequences; ● Workers are responsible for following established OSH procedures, avoiding the exposure of others to health and safety risks, and participating in training provided by the employer. The following general principles from the ILO Occupational Safety and Health Convention of 1981 (No. 155) also apply: ● OSH measures shall not require workers to incur a financial cost; ● Cooperation between employers and workers and/or their representatives within the workplace shall be an essential element of workplace-related prevention measures, such as through workers’ safety delegates, safety and health committees, and collaboration in providing information and training. The ILO’s List of Occupational Diseases Recommendation, 2002 (No. 194) provides that infections and post-traumatic stress disorder, if acquired through occupational exposure, are considered occupational diseases, and that affected workers have the right to compensation, rehabilitation and curative services. Rights and responsibilities of employers and workers in emergency response settings Emergency response workers, including health-care workers, have a contractual obligation and a duty of care to provide services that may put them at risk of infections, toxicities, injuries and diseases. Despite the duty of care, in the face of increased risks inherent to the work in emergencies, emergency response workers may, according to the national context, situation 5Chapter 1. Occupational safety and health during emergencies: management aspects and practice, have the right to remove themselves from a work situation that they have reason- able justification to believe presents an imminent and serious danger to their lives or health. Employers of emergency response workers have an obligation to provide safe work conditions and the necessary means to implement appropriate OSH measures. Employers have an obli- gation to: ● adequately train, equip and protect these workers; ● provide them with the capacity and knowledge to implement OSH techniques; ● provide clear guidelines on the conditions under which these workers should operate, what is expected of them, and the inherent risks of the situation; ● provide appropriate psychological support, as well as implement measures to pro- mote healthy practices; ● provide adequate compensation for the services provided by these workers, in the form of risk premiums and insurance for them and their families and disability benefits for those who contract the infection; ● systematically collect information to support ongoing monitoring and evaluation of the effectiveness of OSH programmes in providing protection. Social protection of workers in emergency response settings Social security, as defined by the ILO, is the protection that a society provides to individuals and households to ensure access to health care and to guarantee income security, particularly in cases of old age, unemployment, sickness, invalidity, work injury, maternity or loss of a breadwinner. It covers all measures that provide benefits, whether in cash or in kind, to secure protection, inter alia, from: lack of work-related income (or insufficient income) caused by sickness, disability, maternity, employment injury, unemployment, old age, or death of a family member; lack of access or unaffordable access to health care; insufficient family support, par- ticularly for children and adult dependants; and general poverty and social exclusion. The higher-than-normal risks associated with an outbreak and other emergency responses highlight the necessity for the social protection of all workers, including migrants, part-time workers and self-employed workers. The ILO Social Security (Minimum Standards) Convention, 1952 (No. 102) provides general guidance on various benefits that may be applicable during emergencies, namely. Box 1. Risk allowance policy, Sierra Leone, for Ebola response workers (ERWs) during the Ebola virus disease (EVD) response [11] • The policy was put into effect on 1 April 2015 until November 2015 when it was later replaced by the EVD-resilient Zero Allowance Policy. The policy included: • categories of ERWs to be covered; • risk allowance rates; • procedures for management and updating of lists; • verification and audit procedures; and • complaints management. 6 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Medical care and sickness benefits ● All workers involved in outbreak and emergency response activities should have cov- erage for medical care and sickness benefit. Another priority is emergency medical evacuation – the capability to move international aid workers who are potentially exposed to infections, hazardous chemicals or radiation to locations where they can receive appropriate medical care; ● During epidemic control operations, post-exposure treatment should be made avail- able for health-care workers providing care to infected patients; ● Health-care workers – including medical staff, laboratory staff, burial teams and facility cleaners, as well as emergency responders involved in rescue and response and with risk of contact with blood and other body secretions from affected persons during response activities – should have the first call on vaccine; ● Workers should be entitled to sickness benefit during periods of isolation or quar- antine. Financial compensation for isolated or quarantined workers should be au- tomatic; this was an essential part of the response strategy during the Ebola virus disease (EVD) response in West Africa. Providing income replacement for workers and self-employed persons is essential to ensure a high rate of compliance with quarantine. If daily wage earners are not compensated during isolation and quar- antine, they may continue to come to work, even with a fever, presenting a risk of infecting others; ● Workers also need to be legally protected from dismissal if, while complying with monitoring, travel restrictions, quarantine or isolation orders, they have to be absent from work. In cases where public health authorities impose quarantine, it may be that a worker is requested by an employer to continue to do some work, perhaps remotely from home or the place of quarantine. In such cases, the management and workers’ representatives should negotiate an agreement regarding salary to be paid, hours to be worked and general conditions during the quarantine period. Employment injury benefits Not all workers have the same level of risk of occupational exposure to highly infectious disease agents, hazardous chemicals or radiation, or are able to claim employment injury benefits. An epidemiological investigation of individual cases will document the occupational or residential source of exposure to highly infectious disease agents, hazardous chemicals or radiation. For those workers with a high intensity of contact with sources of such hazards, the occupational cause of the exposure can be recognized as plausible without an epidemi- ological investigation. Other diseases or disorders – whether caused by biological, physical, chemical, psychological or ergonomic hazards – can be recognized as occupational diseases if a direct link between the hazard exposures arising from work carried out at the request of the employer and the disease contracted by the worker is established scientifically or determined by methods appropriate to national conditions and practices. Health crisis preparedness must include health-worker payment systems and mitigation planning as a core component (Box 2). This requires interagency coordination and country-based needs assessment protocols, development of policies and technical guidance, and the availability and accessibility of quality technical assistance, costing tools and planning frameworks [12]. 7Chapter 1. Occupational safety and health during emergencies: management aspects Survivors’ benefits and funeral expenses The family members and/or dependants of workers who have died as a result of occupa- tional injuries, diseases or exposure to an occupational hazard should be entitled to survivors’ benefits, unless these are already provided to a minimum standard by other social security schemes. The funerals of victims of such cases need to be organized by public health author- ities as part of the safe burial scheme. Maternity benefits and maternity protection Pregnant women should not be deployed to affected countries and should not participate in activities associated with outbreaks and emergency responses. Pregnant or breastfeeding workers should not be allowed to enter workplaces with a risk of infection transmission. 1.3 Overview of health and safety surveillance and monitoring system implemented during the Ebola virus disease response in West Africa Managing the OSH of emergency response workers such as health workers is crucial for sus- taining both response activities and normal delivery of health-care services for all public health needs of the community. With these objectives, throughout the EVD outbreak response of 2014-2015 in West Africa, WHO put in place a system to ensure the OSH of deployed emer- gency response personnel [13]. This system included assistance and guidance before, during and after the deployment pro- vided by the WHO Staff Health and Welfare services and other WHO departments involved in the emergency response. The system was established in the affected countries to ensure that the OSH of deployed staff was supported by multidisciplinary teams, including health and safety officers working closely with IPC and other professionals, at national and district levels. Box 2. Payment programme for Ebola response workers The United Nations Development Programme (UNDP), in consultation with a range of partners that included IFRC,1 UNCDF,2 UNFPA,3 UNMEER,4 WFP5 and the Payments Programme for Ebola Response Workers (PPERW), provided the governments of the three outbreak countries with the technical assistance and strengthened capacity necessary to ensure timely delivery of incentives to ERWs. Specifically, the PPERW had three main objectives: (1) strengthening health-sector human-resource planning through information management systems; (2) strengthening existing payment platforms and digitizing incentive pay; and (3) establishing a UN-run contingency payment platform in Guinea and Liberia. In Sierra Leone, the PPERW was responsible for covering 78% of all ERWs, including not only Ministry of Health and Sanitation employees but also volunteer workers. In Guinea and Liberia, where the ministries of health continued to oversee hazard pay to salaried government health workers, the PPERW was limited to oversight of indemnity payments to volunteer ERWs or those not covered by existing partners (roughly 19% of total ERWs in those countries). In Liberia, UNDP facilitated payments to ERWs and strengthened the existing payment mechanism and the information management system [12]. 1 International Federation of Red Cross and Red Crescent Societies; 2 United Nations Capital Development Fund; 3 United Nations Population Fund; 4 United Nations Mission for Ebola Emergency Response; 5 World Food Programme. 8 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES These teams, in coordination with staff from WHO’s country offices, ensured that deployed staff received full induction training, briefings about the country situation, instructions about their functions, protective equipment and the contact details of persons to be contacted in case of need or emergency. The health and safety officers were appointed to help deployed staff to follow instructions and procedures in order to keep themselves safe and healthy both during and after working hours and to monitor implementation of these measures. Pre-deployment stage The pre-deployment stage consists of the following: Health checks and medical clearance Before an emergency response worker leaves on a mission, it is mandatory to ensure that he or she is physically and mentally prepared. Deployment involves an intense working environment with long hours so good physical health and preparedness are important. The deployment is contraindicated in the case of pregnancy. Once selected for deployment, the emergency response worker needs to obtain medical clear- ance from the Staff Health and Welfare service at WHO headquarters or from a WHO regional office. The medical clearance is given on review and approval of a complete health examina- tion, including laboratory testing and immunizations, by a certified medical practitioner. Preventive immunizations Responders deployed to West Africa during the EVD response were required to be up-to-date with the following vaccines: ● yellow fever (mandatory); ● diphtheria-tetanus (ideally within 5 years) -polio +/- pertussis; ● typhoid vaccine; ● hepatitis A and B; ● meningitis ACYW 135 (mandatory if outbreak is ongoing); ● measles for those born after 1963 who have not had the disease, or 2 doses of MMR ● rabies (recommended); ● cholera vaccine (recommended only in certain situations and based on risk assessment). Chemoprophylaxis against malaria As the countries at highest risk during the EVD outbreak, Guinea, Liberia and Sierra Leone were also endemic for malaria. Chemoprophylaxis and personal protection against mosquito bites day and night are important for preventing malaria and other vector-borne diseases. Therefore, it was mandatory that emergency response workers deployed to affected areas should take chemoprophylaxis before, during and after the mission. This holds true for all countries where malaria is endemic. Induction training Before deployment to the field or on reaching the country of assignment, the emergency response worker received induction training. This training was delivered at WHO headquarters, 9Chapter 1. Occupational safety and health during emergencies: management aspects a regional office or a country office, depending on the starting point and travel arrangements. The induction training aimed to provide an introduction to EVD and essential operational guid- ance to all staff regardless of their functions and affiliations, and to increase awareness about the OSH concerns that the worker should bear in mind. The training package was organized in an electronic format called ePROTECT that has been made available online [14]. In addition, for those emergency response workers required to carry out high-risk work such as patient care, safe burials or laboratory work, additional training was offered at headquarters, regional offices or country offices, depending on the path of deployment and reports from staff already deployed. The emergency response workers were briefed about the country situation before deployment and were provided with reports from staff already deployed. On arrival, they received an addi- tional, more detailed briefing from the health and safety officer. The briefing covered the following: ● immunization status of the responder; ● malarial prophylaxis status on arrival; ● ePROTECT training received and knowledge of hand hygiene; ● key OSH risks and controls to be implemented during deployment; ● provision of medical and hygiene kits and insecticide impregnated bednets. Once it was assured that the above provisions were in place, the responder was allowed to proceed to the assigned deployment area. During deployment During deployment, the code of conduct for health and safety, along with the buddy system, were implemented by the emergency response workers in their respective areas of operation. In addition, worksites and lodging areas are were regularly assessed for IPC and OSH status. Code of conduct Particularly in hotspots where the outbreak was not yet under control, and given that early symptoms of infectious diseases such as EVD are non-specific, deployed staff were advised to adopt the following precautionary behaviours in their social and work life: ● to avoid shaking hands and hugging people; ● to keep a distance of at least 1 metre from colleagues during meetings; ● to avoid sexual activity during the mission (anyone choosing not to follow this recommendation should always use condoms); ● to use respiratory etiquette during sneezing or coughing, and to request others to do the same if they do not; ● to perform hand hygiene frequently, especially in the moments mentioned above. Buddy system The buddy system is a system where two people – i.e. “buddies” – operate together as a single unit so that they are able to monitor and help each other. In dangerous activities, where buddies are often peers, the main benefit of the system is improved safety. Each buddy can 10 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES be there to prevent the other becoming a casualty, or to rescue the other in a crisis. This also allows the less experienced buddy to learn more quickly from close and frequent contact with the experienced buddy than if operating alone. The responsibility of a buddy is: ● to help create a welcoming environment; ● to give tours of the work area; ● to be a source of clarification of the various policies, procedures and protocols; ● to be patient and positive, helping to develop role confidence; ● to answer frequently asked questions to help lessen the tendency to role confusion and uncertainty; ● to introduce colleagues and staff, thus assisting with building effective and pro- ductive networks; ● to assist with training on key processes and procedures, such as using PPE and infection control. Post-deployment All deployed emergency response personnel were requested to undergo a post-deployment debriefing session to gather information on the deployment process in order to improve oper- ations. These debriefings focused on what the response personnel had observed, experienced and learned during their deployment, and how the Organization could potentially benefit from this experience. The experience of feeling listened to about field experience and reviewing organizational prac- tices also serves to reduce stress, if any, in the individual staff member. After deployment, emergency response personnel were required to contact Staff Health and Welfare services in WHO headquarters or the regional staff physician in the regions, to arrange an end-of-mission debriefing. The post-deployment debriefing exercises were conducted by the staff counsellor and/or the staff psychologist and focused on how emergency response personnel responded to the stresses they experienced during their deployment. The debriefing explored what their experiences were, what their thoughts and feelings about their experiences were, and how they dealt with those thoughts and feelings. It focused especially on their current emotional state and any needs they might have for further individual or family support or other interventions. It further included education about the possible delayed impact of stressful experiences on an individual. The diagnosis and treatment of post-traumatic stress disorder requires specialized psychological and medical care which should be sought if suspected. Documentation The guidance on OSH was compiled into the following key resources: ● WHO Ebola outbreak response handbook for health and safety in the field, providing comprehensive information on elements of the surveillance and monitoring required during deployment [13]. ● Training slides on ePROTECT training covering OSH instructions, later organized as online training [14]. 11Chapter 1. Occupational safety and health during emergencies: management aspects ● The GO Training manual covering details of the EVD response, WHO’s role, and guidance on safety and health during deployment, also available online [15]. 1.4 Emergency Responders Health Monitoring and Surveillance The Emergency Responders Health Monitoring and Surveillance (ERHMS) system under the ICS, as designed by the United States National Institute for Occupational Safety and Health (NIOSH), has served as a useful tool for managing the OSH of emergency responders. The system has been successfully used during the emergency response to the Deepwater Horizon oil spill in the Gulf of Mexico in 2010 (Box 3). An overview of the key components of ERHMS is presented below [16]. Pre-deployment Rostering and credentialing: These are required in an emergency response to maintain account- ability for all emergency responders. The registration and credentialing system is designed to support four interdependent, interoperable functions: (1) registration (recording basic and credential information on each worker); (2) emergency credentialing (assigning a credential level on the basis of responder certifications and education); (3) re-verification (periodically verifies responder information); and (4) emergency badging (assigning an identification badge in accordance with the credential level). Health screening: Pre-deployment health screening is intended to establish a baseline of phys- ical and emotional health status and should address the responder’s physical health status, emotional health status and immunization status. Such information may be obtained from an initial physical examination to determine fitness for duty, or from subsequent medical examina- tions. This baseline information allows for more informed interpretation of possible post-deploy- ment adverse health effects and is particularly valuable when exposure information is difficult to obtain or interpret, or when it is absent. Training: The responder is required to be fully certified to perform duty-specific tasks which may have training requirements that are mandated generally, at country level or locally. In addition, the ability of the responder to recognize and avoid possible health and safety risks will influence the responder’s performance, survivability and resilience during and after the disaster response. During deployment On-site rostering: The process of personnel identification, accountability and tracking can be referred to as the responder roster. The roster should be used to record everyone who reports to the disaster area and is engaged in response or remediation work. The logistics team sis responsible for collecting this information. Health monitoring and surveillance: Monitoring refers to the ongoing and systematic collection, analysis, interpretation and dissemination of data related to an individual responder’s injury, illness and exposure status. This allows for the evaluation of the occurrence of an exposure, determination of the level of exposure an individual responder might experience during duties, and assessment of how that exposure affects the responder. Surveillance refers to the ongoing and systematic collection, analysis, interpretation and dissemination of illness and injury data related to the whole group of emergency workers responding to an event. This allows for the tracking of emergency responder health (illness and injury) trends within a defined population 12 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES during response and recovery. A mechanism to allow surveillance should be an integral part of the response to any event. Response activity documentation and safety controls documentation: Response workers and volunteers may be exposed to many different chemical and environmental hazards during their work. Accurate and useful information on worker exposure is a crucial element in ensuring that exposures are correctly characterized, risk is communicated appropriately, and sufficient infor- mation is available to make evidence-based decisions (i.e. PPE and work practice controls) to protect the health and safety of response workers. Communication of exposure and health monitoring and surveillance data during an emergency response: The collection of environmental exposure data and individual health and safety mon- itoring data, along with aggregate surveillance data, is relevant to protecting all the responders involved in an event in both the short and long terms. This information must be communicated to workers intra-organizationally, inter-organizationally, and both within and outside the ICS structure. Post-deployment Out-processing assessment: Out-processing assessments are conducted to determine the extent, if any, to which individual responders have been adversely affected by their work during deployment and to assess trends within the population of workers in order to identify potential risks to others. All responders should receive an out-processing assessment as part of the demobilization process or as soon as possible after demobilization. Tracking of emergency responder health and function: Because of potential health and safety risks inherent in emergency response work, post-event tracking of responder health may be appropriate. The goal is to identify adverse health or functional consequences potentially asso- ciated with response work (e.g. exposure, illness, injury, or disability – including emotional trauma), to intervene early to maximize the chances of recovery, and to stop further exposure for remaining workers (i.e. through exposure control or medical treatment). Lessons learned and after-action assessments: As an event concludes, there is a need to assess how the emergency response has been conducted through the pre-deployment, deploy- ment and post-deployment phases and to try to identify ways to improve the response during each phase. This is often accomplished through a document called an after-action report. 13Chapter 1. Occupational safety and health during emergencies: management aspects Box 3. ERHMS application during the Deepwater Horizon oil spill response An overview of the use of ERHMS used during the Deepwater Horizon response to manage the oil spill in the Gulf of Mexico, USA, covered the following [17]: Pre-deployment stage • Rostering and credentialing activities covered 55 388 workers with different past work experiences until October 2010. • Medical pre-deployment evaluations of emergency responders were conducted to assess their medical status before beginning the response work, to guide medical professionals to identify persons with susceptibilities needing special attention or limitation of their exposures, etc. • Training was provided to emergency responders, as follows: • 8 hours operations training for first responders • 24 hours Occupational Safety and Health Administration (OSHA) Hazpower or HAZMAT technician training, and • 40 hours Hazpower training. Deployment stage • Injury and illness data were collected and compiled weekly. In addition, time trends of heat illness cases were constructed weekly. • Health hazard evaluations were conducted for both on-shore and off-shore activities for beach clean-up, wildlife rehabilitation, equipment decontamination and waste stream management etc. Post-deployment stage • This consisted of out-processing assessments and analysis of exposure data in conjunction with self-reported and health-care provider-generated information. • The exposure and health components were analysed, including analysis of medical monitoring, medical surveillance and exposure assessment, the pre-deployment baseline and medical examination results. Based on analysis of the above, workers were identified for health tracking and long-term tracking options were explored. 15Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks The management systems approach provides an overarching framework to manage OSH risks during outbreaks and emergencies. To manage risks within this framework, certain strate- gies, tools and instruments exist for prevention and control of OSH hazards and risks. These resources can be adapted according to the specific outbreak or emergency situation. This sec- tion provides an overview of the “hierarchy of controls”, the ICS and infection prevention and control strategies. 2.1 International Health Regulations, 2005 The International Health Regulations (IHR) [2] are an international legal instrument that is binding on 196 countries, including all the Member States of WHO. The aim of the IHR is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide. The IHR, which were adopted by the World Health Assembly in 2005, entered into force on 15 June 2007. The regulations require countries to report certain disease outbreaks and public health events to WHO. Building on the unique experience of WHO in global disease sur- veillance, alert and response, the IHR define the rights and obligations of countries to report public health events, and establish procedures that WHO must follow to uphold global public health security. Apart from disease agents, the IHR cover the risk of spread of toxic, infectious or otherwise hazardous materials that may occur naturally (or not) that have contaminated, or have the potential to contaminate, a population and/or a large geographical area. The IHR also include specific measures to be taken at ports, airports and ground crossings to limit the spread of health risks to neighbouring countries, and to prevent unwarranted travel and trade restrictions so that traffic and trade disruption is kept to a minimum. The following recommendations and provisions specified under the IHR for protection of the health and safety of the general public also protect emergency care providers: ● recommendations with respect to persons, baggage, cargo, containers and conveyances; ● recommendations covering airports, ports and general crossings; ● the role of competent authorities; ● core capacity requirements for surveillance and response; Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks 16 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● the decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern. The following public health measures related to health and safety of emergency care providers are recommended: ● health measures on arrival and departure; ● special provisions for conveyances and conveyance operators; ● health provisions related to entry of travellers; ● the Maritime Declaration of Health; ● the health section of the Aircraft General Declaration; ● ship sanitation certificates. 2.2 Incident Command System for managing outbreaks and emergencies The ICS is a standardized on-scene incident management concept designed specifically to allow responders to adopt an integrated organizational structure equal to the complexity and demands of any single incident or multiple incidents without being hindered by jurisdictional boundaries [18]. The ICS enables integrated communication and planning by establishing a manageable span of control. An ICS divides an emergency response into five manageable functions essential for emergency response operations: Command, Operations, Planning, Logistics, and Finance and Administration. Figure 2. Structure of Incident Command System Source: Federal Emergency Management Agency, USA [18]. Incident Commander Public Information Officer Safety Officer Liason Officer Fianance & Administration section Logistics section Planning section Operations section 17Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks Organizational structure ● The minimum ICS should consist of the following and can be expanded according to requirements: ● The command staffs consist of the Public Information Officer, Safety Officer and Liaison Officer. They report directly to the Incident Commander. ● Sections represent the organizational level that has functional responsibility for primary segments of incident management (operations, planning, logistics, finance/ administration). The section level is organizationally between the branch and Inci- dent Commander. ● Each section consists of progressively smaller organizational units – i.e. branch, division, group, unit, task force, strike force and, finally, a single resource. A single resource is an individual piece of equipment and its personnel complement, or an established crew or team of persons with an identified work supervisor that can be used to deal with an incident. ● The ICS is designed by identifying the primary activities or functions necessary to respond effectively to incidents. As incidents have become more complex, difficult and expensive, the need for an organizational manager has become more evident. In the ICS, and especially in larger incidents, the Incident Commander manages the organization and not the incident. In addition to the command function, other desired functions and activities include: ● delegation of authority and provision of a separate organizational level within the ICS with sole responsibility for tactical direction and control of resources; ● provision of logistical support; ● provision of planning services for current and future activities; ● cost assessment, time recording and procurement control necessary to support the response to the incident; ● prompt and effective interaction with the media, and provision of information ser- vices for the incident management team, other involved agencies and the public; ● provision of a safe operating environment in all parts of the incident response; ● ensuring that assisting and cooperating agencies’ needs are met, and that the agencies are used in an effective manner. Role and responsibilities ● The Incident Commander is technically not a part of either the general or command staff. The Incident Commander is responsible for overall incident management, including ensuring safety. ● Command staffs are assigned to carry out the staff functions needed to support the Incident Commander. These functions include interagency liaison, incident man- agement safety and public information. Command staff positions are established to assign responsibility for key activities not specifically identified in the general staff functions. These positions may include the Public Information Officer, Safety Officer and Liaison Officer, in addition to others, as required and assigned by the Incident Commander. 18 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● The general staff are responsible for the functional aspects of the ICS. The general staff typically consists of the operations, planning, logistics and finance/adminis- tration sections. Safety Officer: The key responsibilities of the Safety/OSH Officer include: ● identification and mitigation of hazardous situations; ● ensuring that safety messages are communicated and briefings are given; ● exercising emergency authority to stop and prevent unsafe activities; ● review of the Incident Action Plan for safety implications; ● assignment of assistants qualified to evaluate special hazards; ● initiation of preliminary investigation of accidents within the incident area; ● review and approval of the Medical Plan; ● participation in planning meetings. Organizational measures under the Incident Command System ● The Emergency Management Institute, under the Federal Emergency Management Agency (FEMA) of the USA, lists the following measures as part of health and safety management under the ICS [18]: Risk assessment and management ● The protection of emergency responders must follow a safety management cycle, and those responsible for safeguarding emergency workers must always weigh up whether deploying emergency workers is sufficiently beneficial by taking into account the emergency workers’ OSH risks. ● Risk assessments should follow general principles and cover all possible hazards and risks that emergency workers may encounter. Risk assessment at a disaster scene must, for instance, include assessment of whether domino effects are possible (i.e. whether the present event could cause further damage and danger). All past accidents and near-accidents should be taken into consideration when looking for possible risks. Developed on this basis, early planning should anticipate the likely response requirements and should establish all necessary preventive measures. ● A balance between the OSH risks for emergency workers and the possible benefits of emergency actions must be achieved. Duties are also placed on employees to take reasonable care of themselves and others and to cooperate with their employer; employees should act sensibly and responsibly within the command and control of their employer. To coordinate activities of emergency workers efficiently, authoritarian leadership is the most appropriate style as it functions well in situations requiring unambiguous and rapid instructions. The available equipment, available technical and personnel resources, tasks, the roles of the emergency organizations/teams/workers and the management tasks must therefore be iden- tified and assigned to organizations/teams/persons before disaster strikes in order to make disaster control as efficient as possible. 19Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks Work organization Limiting exposure to workers: By limiting the numbers of personnel at the scene to the min- imum necessary and by releasing personnel no longer needed at the scene as soon as pos- sible, the exposure of emergency workers to hazards at the scene can be reduced. A method for minimizing the exposure of emergency workers and the public to hazards is the creation of “protective-action zones” as a function of the distance from the accident’s source and the intensity of the phenomena resulting from the incident. Job/task rotation: Whenever possible job/task rotation should be considered to reduce exposure to risks and overstrain. Training: ● Emergency workers must be provided with knowledge of all the types of OSH hazards and their risks they may encounter during their professional activities, the consequences of those risks and possible preventive measures. The training should cover physiological symptoms of being exposed to hazardous substances, appropriate decontamination procedures, proper manual handling, specificity of functioning while under great pressure and stress, and proper selection, use, care and maintenance of PPE. ● Training should be developed and given on standard operating procedures related to different scenarios. ● Training might be essential to help emergency workers better cope with violence at work. Emergency Medical Services (EMS) workers, paramedics and fire-fighters have a higher risk of experiencing violence in the course of their duties than other workers. Vaccination: ● Vaccination is an effective prevention measure and should be provided where work- ers may be at risks of hepatitis B, waterborne diseases (cholera, typhoid fever, rotavirus), or exposed to other biological agents that may be used in bioterrorism – such as botulism, tularaemia and smallpox. Maintenance and storage of personal protective equipment: ● PPE must be selected according to the type of emergency, the hazards at the scene, and the typical duties assigned to a specific group of emergency workers. ● The person responsible for disaster control or for the emergency workers’ group in question must take responsibility for selecting additional or alternative PPE. Fit, adjustment, combination with other PPE, specific properties and performance must all be considered. ● For hazard assessment and monitoring at a disaster scene, risks can often be evaluated only by sight, since more complex and detailed monitoring is not possible. ● The correct PPE must be selected, it must be available at the scene and workers must be familiar with it to be able to use it properly. ● In case of terrorist attacks and gun rampages where emergency workers might be soft targets, they might at least be partly protected by bullet-proof and knife-proof vests, safety shoes, helmets and protective clothing. The possible use of protective clothing for rescue workers should therefore also be considered in critical cases and could be routinely available in ambulances. 20 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Standard safety equipment should include high-visibility reflective material (appa- ratus, such as cones and signs, and personal protection clothing such as vests and helmets), and additional warning signs and lights. This is particularly important for the safety of emergency and rescue workers in transport accidents, or at disaster and emergency scenes where heavy machines such as cranes and excavators are deployed and visibility is reduced, and when working during nights. ● Chemical detection equipment, gas detectors, radiation alarm systems, fire systems, and the use of safe vehicles may be required in relevant cases. ● Appropriate protective clothing must be provided (skin and body protection from physical risks and dangerous substances). Some examples may be the use of mos- quito nets that are treated with insecticides and the use of indoor insect spray, alcohol hand-rub for decontaminating hands to protect against infection. To allow clean and antiseptic working, it is important that PPE such as gloves be used and changed regularly. Ergonomic equipment Ergonomic equipment which can reduce workers’ strain and their exposure to risks should be considered wherever possible. Examples of use of ergonomically suitable equipment during emergencies include: ● use of mobile equipment to carry bodies or any necessary apparatus; ● use of devices such as elevators when rescuing people from tall buildings; ● transportation of first aid kits in a backpack rather than in bags when walking long distances to the scene of the emergency; ● provision to emergency medical staff of syringes that have safety features that prevent needle-stick injuries and reduce infection risks, complemented with sharps boxes and special training. Psychological preparedness: Psychological preparedness at work should help emergency workers to cope with the emotional burdens of their jobs. Post-interventions psychological help: Social support during and after deployment in an emergency situation and opportunities to talk and have calm discussions with colleagues or a psychologist have been found to help emer- gency workers to cope with psychological strain. However, in the case of serious or long-lasting symptoms of mental health problems such as post-traumatic stress disorder, professional help may be necessary. Long-term care and health surveillance: ● Health surveillance should be adapted to the tasks required of emergency workers, and should take into consideration potential exposures to different hazards, ● Regular health monitoring through mandatory annual medical examinations, and medical examinations following deployment in major incidents, are helpful in order to: 21Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks ● assess the physical fitness (including cardiopulmonary testing) of emergency workers; ● detect possible diseases and injuries caused by hazard exposure; ● offer the treatment and rehabilitation necessary at an early stage to protect workers from more severe effects; and ● improve their prospects of recovery. 2.3 The World Health Organization Health Emergencies programme WHO is currently reforming its emergency programme with the aim of responding rapidly and effectively to health emergencies. The new programme [19] refines WHO’s role in emergency responses, adding stronger operational capabilities to WHO’s traditional technical and stand- ard-setting roles. Under the programme, WHO is helping countries to address the full risk management cycle of prevention, preparedness, response and early recovery. Organizational structure The Health Emergencies Programme has a common structure across WHO’s country offices, regional offices and headquarters. This means there is one unified emergencies programme with one workforce, one budget, one line of accountability, a single set of processes/systems and a single set of benchmarks. This structure and the results expected are the same in all WHO offices. Figure 3. WHO Health Emergencies Programme incident management structure (simplified) Source: WHO Health Emergencies Programme update: October 2016 [19]. Incident management Staff health and security Partner coordination External relations Fianance and administration Logistics and operational support Health operations and response Planning and information 22 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES The programme is made up of five technical and operational departments, as follows: Infectious hazards management ensures that strategies and capacities are established for pri- ority high-threat infectious hazards. Country health emergency preparedness and the International Health Regulations (2005) ensure that country capacities are established for all-hazards emergency risk management. Health emergency information and risk assessments provide timely and authoritative situation analysis, risk assessment and response monitoring for all major health threats and events. Emergency operations ensure that emergency-affected populations have access to an essential package of life-saving health services. Emergency core services ensure that WHO emergency operations are rapidly and sustainably financed and staffed. Partner coordination The Health Emergencies Programme works with its partners to protect and save people’s lives in all health emergencies. During a crisis, WHO works with the local Ministry of Health and other partners to identify where health needs are greatest and to coordinate the efforts of partner organ- izations in order to ensure that these areas are covered by both medical supplies and personnel. WHO regularly collaborates with partner networks to leverage and coordinate the expertise of hundreds of partner agencies. The key partners include the following: Global Health Cluster: More than 300 partners are responding in 24 crisis-affected countries. Emergency Medical Teams: More than 60 teams from 25 countries are classified by WHO to provide clinical care in the wake of emergencies. Global Outbreak Alert and Response Network (GOARN): Since 2000, approximately 2500 health personnel have been deployed in response to over 130 public health emergencies in 80 countries. Standby Partners: In 2015, WHO’s Standby Partners deployed 207 months of personnel sup- port to 18 countries. Inter-Agency Standing Committee (IASC): WHO is an active member of IASC, the primary mech- anism for inter-agency coordination relating to humanitarian assistance in response to complex and major emergencies under the leadership of the Emergency Relief Coordinator. Country support WHO’s Health Emergencies Programme provides the following services to countries: ● support to the assessment of country health emergency preparedness, and devel- opment of national plans to address critical gaps in capacity; ● development of strategies and capacities to prevent and control high-threat infec- tious hazards; and ● monitoring of new and ongoing public health events to assess, communicate and recommend action for public health risks. In addition, WHO is working with countries and partners to: ● ensure readiness to diminish public health risks in countries with high vulnerability; and ● provide life-saving health services to affected populations in countries with ongoing emergencies. 23Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks 2.4 Occupational safety and health controls To manage the health and safety risks due to various hazards, measures need to be in place for both prevention and mitigation. In OSH, the hierarchy of controls (Figure 4) refers to the preferred order of selecting control measures, from the most effective to the least effective [20]. The underlying philosophy is that it is always best to first try to eliminate the hazard. Where that is not possible, the hazard should be firstly contained at the source, secondly along the path, and lastly at the person. Each setting is different, making a workplace assessment necessary to identify hazards and to define control measures. Controlling at the source means eliminating the hazard, or whatever is exposing the workers to risk. This can include implementing a triage process to avoid placing patients with highly infectious diseases, such as viral haemorrhagic fevers, in general health-care facilities outside treatment and care centres for infectious diseases, plus killing/inactivating the virus in spec- imens for laboratory-testing, containing excreta to allow for natural virus die-off, destroying contaminated waste through incineration or autoclaving, and choosing the least hazardous alternative (e.g. oral instead of intravenous administration of rehydration therapy, and using a prick test instead of phlebotomy for drawing blood samples). Control along the path refers to engineering and administrative controls that create a barrier between the source of the hazard and the worker. For example, safety-engineered devices are more effective in preventing needle-stick injuries and associated exposure to bloodborne pathogens than training individuals to use needles safely. Engineering controls for highly infectious diseases, such as EVD and other viral haemorrhagic fevers, include laminar flow boxes in laboratories, negative pressure rooms and containment (bubble) beds for clinical care, and needleless intravenous systems to reduce the risk of sharps injuries. In addition, safe water and sanitation services are necessary to ensure sufficient water for hygiene measures and proper disposal of excreta. Figure 4. Hierarchy of occupational safety and health controls Source: USA Hierarchy of controls, NIOSH [20]. Hierarchy of ControlsMost effective Least effective Physically remove the hazard Replace the hazard Isolate people from the hazard Change the way people work Protect the worker with Personal Protective Equipment 24 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Administrative controls aim to prevent risky behaviours and include training workers in safe working methods, defining standard operating policies and procedures for safer work practices, and restricting access to high-risk workplaces. Training on policies and procedures, in donning and doffing (putting on and removing) PPE, and in quarantine and isolation procedures are examples of administrative measures to prevent transmission of highly infectious diseases such as EVD and other viral haemorrhagic fevers. Triage is the process of sorting. In specialized treatment units such as those for cholera and EVD, triage is a crucial administrative control that prevents spread of infection among patients and to health-care workers. Another form is the medical surveillance of workers at risk in order to detect any unfavourable health effects of occupational hazards at an early stage when it is easier to treat the disease (e.g. by monitoring workers for fever or other early symptoms of infectious disease). Control at the person is the least effective measure in the hierarchy of controls. It involves the use of PPE, including impermeable gown or coverall (if the gown is not impermeable, an impermeable apron should be worn), double gloves, respirator, hood to cover neck and face, eye protection (goggles or face-shield) and boots/closed shoes with overshoes. In addition, training in proper PPE wear, removal, storage and maintenance is needed to ensure that the highest possible level of protection is achieved. In general, the above-recommended PPE should be worn, but risk assessments should be completed for specific tasks in order to select the most appropriate PPE for them. Medical examinations assessing fitness for work aim to identify health conditions that can be exacerbated or made worse by exposure to occupational hazards. In the disease out- break response in West Africa, access to quality medical care in the field was extremely limited. Therefore, medical clearance to ensure fitness for work was necessary to avoid any complications from pre-existing medical conditions during deployment in outbreak-affected countries. However, during outbreaks of highly infectious agents, the use of PPE becomes one of the most immediate measures for safeguarding the health and safety of care providers, along with other administrative controls. 2.5 Strategies for infection prevention and control IPC strategies also involve a hierarchy of controls. Administrative controls are the most impor- tant components of infection prevention strategies, and include implementation and facilitation of IPC precautions and safe patient care practices. Environmental and engineering controls can help reduce the spread of some pathogens associated with health care, but safe behaviour is the key. Last in the hierarchy of controls is PPE. Administrative controls provide policies and standard operating procedures to prevent exposure to, and transmission of, infectious agents to a susceptible person. These include: organizational support for IPC and for management of outbreaks; organization of services; policies on rational use of available supplies and strengthening of IPC infrastructure; education of health-care workers; point-of-care risk assessment; patient triage for early detection; patient placement and reporting; patient flows; zoning; dedicated personnel; regulating entries to isolation facil- ities; restricting visitors; procedures for environmental cleaning; management of linen and waste; and reduction of intravenous procedures. Engineering and environmental controls include, for instance, the following: isolation rooms with private toilet facilities for patient triage; physical barriers; ventilation; installation of point-of-use sharps containers; hand-washing facilities and appropriately functioning and accessible hand-rub 25Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks dispensers; an appropriate number of commodes; safe needle devices; and safe water and sani- tation services, including off-site disposal and treatment of sewage and health-care waste. 2.5.1 Standard precautions Standard precautions are meant to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients [21]. Hand hygiene is a major component of standard precautions and is one of the most effective methods to prevent transmission of pathogens associated with health care. In addition to hand hygiene, the use of PPE should be guided by risk assessment and the extent of exposure antic- ipated with blood and body fluids or pathogens. “My 5 moments for hand hygiene” is an approach developed by WHO that defines the key moments when health-care workers should perform hand hygiene. The situations where hand hygiene is required in clinical care settings include following: 1. Before touching a patient: to protect the patient against colonization and, in some cases, against exogenous infection, by harmful germs carried on care providers’ hands ● Cleaning of hands before touching a patient when approaching him/her. 2. Before clean/aseptic procedure: to protect the patient against infection from harmful germs, including his/her own germs, entering his/her body ● Hands must be cleaned immediately before accessing a critical site with infec- tious risk for the patient (e.g. a mucous membrane, non-intact skin, an invasive medical device). 3. After body fluid exposure risk: to protect the care provider from colonization or infection with the patient’s harmful germs and to protect the health-care environment from germ spread ● Cleaning of hands as soon as the task involving an exposure risk to body fluids has ended (and after glove removal). 4. After touching a patient: to protect the care provider from colonization with the patient’s germs and to protect the health-care environment from germ spread ● Cleaning of hands when leaving the patient’s side, after having touched the patient. 5. After touching the patient’s surroundings: to protect the care provider from colonization with the patient’s germs that may be present on surfaces/objects in the patient’s surroundings and to protect the health-care environment against germ spread ● Cleaning of hands after touching any object or furniture when leaving the pa- tient’s surroundings, without having touched the patient. 26 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Summary technique ● Hand-washing (40–60 seconds): wet hands and apply soap; rub all surfaces; rinse hands and dry thoroughly with a single-use towel; use towel to turn off faucet. ● Hand-rubbing (20–30 seconds): apply enough product to cover all areas of the hands; rub hands until dry. Hand hygiene and use of medical gloves ● The use of gloves does not replace the need for cleaning hands. ● Hand hygiene must be performed when appropriate, regardless of the indications for glove use. ● Remove gloves to perform hand hygiene when an indication occurs while wearing gloves. ● Discard gloves after each task and clean hands (gloves may carry germs). ● Wear gloves only when indicated according to Standard and Contact Precautions; otherwise they become a major risk for germ transmission. Prevention of needle-stick injuries and other blood exposures using a hierarchy of controls A hierarchy of controls to prevent needle-stick injuries and other blood exposures among health workers, as recommended in WHO best practices for injections and related procedures [22] is given below by order of effectiveness (most effective first). Elimination of hazard: Complete removal of a hazard from the work area is the most effective way to control a hazard. This approach should be used whenever possible. Examples include removing sharps and needles when possible (e.g. by substituting jet injectors for needles and Figure 5. My 5 moments for hand hygiene Source: World Health Organization [21] 27Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks syringes, or using needleless intravenous systems), eliminating all unnecessary injections, and eliminating unnecessary sharps such as towel clips. Engineering controls: These are used to isolate or remove a hazard from a workplace. Examples include: sharps disposal containers; when possible, use of sharps protection devices for all procedures (devices with needles that retract, sheathe or blunt immediately after use). Administrative controls: These are policies, such as standard operating procedures, which aim to limit exposure to the hazard. Examples include: allocation of resources demonstrating a commitment to health-worker safety; a needle-stick injury prevention committee; an exposure control plan; removal of all unsafe devices; and consistent training on the use of safe devices. Work practice controls: These are controls to change the behaviour of workers in order to reduce exposure to occupational hazards. Examples include: no needle recapping; placing sharps containers at eye level and within arms’ reach; sealing and discarding sharps containers when they are three quarters full; and establishing means for the safe handling and disposal of sharps devices before beginning a procedure. Personal protective equipment The level of personal protective equipment is the same to elimination of hazards, engineering controls, administrative controls, and work practice controls. It is the 5th element of hierarchy of controls. The use and disposal PPE is essential for reducing exposure. Policies and proce- dures should specify details on selecting PPE for each job, the location of PPE, and training on how to put on PPE – including the order of donning, decontamination, removal of PPE, and disposal or storage. Additionally, training that includes emphasis on a buddy system, partnering for assistance and review, on donning, use and doffing can increase successful use of PPE. Selecting PPE: The use of PPE requires selection factors that include supply, size, fit, protection level, comfort, design and experience in use. For example, glove selection is based on the type of exposure. Non-latex gloves are used for protection from infectious diseases, while chemical-re- sistant gloves are used for protection from chemicals. Other considerations include providing PPE in various sizes and manufactures for fit and comfort which can be key factors in appropriate use. Gloves Gloves must be worn according to Standard and Contact Precautions: ● Hand hygiene should be performed when appropriate, regardless of indications for glove use. ● Use of sterile gloves is indicated when an invasive procedure involving mucus membranes or blood is involved (e.g. surgical operations, vaginal delivery, invasive radiological procedures, invasive cardiovascular procedures, total parenteral nutrition and chemotherapeutic agent). ● The use of examination gloves is indicated when there is potential for touching blood, body fluids, secretions, excretions and items visibly soiled by body fluids. ● Situations with risk of direct human exposure include: contact with blood, contact with mucous membrane and with non-intact skin, and the potential presence of highly infectious and dangerous organisms; epidemic or emergency situations; IV insertion and removal; drawing blood; discontinuation of venous line; pelvic and vaginal examination; and suctioning non-closed systems of endotracheal tubes. 28 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Situations with risk of indirect patient exposure include: emptying emesis ba- sins, handling cleaning instruments, handling wastes, and cleaning spills of body fluids. ● Use of gloves is not indicated except for Contact Precautions, when there is no potential for exposure to blood, body fluids or a contaminated environment. ● Situations with risk of direct human exposure include: taking blood pressure, tem- perature and pulse; performing subcutaneous and intramuscular injections; bathing and dressing the patient; transporting patients; caring for eyes and ears (without secretions); and any vascular line manipulation in the absence of blood leakage. ● Situations with risk of indirect patient exposure include using the telephone; writing in the patient chart; giving oral medications; distributing or collecting patient die- tary trays; removing and replacing linen for the patient’s bed; placing non-invasive ventilation equipment and oxygen cannula; and moving patient’s furniture. Facial protection (eyes, nose, and mouth) A surgical or procedure mask and eye pro tection (eye visor, goggles) or a face-shield should be worn to protect mucous membranes of the eyes, nose and mouth during activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Shoe/boot covers, hoods and aprons should also be worn. Gowns and coveralls Gowns and coveralls should be worn to protect skin and to prevent soiling of clothing during activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. The soiled gown or coverall should be removed as soon as possible, and hand hygiene should be performed. Respirators Respirators protect workers from airborne hazards. ● There are two types of respirator: air-purifying and atmosphere-supplying. Res- pirators can also be classified as tight-fitting or loose-fitting. N95 respirators or respirators with a higher protection factor should be used when inhalation hazards are present. Tight-fitting respirators include a tight seal between the respirator and the face and/or neck of the user. ● If the respirator’s seal leaks, contaminated air will be pulled into the face-piece and can be breathed in. Therefore, anything that interferes with the respirator seal (such as facial hair, earrings, headscarves, wigs and facial piercings) is not permitted. Loose-fitting respirators do not depend on a tight seal with the face to provide protection and therefore they do not need to be fit-tested. ● The employee must be medically cleared and fit-tested with the same make, model, style and size of respirator that will be used. Fit-testing is done to be sure that the respirator’s face-piece fits the face. Respirators must be fit-tested before being used for the first time. Retesting should be conducted at least every 12 months to be sure that the respirator continues to fit. Additionally, fit-testing needs to be repeated if there are changes in facial features from surgery or weight gain. ● A user seal check is performed by the wearer each time the respirator is put on. The check determines if the respirator is properly seated to the face or needs to be readjusted. 29Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks ● Masks or surgical masks are NOT respirators and do not protect the user from exposure to airborne hazards. Donning and doffing of personal protective equipment For effective use of PPE to protect health workers, it is essential to follow standard procedures for putting on and take off the equipment. Donning PPE Gown: ● Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. ● Fasten at back of neck and waist. Use duct tape to secure. Mask or respirator: ● Secure ties or elastic bands at middle of head and neck. ● Fit flexible band to nose bridge. ● Fit snug to face and below chin. ● Fit-check respirator. Goggles or face-shield: ● Place over face and eyes and adjust to fit. Gloves: ● Extend to cover wrist of isolation gown. Doffing PPE Gloves: ● Outside of gloves is contaminated! ● Grasp outside of glove with opposite gloved hand; peel off. ● Hold removed glove in gloved hand. ● Slide fingers of ungloved hand under remaining glove at wrist. ● Peel off the second glove. ● Discard gloves in waste container. Goggles or face-shield: ● Outside of goggles or face-shield is contaminated! ● To remove, handle by head band or ear pieces. ● Place in designated receptacle for reprocessing or discard in waste container. Gown: ● Gown front and sleeves are contaminated! 30 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Unfasten ties. ● Pull away from neck and shoulders, touching inside of gown only. ● Turn gown inside out. ● Fold or roll into a bundle and discard. Mask or respirator: ● Front of mask/respirator is contaminated — DO NOT TOUCH! ● Grasp bottom, then top ties or elastics and remove. ● Discard in waste container. Figure 6. Putting on personal protective equipment Source: World Health Organization [13] 31Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks Additional (transmission-based) precautions Additional (transmission-based) precautions are taken while ensuring that standard precautions are maintained. Additional precautions, as described by WHO in Practical guidelines for infec- tion control in health-care facilities [23] include airborne precautions, droplet precautions and contact precautions. Airborne precautions Airborne precautions are designed to reduce the transmission of diseases spread by the air- borne route. Airborne transmission occurs when droplet nuclei (evaporated droplets) less than 5 microns in size are disseminated in air. These droplet nuclei can remain suspended in the air for some time. Droplet nuclei are the residuals of droplets and, when suspended in the air, dry and produce particles in the range of 1-5 microns. These particles can remain suspended in the air for long periods of time, especially when bound to dust particles. Diseases which spread by this mode include open/active pulmonary tuberculosis (TB), measles, chicken pox, pulmonary plague and haemorrhagic fever with pneumonia. The following precautions need to be taken: ● Implement standard precautions. ● Place the patient in a separate room that has a monitored negative airflow pressure (often referred to as a “negative pressure room”). ● The air should be discharged to the outdoors, or should be specially filtered before it is circulated to other areas of the health-care facility. ● Keep doors closed. ● Anyone who enters the room must wear a special, high filtration, particulate respi- rator (e.g. N95) mask. ● Limit movement and transport of the patient from the room to essential purposes only. ● If transport is necessary, minimize dispersal of droplet nuclei by masking the patient with a surgical mask. ● Gain the support of engineering services to ensure that the negative airflow pressure is maintained. Droplet precautions Diseases which are transmitted by this route include pneumonias, pertussis, diphtheria, influ- enza type B, mumps and meningitis. Droplet transmission occurs when there is adequate contact between the mucous membranes of the nose and mouth or conjunctivae of a sus- ceptible person and large particle droplets (> 5 microns). Droplets are usually generated from the infected person during coughing, sneezing, talking or when health-care workers undertake procedures such as tracheal suctioning. The following precautions need to be taken: ● Implement standard precautions. ● Place the patient in a separate room (or in a room with another patient infected by the same pathogen). 32 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Wear a surgical mask when working within 1-2 metres of the patient. ● Place a surgical mask on the patient if transport is necessary. ● Special air-handling and ventilation are not required to prevent droplet transmission of infection. Contact precautions Diseases which are transmitted by this route include colonization or infection with multiple antibiotic-resistant organisms, enteric infections and skin infections. The following precautions need to be taken: ● Implement standard precautions. ● Place the patient in a separate room (or in a room with another patient infected by the same pathogen). ● Consider the epidemiology of the disease and the patient population when deter- mining patient placement. ● Wear clean, non-sterile gloves when entering the room. ● Wear a clean, non-sterile gown when entering the room if substantial contact with the patient, environmental surfaces or items in the patient’s room is anticipated. ● Limit the movement and transport of the patient from the room. Patients should be moved for essential purposes only. If transportation is required, use precautions to minimize the risk of transmission. Environmental cleaning ● Routine cleaning is important to ensure a clean and dust-free hospital environment. Many microorganisms are usually present in “visible dirt”, and routine cleaning helps to eliminate this dirt. ● Administrative and office areas with no patient contact require normal domestic cleaning. ● Most patient care areas should be cleaned by wet mopping. ● Dry sweeping is not recommended. The use of a neutral detergent solution improves the quality of cleaning. Hot water (80°C) is a useful and effective environmental cleaner. ● Bacteriological testing of the environment is not recommended except when seeking a potential source of an outbreak. ● Any areas visibly contaminated with blood or body fluids should be cleaned imme- diately with detergent and water. ● Isolation rooms and other areas that have patients with known transmissible infec- tious diseases should be cleaned with a detergent/disinfectant solution at least daily. ● All horizontal surfaces and all toilet areas should be cleaned daily. Laundry Linen: The basic principles of linen management are as follows: ● Place used linen in appropriate bags at the point of generation. 33Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks ● Contain linen soiled with body substances or other fluids within suitable imperme- able bags and close the bags securely for transportation to avoid any spills or drips of blood, body fluids, secretions or excretions. ● Do not rinse or sort linen in patient care areas (sort in appropriate areas). ● Handle all linen with minimum agitation to avoid aerosol generation of pathogenic microorganisms. ● Separate clean linen from soiled linen and transport/store separately. ● Wash used linen (sheets, cotton blankets) in hot water (70-80°C) and detergent, rinse and dry preferably in a dryer or in the sun. (Heavy duty washers/dryers are recommended for hospital laundry.) ● Autoclave linen before it is supplied to the operating rooms/theatres. ● Wash woollen blankets in warm water and dry in the sun, in dryers at cool temper- atures or dry-clean. Bedding: ● Mattresses and pillows with plastic covers should be wiped over with a neutral detergent. ● Mattresses without plastic covers should be steam-cleaned if they have been contaminated with body fluids. If this is not possible, contaminations should be removed by manual washing, ensuring adequate personnel and environmental protection. ● Wash pillows either by using the standard laundering procedure described above, or dry-clean if contaminated with body fluids. Reprocessing of instruments and equipment Reprocessing of instruments and equipment in an effective way includes following activities: ● cleaning instruments and equipment immediately after use to remove all organic matter, chemicals and ● disinfection (by heat and water or chemical disinfectants) or ● sterilization. Patient care equipment ● Equipment soiled with blood, body fluids, secretions, excretions etc. should be handled in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of pathogens to other patients or the environment. ● Reusable equipment should be cleaned, disinfected and reprocessed appropriately before use with another patient. Used personal protective equipment WHO’s Practical guidelines for infection control in health-care facilities recommends certain measures (see Table 1) for management of used PPE [23]. 34 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Health-care waste management Hospital waste is a potential reservoir of pathogenic microorganisms and requires appropriate, safe and reliable handling. The main risk associated with infection is sharps contaminated with blood. There should be a person or persons responsible for the organization and management Table 1. Management of used personal protective equipment Equipment Standard procedure Comments N95 or standard surgical mask Use disposable only Discard in an appropriate waste bag according to the health-care facility guidelines HEPA (P100) mask Use disposable filters only Separate the filters from the mask and discard the filters. Clean the mask with detergent and water, dry and disinfect with 70% alcohol before reuse. Discard the filters in an appropriate bag according to the health-care facility guidelines. Eye protector, goggles, face- shield Use of disposable items is recommended If reusable, clean with detergent and water, dry, and disinfect with 70% alcohol or soak in 1% hypochlorite solution for 20 minutes and rinse and dry. If disposable, discard in appropriate waste bag according to the health-care facility guidelines. Gown Use of disposable gowns is recommended If reusable: launder according to the health-care facility guidelines for soiled linen e.g. launder in hot water (70-80°C) if possible OR Soak in clean water with bleaching powder 0.5% for 30 minutes. Wash again with detergent and water to remove the bleach. If disposable, discard in an appropriate waste bag according to the health-care facility guidelines. If reusable, ideally dry on a clothes drier or in the sun. Apron Use of disposable aprons is recommended If reusable Clean with detergent and water, dry, and disinfect with 70% alcohol. If disposable, discard in an appropriate waste bag according to the health-care facility guidelines. Cap and shoe covers Use of disposable caps is recommended If reusable, launder according to the health-care facility guidelines for soiled linen (e.g. launder in hot water (70- 80°C) if possible. OR Soak in clean water with bleaching powder 0.5% for 30 minutes. Wash again with detergent and water to remove the bleach. If disposable, discard in an appropriate waste bag according to the health-care facility guidelines. If reusable: ideally dry in a clothes-drier or in the sun. Gloves Use disposable only Discard in the appropriate waste bag according to the health-care facility guidelines Reusable boots Clean with detergent and water, dry, disinfect with 70% alcohol 35Chapter 2. Strategies and tools for protecting occupational safety and health in emergencies and outbreaks of waste collection, handling, storage and disposal. Waste management should be conducted in coordination with the infection control team. In its guidance on Safe management of wastes from health-care facilities WHO [24] lists the following steps for the management of health-care waste: ● generation ● segregation/separation ● collection ● transportation ● treatment and disposal. Principles of health-care waste management The safe management of health-care waste involves a systematic approach based on regulatory requirements and available resources for handling and disposal. The key elements include the following actions by facility managers. ● Develop a waste management plan which is based on an assessment of the current situation and which minimizes the amount of waste generated. ● Separate the clinical (infectious) waste from nonclinical waste in dedicated containers. ● Transport waste in a trolley used only for that purpose. ● Store waste in specified areas with restricted access. ● Collect and store sharps in sharps containers. Sharps containers should be made of plastic or metal and have a lid that can be closed. They should be marked with the appropriate label or logo – e.g. a biohazard symbol for clinical (infectious) waste. ● Mark the storage areas with a biohazard symbol. ● Ensure that carts or trolleys used for the transport of segregated waste collection are not used for any other purpose; they should be cleaned regularly. ● Identify a storage area for waste prior to treatment or before it is taken to final disposal area. ● Treatment of hazardous and clinical/infectious waste must be carried out in accord- ance with national regulations and WHO guidelines. This may involve transportation of infectious waste to a centralized waste treatment facility or on-site treatment of waste. 2.5.2 Prevention of occupational respiratory infections in health-care settings To prevent the transmission in health-care settings of all respiratory infections (including influ- enza, meningococcal meningitis) where infection spreads through droplets, the following infec- tion control measures should be implemented at the first point of contact with a potentially infected person. These measures should be incorporated into infection control practices as one component of Standard Precautions. 1. Visual alerts Visual alerts (in appropriate languages) should be displayed at the entrance to outpatient facil- ities (e.g. emergency departments, physicians’ offices, outpatient clinics) instructing patients 36 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES and persons who accompany them (e.g. family, friends) to inform health-care personnel of symptoms of a respiratory infection when they first register for care, and to practice respiratory hygiene/cough etiquette. The following precautions must be taken to prevent spread of infection from cough: ● Close contact with people who are sick should be avoided. ● Stay at home when sick. ● Cover mouth and nose with a tissue while coughing or sneezing. ● Wash hands often with soap and warm water for 60 seconds. If soap and water are not available, use an alcohol-based hand-rub. ● Avoid touching one’s eyes, nose or mouth. ● Practice other good health habits. Clean and disinfect frequently-touched surfaces at home, work or school, especially when someone is ill. Have plenty of sleep, be physically active, manage your stress, drink plenty of fluids and eat nutritious food. 2. Respiratory hygiene/cough etiquette The following measures to contain respiratory secretions are recommended for all individuals with signs and symptoms of a respiratory infection: ● Cover mouth and nose with a tissue when coughing or sneezing. ● Use the nearest waste receptacle to dispose of the tissue after use. ● If you do not have a tissue, cough or sneeze into your upper sleeve, not your hands. ● Perform hand hygiene (e.g. hand-washing with non-antimicrobial soap and water, alcohol-based hand-rub, or antiseptic hand-wash) after having contact with respira- tory secretions and contaminated objects/materials. Health-care facilities should ensure the availability of materials for respiratory hygiene/cough etiquette in waiting areas for patients and visitors. ● Provide tissues and no-touch receptacles for used tissue disposal. ● Provide conveniently located dispensers of alcohol-based hand-rub; where sinks are available, ensure that supplies for hand-washing (i.e. soap, disposable towels) are consistently available. 3. Masking and separation of persons with respiratory symptoms During periods of increased respiratory infection activity in the community (e.g. work settings and increased medical office visits by persons complaining of respiratory illness), offer masks to persons who are coughing. Either procedure masks (i.e. with ear loops) or surgical masks (i.e. with ties) may be used to contain respiratory secretions (respirators such as N-95 or above are not necessary for this purpose). Where space and chair availability permit, encourage per- sons who are coughing to sit at least three feet away from others in common waiting areas. Some facilities may find it logistically easier to institute this recommendation all year round. 4. Droplet precautions Advise health-care personnel to observe Droplet Precautions (i.e. wearing a surgical or proce- dure mask for close contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory infection, particularly if fever is present. These precautions should be maintained until it is determined that the cause of symptoms is not an infectious agent that requires such precautions. 37Chapter 3. Common risks for safety and health in emergencies Because of the high degree of infectivity and the case-fatality rate, infection with microbial agents is by far the main occupational health concern for persons involved in outbreak response and preparedness. However, in tropical and subtropical climatic conditions, emergency workers can also be at risk of exposure to common endemic diseases such as malaria, typhoid fever, cholera, hepatitis A and B, HIV/AIDS, tuberculosis, water and foodborne infections and other communicable diseases. Apart from highly infectious agents, other hazards can further endanger the health of emergency responders and health-care workers. Endemic diseases, psychosocial stress, fatigue and violence in particular can reduce the working capacity of health-care and response workers and hinder the effectiveness of IPC measures. Heat stress due to prevailing climatic conditions as well as from working in heavy PPE can cause illness and can impose serious limitations on working capacity and productivity. Ergonomic concerns, such as manual handling of loads – i.e. patients and heavy materials – with awkward postures, can cause acute musculoskeletal injuries, diminishing work capacity and reduced ability to adhere to strict work practices thus increasing absenteeism. Short-term expatriate workers and volunteers from all over the world comprise a significant part of the emergency response workforce. Their medical care, security and safety, accommodation, relations with local staff and communities, and adaptation to the climate and sociocultural context of affected countries can also be challenging. This calls for a comprehensive multidis- ciplinary approach to protecting the health, safety and welfare of the outbreak and emergency response workforce, including measures in OSH, IPC, emergency response, logistics and social welfare. This section presents information on hazards that occur to varying degrees in almost all types of outbreaks and emergencies, plus measures for their prevention and control 3.1 Vector-borne diseases Countries affected by highly infectious pathogens such as cholera, yellow fever and viral haemor- rhagic fevers (e.g. Ebola or Marburg virus disease), are also often endemic for malaria, dengue and other vector-borne diseases. Malaria causes fever and can resemble viral haemorrhagic fevers such as EVD in the early stages, potentially leading to misclassification and isolation in a specialized treatment unit. Chemoprophylaxis for malaria and vigilance in personal protection against mos- quitoes and other vectors during day and night are important in preventing vector-borne diseases. Workers deployed in affected areas with high endemicity of vector-borne diseases such as malaria should take the following precautions: ● Wear long-sleeved clothes. Chapter 3. Common risks for safety and health in emergencies 38 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Use insect repellent day and night. ● Sleep under an insecticide-impregnated bednet. ● Take malaria chemoprophylaxis before, during and after the deployment, as advised by a medical professional. ● Be aware of the risk, the incubation period, the possibility of delayed onset, and the main symptoms (fever plus influenza-like symptoms, diarrhoea). ● Immediately seek diagnosis and treatment if a fever develops 1 week or more after entering an area where there is a malaria risk and up to 3 months (or, rarely, later) after departure from a risk area. ● Carry standby treatment for malaria, as advised by a medical professional. 3.2 Water and foodborne diseases Emergency responders have to work in remote areas and difficult conditions where safe food and water may not be available; their stay may involve drinking water from locally available sources as well as cooking locally available foods. In its guidelines for drinking water quality [25], WHO recommends the following measures to travellers to prevent hazards and risks from unsafe water: ● Always avoid consumption or use of unsafe water (even when brushing teeth) if water quality cannot be ensured. ● Avoid unpasteurized juices and ice made from untreated water. ● Avoid salads or other uncooked meals that may have been washed or prepared with unsafe water. ● Drink water that has been boiled, filtered and/or treated with chlorine or iodine and stored in clean containers. ● Consume ice only if it is known to be of drinking-water quality. ● Drink bottled water if it is known to be safe, carbonated bottled beverages (water and sodas) only from sealed, tamper-proof containers and pasteurized/canned juices and pasteurized milk. ● Drink coffee and tea made from boiled water and served and stored in clean containers. Food safety In its food safety guidance [26], WHO has specified “five keys to food safety” that cover the following areas of food safety that are required for food preparation and serving in order to maintain the quality and safety of food: Keeping food preparation areas clean: While most microorganisms do not cause disease, dan- gerous microorganisms are widely found in soil, water, animals and people. These microorgan- isms are carried on hands, wiping cloths and utensils – especially cutting boards – and the slightest contact can transfer them to food and cause foodborne diseases. Therefore, hand hygiene, environmental sanitation and pest control must be applied in kitchen and storage areas. 39Chapter 3. Common risks for safety and health in emergencies Separation of raw and cooked food: Raw food – especially meat, poultry and seafood, and their juices – can contain dangerous microorganisms which may be transferred onto other foods during food preparation and storage. To prevent this, raw meat, poultry and seafood should be kept separate from other foods, and separate equipment and utensils such as knives and cutting boards should be used. Food should be stored in containers to avoid contact between raw and prepared foods. Thorough cooking of food: Proper cooking kills almost all dangerous microorganisms. Studies have shown that cooking food to a temperature of 70°C can help ensure that it is safe for con- sumption. Foods that require special attention include minced meats, rolled roasts, large joints of meat and whole poultry. Consequently it is essential that food is cooked thoroughly – espe- cially meat, poultry, eggs and seafood – and if cooked food needs to be reheated this should be done thoroughly. Foods like soups and stews need to be brought to boiling to make sure that they have reached 70°C and, for meat and poultry, to ensure that the juices are clear, not pink. Keeping food at safe temperatures: Microorganisms can multiply very quickly if food is stored at room temperature. By holding food at temperatures below 5°C or above 60°C, the growth of microorganisms is slowed or stopped. It is essential that cooked food should not be kept at room temperature for more than 2 hours. All cooked and perishable food should be refrigerated preferably below 5°C. Even food in the refrigerator should not be stored for long and frozen food should be thawed at room temperature before cooking. The cooked food should be kept piping hot, preferably at more than 60°C prior to serving. Use of safe water and raw materials: Raw materials, including water and ice, may be con- taminated with dangerous microorganisms and chemicals. Toxic chemicals may be formed in damaged and mouldy foods. Care in selecting raw materials and simple measures such as washing and peeling may reduce the risk. It is essential that safe water is used, or water should be made safe by boiling or by use of chlorine tablets or solutions. Fresh and wholesome foods should be selected, pasteurized milk should be used, and fruits and vegetables, especially if eaten raw, must have been washed thoroughly. Packaged food should not be used beyond its expiry date [26]. 3.3 Vaccine-preventable diseases Immunization against vaccine-preventable endemic diseases is one of the most valuable pro- tective measures to protect health-care workers and emergency responders from highly com- municable diseases. Workers deployed to areas with high prevalence of endemic diseases should be up to date with the vaccinations required for the area of deployment. WHO has summarized guidance for immunization of health-care workers against various vac- cine-preventable diseases on its website [27]. For example, for the responders deployed in the Ebola response in West Africa, WHO recom- mended that vaccines be given against the following diseases prior to deployment [28]: ● yellow fever (mandatory); ● diphtheria-tetanus (ideally within 5 years), polio, pertussis; ● typhoid fever; ● hepatitis A and B; ● meningitis ACYW 135 (mandatory if outbreak is ongoing); 40 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● measles for persons born after 1963 who did not have the disease, or 2 doses of measles-mumps-rubella vaccine (MMR); ● rabies; ● cholera (vaccine recommended in limited situations, based on risk assessment). 3.4 Heat stress Emergency workers who are exposed to extreme heat or who work in hot environments may be at risk of heat stress. Exposure to extreme heat can result in occupational illnesses and inju- ries. Heat stress can result in heat stroke, heat exhaustion, heat cramps or heat rashes. Heat can also increase the risk of injuries in workers as it may result in sweaty palms, fogged-up safety glasses, and dizziness. Burns may also occur as a result of accidental contact with hot surfaces or steam. Emergency response work during natural disasters, chemical and radiological incidents and outbreaks often involves prolonged exposure to heat due to working outdoors under the sun. In addition, emergency responders working to fight fires during disasters, wildfires and other fire-related emergencies may suffer from direct impacts such as burns. Use of recommended PPE which covers the entire body, or a large part of the body/skin sur- face, in semi-permeable and impermeable materials – as required by fire-fighters and health- care workers in specialized treatment units – traps heat and sweat. This limits the body’s protective mechanism of evaporative cooling and instead promotes heat storage and increased body temperature. This is compounded in settings where care is provided outdoors in hot and humid conditions, and where electrical power and air-conditioning are lacking. The following administrative and work practice measures to prevent and manage heat stress and its impacts are advised by the United States Centers for Disease Control and Prevention (USCDC) [29]: ● Time for acclimatization: For workers who are new to the hot region, work exposure time in hot environmental conditions should be increased gradually over 7-14 days to reduce the risk of heat-related illnesses and increase the ability to work safely. If this is not possible, workers new to the climate should work shorter shifts until their bodies adjust to the heat. Workers new to the climate should be scheduled to carry out no more than 20% of the usual work shift on their first day, with no more than a 20% increase on each additional day. Workers with previous experience with the job in this climate should be scheduled for no more than 50% of the usual work shift on Day 1, 60% on Day 2, 80% on Day 3 and 100% on Day 4. ● Increasing awareness of all workers: Workers need to be able to recognize the symptoms of heat-related illnesses. These illnesses include a continuum of health effects ranging, with increasing severity, from heat rash, heat cramps, heat syncope (fainting), heat exhaustion and breakdown of skeletal muscle to heat stroke requiring emergent medical attention to prevent organ damage (i.e. brain, heart, kidney, liver or muscle) and death. The serious risks associated with heat-related illnesses, coupled with the increased risk of becoming incapacitated or compromised while working in a hot environment, make it important for all workers, co-workers and supervisors to recognize the signs and symptoms of heat-related illnesses. 41Chapter 3. Common risks for safety and health in emergencies ● Buddy system: Workers need to use a buddy system to inform supervisors immedi- ately when they recognize signs or symptoms of heat-related illness in themselves or others. Buddies should be instructed to ask their buddy co-worker periodically how he/she feels and leave the work area with the co-worker if needed. ● Limiting the exposure time: For workers working in specialized treatment units and wearing full PPE, the working time should be limited to a maximum of one hour before taking rest. Work in an outdoor hot environment must be performed during morning and evening hours if possible to avoid exposure to heat. ● Duration of rest: Adequate periods of rest and rehabilitation/cooling areas should be provided for staff. ● Access to potable water: Workers should have easy access to adequate amounts of cool (i.e. 10-15°C or 50-59°F) potable water and electrolyte replacement fluids or oral rehydration salts during rest/rehabilitation periods. ● Monitoring of hydration status: Workers should monitor the colour and volume of their urine output and drink fluid often to maintain hydration. ● Emergency procedures: Emergency procedures should be established for workers who exhibit heat-related symptoms, including consideration of cool water baths for symptomatic persons who are severely affected. ● Overall well-being: The overall well-being of workers should be promoted and the impacts of heat stress should be prevented by encouraging adequate sleep, diet and hydration on work and non-work days, and limiting the use of alcohol, caffeinated products and sleep aids. 3.5 Slips, trips and falls Accidents and incidents due to slips, trips and falls can contribute to human suffering and the loss of precious manpower during an outbreak or emergency. In addition, weather and other conditions, as well as urgent requirements for work to be done, can contribute to such inci- dents. These are one of the major causes of serious injuries to workers in health-care facilities. The main causes of slips, trips and falls, as enumerated by USCDC in Slip, trips and fall pre- vention for health-care workers, include the following [30]: ● Contaminants on the floor (water, grease, oil, fluid, food): Contaminants on the floor are the leading cause of slips, trips and fall incidents in health-care facilities. Water, grease and other fluids can make walking surfaces slippery. ● Poor drainage: pipes and drains: Water pipes and drains that are improperly aligned can cause liquid to spill onto walking surfaces, while clogged drains can cause water to back up onto the floor. ● Walking surface irregularities: Poorly-maintained uneven ground, protruding structures, holes, rocks, leaves and other debris can cause employees to stumble, trip, slip or fall. ● Weather conditions (rain, ice and snow): Rainwater, ice and snow can cause em- ployees to slip and fall. ● Inadequate lighting: Common areas where inadequate lighting poses a hazard in- clude parking structures, storage rooms, hallways, stairwells and walkways both inside and outside the facility. 42 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Improper use of ladders and step-stools: Ladder and step-stools used to work from heights can create a hazardous situation if not used properly. ● Tripping hazards (clutter, including loose cords, hoses, wires, medical tubing): Clut- ter can build up in storage areas, work areas, hallways and walkways potentially leading to a slip, trip or fall incident. Exposed cords on the floor, stretched across walkways and tangled near work spaces, can catch an employee’s foot and lead to a trip and fall incident. Human factors associated with slips, trips and falls Human factors represent the ways in which people relate to their environment. Human factors that can affect the risk of a slip or trip include: ● communication: whether safety instructions, signs and labels are understood correctly; ● fatigue: how tiredness can affect the ability to carry out a task; ● personality: how people react differently to instructions (e.g. some ignore them, some take risks); ● capability: asking someone to do something beyond their capability (e.g. lack of training); ● behaviour: how people act (e.g. rushing around, taking short-cuts); ● perception: ability to take in information about one’s environment (e.g. being distracted). Certain activities can affect slips and trips. For instance: ● Carrying/lifting: One may not see a hazard on the floor and if a person loses balance, he/she is more likely to fall. ● Pushing/pulling: One needs more grip and may not see a hazard on the floor. ● Rushing: When one is moving faster, one needs more grip and one has less time to react to a hazard. ● Distraction: If a person’s attention is drawn to something or to someone nearby, that person may be less likely to see a hazard on the floor. The European Agency for Safety and Health at Work (EU-OSHA) [31] recommends the fol- lowing preventive actions: ● Good housekeeping: Poor housekeeping and general untidiness are major causes of slips and trips. Keep the working environment clean and tidy, with floors and access routes kept clear of obstacles. Remove rubbish regularly so it does not build up. ● Cleaning and maintenance: Regular cleaning and maintenance will minimize risks. Rubbish should be removed regularly and work areas kept clear. Cleaning methods and equipment must be suitable for the surface being treated. During cleaning and maintenance work, take care not to create new slip and trip hazards. ● Lighting: Ensure good lighting levels, functioning and position of lights to ensure that all floor areas are evenly lit and all potential hazards (e.g. obstructions and spills) can be clearly seen. Lighting levels need to allow safe passage through the premises. Exterior lights may be required as outdoor workplaces must be adequately lit. 43Chapter 3. Common risks for safety and health in emergencies ● Walking surfaces: Surfaces such as floors should be checked for damage regularly and maintenance carried out when necessary. Potential slip and trip hazards include holes and cracks and, indoors, loose carpets and mats. In any location, the floor surface should be suitable for the work carried out (e.g. it may need to be resistant to oil and chemicals used in production processes). Coating or chemically treating existing floors can improve their slip-resistant properties. The floor should be kept clean ● Spillages: Spills should be cleaned up immediately using an appropriate cleaning method (chemical treatment may be required). Warning signs should indicate where the floor is wet and alternative routes should be arranged. ● Obstructions: Where possible, obstructions should be removed to prevent trips occurring. If it is not possible to remove an obstruction, then suitable barriers and/ or warning notices should be used. ● Trailing cables: Equipment should be positioned so that cables do not cross pedes- trian routes. Cable covers should be used to fix cables securely to surfaces. ● Footwear: Workers need to have footwear that is suitable for their working environ- ment, taking account of the type of job, floor surface, typical floor conditions and the slip-resistant properties of the soles. ● Outdoor workplaces: Outdoor workplaces must be arranged so that risks of slipping and tripping are minimized (e.g. through anti-slip measures in icy conditions and suitable footwear). 3.6 Road traffic injuries Outbreaks and emergency responses require intensive use of vehicles for road transport – ranging from bicycles and motorcycles to heavy trucks – both for rapid movement of responders as well as of materials and supplies. Social mobilization and contact-tracing activities may require the frequent use of bicycles and motorcycles. During an outbreak emergency response, it is very difficult to obtain adequate health care and even minor road traffic injuries can have major consequences. In addition, the climatic conditions in many tropical countries cause continuous heavy rain for months together that wash away the roads and make transportation extremely difficult and hazardous. Some 90% of road traffic deaths and injuries occur in low-income and middle-income coun- tries, yet those countries account for only 54% of the world’s registered vehicles [32]. Practical steps that governments, policy-makers, planners, employers, communities and individuals can take to improve the occupational health and safety of drivers and ensure a safe workplace transportation system include: managing speeding, controlling drinking and driving, using seat- belts and helmets, avoiding long driving or working hours, avoiding using a mobile telephone while driving, ensuring a safe road design, guaranteeing safer vehicles, ensuring quality post- crash care and enforcing road safety regulations. A safe and efficient transportation system is even more important during outbreaks or other emergencies. The key elements required for a safe transportation system include: Roads and transport infrastructure ● Roads and paths are defined and there should preferably be a one-way system with a divider in the middle of the road to separate traffic travelling in opposite directions. 44 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Roads are such that the need for reversing is eliminated or minimized. ● Road surfaces are in good condition through proper maintenance. ● Speed breakers are in place at specified locations, especially near schools, hospitals, markets and other busy places. ● Pedestrian crossings are in place. Vehicles ● Vehicle selection criteria such as good driver access/visibility are considered when purchasing or deploying vehicles. ● Vehicles are maintained in good condition with special attention to tyres, brakes, horns and lights. ● Reversing aids such as a reverse horn and rear-view mirrors are provided. Procedures ● Speed limits are set for vehicles in accordance with regulatory requirements. ● Reversing is controlled through proper parking. ● Drivers have proper authorization to drive. ● The driver is in a safe position during loading of heavy materials. ● Mobile telephone use while driving is prohibited; ● The use of seat belts by drivers and travellers is compulsory. ● There is an incident reporting system for recording and investigating incidents in order to prevent accidents. People ● Competent drivers are employed and monitored through regular driving competency and medical fitness tests. ● Drivers are required to keep to the speed limit. ● Pedestrians are aware and use designated walkways. In addition, regular maintenance of vehicles and ensuring fitness of drivers are essential for preventing road traffic accidents. 3.7 Ergonomic hazards Many ergonomic hazards are created or exacerbated by activities conducted during outbreak and emergency responses. These hazards can cause pain and disability, hindering an effective response. Some ergonomic hazards are addressed here, along with measures to reduce risk. Manual handling of loads: During disasters such as earthquakes, fires, hurricanes and tsunamis, rescue and response operations involve the search for injured and dead among destroyed struc- tures. Heavy materials and obstructions have to be moved and bodies have to be handled and transported to medical facilities. Such activities put workers at risk of back injuries. Manual moving of heavy loads should be minimized. 45Chapter 3. Common risks for safety and health in emergencies Awkward postures: In nearly all emergencies, and especially in earthquakes and structural collapses, bending and twisting are significant risk factors for back and other musculoskeletal injuries among first responders. Similarly, during outbreak responses, handling dead bodies and patients in communities and health-care facilities, and frequent bending and kneeling to give medication, feed and clean patients on mattresses on the floor puts health workers under unusual physical strain. Awkward positions can cause acute back injuries and can significantly reduce work capacity and productivity. Measures for prevention and control of ergonomic hazards during outbreaks and emergencies may include the following: ● Use of backpacks instead of bags: For transportation of first aid and other emer- gency materials over long distances and difficult terrain, the use of backpacks may help to reduce ergonomic strain. ● Placing patients on beds whenever possible: A “cholera bed”, also known as a “cholera cot”, is a wooden pallet with a hole cut in the centre. It is designed to stand at an appropriate height so that health-care workers do not have to bend to provide care. Waterproof sheeting is placed over the pallet, while the hole allows stool to be channelled into a receptacle placed directly underneath the bed. Faecal excretions and vomiting are collected into buckets. Cots such as these are preferable to health-care workers bending to treat patients placed on mattresses on the floor. ● Provision of large enough work spaces: The staff changing room between the high- risk and low-risk zones should be large enough and adequately equipped to allow more than one person to disinfect and undress at the same time (with large staff numbers, allow space for 4-6 persons). ● Bed spacing: It is important to allocate adequate space between beds. In undivided wards, there should be sufficient space (2 metres or 6.5 feet) between beds to allow staff to work unhindered. ● Use of mechanical aids (e.g. stretchers or wheelchairs for lifting and transport): Lifting devices or devices for moving materials have generally not been available during the outbreak and emergency response, especially during the initial stages. However, efforts should be made to avoid lifting and moving patients or exposed persons by hand. All patients or exposed persons unable to walk, including children, should be moved on stretchers, or on sheets if stretchers are not available. At least two response persons should be available when a person is moved. ● Safe manual handling: To move bodies in the absence of stretchers, at least four, and if possible six, people should be available. It is important to keep at least one stretcher clean and available at all times in vehicles for transporting patients, as well as one available for triage/moving individuals. ● Use of steps and/or ramps: Steps or ramps can be installed at the rear of the ambulance or transport vehicle for patients who can move without assistance and for easy transportation of materials. ● Advanced task planning: Tasks should be planned carefully to avoid strains. Pre-in- tervention planning of tasks and resources required to reduce ergonomic stress and strains is particularly important. For example, performing tasks in full PPE can be difficult due to altered sensory input, diminished dexterity and a greater susceptibility to fatigue. 46 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 3.8 Violence Violence can occur in emergency situations. The high fatality rate caused by highly infectious diseases, chemicals and radiation leakages, together with their unpredictable onset and the nature of symptoms, can provoke fear which can lead to violent incidents. In the case of infectious diseases, there may be doubts about the existence of the disease agent, prompting some people to question the intentions of health-care workers. Mistrust can turn to hostility and violence, which can be directed at health-care workers and others dealing directly with patients and their families. Workers conducting safe burials are also at risk. Similarly, during natural disasters, community emotions due to deaths and injuries, loss of livelihood and the sufferings of children and older persons can be directed against emergency workers in the form of violent actions. Violence against emergency workers can take the form of physical or verbal abuse, and can happen inside or outside the workplace. Physical violence, including rape and death, may result in psychological and/or physical harm. Psychological violence includes stigma and dis- crimination, and can take the form of verbal abuse, bullying and threats. Sexual harassment is also possible in both physical and psychological forms. Community hostility leading to violence can be encountered when: ● traditional practices (caring for a sick family member, burials, etc.) are interrupted by infection control specialists for safety and infection control reasons; ● communities misunderstand the disease or doubt its existence, and health-care workers are perceived as infecting people instead of helping them. For instance, during the EVD outbreak response, in a rural village in Guinea, a team of eight health-care workers, journalists and politicians were killed while on an outreach visit that aimed to educate the community about Ebola. Strategies to prevent violence in the context of outbreaks and emergency response The following strategies are useful in mobilizing and sensitizing families and communities to outbreaks and emergency response interventions, and reducing hostility and potential violence: ● Good communication with families and communities can be sustained by delivering a culturally appropriate educational campaign. Such a campaign can begin by assessing the social and cultural issues affecting the disease response, and can be delivered by local people. However, stigmatization and the safety of the messenger must be taken into account. It is important to involve community leaders, as they can reassure communities by reducing harmful rumours and encouraging families to adopt safe practices. ● Giving communities the opportunity to voice their concern and give feedback can be useful in ensuring that emergency response measures are accepted. The method used to receive community input should be decided according to the resources available. ● Establishing a good rapport with patients’ or victims’ families depends on com- munication. Families appreciate clear and comprehensible explanations of what has happened to the person, or to the dead body, and why. This helps prevent misinterpretation and hostility. 47Chapter 3. Common risks for safety and health in emergencies ● To show respect for tradition without compromising safety, response teams must develop a good understanding of cultural traditions affecting the outbreak or epi- demic. Traditional customs and practices should be encouraged so long as they can be carried out safely by, or with, trained staff. For instance, the burial team must treat dead bodies in a dignified and respectful manner. ● Families traditionally care for the sick, and need to remain in continuous commu- nication with the patient. Family members should wear PPE if they have contact with a patient. Protecting emergency workers from violence ● Monitoring and assessing the level of acceptance or hostility in the community is crucial to ensure that community workers are not put in unsafe situations. ● Workers should always work in teams, and should never enter a house without consent. ● A driver should always remain nearby and monitor the activity of workers to ensure that transportation is readily accessible if there is a need to evacuate quickly. ● Protocols can help workers feel confident and safe about performing their work. Levels of community acceptance should be assessed at regular intervals as beliefs and behaviours regarding disease transmission evolve. ● Reliable communication (via radio or other means) must be maintained with the health-care team deployed to rural areas. ● can stay in the car, monitor the team’s activities, and report any incidents to the radio operator. ● The team should avoid entering a village in full PPE. Arriving in normal clothes helps to humanize the process and the villagers’ response. Full protective gear can be put on after procedures have been clearly and transparently explained to the community. Personal safety and security measures Workers involved in outbreak and emergency responses need to be aware of the higher like- lihood of encountering crime and violence. Pre-deployment training in security is highly recommended. 3.9 Fatigue Emergency response workers often work longer and more consecutive shifts than the typical 40-hour work week. Working longer hours may increase the risk of work injuries and accidents and can contribute to poor health. Evidence suggests that working more than 12 hours per day is associated with a 37% increased risk of injury [33]. Fatigue and stress from strenuous work schedules can be compounded by heavy workloads, unfavourable environmental condi- tions (e.g. inadequate or damaged infrastructure, hazardous materials and debris, sparse living conditions), long commutes and personal demands on workers. To confront these challenges, emergency response organizations need to develop their own fatigue management programmes that can be tailored to specific incidents. Organizations need to assess the types of activities they expect to conduct during a response, estimate the 48 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES conditions in which these activities may be performed, identify the factors typically present at response sites that can result in fatigue risk factors, define controls that target these risk factors, and establish evaluation schedules to assess the effectiveness of the controls. Fatigue risk factors ● Many factors can lead to increased risk of fatigue, reduced alertness and productiv- ity, and increased risk of errors, hazardous exposures and injuries in the workplace. The risk factors that should be considered when developing policies and procedures to manage worker fatigue include the following: ● long working hours; ● insufficient or fragmented sleep (less than 7-8 hours of uninterrupted sleep); ● shift work/rotating shifts/night shift work; ● sleeping during the day; ● sleep debt with no possibility to make up lost sleep; ● lack of, or limited, rest breaks; ● physically and mentally demanding work; ● exposure to temperature and other environmental extremes; ● exposure to biological, chemical and physical hazards, particularly if not well characterized; ● work requiring the use of PPE; ● limited access to recreational/fitness equipment; ● exposure to psychological stressors (e.g. close contact with sick or dead victims); ● unfamiliar work environment and/or work task/operations; ● temporary or communal living conditions (which may contribute to psychological stress and result in insufficient or fragmented sleep); ● limited access to nutritious meals; ● travel time to work site. Fatigue risk assessment should consider the following: work hours, work rotations, shifts and rest periods in the different operations of the organization; ● the range of conditions that can be encountered by responders, (e.g. the extent of disruption of normal activities, infrastructure status, population displacement, tensions, worksite security); ● the nature of the accommodation provided for workers during operations (e.g. hotel/ motel, trailer, tent; food service or ready-to-eat meals; sanitary facilities; recreational opportunities); ● the various types of work performed in the operation and, considering any mission changes, likely to be performed in future operations; ● the management and administrative support functions and services (e.g. contracting, financial services, clerical support); 49Chapter 3. Common risks for safety and health in emergencies ● the types of stressful situations experienced by workers and likely to be experienced at future events (e.g. exposure to bodies or seriously ill persons, severe devastation, homeless victims, orphans). Strategies to prevent fatigue NIOSH, in the USA, recommends the following strategic measures to prevent fatigue during response situations [34]; ● Regular rest: Establish at least 10 consecutive hours per day of protected time-off duty to obtain 7-8 hours of sleep. Rest and a full complement of daily recovery sleep are the best protections against excessive fatigue in sustained operations. Allowing only shorter off-duty periods (e.g. 4-5 hours) can compound the fatigue of long work hours. ● Rest breaks: Frequent brief rest breaks (e.g. every 1-2 hours) during demanding work are more effective against fatigue than a few longer breaks. Allow longer breaks for meals. ● Shift lengths: Five eight-hour shifts or four 10-hour shifts per week are usually tolerable. Depending on the workload, 12-hour days may be tolerable with more frequent interspersed rest days. Shorter shifts (e.g. eight hours) during the evening and night are better tolerated than longer shifts. Fatigue is intensified by night work because of night-time drowsiness and inadequate day-time sleep. ● Workload: Examine work demands with respect to shift length. Twelve-hour shifts are more tolerable for “lighter” tasks (e.g. desk work). Shorter work shifts help coun- teract fatigue from highly cognitive or emotionally intense work, physical exertion, extreme environments or exposure to other health or safety hazards. ● Rest days: Plan one or two full days of rest to follow five consecutive eight-hour shifts or four 10-hour shifts. Consider two rest days after three consecutive 12-hour shifts. Measures for control of fatigue Specific measures to prevent and reduce worker fatigue during an emergency response include: ● Education: Provide information on signs, symptoms and health effects of fatigue, as well as deployment preparedness training. The programme should address the process used to educate/inform workers. ● Advance planning: The following elements should be in place under the plan: ● contingency planning for incident mobilization and identifying who does what and when (e.g. the roles of advance incident management teams); ● support services that are critical for managing fatigue; ● policies for assignment of personnel to positions for which they are specifically trained and medically cleared, and for the provision of PPE when needed; ● consideration of additional medical requirements (e.g. unique vaccinations), and the typical procedures in place for checking workers in and out so that worker locations are tracked throughout the incident; ● base camp/site security and ensuring that workers practise advance planning (e.g. have “go kits” ready, have alternatives in place for child care, pet care and bill-paying). 50 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Work hours and rest periods: Establish policies regarding duration of deployments, work hours, work shift rotation and rest breaks during each phase of an operation. Include time off after a predetermined number of consecutive days of work (e.g. minimum of 10 hours of rest in a 24-hour period, with as much of that as possible in consecutive hours; and 48 hours off after 14 consecutive days of work). Move as quickly as possible to regular work schedules so that workers can manage their own rest. Describe how this policy will be managed and enforced (e.g. provisions in place to ensure that sufficient personnel who are properly trained and medically qualified will be available for deployment). ● Transportation: Know the range of transportation method(s) to be used. Include a variety of options to reflect the various situations workers will face. Recognize the potential for worker impairment and driver impairment from long work hours. ● Living conditions: Describe the range of lodging options (e.g. commercial hotels/ motels, trailers, tent cities), as well as options for providing meals, privacy, quiet sleep areas, sanitation facilities, security, laundry facilities, vector control and ma- laria prevention. ● Recuperation provisions: Establish opportunities for exercise and recreation, recog- nizing that these opportunities help to maintain worker functionality. ● Health-care services: Describe the available medical, mental health and stress management services that can be provided. 3.10 Psychosocial stress during outbreaks and emergencies Workers responding to outbreaks and emergencies can encounter many sources of stress. Stress refers to a psychological response, which often includes worry, anxiety, feeling over- whelmed or run-down, or a sense of depression or of not doing well enough. Often these feelings come with somatic complaints such as body pain. Not all stress is problematic; some level of stress helps a person to keep safe and to work well in challenging situations. However, often this stress response becomes too much – especially in situations of chronic adversity such as an emergency – and can lead to a state of chronic stress in which the person feels overwhelmed or unable to cope. High stress and the problems associated with it are normal in a difficult situation and do not mean that persons are weak, incompetent or unable to do their jobs. It may be the case that persons are so committed to work that they do not take enough time to care for themselves. Other problems in life – such as problems at home, lack of social supports, health problems or other uncertainties – can make the work stress harder to deal with. Stress at work can be kept to a manageable level if the individual and the team or organization implements a number of strategies, some of which are easy and quick to implement. This is helpful for individuals and also for those they are trying to help, as self-care is likely to mean that persons are more effective in their roles and less likely to experience a level of stress so great they need to take time off work. These strategies are explained in this section. During the deployment, there may be many sources of stress related to the type of emer- gency, resources available or the uncertainty or limited impact possible. Sources of stress may include: 51Chapter 3. Common risks for safety and health in emergencies ● fear for one’s own well-being or that of family members and co-workers who might contract a deadly disease or suffer health effects from chemicals or radiation (this may be particularly relevant in areas where fatality rates are high, or where there is rapid deterioration or obvious symptoms, as with viral haemorrhagic fevers); ● work-related pressures such as limited time, long hours, performing tasks following strict OSH procedures, or communicating with large teams, often from different cultures and disciplines; ● physical exertion compounded by cumbersome equipment (e.g. PPE), often accom- panied by heat stress, dehydration and exhaustion; ● lack of basic safety equipment for personal protection; ● stigmatization of people working in high-risk areas which may lead to being shunned by family or community or even exposed to violence; ● lack of social support or social networks; ● tension between established safety protocols and the desire to care for or support individuals (e.g. ensuring safe burial practices, isolation, and implementing no-touch policies); ● limited understanding of cultural belief systems that may have relevance (such as not understanding or accepting why some persons may follow burial practises that may increase the risk of infection); ● difficulty in maintaining self-care activities such as exercise, good eating habits and getting enough rest; ● a desire to fulfil one’s duties and to help, despite not having been paid for months. Following deployment, factors that cause stress may include; ● memories related to the adverse events and human tragedy observed during the response; ● fear of long-term effects of exposure to chemicals, infectious diseases or radiation; ● difficulties in readjusting to life after deployment. People may react to stress in different ways in emergency situations. There may be changes in behaviour, such as a change in activity level or job performance, increased use of substances as a way of coping, or changes in the person’s ability to relax or level or irritability. A range of phys- ical reactions (which may have other causes) can also occur, such as stomach problems, changes to weight, fatigue, headaches or other unexplained aches and pains. Psychological changes may include increased anxiety, low mood, low motivation, anxious or depressive thoughts, and related behavioural changes such as frequent crying, isolation or difficulty in accepting help. In most cases, stress related to work will be manageable with good organizational and mana- gerial support. However, in some cases people may present with symptoms of a mental health condition which may be related to the high-stress environment. Assessment of such a problem by a health worker should be considered if the person asks for an assessment or his/her func- tioning and the ability to undertake a number of tasks is impaired. Post-traumatic stress disorder: It is common for people to develop a wide range of psycholog- ical reactions or symptoms after experiencing extreme stress during humanitarian emergencies. For most people, these symptoms are transient. 52 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES When a specific, characteristic set of symptoms (re-experiencing, avoidance and heightened sense of current threat) persists for more than a month after a potentially traumatic event, the person may have developed post-traumatic stress disorder (PTSD). Persons presenting with PTSD often report very similar symptoms to those of persons with moderate depressive disorder (e.g. poor sleep, low mood). Assessment by a qualified health worker may be required to identify the PTSD symptoms of re-experiencing events, avoidance and difficulty in falling asleep or staying asleep. Burnout: Burnout is a term commonly used to refer to long-term exhaustion and diminished interest in work as a result of long-term stress and work overload. It can occur particularly among individuals who are highly motivated, dedicated and involved in the work in which they participate. The desire to achieve high goals and expectations may contrast with physical, emotional and mental exhaustion, resulting in an inability to achieve. Some persons – such as those with a history of mental health problems, ongoing critical per- sonal stressors (e.g. personal illness, illness of a family member, history of family violence, risk of poverty or loss of work) or with reduced social support networks, or persons exposed to extreme stressors or potentially traumatic events – may be at increased risk of impairing levels of stress or mental health problems post-deployment. Preventing and managing response work-related stress Organizations deploying aid workers should develop policies for the following areas: ● pre-deployment and post-deployment screening and assessment of the capacities of staff to respond to anticipated stressors; ● appropriate pre-assignment preparation and training in managing stress; ● regular monitoring of staff response in the field; ● ongoing training and support to help staff deal with their daily stressors; ● specific and culturally-appropriate support to staff and teams in the wake of critical or traumatic incidences or unusual/unexpected sources of severe stress; ● practical, emotional and culturally-appropriate support for staff at the end of the assignment or contract; ● ongoing support for staff adversely affected by exposure to stress, trauma or disease during their deployment. Measures to prevent workplace stress Team-based practices ● Good communication: One of the best ways to reduce stress is to provide as much good-quality information as possible, to enable workers to feel informed and to give them a sense of control. ● Sharing up-to-date information with the workforce: Information-sharing is very important in reducing stress. There should be a mechanism for the clear flow of information about the hazard, modes of transmission and symptoms, as well as protective measures for workers. Information should also be shared with the community and should be regularly updated. It is especially important to inform 53Chapter 3. Common risks for safety and health in emergencies health-care workers promptly if one of their co-workers has become ill. The unit supervisor should gather staff together as soon as possible and give workers an opportunity to ask questions, express concerns and make suggestions. Health-care workers should not have to hear that a colleague has fallen ill through rumour, and should not have to wonder how this happened. ● A venue to express concerns and ask questions: It is especially important that workers have a place where they can ask questions and express concerns about the health risks to themselves and colleagues. Care should be taken to ensure confidentiality of people’s health status. For instance, a manager may convey to a team that a colleague is unwell but is not in a critical condition without divulging the details of the health problems. ● Multidisciplinary team sessions: At least weekly, the multidisciplinary team of direct care-givers, supply managers, cleaners and others involved in the response should meet to exchange concerns. This could be a meeting of the supervisors of each of these groups. The purpose of these meetings is to identify concerns, including about the well-being of staff, and to work together on strategies to solve problems. ● Checklist and buddy system: It is important that health-care workers assess and understand their own strengths, weaknesses and limitations, including recognizing signs of stress and burnout in them and in others. General measures to assist individual coping mechanisms should be explained. It is also important for health- care workers to have an opportunity to register their concerns and complaints con- fidentially, yet in a manner that will maximize the likelihood that these concerns are indeed addressed. The buddy system is a useful way in which psychological support can be provided, and is a good way to monitor stress and burnout. ● Psychological first aid: In the guide for field workers on psychological first aid (PFA) [35], WHO has described the key characteristics of this approach that facilitate its application in field situations. PFA: ● provides practical care and support which does not intrude; ● assesses needs and concerns; ● helps people to address basic needs (e.g. food and water, information); ● involves listening to people, but does not pressure them to talk; ● comforts people and helps them to feel calm; ● helps people to connect to information, services and social supports; ● protects people from further harm. ● Campaigns to reduce stigma: Because the public is aware that health-care workers are at higher risk of contracting disease such as EVD through occupational exposure, health-care workers are often stigmatized and socially isolated. Even families of health-care workers have been known to be stigmatized and socially avoided by friends and acquaintances. As such, comprehensive public education campaigns should address the social stigma and exclusion of health-care workers resulting from the public’s potentially excessive fear of contagion or contamination, as well as other commonly-held beliefs. Importantly, campaigns should encourage the public to value the role of the men and women on the frontline fighting the epidemic, so that workers feel proud of what they are doing. Such campaigns can be organized as part of the social mobilization packages in outbreaks. 54 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Use of humour and participatory techniques: These can promote dialogue, innovative solutions and positive changes in attitude. Methods such as participatory theatre have been used with health-care workers to address the problem of workplace bullying, by creating a feeling of bonding among participants. Creative techniques may also dissipate fear by promoting humour. Organizational culture: ● Team-building techniques should be practised, including facilitating communication and conflict management. The organizational culture should be sensitive to others, as families of local staff may be affected by the outbreak. ● A mental health professional should contact all national and international staff members (including translators, drivers, volunteers etc.) who have survived a crit- ical incident 1-3 months following the event. The professional should assess how the survivor is functioning and feeling, assess for mental health conditions (e.g. depression, PTSD, substance use) and refer for clinical treatment those persons with substantial problems that have not healed over time. Individual practices ● Regulated rest periods: Managers need to be familiar with, and convey to staff, health and safety practices and procedures, including the need for sufficient rest and breaks during the work day. ● Basic needs: Managers need to ensure that there are opportunities to promote phys- ical health, including exercise, and the workers can maintain healthy eating habits. ● Psychological support: A venue should be provided where health-care workers can share fears and worries confidentially. A psychologist should be available to go to the worksite at particularly stressful times, such as when a member of the team dies. ● Role-modelling by organization and field managers: Managers should be role models for staff under their supervision and should conduct themselves in ways that show how to mitigate stress (e.g. taking appropriate work breaks, practising stress-re- duction and relaxation exercises). Most importantly, the field manager must ensure that the basic needs of staff are met and protective equipment provided, that the workforce is valued, and that its efforts are appreciated. Measures for managing stress during different stages of the emergency response In its guide to managing stress in crisis response situations, the United States Department of Health and Human Services recommends the following measures to be implemented by emer- gency managers during different stages of the emergency response [36]: Minimizing stress before the crisis ● Ensure that workers become familiar with the overall emergency response system and the roles and responsibilities of key teams, including their own, in it. ● Establish clear lines of authority and responsibility to minimize stress by eliminating confusion about who reports to whom. ● Provide regular training on stress management techniques. ● Create a facility evacuation plan and practise drills regularly. 55Chapter 3. Common risks for safety and health in emergencies ● Provide ongoing training to ensure that workers are thoroughly familiar with safety procedures and policies. ● Develop guidelines to help workers prepare for deployment. ● Maintain an updated list of family members’ contact information for each employee. Minimizing stress during the crisis ● Clearly define individual roles and re-evaluate them if the situation changes. ● At each shift change provide briefings on the current status of the work environment, safety procedures and required safety equipment. ● Partner inexperienced workers with experienced veterans. The buddy system is an effective method to provide support, monitor stress and reinforce safety procedures. Ensure that outreach personnel enter the community in pairs. ● The system can also help in provision of PFA to the person who experiences stress at an initial stage. ● Rotate workers from high-stress to lower-stress functions. ● Initiate, encourage and monitor work breaks, especially when casualties are involved. During lengthy events, implement longer breaks and days off, and curtail weekend work as soon as possible. ● Establish respite areas that visually separate workers from the scene and the public. At longer operations, establish an area where responders can shower, eat, change clothes and sleep. ● Implement flexible schedules for workers who are directly impacted by an event. This can help workers balance home and job responsibilities. ● Monitor and manage the work environment, transport and living conditions as follows: ● Provide personal protective equipment for protection against high noise, dust and fumes wherever required. ● Mitigate the effects of extreme temperatures through the use of protective clothing, proper hydration and frequent breaks. ● Ensure that lighting is sufficient, adjustable and in good working order. ● Provide security for workers at facilities or sites in dangerous areas. ● Provide mobile telephones for workers in dangerous environments. Ensure that staff know who to call when problems arise. Minimizing stress after the crisis ● Allow time off for workers who have experienced personal trauma or loss. Arrange to bring these persons back into the organization by initially assigning them to less demanding jobs. ● Develop protocols to provide workers with stigma-free counselling so that they can address the emotional aspects of their experience. ● Organize exit interviews to help workers put their experiences in perspective and validate what they have seen, done, thought and felt. Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings The climate of many tropical countries is favourable to the development and spread of out- breaks of various diseases - especially those with vectors that do not survive cold winters and that multiply in rainy seasons. The interaction of hosts, microbes and the environment determines the development and spread of infectious diseases, which has become greater and faster with the increase in travel, globalization and population growth, particularly in countries that lack capacities for public health preparedness and response. These infections may spread and lead to an event that might become a public health emergency of international concern. According to the IHR, the following categories of events may constitute a public health emer- gency of international concern: ● A case of the following diseases is unusual or unexpected and may have serious public health impact, and thus shall be notified: smallpox, poliomyelitis due to wild-type poliovirus, human influenza caused by a new subtype, SARS. ● An event involving the following diseases shall always lead to utilization of the algorithm, because they have demonstrated the ability to cause serious public health impact and to spread rapidly internationally: cholera, pneumonic plague, yellow fever, viral haemorrhagic fevers (Ebola, Lassa, Marburg), West Nile fever, other diseases that are of special national or regional concern (e.g. dengue fever, Rift Valley fever, meningococcal disease). ● Any event of potential international public health concern, including those of un- known causes or sources and those involving events or diseases other than those listed above. Examples under this category include events with risk of spread of toxic, infectious or otherwise hazardous materials that may occur naturally or other- wise and that have contaminated or have the potential to contaminate a population and/or a large geographical area. Large numbers of health workers are actively involved in management of such outbreaks (Box 4). They include first responders from emergency medical teams, health-care workers in emer- gency units and specialized treatment units, and laboratories that are directly involved in rescue, transportation, first aid, emergency care and treatment of affected communities. The prevention and control of occupational infections among care providers in infectious out- break response require close collaboration between OSH and infection control specialists, rep- resentatives of the organization’s management and frontline health-care and others to evaluate the hazards, compile the data on potential exposures that have occurred, and make recommen- dations for prevention. When several employers or organizations use the same facility, work- place, or process they need to collaborate closely to ensure that all workers, both expatriate and domestic, regular and subcontractors, are equally and effectively protected from infection and occupational illness and injuries. 57Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings 58 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 4.1 Occupational safety and health in Ebola treatment and care units In order to ensure the safety of both patients and health-care workers, the following OSH pro- visions must be in place in facilities for treatment of cases: ● The facilities need to be designed with optimal separation between the green zone (the least contaminated area) and the red zone (the most contaminated area) and with unidirectional flow (always green to red and never the reverse). In some contexts (e.g. remote rural areas or larger Ebola treatment units) there may also be one or more “lowest risk” areas – e.g. offices or staff living quarters where street clothes and shoes may be worn. These areas must be completely fenced off and kept separate from the green and red zones. ● There should be separate entrances for patients, staff and visitors. This area should allow direct access to patients who arrive on foot or by ambulance, eliminating any interaction with staff or other patient areas. There must be adequate space near the ambulance arrival area for ambulance decontamination. ● The staff entrance must permit screening upon arrival and should provide direct access to a changing room. Staff must change into scrubs and boots before entering the rest of the Ebola treatment unit compound. This area should have secure storage for staff clothes and belongings. ● The triage area should be large enough to allow one metre of distance between patients, have at least one hand-washing station, offer protection from sun and rain, and have a dedicated latrine. Moreover, an outdoor waiting area should be provided for persons accompanying patients and should incorporate the elements listed above. Box 4. OSH risks and impacts on health-care and other workers during the Ebola virus disease outbreak in West Africa The unprecedented EVD outbreak posed serious health risks for workers in health care and other occupations. According to a WHO preliminary report [6] of the period from 1 January 2014 to 31 March 2015, 815 confirmed and probable cases among health workers were recorded in the VHF database, with 328 in Sierra Leone, 288 in Liberia and 199 in Guinea. During the same period, health workers accounted for 3.9% (815 of 20 955) of all confirmed and probable cases reported (all ages). Except for the first few months, during which there were only a few reported cases, health- worker infections as a proportion of all monthly numbers of cases peaked in July 2014 and decreased thereafter. The decrease from 12% in July 2014 to a low of 1% in February 2015 reflects the effective implementation of preventive interventions. In countries with widespread and intense transmission of EVD, it was difficult to distinguish between occupational and community or residential exposure, particularly among local workers who maintained daily contact with their family members and the community. In addition to health-care staff, other workers at risk included cleaners, laboratory workers, traditional healers, traditional midwives, funeral and burial workers, home-care workers and religious leaders. Workers at risk of contact with undiagnosed patients included those conducting contact-tracing (including public health and community workers), point-of-entry and exit screening personnel, and travel industry staff (i.e. on aircraft, ground transport and ships). Taxi drivers, security forces (guards, police and soldiers), sex workers and workers handling waste in Ebola-affected communities were also at risk. 59Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings ● The use of PPE is the most visible in the hierarchy of controls. However, such controls are the weakest and should not be relied upon as a stand-alone primary prevention strategy. PPE provides physical barriers between an uninfected person and an infectious agent or source of infection. This protection includes, but is not limited to, gloves, gowns, masks, facial and eye protection and respirators. ● The effective and appropriate use of PPE relies on the user’s adherence to protocols and is therefore the most easily compromised control. Focusing only on the availability and use of PPE, to the exclusion of engineering and administrative controls, results in suboptimal protection of all persons in health-care settings, including workers. Infection prevention and control The prevention and control of highly infectious diseases such as EVD and other viral haemor- rhagic fevers in all health-care settings requires the strengthening and careful application of standard precautions when providing care to all patients, regardless of the signs and symptoms they present with. These IPC measures include [37]: ● hand hygiene; ● risk assessment for the appropriate use of PPE; ● injection safety and prevention of injuries from needles and other sharp instruments; ● cleaning and disinfection of the patient environment and patient-care equipment; ● laundry and waste management; ● respiratory hygiene. 4.2 Occupational safety and health in the cholera treatment unit A cholera treatment unit (CTU) is a specialized treatment unit for clinical management of cases of cholera and waterborne diseases. The strategies for protection of health-care workers in CTUs are similar to those used in Ebola treatment units and include the following: ● triage; ● isolation of patients; ● disinfection; ● hand-washing; ● personal protective equipment. The CTU consists of the following four sections that prevent infections among patients and health-care workers [38]: ● selection and observation; ● hospitalization; ● convalescent room for treatment with oral rehydration solutions; ● neutral area (for kitchen, stocks of material etc.). The key health and hygiene rules for infection prevention and control in CTUs are provided in Table 2. 60 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 4.3 Managing occupational safety and health in laboratories handling infectious agents WHO’s Laboratory biosafety manual [39] covers various levels of biosafety requirements for different types of laboratories. In addition, in its guidance on handling highly infectious spec- imens (e.g. of avian influenza), WHO recommends that the following measures should be in place to protect the health and safety of laboratory workers [40]: ● Responsibility for developing a comprehensive safety policy, including a safety manual, and supporting programmes for its implementation normally rests with the director or head of an institute or laboratory. Laboratory safety is also the responsibility of all supervisors and laboratory employees, and individual workers are responsible for their own safety and that of their colleagues. Table 2. Health and hygiene rules in the cholera treatment unit Mode of transmission Essential rules Additional recommended rules People Access limited to patient + one family member + staff One-way flow of people (i.e. from clean to unclean areas only) No more than one caregiver per patient Water Safe water (chlorination concentration according to specific use) Large quantity needed (minimum 10 litres per person per day) Ideally 50 litres per patient per day Hands Hand-washing stations with safe water Wash hands with water and soap - before and after taking care of patients - after using latrines - before cooking or eating - after leaving the admission ward Cut and clean nails Food Cooked food Health-care workers should not handle food or water Food provided by CTU (rather than by families)   Clothes and bedding Wash clothes and bedding with the appropriate chlorine solution based on guidelines If chlorine is unavailable, wash clothes with soap and dry them in the sun Environmental contamination (faeces and waste) Ensure exclusive latrines for the facility Disinfect buckets, soiled surfaces and latrines regularly with the appropriate chlorine solution Use incinerator for medical waste Latrines should be sited at least 100 metres from wells or surface sources Special cholera beds (cholera cots) Corpse Separate morgue Disinfect corpses Identify safe funeral practices Dispose of corpses as soon as possible 61Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings ● Good microbiological technique is fundamental to laboratory safety. The use of safety equipment, combined with good procedures and practices, will help to reduce the risks involved in dealing with biosafety hazards. ● Standard precautions should always be followed; barrier protection (gowns, gloves) should be used whenever samples are obtained from patients. In addition to these standard precautions, eyes should be protected. ● Basic containment – Biosafety Level 2 (BSL2) – practices and procedures should be the minimum requirement for handling specimens. ● Good laboratory practices should be followed. Eating, drinking, smoking, applying cosmetics and handling contact lenses are prohibited in the laboratory working areas. ● PPE (gown, gloves, eye protection) should be worn in the laboratory when handling and processing specimens and performing diagnostic testing. ● All technical procedures should be performed in a way that minimizes the formation of aerosols and droplets. ● Biological safety cabinets or other physical containment devices should be used for all manipulations that may cause splashes, droplets or aerosols of infectious materials (e.g. centrifugation, grinding, blending, vigorous shaking or mixing, sonic disruption, opening of containers of infectious materials whose internal pressure may be different from the ambient pressure). ● The use of hypodermic needles and syringes should be limited. They must not be used as substitutes for pipetting devices or for any purpose other than parenteral injection or aspiration of fluids from laboratory animals. Mouth pipetting must be strictly forbidden. ● Adequate and conveniently located biohazard containers should be available for the disposal of contaminated materials. ● Work surfaces must be decontaminated after any spill of potentially dangerous material and at the end of the working day. In general, freshly prepared bleach solutions are appropriate for dealing with biohazardous spillage. ● Personnel must wash their hands often – especially after handling infectious materials and animals, before leaving the laboratory working areas, and before eating. ● PPE must be removed before leaving the laboratory. 4.4 Management of exposure to blood, body fluids and other contaminants in health-care settings Unprotected exposure of mucous membranes and skin to body fluids of suspected or confirmed patients, contaminated objects and bodies of the deceased should be considered as high-risk exposure incidents. In most cases, such incidents include touching unprotected skin while removing PPE, sharps injuries while providing care to patients, and touching an infectious person or contaminated objects. Exposure incidents related to infectious materials such as blood, vomit and other body secretions should be reported and investigated [41]. 62 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES In case of such incidents involving cases of highly infectious diseases such as VHFs like Ebola, Marburg and other viral haemorrhagic fevers, health-care and other workers should follow these actions: ● Immediately and safely stop any current tasks, and leave the patient care and workplace areas. ● Remove PPE carefully, following appropriate procedures. Exposure during PPE removal can be dangerous and may result in occupational transmission of viral haemorrhagic fevers such as EVD. ● Immediately after removal of PPE, wash the affected skin surfaces or the site of the injury with soap and running water or saline for at least 15 minutes. Accordingly, irrigate mucous membranes (e.g. conjunctiva) with copious amounts of water or an eyewash solution. Do not use chlorine solutions or other disinfectants. ● Immediately report the incident to the local coordinator. This is a time-sensitive task and should be performed as soon as the health-care worker leaves the patient care unit. ● Exposed persons should be medically evaluated, taking into account other potential bloodborne exposures (e.g. HIV, hepatitis B and C), and should receive follow-up care, including fever monitoring twice daily for 21 days (i.e. maximum duration for of incubation period for EVD) after the incident. Immediate consultation with an expert in infectious diseases is recommended for any person who develops fever within 21 days of exposure. ● Workers suspected of being infected should be isolated and should receive care until a negative diagnosis is confirmed. ● It is essential to conduct contact-tracing and follow-up of family, friends, co-workers and other patients who may have been exposed to viral haemorrhagic fevers such as EVD through close contact with the infected health-care worker. ● Infection with viral haemorrhagic fevers such as Ebola and Marburg viruses in persons who have had occupational contact with sources of the virus should be considered an occupational disease in the context of the ILO list of occupational diseases. Post exposure prophylaxis WHO’s current recommendations on post-exposure prophylaxis (PEP) [42] are based on scien- tific evidence and include: ● PEP should be offered, and initiated as early as possible (and ideally within 72 hours), to all persons with exposure that has the potential for HIV transmission. ● Assessment for eligibility should be based on the HIV status of the source when- ever possible and may include consideration of background prevalence and local epidemiological patterns. ● Exposures that may warrant PEP include parenteral or mucous membrane exposure (sexual exposure and splashes to the eye, nose or oral cavity). Exposure to the following body fluids may pose a risk of HIV infection: blood, bloodstained saliva, breast-milk, genital secretions, and cerebrospinal, amniotic, rectal, peritoneal, syn- ovial, pericardial or pleural fluids. ● Exposures that do not require PEP include those when the exposed person is already HIV-positive, when the source is established to be HIV-negative, and when exposure is to body fluids that do not pose a significant risk (e.g. tears, non-bloodstained saliva, urine, sweat). 63Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings ● Although PEP is ideally provided within 72 hours of exposure, people may not be able to access services within this time. Providers should consider the range of other essential interventions and referrals that should be offered to clients presenting more than 72 hours after exposure. ● In some settings with high background HIV prevalence or where the source is known to be at high risk for HIV infection, all exposure may be considered for PEP without risk assessment. ● The fluids, as mentioned above, carry a high risk of HIV infection, but this list is not exhaustive and all cases should be assessed clinically and decisions made by the health-care workers as to whether exposure constitutes significant risk. Assessment The assessment of the person exposed, conditions during exposure and the status of the source person need to be assessed as follows: ● clinical assessment of exposure; ● eligibility assessment for HIV PEP; ● HIV-testing of exposed persons and source if possible; ● provision of first aid in case of broken skin or wound. Counselling and support These are required to prepare the person for investigations, treatment and follow-up, including potential adverse effects of treatment with medicines. The following elements need to be covered: ● risk of HIV; ● risks and benefits of HIV PEP; ● side-effects; ● enhanced adherence counselling if PEP is to be prescribed; ● specific support in cases of sexual assault. Prescription This includes selection and initiation of treatment with appropriate medicines and must cover: ● PEP initiated as early as possible following exposure; ● 28-day prescription of recommended age-appropriate antiretroviral medicines; ● information on medicines; ● assessment of underlying comorbidities and possible drug-drug interactions. Follow-up The follow-up is an essential part of PEP and covers: ● an HIV test at 3 months after exposure; ● a link to HIV treatment if possible; ● provision of prevention intervention as appropriate. 64 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES The steps to achieve these include: ● Provide first aid immediately. ● Assess exposure for potential HIV or other bloodborne infections. ● Test the exposure source for HIV and hepatitis B and C infection. ● Test the health worker who was exposed and provide counselling and care referral. ● Maintain confidentiality of both health worker and patient. ● Ensure follow-up testing and clinical evaluation. ● Provide PEP if needed, with counselling. ● Analyse cases of exposure to improve practice. ● Have an established compensation procedure in the event of claims. Management of possible exposure to other conditions (e.g. hepatitis B and C): ● The risk of transmitting hepatitis B virus (HBV) and hepatitis C virus (HCV) is higher than the risk of transmitting HIV in most cases of exposure, especially in the health-care setting. ● Previous HBV vaccination should be assessed and vaccination offered if required according to age-appropriate national immunization schedules. ● Hepatitis B immunoglobulin protects by passive immunization if given shortly after exposure and should be considered if available for unvaccinated or partly vaccinated persons in addition to vaccination. ● Screening for HCV should be offered in accordance with WHO guidelines. Individ- uals should be counselled on the risk of acquiring HCV and should be referred to specialist care if seroconversion occurs. 4.5 Occupational safety and health protection of health workers from acute respiratory diseases during respiratory disease outbreaks WHO’s interim guidelines on IPC of epidemic- and pandemic-prone acute respiratory diseases in health care [43] recommend the following measures for protection of health workers against acute respiratory diseases (ARDs): ARDs that may constitute a public health emergency of international concern due to their out- break and epidemic potential may include: ● severe acute respiratory syndrome (SARS); ● new influenza virus causing human infection; ● novel ARD with potential to have a high public health impact. Severe acute respiratory syndrome: SARS is caused by a SARS-associated coronavirus (SARS-CoV) which can infect animals and humans. Human-to-human transmission of SARS occurs mainly through droplets or contact, although transmission through infectious respiratory aerosols of various sizes may occur at short range. 65Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings New influenza virus causing human infection: Avian influenza A viruses typically infect birds, but sometimes can infect other animals and humans, and have been associated with clusters of human cases. The strain associated with the largest number of human episodes is H5N1. Novel ARD with potential to have a high public health impact: Infectious diseases have spread across populations and regions throughout history and it is likely that newly-emerging infec- tious diseases will continue to be identified. Many infectious diseases have animal reservoirs and can infect humans under certain circumstances. The rationale for protection of health workers from ARDs include: ● During seasonal or pandemic influenza outbreaks, health workers can become in- fected with influenza through exposure either in the community or in the health-care facility (not necessarily as a result of patient exposure). Once infected, they can serve as sources of virus transmission to other staff and to their patients, who are at increased risk of complications associated with ARD. ● While seasonal influenza vaccine does not provide protection against new influenza viruses, such as avian influenza, it will help to prevent concurrent infection with seasonal human influenza and thus reduce confusion in diagnosis and unnecessary absence from work. ● Prevention of seasonal influenza would also theoretically minimize the possibility of assortment of human and novel influenza viruses within the immunized health-care worker. ● Health-care workers who provide care for any patient with an ARD of potential concern may potentially be exposed to these pathogens and should be monitored and supported as needed. Recommendations for health facility administrators ● Whenever possible, immunize health-care workers against seasonal influenza and monitor vaccine uptake. ● Health-care workers who are at high risk for complications of ARDs of potential concern (e.g. pregnant women, immunocompromised persons, and persons with cardiopulmonary or respiratory diseases) should be informed about the medical risks and offered work assignments that do not involve providing care to ARD patients. Special recommendations for health-care facilities managing patients with ARDs of potential concern include the following: ● A register should be kept of health-care workers who have provided care to patients with ARDs of potential concern for contact-tracing. ● A surveillance system for health-care worker influenza-like illness should be de- veloped. Health-care workers with influenza-like illness should be excluded from high-risk units (e.g. neonatal intensive care units). ● A system should be developed to monitor health-care workers’ health – especially health-care workers providing care to patients with ARDs of potential concern – with self-reporting by symptomatic health-care workers. ● If antiviral prophylaxis is recommended by local policy, health facility administrators should develop a system to provide antiviral prophylaxis to health-care workers exposed to patients with ARDs of potential concern. If necessary, the administration 66 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES should contact public health officials for assistance in obtaining adequate supplies for prophylaxis of health-care workers providing care for patients with ARDs of potential concern, in line with local guidance. ● It should be ensured that health-care workers (especially those taking care of patients with ARDs of potential concern) have timely access to newly-developed vaccines to prevent acquisition of ARDs of concern. ● Methods should be developed to provide additional support to health-care workers (e.g. emotional and family support), as necessary. Recommendations for health-care workers who have provided care for patients known or sus- pected to be infected with an ARD of potential concern: ● Organize health-care workers into groups designated for caring for patients and check health-care workers’ temperature regularly (e.g. before each work shift); mon- itor for symptoms of influenza-like illness (cough, sore throat, difficulty in breathing) for 7–10 days after the last possible exposure to a patient with ARD of potential concern. ● In the event of fever > 38°C, or the development of influenza-like illness, health-care workers should immediately limit their interactions with others, be kept out of work, exclude themselves from public areas, and notify the infection control/occupational health team (and/or their health-care provider) that they are symptomatic and have had contact with patients with an ARD of potential concern. 4.6 Occupational safety and health in outbreak response in community settings The emergency response to the outbreak includes actions carried out by different organiza- tions, both local and international. The response includes government and local authorities in affected at-risk countries, civil society, the private sector, NGOs, multilateral organizations, international financial institutions and agencies of different countries. The strategic objectives of the response strategy are to stop the outbreak, treat the infected, ensure essential services, preserve stability and prevent outbreaks in other countries. Apart from specialized treatment units such as those for EVD and cholera, these activities are carried out in different care settings, including homes, health centres, during transport by air, sea and road, and at entry points to countries or districts. In addition to health-care workers in health facilities, other categories of workers are also at high risk of infection. This section describes the requirements for preventing occupational infections in the most typical community settings of the outbreak response, where response activities pose OSH risks and hazards to emergency responders. 4.6.1 Community work (e.g. social mobilization, contact-tracing, case-finding) Work in the community – such as case-detection, contact-tracing and social mobilization – involves a high risk of contact with undetected cases and poses a high occupational health risk 67Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings of infection for health workers. Consequently, such work must always be carried out with the following safeguards in place: ● Shaking hands and any other social contacts during social mobilization activities and interviews should be avoided. ● PPE such as an impermeable gown, face mask, eye protection and examination gloves, boots and hand hygiene products (preferably an alcohol-based hand-rub solution) should be available for use. ● Distance of more than one metre (about 3 feet) should be maintained between the responder and the interviewee even if the person does not appear to be sick. ● Any physical contact with the interviewee and with the environment is to be avoided. ● When these precautions are adopted and when interviewing asymptomatic individ- uals (e.g. no fever, diarrhoea, bleeding or vomiting), PPE is not required. ● Hand hygiene is to be carried out after any contact with a suspected case and a potentially contaminated environment, and when leaving the place where interviews were conducted for contact-tracing and case-finding in the community. 4.6.2 Ambulances and vehicles for patients or dead bodies Persons transporting a patient with highly infectious disease are at risk of exposure through contact with the patient’s body fluids. Those transporting the bodies of persons who have died from highly infectious diseases are also at risk. Cleaning and disinfecting the vehicle also poses a risk of infection. The following control measures should be applied: ● Response personnel who have direct physical contact with a suspected or confirmed case (e.g. helping the patient to enter the ambulance, providing care to patients during transport) should use appropriate PPE. ● If a patient is not vomiting or bleeding and does not have diarrhoea, PPE should include at least gloves, mask and gown. ● If a patient is vomiting, bleeding or has diarrhoea, or when handling dead bodies, PPE should always include either coverall or full protection with double gloves, respirator such as N95, impermeable gown (or a waterproof apron over a non-im- permeable gown), eye protection (goggles or face-shield) and boots/closed shoes with overshoes. ● A patient who is coughing should be asked to wear a mask. ● Before a dead body is loaded into a vehicle, the body should be put in a double plastic body bag. The outer surface of each body bag should be wiped with a suit- able disinfectant (e.g. 0.5% chlorine solution), and the bag should then be sealed and labelled as highly infectious material. ● PPE should always be changed and safely disposed of after assisting a patient who has been vomiting or bleeding or has had diarrhoea, or after loading dead bodies. ● PPE should be put on and carefully removed according to WHO instructions and pictograms. When removing PPE, care should be taken to avoid any contact between the soiled items (e.g. gloves, gowns) and any area of the face (i.e. eyes, nose or mouth) or non-intact skin. 68 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● PPE should be disposed of in waste containers or plastic bags for highly infectious material. ● Responders should perform hand hygiene with an alcohol-based hand-rub solution or with soap and water after exposure to a patient’s blood and body fluids, after touching contaminated surfaces/items/equipment, and after removal of PPE. ● PPE is not required for persons driving or riding in the vehicle, provided that drivers or riders will not touch any patient or any person accompanying a patient, and will not help to load or handle a dead body. ● Ambulances and other vehicles used for patient transport should be regularly (at least once a day) cleaned and decontaminated with standard detergents/disinfect- ants (e.g. a 0.5% chlorine solution). If the surfaces have been soiled with blood or body fluids, they should be cleaned and decontaminated immediately. ● Ambulances and other vehicles used for patient transport should always be equipped with gloves, masks and full PPE sets, alcohol-based hand-rub solutions, waste bags, body bags, a water tank, wipes, detergent and disinfectant. Ambulance operators should be trained to ensure this, as well as to undergo the fit-test required for use of respirators. 4.6.3 Post-mortem examinations Post-mortem examination of the remains of patients who died due to a suspected infectious disease such as cholera, Ebola or Marburg disease should be limited to essential evaluations only and should be performed by trained personnel [37]. The following precautions need to be taken while conducting post-mortem examinations: ● The IPC staff should be consulted for any decision-making on post-mortem examinations. ● Post-mortem examination of such patients’ remains should be limited to essential evaluations only and should be performed by trained personnel. ● Personnel examining remains should wear a full set of PPE. ● In addition, personnel performing autopsies of cases of known or suspected haem- orrhagic fever or other acute respiratory diseases should wear a particulate respirator (e.g. FFP2, or EN-certified equivalent, or US NIOSH-certified N95) or a Powered Air Purifying Respirator (PAPR). ● When removing PPE, avoid any contact between soiled gloves or equipment and the face (i.e. eyes, nose or mouth). ● Hand hygiene should be performed immediately following the removal of PPE. ● Place specimens in clearly-labelled, non-glass, leak-proof containers and deliver directly to designated specimen-handling areas. ● All external surfaces of specimen containers should be thoroughly disinfected (using an effective disinfectant) prior to transport. ● Tissue or body fluids for disposal should be carefully placed in clearly marked, sealed containers for incineration. 69Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings 4.6.4 Safe and dignified burials Hazards posed by the corpse Dead body management workers, sprayers, technical supervisors, and family and community liaison workers are at risk of exposure through direct contact with body fluids on a corpse, clothing, bedding or other surfaces/objects. Other risk factors include heat stress from working outside in full PPE, violence from family and community members, ergonomic problems from manual handling of loads (bodies and coffins), and psychological distress from dealing with human remains and witnessing human suffering. The bodies of people who have died from highly infectious diseases such as cholera, Ebola or Marburg virus are highly infectious and require burial by special teams who are properly trained and equipped. Safe burials, as recommended by WHO [44], include the following 12 steps: Step 1: Prior to departure: team composition and preparation of disinfectants Step 2: Assemble all necessary equipment Step 3: Arrival at deceased patient home: prepare burial with family and evaluate risks Step 4: Put on all PPE Step 5: Place the body in the body bag Step 6: Place the body bag in a coffin, where culturally appropriate Step 7: Sanitize family’s environment Step 8: Remove PPE, manage waste and perform hand hygiene Step 9: Transport the coffin or body bag to the cemetery Step 10: Burial at the cemetery: place the coffin or body bag into the grave Step 11: Burial at the cemetery: engage community for prayers as this dissipates tensions and provides a peaceful time Step 12: Return to the hospital or team headquarters. Burial teams should include seven members: four for dead body management (with full PPE gear), one sprayer (with full PPE gear), one technical supervisor (not wearing PPE) and one person to interact with family and community (not wearing PPE). The team should also use body bags, disinfectant and transportation. The essential materials that need to be assembled include: ● For hand hygiene: alcohol-based hand-rub solution (recommended) OR clean running water, soap and towels (recommended) OR chlorine solution 0.05% (when options above are not available). ● PPE: one pair of disposable gloves (non-sterile, ambidextrous), one pair of heavy-du- ty gloves, disposable coverall suit (e.g. Tyvec suit), impermeable plastic apron, face protection (goggles and mask), footwear (rubber boots recommended OR, if not available, shoes with puncture-resistant soles and disposable overshoes). ● For waste management: disinfectant, one hand sprayer (0.05% chlorine solution), one back sprayer (0.5% chlorine solution), leak-proof and puncture-resistant sharps container. 70 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES IPC recommendations for the handling of the remains of persons who have died from highly infectious diseases such as Ebola include [44]: ● Only trained personnel should handle remains during the outbreak. ● Health-care workers, family members and burial teams must observe standard precautions in health care when handling a body that has died from Ebola or Marburg virus. This includes: the use of full PPE when handling the dead body of a suspected or confirmed case of haemorrhagic fever, compliance with hand hygiene guidelines, and standard precautions for contact with infected blood, body fluids and materials – especially splashes on surfaces. The handling of human remains should be kept to a minimum. The following recommendations should be adhered to in principle, but may need some adaptation to take account of cultural and religious concerns: ● Hand hygiene should be performed immediately before putting on gloves and im- mediately after the removal of PPE. ● Plug natural orifices. Place the body in a double bag, wipe over the surface of each body bag with a suitable disinfectant (e.g. 0.5% chlorine solution) and seal and label with an indication of highly infectious material. Immediately move the body to the mortuary. ● PPE should be put on at the site of collection of human remains and worn during the process of collection, placement of the body in a body bag, and placement of body bag into a coffin. The PPE should be removed only once the body is secure in the coffin, and should be removed immediately afterwards. ● Remains should not be sprayed, washed or embalmed. Any practice of washing the remains in preparation of “clean burials” should be discouraged. ● PPE is not required for persons driving or riding in a vehicle to collect human re- mains, provided that drivers or riders will not be handling a dead body of a suspected or confirmed case of haemorrhagic fever. ● The bearers of the coffin must wear thick (heavy duty) gloves. ● After being wrapped in sealed, leak-proof material, remains should be placed inside a coffin if possible, and buried promptly. ● It is strongly recommended that the graves of such victims be identified in accord- ance with local customs. The burial process is a very sensitive matter for the family and the community and can be the source of trouble or even open conflict. Consequently, before starting any procedure, the family must be fully informed about the dignified burial process and their religious and per- sonal rights to show respect for the deceased. Ensure that the formal agreement of the family has been given before starting the burial. No burial should begin until family agreement has been obtained. Stretchers should be used to move human remains. There should be a sufficient number of persons in the team so that at least four people can carry the body. The work should be organ- ized to allow for breaks without PPE, and proper hydration. 71Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings 4.6.5 Points of entry and exit, land crossings, airports and sea ports Workers at points of entry and exit at airports, seaports and land crossings provide services that include: control of documentation, scanning of body temperature and health assessments of international travellers, and handling of baggage, cargo, containers, conveyances, goods and postal parcels. Risk factors for workers at points of entry and exit include contact with the body fluids of international travellers, and contaminated surfaces and clothes [45]. ● Workers carrying out screening of passengers should be supplied with PPE commen- surate with the risk assessment for their tasks. PPE should include, at the minimum, disposable gloves. Workers should avoid touching travellers and should maintain a safe distance of 1 metre or 3.2 feet wherever possible. ● Workers should perform hand hygiene with soap and water or alcohol-based hand-rub. ● Medical or public health staff conducting health assessments of sick or suspect travellers should be supplied with PPE – including disposable gloves, long-sleeved impermeable gown, face mask, eye protection (i.e. face-shield or goggles) and closed-toed shoes with shoe coverings or gum boots. Face mask, eye protection and a water-resistant apron are important in case the gown is not impermeable, particularly if there is any risk of blood or body fluid splashes (e.g. if the patient is vomiting, bleeding or has diarrhoea). ● Workers conducting exit screening should be trained in the correct use of PPE and infection control when handling suspected cases, and must perform hand hygiene with soap and running water or an alcohol-based hand-rub solution and a single-use towel. ● Personnel at points of entry and exit, including cargo handlers, should not handle packages that are visibly soiled with blood or body fluids. 4.6.6 Aircraft Travelling in an aircraft to distant areas or countries by a suspect or known case of highly infectious disease poses huge challenges for controlling the spread of disease agents to regions or countries not affected by the disease. In such cases, it is essential that airport ground personnel and cabin crew should be appropriately trained, and medical and universal precaution kits for managing cases/contacts should be available on board in accordance with International Civil Aviation Organization (ICAO) guidelines. At points of entry and exit, crew should follow International Air Transport Association (IATA) standard operating pro- cedures on the management of communicable disease on board that provide the following guidance [46]: Handling an inbound case of suspected communicable disease on an aircraft ● The case definition of a “suspect case”, based on IATA guidelines, includes fever (temperature 38°C/100°F or greater) associated with one or more of the follow- ing signs or symptoms: appearing obviously unwell, persistent coughing, impaired breathing, persistent diarrhoea, persistent vomiting, skin rash, bruising or bleeding without previous injury and confusion of recent onset. 72 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● If an on-board suspect case of communicable disease is identified by the cabin crew, the flight crew should notify the en route air traffic controller who will in turn notify air traffic control at the destination airport. The information transmitted will include details such as flight number, origin, destination, expected time of arrival, number of persons on board and number of suspect cases. The public health authority should be notified of the case by the destination air traffic controller in accordance with local arrangements. The time before the arrival of the aircraft may allow the public health authority to carry out “remote risk assessment”, usually indirectly via the airline operations control centre or ground-to-air medical adviser. Proactive risk assessment may determine whether any public health response is required and will allow measures in the local response plan to be initiated prior to the aircraft’s arrival, thus minimizing delay. The benchmark for the maximum delay to passengers and/or aircraft attributable to the public health authority management of a case of suspected communicable disease should be one hour. On board an aircraft, the following measures should be immediately considered, in accordance with operational procedures recommended by IATA: ● Distance other passengers if possible and reseat them away from the symptomatic passenger, preferably placing the sick traveller near a toilet for his/her exclusive use. ● Cover the nose and mouth of the patient with a medical face mask (if tolerated) if there are respiratory symptoms (e.g. coughing or sneezing). If the mask cannot be tol- erated, the sick passenger should be provided with tissues and asked to cover his/her mouth and nose when coughing or sneezing and to perform hand hygiene afterwards. ● Provide the sick passenger with a plastic bag for disposing of used tissues, and an air sickness bag if experiencing nausea or vomiting. ● Store soiled items (used tissues, face masks, linen, pillows, blankets, seat pocket items, etc.) in a biohazard bag if one is available; if not, use a sealed plastic bag and label it “biohazard”. ● Limit contacts of the passenger to the minimum necessary. Only one (or two if a sick passenger requires more assistance) cabin crew should care for the sick pas- senger and preferably only cabin crew members who have already had contact with that passenger. This cabin crew member or anyone in direct contact with the sick passenger should use universal precautions. They should wear gloves and perform hand hygiene after removing them. ● Instruct cabin crew members to perform hand hygiene by hand-rubbing with an alcohol-based hand-rub solution for 20-30 seconds or hand-washing with soap and water for 40-60 seconds if hands are visibly dirty, after any direct contact with the sick passenger or with his/her personal belongings or any objects/surface potentially contaminated with blood or body fluids from the sick passenger, and after removing gloves. If gloved hands are visibly dirty with body fluids (e.g. vomit) gloves should be removed at the site of the sick passenger and hand hygiene performed immediately. Dedicated crew members assisting the sick traveller should use suitable PPE for dealing with the traveller and for cleaning procedures on board as necessary. ● The possibility of transmission to other passengers and crew on board the aircraft should be assessed by health-care providers on arrival. In the vast majority of cases, the condition will be due to illness such as malaria or minor illness such as common influenza [47]. 73Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings ● If the investigation concludes that the passenger has symptoms compatible with communicable disease and had a risk of exposure in affected countries in the past, passengers and crew members may be at risk if they have been in direct contact with body fluids or heavily contaminated objects. The following epidemiological measures based upon proximity to the index patient should be considered: Passengers and crew with reported direct contact To gather this information, any records of significant events on the flight should be obtained from the airline. Co-travellers and crew members who report direct body contact with the index case and passengers who were seated adjacent to the index case – on the side, in front or behind, including across the aisle – should undergo contact-tracing. Cleaning of contaminated aircraft If the case is suspected or diagnosed after leaving the aircraft, staff who cleaned the section and seat where the index case was seated should also undergo contact-tracing. Passengers, crew members and cleaning staff who are identified through contact-tracing should be assessed for their specific level of exposure. Passive self-monitoring of temperature (e.g. monitoring temperature only if feeling feverish) and symptoms or active self-monitoring (e.g. by regular temperature measurement twice a day) for those at a higher risk level should be continued for the longest incubation period (e.g. 21 days for viral haemorrhagic fevers such as EVD). 4.6.7 Ships The IHR model of a maritime declaration of health [48] contains questions that include the fol- lowing symptoms as grounds for suspecting the existence of a disease of an infectious nature: (a) fever, persisting for several days or accompanied by (i) prostration; (ii) decreased consciousness; (iii) glandular swelling; (iv) jaundice; (v) cough or shortness of breath; (vi) unusual bleeding; or (vii) paralysis. (b) with or without fever: (i) any acute skin rash or eruption; (ii) severe vomiting (other than sea sickness); (iii) severe diarrhoea; or (iv) recurrent convulsions. The major risks for ship workers are contact with body fluids from passengers or crew members or surfaces and clothes contaminated with their body fluids. The key control measures are as follows: ● Maintain a safe distance (1 metre or 3.2 feet) from passengers or crew members; use gloves to handle documents. ● Avoid touching belongings and contact with surfaces and clothing that have had possible contact with body fluids. Frequently perform hand hygiene. ● Ensure that the ship’s master, doctor or crew member appointed to deal with health problems on board is fully informed and is educated about the risks of viral haem- orrhagic fevers such as EVD, and the precautions and protective measures to be taken by crew members to prevent them from contracting the virus. ● Crew members should follow the recommendations in WHO’s Travel and transport risk assessment: interim guidance for public health authorities and the transport sector [45]. 74 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Guidance for ship operators In case a passenger presenting with symptoms compatible with viral haemorrhagic fevers – such as EVD (fever, weakness, muscle pain, headache, sore throat, vomiting, diarrhoea, bleeding) – is on board a ship, the following precautions must be applied: ● Keep the affected person’s cabin doors closed; if not, place in an isolation room on board. ● Provide information about the risk of viral haemorrhagic fevers such as EVD to persons who will take care of the patient or will enter the patient’s cabin or isolation room. ● Maintain a log of all persons entering the cabin or isolation room; all should be considered contacts unless a diagnostic test is reported as negative. ● Ensure that a health worker who enters the cabin or isolation room to provide care to the affected person or to clean the cabin uses PPE as follows: ● non-sterile examination gloves or surgical gloves; gloves (cleaners should pref- erably use heavy duty/rubber gloves); ● a disposable impermeable long-sleeved gown to cover clothing and exposed skin, a medical mask and eye protection (eye visor, goggles or face-shield) when coming in close contact with the affected person and/or if any exposure to blood or body fluids is expected; if unavailable, a waterproof apron should be worn over a non-impermeable gown; ● rubber boots or closed, puncture- and fluid-resistant shoes with overshoes; ● before exiting the cabin or isolation room, PPE should be removed in such a way as to avoid contact with the soiled items and any area of the face. ● anyone providing care to the person in isolation should perform hand hygiene by hand-rubbing with an alcohol-based hand-rub solution for 20-30 seconds or hand-washing with soap and water for 40-60 seconds if hands are visibly dirty, before putting on gloves, after any direct contact with the affected passenger or with his/her personal belongings or any objects/surface potentially contaminated with his/her blood or body fluids and after removing PPE [49]. WHO guidance for prevention and control of acute respiratory disease, such as H1NI1 influ- enza, on ships includes the following [50]: ● Where there has been, or there continues to be, a number of travellers with influen- za-like symptoms on board, efforts should be made by the ship operator to separate sick and suspect passengers leaving the ship from those who are about to board. It may be necessary to use separate halls to prevent human-to-human transmission. If both sets of passengers are obliged to use the same area, it should be cleaned effec- tively after disembarking passengers have left and before embarking passengers arrive. ● The ship’s operator may, if so required by the Member States and available on board, appoint a medical officer or trained crew member to take responsibility for the basic health preventive and control measures and emergency medical treatment, such as: ● initiate active surveillance (case-finding) among the crew members to detect new cases once a person with influenza-like symptoms has been identified and to oversee surveillance activities; 75Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings ● improve awareness of passengers and crew members about the symptoms and signs of pandemic influenza (H1N1) 2009, complications from infection, and infection control measures such as hand hygiene and social cough etiquette; ● promote the practice of hand hygiene and cough etiquette; ● collect the surveillance case data in a timely and appropriate manner and report to the ship operator daily, if so required and possible; ● review medical log data daily for both passengers and crew members to evaluate illness trends and to alert the ship’s master of the need to investigate and contain outbreaks. 4.6.8 Taxis and public transport In countries with intensive transmission of highly infectious communicable diseases (e.g. influ- enza, EVD, Marburg virus etc.), taxi drivers (vans, cars, motorcycles) are at risk of exposure through contact with the coughs and/or sneezing of passengers, or contact with the body fluids, especially if the driver assists passengers to enter the vehicle. Transmission may also come from clothes or belongings contaminated with body fluids that are placed on seats or other surfaces of the vehicle. Control measures include identifying possible or confirmed Ebola cases by asking passengers questions about recent illnesses or visits to a medical facility, and observing passengers for signs or symptoms (e.g. bleeding, inability to stand or move without assistance). Do not touch possible and confirmed Ebola cases or their belongings. Decontaminate the vehicle as soon as possible using bleach. Workers decontaminating the vehicle should wear full PPE. Social mobilization should be used to educate the community that taxis or public transport should not be used to move patients with signs and symptoms of viral haemorrhagic fevers such as EVD. Instead, health-care workers should be contacted and private vehicles used to transport patients to health-care facilities. In areas with widespread and intense transmission of viral haemorrhagic fevers, taxi drivers should be advised to: ● set up a partition between the front and the back seats of the car; ● avoid shaking hands with customers; ● perform hand hygiene frequently with either water and soap or alcohol-based hand- rub, particularly after touching surfaces or objects soiled with blood and body fluids, even if gloves were used; ● cover the back seats with plastic sheets, which should be immediately changed and disposed of in a sealed waste bag if soiled with blood and body fluids (do this while wearing gloves); ● carry alcohol-based hand-rub, gloves, waste bags, wipes and a disinfectant; ● drivers should refer immediately to a health-care facility/authority if they have been exposed to a sick person likely to have a viral haemorrhagic fever such as EVD (physical contact with the patient or with his/her blood or body fluids). 76 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 4.6.9 Waste-water workers Pathogenic microbes such as Ebola virus, V. cholerae and leptospirosis may be found in the faeces and urine (excreta) of infected persons. Waste-water workers who come into direct contact with excreta should take precautions, including hand hygiene and wearing PPE. This includes waste-water workers in health-care facilities, those transporting waste, sewage workers and workers at waste-water treatment plants receiving sewage from specialized treatment units and affected communities. Basic hygiene practices for workers handling waste ● Avoid smoking, chewing tobacco or gum while handling human waste or sewage. ● Cover sores, cuts and wounds with clean, dry bandages. ● In case of accidental spillage of human waste or sewage in the eyes, gently flush the eyes with safe water. ● Use waterproof gloves to prevent cuts and contact with human waste or sewage. ● Wear rubber boots at the worksite and during the transport of human waste or sewage, remove rubber boots and work clothes before leaving the worksite. ● Clean contaminated work clothing daily with 0.05% chlorine solution (1 part house- hold bleach to 100 parts water). ● Follow hand hygiene procedures. ● Before eating, remove soiled work clothes and eat in designated areas away from human waste and sewage-handling activities. Personal protective equipment for workers handling sewage and waste water When dealing with sewage and waste water, PPE should include: ● protective face mask or splash-proof face-shield to protect nose and mouth from splashes of human waste or sewage; ● goggles to protect eyes from splashes of human waste or sewage; ● liquid-repellent coveralls to keep human waste or sewage off clothing; ● waterproof gloves to prevent exposure to human waste or sewage; ● rubber boots to prevent exposure to human waste or sewage. 4.6.10 Insecticidal spraying for vector control activities Vector control activities may be a crucial component of emergency response in the case of vec- tor-borne disease outbreaks such as those of dengue, yellow fever and malaria. Vector control may also be required after floods, tsunami and cyclones as well as part of routine activities in camp sites providing temporary lodging for the community affected by disaster. Methods for mosquito control include space spraying of insecticides, applying larvicides and, in some cases, indoor residual spraying of insecticides (applied to selected indoor surfaces such as walls or under furniture). Vector control workers are exposed to insecticides when opening containers, mixing and loading spray solutions, spraying insecticide products with hand-carried or vehicle-mounted equipment, 77Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings washing and maintaining spray equipment, and disposing of empty containers. Spills, splashes and leaks of insecticide in concentrated form can lead to exposure by accident. In its interim guidance on protection of spray workers during the handling of insecticides for control of Zika virus outbreaks, WHO recommended the following measures [51]: ● planning for protective measures, such as identifying relevant national regulations on pesticide purchase, use and application techniques, information on ingredients and their potential health effects, and making information available through a globally harmonized system of hazard communication [52]; ● protecting the health and safety of operators, such as by providing protective equip- ment (cotton overall covering arms and legs, rubber chemical-resistant protective gloves, hat with broad rim, chemical googles or face-shield, rubber boots and ear muffs); ● spraying of insecticides in a way that minimizes exposure of operators and residents; ● compulsory training of workers in the safe use of insecticides; ● strict personal hygiene such as regular washing, changing clothes and cleaning of equipment; ● storage and disposal of insecticides in a safe, secure place and in line with the manufacturer’s label recommendations; ● provision of medical supervision of spray operators; ● managing acute poisoning with insecticides, such as first aid and decontamination (washing) of the skin and eyes as soon as possible after exposure and treatment (there is no specific treatment; symptoms are treated and further absorption should be prevented). Measures during application of insecticides should include: ● daily briefings on measures to protect workers’ health and for safe work practices; ● prohibition of smoking, eating and drinking during the application of insecticides and larvicides; ● use of appropriate PPE; ● use of correct maintenance procedures for equipment to ensure that no leakages occur during spraying operations; ● recalibration of spray equipment after 25 hours of operation, major maintenance or a change of product; ● use of semi-closed automatic dilution machine for water-diluted sprays. The selection of PPE depends on the OSH risks associated with the different tasks. PPE must comply with national regulations on pesticide use and manufacturers’ recommendations must be taken into account. Personal protective equipment to be used during handling and spraying insecticides When handling concentrated insecticide products, pouring out, mixing or preparing a spray liquid, and filling equipment: 78 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● cotton coverall covering the arms and legs (two sets should be provided per worker per day to allow for change in case of wetting); ● rubber chemical-resistant protective gloves; ● hat with broad rim; ● chemical goggles or face-shield; ● rubber boots. In addition to the above, when spraying with hand-held devices and operating vehicle mount- ed-foggers by hand, wear air-purifying half-mask respirator with organic vapour cartridge(s) in combination with filters for aerosols and particles, such as N95, R95 or P95 filter (respirator filters must be changed periodically in accordance with the manufacturer’s instructions), and ear muffs when working with noisy foggers. When applying microbial larvicides and growth regulators: ● working clothes; ● rubber gloves; ● dust masks when handling formulations in granular form. Storage and disposal of insecticides All insecticides used in space treatment or larviciding should be stored in a safe, secure place and in accordance with the manufacturer’s label recommendations. Unused, diluted insecticide must not be left in the spray equipment after fogging or larviciding, and should not be stored. Unused diluted insecticide and empty containers and sachets should be disposed of in accord- ance with national guidelines and regulations and the recommendations of the manufacturer. Empty containers should be triple-rinsed with the solvent being used (e.g. kerosene oil, diesel, water) and rendered useless before disposal. The rinsate should be used in preparing the subsequent spray liquid as applicable, or disposed of in accordance with national guidelines. Decontamination ● All contaminated clothing should be removed to prevent further absorption. Affected skin should then be washed with soap and flushed with large quantities of water. If the eyes are contaminated, the lids should be gently opened with the fingers and the insides (conjunctivae) washed with clean running water for several minutes. Care should be taken that runoff from one eye does not enter the other eye. ● Decontamination of the skin and eyes should take place as soon as possible after exposure. Special medical treatment should be sought promptly after decontami- nation. Specific measures are needed for different groups of insecticides that are found in the globally harmonized system information for that product. Pre-placement examination ● All operators should go through a preliminary health assessment to determine if there are any contraindications to working with the specific insecticides being used. ● The preliminary health assessment should consist of a physical examination, medical history, occupational history, comprehensive metabolic panel (blood sugar, electro- 79Chapter 4. Occupational safety and health in outbreaks of communicable diseases: clinical and community settings lyte and fluid balance, kidney and liver functions), baseline cholinesterase RBC/ plasma tests (for those using organophosphates and carbamates) and pulmonary function test (for those required to wear a respirator). ● Working with organophosphates and carbamates may cause complications of pre-ex- isting peptic ulcer, bronchial asthma, anaemia, degenerative diseases of the central nervous system, chronic colitis, a history or evidence of psychosis, and diseases such as myasthenia gravis and glaucoma, which are treated with cholinesterase-inhibiting drugs. Medical surveillance ● Arrangements must be made to ensure that any exposed person can easily report any symptoms to a supervisor, who will then notify a medical officer. In particular, any unusual illness not associated with well recognized signs and symptoms of poisoning by a specific insecticide should be noted and reported to the appropriate health authorities. ● Monitoring should be implemented to detect any subtle neurological effects in exposed persons, such as loss of ability to understand written material and to concentrate. In addition to clinical surveillance, quantitative biochemical tests can be carried out to assess the degree of exposure, both during pre-placement and during employment on a periodic basis. ● All cases of acute or chronic poisoning of operators and other personnel resulting from occupational exposure to insecticides should be reported to the competent authority dealing with registration and compensation of occupational diseases and injuries according to established national practice and regulations. 5.1 Emergencies caused by chemical incidents Chemical incidents of varying scales and consequences are a common occurrence in most parts of the world. They may arise from a technological incident, a natural disaster or a delib- erate act. A chemical incident can involve a release of chemicals into the environment (e.g. from an explosion, containment failure or illegal dumping) and also from the adulteration or contamination of products such as food, drink or medicines. This chapter applies to chemical releases into the environment. Some examples are provided in Table 3. Between 2000 and 2009, almost 3200 technological disasters were reported worldwide, with approximately 100 000 people killed and more than 1.5 million affected. These chemical incidents involved chemicals released from chemical plants due to explosions and emissions, natural disasters, dumping of toxic waste, conflicts and terrorism. Some examples of major chemical incidents between 2000 and 2010 are listed in Table 3. 5.2 Occupational safety and health hazards and risks of chemicals A chemical incident has been defined by WHO’s Manual for public health management of chemical incidents as “an unexpected uncontrolled release of a chemical from its contain- ment”. A public-health chemical incident has been defined as “where two or more members of the public are exposed (or threatened to be exposed) to a chemical” [56]. Chemical incidents may be sudden events with a rapid release of chemicals over a limited period of time or more chronic events that can continue for days or even years. Major industrial incidents can be caused by explosions of large vapours or flammable gases, fires or toxic releases. Common toxic releases from plants include chlorine, ammonia, sulfuric acid, hydrogen chloride, phosgene and hydrogen sulphide. For instance, in December 1984 a toxic gas plume of methyl-isocyanate was released into the air from a chemical plant in Bhopal, India, following failure of safety valves and other safety controls. Chemical release may also happen during transportation of gases through pipelines, or by rail, road and waterways. Chemical incidents affect people in a number of ways, including: ● the toxic effects of the chemicals; ● the effects of fire; ● the effects of explosion. Chapter 5. Occupational safety and health in chemical incidents 81Chapter 5. Occupational safety and health in chemical incidents 82 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Toxic effects of chemicals Chemicals enter the body through the skin, eyes, lungs or digestive tract. Absorption is affected by factors such as the properties of the chemical, the route and duration of exposure and the person’s age (young children absorb proportionately more than adults). Ambient conditions such as temperature may also affect absorption by changing the physical state of a chemical. In the context of emergency response, the most likely routes of exposure will be inhalation, and dermal and eye exposure. Absorption via the lungs is usually rapid whereas dermal absorption is slower. The effects of exposure are determined by the toxicity of the chemical, the amount absorbed that reaches target tissues, and factors that influence susceptibility – e.g. age, general health, genetic factors (such as slow or fast metabolizers) and concomitant exposure to other chemicals. A short exposure to a high concentration may be enough to cause toxic effects. When the exposure is prolonged and the dose rate low, it may be the total cumulative dose that causes toxicity. Toxic effects can be local (e.g. burning or blistering of the skin, eyes or respiratory tract) as caused by corrosive agents, irritant gases and some organic solvents, or the effects may be systemic (e.g. toxicity due to lead, mercury, organophosphorus insecticides or cyanide). Some Table 3. Examples of major chemical incidents, 2000-2010 Year Location Description of incidence Consequence 2003 Gao Qiao, China Gas well blowout releasing large quantities of hydrogen sulphide 243 deaths, 9000 people poisoned, 64 000 people evacuated 2006 Côte d’Ivoire Dumping of toxic wastes in the city of Abidjan 10 deaths, thousands made ill 2006 China Plant explosion and fire, with release of 100 tonnes of pollutants in the Songhua river which crosses international borders Five deaths, millions of population without water for several days 2008 China Milk and infant formula adulterated with melamine Some 300 000 infants and 50 000 children hospitalized, with 600 children dying with kidney stones and other kidney defects 2010 Nigeria Lead poisoning from informal gold mining in an area where lead is prevalent, using crude dust- generating technology More than 400 children showing toxicity died and many communities affected 2010 Hungary Burst of sludge reservoir at aluminium plant, with pollutants released to nearby villages and the Danube river which crosses international borders At least 9 deaths and 150 injuries due to corrosive effects of reservoir sludge 2010 USA Explosion of the Deepwater Horizon oil rig in Gulf of Mexico 11 deaths from explosion, minor injuries and effects on health of health workers, other workers and volunteers living near shoreline, with possible long-term effects [53] 2012 Republic of Korea Release of 8 tonnes of hydrogen fluoride from a chemical plant in Gumi 5 deaths, at least 18 injured, evacuation of local residents, crops destroyed, declaration of a special disaster zone [54] Source: International Health Regulations 2005, WHO, 2008 [55] 83Chapter 5. Occupational safety and health in chemical incidents effects (e.g. eye and respiratory irritation or central nervous system depression) can occur within minutes or hours of the exposure, as in the case of nerve agent poisoning. Other effects (e.g. congenital malformations or cancers) may take months or years to appear. Toxic effects of gas release Based on their health effects, gases can be classified as irritant or asphyxiating. Irritant gases have corrosive properties – i.e. they cause injuries to surface tissues such as skin and mucus membranes and cause inflammation of air passages. Examples include ammonia, chlorine and sulfur oxides. Asphyxiating gases are those that interfere with the supply and utilization of oxygen in the body. Chemical asphyxiation causes death by preventing the transportation of oxygen by blood (e.g. carbon monoxide) or by inhibiting cellular respiration (e.g. hydrogen cyanide). Exposure to chemicals in fire The key threats to life during a fire include thermal injury, heat stress, toxic gases and oxygen deficiency. Depending on the substances that are burning, the smoke can be a complex mix- ture of many hazardous chemicals. Typical constituents include soot, carbon monoxide, carbon dioxide, sulfur dioxide, nitrogen oxides, hydrogen chloride, phenol, formaldehyde, isocyanates, benzene and others. Carbon monoxide is a key factor in most fires. Hydrogen cyanide is formed in fires involving polyurethane, nylon, silk and wool. In cases of explosion, there is sudden release of chemicals and pressure effects that cause physical injuries along with chemical and other effects associated with fire. Chemical burns Chemical burns can be caused by many substances – such as strong acids, alkalis, drain cleaning agents, organic solvents and gasoline. In some cases, pain and redness may develop hours after the exposure. The damage may be worse than one would expect from the burn on the skin. As in case of hydrogen fluoride acid, the burn may initially appear mild but may progress to a full thickness burn if not treated [57]. The International Chemical Safety Cards (ICSC) database [58], a joint undertaking between WHO and ILO with the cooperation of the European Commission (EC), is available online and provides essential health and safety information on chemicals. 5.3 Occupational safety and health management of emergency responders during chemical incidents This section describes some basic principles of chemical incident response. It highlights the roles of emergency responders that can result in chemical exposure, as well as the protective measures that should be put in place. 5.3.1 Incident Command System for managing chemical emergencies Where there is an organized response to a chemical incident, this is usually managed through an Incident Command and Control centre. The functions of incident command in a chemical emergency include ensuring that the following tasks are implemented: 84 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● assessment of the situation; ● rescue of people; ● evacuation of people from hazardous areas; ● establishment of safety and security parameters; ● entry to hazardous areas is limited to essential and authorized staff only, through the establishment of exclusion and access zones; ● personal protection guidelines are followed; ● conventional hazards such as fire are dealt with; ● deployment of other teams, such as for monitoring and decontamination. Zoning of the incident scene To manage a chemical incident such as a chemical spill, a series of zones may be established around the incident site to control access and establish a corridor for controlling contamination. Typically, there will be three zones: ● Red, hot or exclusion zone: This is the area where there is active or suspected re- lease of chemicals. This zone should extend far enough to prevent contamination of people and materials outside this area. Very limited activities can be performed here (e.g. operations to control the release and to rescue victims). No decontamination or patient care is provided in this zone. Personnel should wear full chemical PPE. Figure 7. Zoning of the chemical incident scene Source: Adopted from WHO mannual: the public health management of chemical incidents. Geneva: World Health Organization; 2009. [56] Cold or green zone (medical, Incident Command, communication, etc.) Warm or yellow zone (decontamination, rescuscitation) Hot or red zone (response, rescue) 85Chapter 5. Occupational safety and health in chemical incidents ● Yellow, warm or contamination-reduction zone: There may or may not be active release but the concentration of chemicals will be lower than in the hot zone. Emer- gency response personnel will still need chemical protection. Victims, emergency responders and equipment are normally decontaminated at the boundary between this and the cold zone. There is a risk of secondary contamination. ● Green or cold zone: There is no contamination. The contaminated victims, emer- gency response personnel and equipment must be decontaminated before entering this zone. This zone contains all administrative functions for managing the chemical incident (e.g. the command unit and ambulances). Access control – i.e. limiting entry to different zones only to authorized persons – is an impor- tant measure to control the spread of contamination to emergency responders. Safe work practices to be followed by emergency responders in red and yellow zones Emergency responders in red and yellow zones should: ● minimize exposure time to that essential for lifesaving or initial monitoring; ● avoid unnecessary contact with surfaces or potentially contaminated material; ● use natural ventilation flows to reduce exposure (e.g. position upwind of the chemical release, as in the case of gas leaks); ● ensure mandatory decontamination; ● carry out post-exit evaluation for signs and symptoms of exposure. The United Nations Office for the Coordination of Humanitarian Affairs (UN OCHA) suggests guidance for emergency responders undertaking hazardous materials operations [59]. Prior to committing resources to a contaminated site, the following should be considered: ● A risk analysis should be conducted on the basis of a hazard/risk assessment and the site survey. ● Teams should evaluate the risk in relation to the rescue of viable victims versus recovery of the dead. ● Teams should also consider other search and rescue priorities within the immediate vicinity. In general, the following tactics should be adopted while assessing a site that is suspected to be contaminated: ● Ensure a safe approach – usually downwind or, in the event of a liquid spill, up a slope. ● Ensure that clear command and control arrangements are in place and are well understood by all present. ● Secure the site as best as possible to ensure the safety of others. ● Attempt to identify the contaminant (using UN numbers, Dangerous Goods or Hazchem codes). ● Assess the potential harm and minimize environmental contamination where possible. 86 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Call in assistance (e.g. expert advice, additional resources) if possible. ● If within the team’s capability, render the site safe. ● Always assume the worst until proven otherwise. Decontamination can be both equipment- and labour-intensive. Therefore consideration should be given to avoiding overextending the teams’ capability in this area. Whenever protective clothing or equipment is used, decontamination strategies need to be considered. While undertaking search and rescue operations at any worksite, teams should consider the following issues and implement a monitoring regime for the duration of the operations: ● oxygen levels; ● flammability of substance or surrounding atmosphere; ● toxicity levels; ● explosive limits; ● radiological monitoring. The following considerations may affect the decision of whether to conduct search and rescue operations: ● Condition of voids: if the hazard can be easily isolated or mitigated and this is carried out, the situation is considered handled and operations are to continue. ● Time required to access victims: this will be an estimate of the time required to reach the first victim. It should include the time it would take to mitigate hazards, cut through floors, walls, roofs etc., and to shore up and brace the access route as well as relevant adjacent structures, if required. ● Special occupancy information: increased attention and monitoring will be given to certain types of target hazards, especially those involving nuclear energy, radiolog- ical elements, specialized military facilities, chemical manufacture, and biological production or storage. ● Decontamination: careful planning is needed to ensure that the team has procedures in place to provide adequate decontamination of members, including search dogs. The following should be considered when undertaking detection and monitoring: ● Operational worksite detection and monitoring should be performed by the assigned Hazmat specialist in the team and should include the following: ● establishment of safe perimeters for each assigned structure; ● establishment of clean entry points to each assigned structure; ● planning for the need to monitor additional voids or potential spaces encountered during operations; ● establishment of decontamination sites, including appropriate disposal of contam- inated runoff; ● ensuring decontamination of assigned tools and equipment, including protective clothing; ● ensuring decontamination of assigned transportation vehicles. 87Chapter 5. Occupational safety and health in chemical incidents 5.3.2 Personal protective equipment Emergency response personnel and staff in health-care facilities who are managing contami- nated victims/patients may become exposed to toxic chemicals through direct contact with the chemical on the patient’s skin or clothing or by inhalation or mucosal contact with a vapour hazard. These personnel should therefore be provided with appropriate PPE and be trained in its use. The level of PPE depends on the likely degree of exposure and the toxic properties of the chemical concerned. The greater the likely exposure or the more severe the toxicity of the chemical concerned, the higher the degree of chemical protection needed. As an example, personnel involved in controlling a chemical release or rescuing exposed victims (e.g. those operating in the red zone) may need the highest level of chemical protection. Health-care personnel managing patients exposed to a chemical that has limited dermal and inhalational absorption may need little more than aprons and gloves. When deciding on the appropriate level of PPE, the need for adequate protection against toxicity must be balanced against the potential difficulties and discomfort associated with working in high-level equipment. Depending on the type, PPE should be decontaminated prior to removal or else carefully removed and disposed of safely. Levels of PPE protection Use of PPE by first responders during a chemical emergency is grouped by the Occupational Safety and Health Agency of the USA into four categories [60] on the basis of the degree of protection afforded. Level A protection should be worn when the highest level of respiratory, skin, eye and mucous membrane protection is needed. A typical Level A ensemble includes: ● positive-pressure (pressure demand), self-contained breathing apparatus (SCBA), or positive-pressure supplied air respirator with escape SCBA; ● fully encapsulating chemical protective suit; ● gloves, inner, chemical-resistant; ● gloves, outer, chemical-resistant; ● boots, chemical-resistant, steel toe and shank (depending on suit boot construction, worn over or under suit boot). Level B protection should be selected when the highest level of respiratory protection is needed but a lesser level of skin and eye protection is needed. Level B protection is the minimum level recommended on initial site entries until the hazards have been further identified and defined by monitoring, sampling and other reliable methods of analysis, and until equipment corresponding to those findings is utilized. A typical Level B ensemble includes: ● positive-pressure (pressure demand), self-contained breathing apparatus (SCBA), or positive-pressure supplied air respirator with escape SCBA; ● chemical-resistant clothing (overalls and long-sleeved jacket, coveralls, hooded two- piece chemical splash suit, disposable chemical resistant coveralls); ● gloves, outer, chemical-resistant; ● gloves, inner, chemical-resistant; ● boots, outer, chemical-resistant, steel toe and shank. 88 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Level C protection should be selected when the type of airborne substance is known, concen- tration is measured, criteria for using air-purifying respirators are met, and skin and eye expo- sure is unlikely. Periodic monitoring of the air must be performed. A typical Level C ensemble includes: ● full-face or half-mask, air-purifying respirator; ● chemical-resistant clothing (one-piece coverall, hooded two-piece chemical splash suit, chemical-resistant hood and apron, disposable chemical-resistant coveralls); ● gloves, outer, chemical-resistant; ● gloves, inner, chemical-resistant; ● boots, steel toe and shank, chemical-resistant. Level D protection is primarily a work uniform and is used for nuisance contamination only. It requires only coveralls and safety shoes/boots. Other PPE is based on the situation (types of gloves, etc.). It should not be worn on any site where respiratory or skin hazards exist. For contact hazards, nitrile or butyl rubber gloves, not latex, are suitable. In addition, chemi- cally-resistant clothing is suitable. In its absence, fluid-resistant clothing or gown can also be used and regularly changed. Standard medical and surgical masks provide no protection to mucus membranes from toxic vapours. An air-purifying respirator such as one fitted with an activated charcoal filter or SCBA is required. SCBAs require proper training, safety and fit-testing and can be worn by the user for a limited period only. 5.3.3 Decontamination of emergency response personnel Emergency response personnel who become contaminated with chemicals in the course of their work should undergo decontamination at the first opportunity and certainly before leaving the yellow zone, receiving medical treatment or leaving work. Prompt and effective decontam- ination is important to protect against both acute and long-term toxic effects of the chemical concerned. Basic equipment for decontamination is listed in Box 5. It is also important for protecting others (e.g. colleagues and family members) from secondary contamination. Decontamination is usually achieved through the physical removal of the chemical or, in certain limited circumstances, by chemical inactivation. Taking off contaminated clothing will usually remove a significant amount of the chemical. Decontamination methods are divided broadly into wet (using soap and water to wash off the chemical) and dry (using absorbent materials to soak up and brush off the chemical). Chemicals of a viscous or oily nature can be difficult to remove using one method alone. Organizing a decontamination unit in a health-care facility WHO’s Interim clinical management of patients exposed to chemical weapons: interim guidance document [61] covers the following aspects related to decontamination in a health-care facility: ● Decontamination should be carried out in a designated area and cleansing mate- rials such as water, soap and sponges should be provided. The decontamination area should have clearly indicated zones for receiving contaminated personnel (the pre-decontamination zone) and for carrying out decontamination. Additionally, the 89Chapter 5. Occupational safety and health in chemical incidents “clean zone” is where personnel can dress and be given treatment if necessary. Movement should be in one direction only, from the pre-decontamination zone to the decontamination zone to the clean zone. ● The decontamination zone includes any areas where the type and quantity of hazardous substance is unknown and where contaminated victims, contaminated equipment or contaminated waste may be present. It is reasonably anticipated that employees in this zone might have exposure to contaminated victims, their belong- ings, equipment or waste. This zone includes, but is not limited to, places where initial triage and/or medical stabilization of possibly contaminated victims occurs, the pre-decontamination waiting (staging) areas for victims, the actual decontamination area, and the post-decontamination victim inspection area. This area will typically end at the emergency department door. In other documents this zone is sometimes called the “warm zone”. ● The post-decontamination zone is an area considered uncontaminated. Equipment and personnel are not expected to become contaminated in this area. At a hospital receiving contaminated victims, the hospital post-decontamination zone includes the emergency department (unless contaminated). This zone is also sometimes called the “cold zone”. ● Pregnant health-care providers should not be permitted to work in the pre-decon- tamination and decontamination areas. Decontamination at the end of a work cycle by able-bodied personnel If wearing chemical protection suits, responders must wash their PPE before removing it, using a soap and water solution and a soft brush, starting from the head and working down to the feet until contamination is removed. The PPE should be removed by rolling it downward (from head to toe) rather than pulling it over the head. SCBA should be removed after the other PPE has been removed. After removal, all PPE should be placed in labelled and durable polyeth- ylene bags. The person should then shower, taking care to cleanse all areas, including skin folds, with soapy water, and then put on clean clothing. Other types of PPE should be carefully removed, again avoiding pulling items over the head. Clothes should be placed in a labeled and durable polyethylene bag for later cleansing or disposal as hazardous waste, depending on the chemical concerned. The person should then shower, taking care to cleanse all areas including skin folds with soapy water, and then put on clean clothing. Decontamination of contaminated/disabled personnel If an emergency responder has become disabled as a result of contamination or as a conse- quence of trauma, he/she must be decontaminated by others using the following procedure: ● Decontamination should take place before entry into a health-care facility. ● Clothing should be carefully removed in such a way as to avoid exposing unexposed areas. Clothing should be cut off if necessary. ● Decontamination should be carried out and supervised by an appropriately trained responder wearing adequate PPE. ● The use of a dry or wet method should be adapted to local resources and the situation. Information on the rinse-wipe-rinse technique is given below. 90 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Decontamination may need to be accompanied by other activities such as triage and medical resuscitation. ● Contaminated materials and clothing should be disposed of safely as hazardous chemical waste. Emergency decontamination using rinse-wipe-rinse technique The key steps of the procedure are as follows: 1. Any liquid on the skin should be blotted off with clean absorbent material (e.g. wound dressing). Gently rub off any solids (e.g. powder). 2. Affected areas should be gently rinsed or washed with soapy water (use 0.9% saline for open wounds) to dilute the contaminants and remove particulates. Start with the face and work down to the toes, paying special attention to skin folds, skin creases, nails, ears and hair. Eyes should be flushed copiously with 0.9% saline, as using only small amounts may facilitate the spread and absorption of some chemicals. 3. Affected areas should be wiped gently but thoroughly with a sponge or soft brush or washcloth to remove organic chemicals and petrochemicals (hot-water soluble). Sponges and washcloths must be replaced regularly. 4. Affected areas should be rinsed and, once clean, dried gently with disposable towels. ● The following information about the exposed individual should be recorded: ● details of the person (e.g. name, age, sex, address, medical history); ● the way in which the person was exposed to the chemical; ● exposure time (time of day and duration); ● exposure pathway (i.e. air, soil, or water); ● symptoms, including their time course; ● samples collected (e.g. biomarkers); ● treatment indicated and provided. Box 5. Basic equipment for emergency decontamination for chemicals • Scissors • Buckets (5-10 litres capacity) • Sponges, soft brushes (for washing clothes) • Clean water source (ideally lukewarm water), hosepipe for moist rinsing, saline solution (for wound irrigation, eyes and other mucous membranes), distilled water, if possible • Liquid soap, washing-up liquid, shampoo without conditioner • Disposable towels, drying cloths • Large plastic bags (for clothing and double-bagging) • Small clear plastic bags • Identification/triage labels/tags, pen • Sturdy containers (for used decontamination equipment) • Replacement clothing or sheets, blankets • Stretchers Source: Interim clinical management of patients exposed to chemical weapons: interim guidance document [61]. 91Chapter 5. Occupational safety and health in chemical incidents 5.3.4 Medical surveillance of emergency responders As chemicals have both acute and long-term toxic effects on health, it is essential that all emergency responders are subject to medical surveillance throughout their deployment. This requires the following elements to be in place: ● A detailed medical check-up for determining fitness for deployment should take place in the pre-deployment phase, including a check of the respiratory system to assess fitness for using respirators. ● During deployment, as much information as possible should be collected on the nature of the work and type of hazards, duration of work, exposure concentration of chemicals in the working environment, incidents of contamination and adverse health effects, if any. ● Immediately after the response, a post-deployment medical examination should focus on exposures during deployment, including a psychological assessment. Thereafter, based on the type of exposures during deployment, the responders may be examined periodically. ● Medical treatment of all exposed persons is to be carried out whenever required during the deployment cycle. For complex systemic involvement of body systems, the treatment may involve consultation with a clinical toxicologist and, in some cases, the use of antidotes at tertiary-care health facilities. 93Chapter 6. Occupational safety and health in radiation incidents Chapter 6. Occupational safety and health in radiation incidents Nuclear and radiological incidents are infrequent when compared with events involving other hazardous materials such as chemicals. Despite their low frequency, however, nuclear and radiological events generate high levels of public concern and political engagement at local, national and international levels. In addition, concerns regarding potential malicious uses of radioactive and nuclear materials have increased with the heightened awareness of interna- tional terrorism and a variety of radiation and nuclear scenarios can be postulated. Significant incidents at nuclear installations include those at Windscale, United Kingdom (1957), Three Mile Island, USA (1979), Chernobyl, Ukraine (1986), Tokaimura, Japan (1999) and Fukushima, Japan (2011). Incidents involving significant radiation exposures to radioactive sources include exposure of people to abandoned sources (New Delhi, India, 2010), occupa- tional accidents (Chile, 2005), and medical overexposures (Epinal, France, 2004) [62]. Consequently, the scale and types of radiological and nuclear emergencies may range from an isolated occupational or medical over-exposure of one person to a major catastrophe with global dimensions. Regardless of the scale or cause of an accident, there is a common denom- inator - i.e. impacts on human health. The IHR include radionuclear hazards in their scope. 6.1 Sources and scenarios of radiation incidents A radiological emergency is an emergency in which there is, or is perceived to be, a hazard due to radiation exposure from a source may include the following1: ● medical symptoms of radiation exposure; ● loss or theft of a dangerous radioactive source; ● public radioactive contamination/exposure; ● a transport emergency involving radioactive materials; ● detection of elevated radiation levels; ● presence of a radiological dispersal device (RDD). The sources of radiation are used in various fields, including industry, medicine and research; therefore radiological emergencies may occur anywhere. 1 See: www-ns.iaea.org/tech-areas/emergency/iec/frg/what-is-a-rad-emergency.asp, accessed 12 October 2017. 94 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Any source of radiation has the potential to give a radiation dose through external or internal routes as follows: External routes: Individuals can be exposed to radiation from radioactive material in the environment: ● directly from a radioactive source or from radioactive material deposited on the ground or other surfaces; ● dispersion of a radioactive material in gaseous or vapour form in the atmosphere. Internal routes: Individuals can be exposed to radiation from radioactive material within the body by: ● inhaling radioactive material in the atmosphere from the incident or re-suspended from the ground; ● ingesting food/water that has been contaminated with radioactive material; ● absorbing radioactive contamination through the skin or open wounds into the body. Health effects from exposure to radiation include one or more of the following: ● short-term effects such as skin burns or acute radiation syndrome at high doses of radiation; ● long-term effects such as an increased risk of certain types of cancer reported at doses above 100 mSv; ● psychological effects even where little or no radiation exposure has occurred. 6.2 Occupational safety and health management of emergency responders during radiation emergencies The International Basic Safety Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources (BSS) [63] define an emergency exposure situation as a situation of exposure that arises as a result of an accident, a malicious act or any other unexpected event, and that requires prompt action in order to avoid or to reduce adverse consequences. Preventive measures and mitigation actions have to be considered before an emergency expo- sure situation arises. However, once an emergency exposure situation does arise, exposures can be reduced only by implementing protective actions. During an emergency, each particular protective action (elaborated in emergency prepared- ness and response planning) might be implemented separately, and optimization of the entire strategy needs to consider all pathways of exposure, in order to ensure that the residual dose2 is reduced to as low as reasonably achievable. The optimized protection strategy is to be implemented when generic criteria, for use in protection strategies that are compatible with reference levels, are exceeded, to provide for rapid action. Such actions are often needed in the absence of detailed radiological information that is usually associated with planned expo- sure situations in which the source is under control. In emergency situations, reference levels 2 Residual dose refers to the dose expected to be incurred after protective actions have been terminated (or after a decision has been taken not to take protective actions). 95Chapter 6. Occupational safety and health in radiation incidents should be selected to be within, or if possible below, the 20–100 mSv band3 18 recommended in the ICRP Recommendations of 2007 (Publication 103). Occupational exposures in emergency and existing exposure situations are to be subject to the available operational and procedural arrangements, including assessment, monitoring, engage- ment and training. Individual exposure should be optimized, with appropriate boundaries of reference levels. Depending upon the prevailing circumstances, these reference levels may be greater than the recommended values of dose limits that are applicable to planned exposure situations. In emergency or existing exposure situations, the reference levels represent the level of dose or risk, above which it is judged to be inappropriate to plan to allow exposures to occur, and for which therefore protective actions should be planned and optimized. The initial intention would be to not exceed, or to remain at, these levels. The higher levels of exposure in an emergency may be necessary and appropriate over a short period of time, given the prevailing circumstances, and subject to optimization of protection. Such levels would not be expected to continue for extended periods because reductions in exposures can be realized as additional information becomes available, and some measure of control over the source and the exposure situation is achieved. The relevant recommendations of the ICRP are set to prevent tissue reactions and the ambition is to reduce all doses to levels that are as low as reasonably achievable, economic and social factors being taken into account. In exceptional situations such as in nuclear and radiological emergency operations, informed emergency workers may volunteer to take actions where there is a probability of receiving doses that might exceed 50 mSv (the occupational dose limit for workers in a single year). The only situations in which this is applicable are listed as follows (paragraph 4.17 of the BSS): ● No emergency worker is subject to an exposure in an emergency in excess of 50 mSv other than: (a) for the purpose of saving life or preventing serious injury; (b) if undertaking actions intended to avert a large collective dose; or (c) if undertaking actions to prevent the development of catastrophic conditions. ● When undertaking intervention under these circumstances, all reasonable efforts shall be made to keep doses to workers below twice the maximum single-year dose limit, except for life-saving actions, in which every effort shall be made to keep doses below 10 times the maximum single-year dose limit in order to avoid deterministic effects on health. In addition, workers undertaking actions in which their doses may approach or exceed 10 times the maximum single-year dose limit shall do so only when the benefits to others clearly outweigh their own risk. 3 The ICRP Recommendations of 2007 (Publication 103) gives three bands for use in selecting reference levels: (1) The dose constraint or reference level of up to about 1 mSv, in the case when individuals are exposed to radiation from a source that yields little or no benefit for them, but which may benefit society in general. (2) Reference levels of 20–100 mSv would be used where individuals are exposed to radiation from sources that are not under control or where actions to reduce doses would be disproportionately disruptive. (3) Dose of greater than 100 mSv being incurred within a short period of time or in one year would be considered unacceptable, except under the circumstances relating to exposure of emergency workers that are addressed specifically. 96 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Response organizations and employers should ensure that emergency workers re- ceived might exceed 50 mSv do so voluntarily; that they have been clearly and comprehensively informed in advance of the associated health risks, as well as of available measures for protection and safety; and that they are, to the extent possible, trained in the actions that they may be required to take. ● Workers undertaking an emergency intervention may include, in addition to those employed by registrants and licensees, such assisting personnel as police, fire-fight- ers, medical personnel and drivers and crews of evacuation vehicles. ● The person legally responsible for ensuring compliance with the foregoing require- ments shall be specified in emergency plans. According to the BSS, it is essential that emergency preparedness and response planning be undertaken in advance based on the optimization of a protection strategy, which may be com- posed of several specific actions based on the circumstances. In line with the requirements embodied in the ILO Radiation Protection Convention, 1960 (No. 115) which applies to all activities involving exposure of workers to ionizing radiations, including emergency workers, exceptional exposure of workers is neither justified for the purpose of res- cuing items of high material value, nor, more generally, because alternative techniques of inter- vention, which do not involve such exposure of workers, would involve an excessive expense. It is therefore essential that activities that have associated significant potential exposures be examined and addressed in the authorization process, and that the appropriate resources are identified and emergency plans put in place to minimize or eliminate the exposure of workers. The ILO Radiation Protection Recommendation 1960 (No. 114) provides that, so far as is prac- ticable, a complete record of all doses received in the course of work by every worker should be kept so that the cumulative dose may be taken into account for employment purposes. Paragraph 3.83(d) of the BSS 2014 outlines that workers should provide to the employer, reg- istrant or licensee such information on their past and present work that is relevant for ensuring effective and comprehensive protection and safety for themselves and others. Once emergency operations have ended, other activities (source recovery, clean-up, waste disposal, etc.) should follow occupational radiation protection guidance as directed by a radi- ological assessor. ● All reasonable steps shall be taken to assess and record the doses received by workers involved in emergency intervention. The doses received and the consequent health risk shall be communicated to the workers involved. ● Workers shall not normally be precluded from incurring further occupational ex- posure because of doses received in an emergency exposure situation. However, qualified medical advice shall be obtained before any such further exposure if a worker who has undergone an emergency exposure receives a dose exceeding 10 times the maximum single-year dose limit or at the worker’s request. The ICRP Recommendations of 2007 (Publication 103) states that workers undertaking recovery and restoration operations in a later phase of emergency exposure situations should be considered as occupationally exposed workers and should be protected according to normal occupational radiological protection standards, and their exposures should not exceed the occupational dose limits recommended by the ICRP. Workers undertaking work 97Chapter 6. Occupational safety and health in radiation incidents such as repairs to plant and buildings or activities for radioactive waste management, or under- taking remedial actions for the decontamination of the site and surrounding areas, should be subject to the relevant requirements for occupational exposure in planned exposure situations as outlined in section 3 of the BSS. 6.2.1 Guidance for protection of emergency responders during radiation emergencies Based on the basic principles of radiation protection, the general guidelines that should always be followed by emergency responders during radiation emergencies include the following4: ● Female workers who become aware that they are pregnant or are breastfeeding should be encouraged to immediately notify their employers and should be excluded from emergency duties. ● Avoid touching suspected radioactive items. ● Ensure you are visually identifiable and that you are in the accountability system when within the inner cordoned area. ● Perform only life-saving and other critical tasks near a potentially dangerous radi- oactive source. ● Minimize time spent within 10 metres of suspected dangerous radioactive materials/ source. ● Avoid the smoke, or use available respiratory protection equipment (for response personnel), within 100 metres of a fire or explosion involving a potentially dangerous radioactive source. ● Keep hands away from the mouth and do not smoke, eat or drink until hands and face are washed (to avoid inadvertent ingestion). ● Change clothes and shower as soon as possible. ● When treating or transporting contaminated persons, use normal barrier methods (standard precautions) such as surgical gloves and masks. ● Workers who may have been significantly contaminated or exposed (e.g. those within the inner cordoned area) should be monitored for radioactive contamination. If monitoring cannot be performed immediately, shower and change clothing as soon as possible. ● Medical evaluation of those potentially exposed and/or contaminated may be nec- essary in order to determine their subsequent medical management. Therefore, persons who are involved in a radiological emergency should be registered. ● Instruments of the type normally used by emergency services that measure gamma dose rate, including radiation pagers, cannot detect hazardous levels of all forms of radioactive materials. Only a trained and properly equipped radiological assessor can perform a complete assessment of the radiological hazards. Therefore, per- sonnel protection guidelines should always be followed until a radiological assessor evaluates the hazard and provides specific recommendations. 4 See: http://www-pub.iaea.org/MTCD/Publications/PDF/EPR_FirstResponder_web.pdf, accessed 12 October 2017. 98 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES Guidelines that should be followed if gamma dose rate is known ● Follow guidelines listed above that should always be followed. ● If ambient dose rate in a particular area is greater than 100 mSv/h: – perform only lifesaving actions. – limit total time of staying there to under 30 minutes. ● Do not proceed into an area with an ambient dose rate of greater than 1000 mSv/h unless directed by the radiological assessor. Guidelines that should be followed if self-reading dosimeters are being used ● Follow guidelines listed above that should always be followed. ● Follow the “Emergency worker turn back guidance” as provided in Manual for first responders to a radiological emergency (Vienna: International Atomic Energy Agency; 2006). Instructions for health and safety of the first responder monitor during monitoring of responders and the public ● Establish a monitoring location in an area with ambient dose rates below 0.3 Sv/h that is close to the decontamination area. ● Wear gloves and protective clothing as available. Change gloves regularly. ● Follow personnel protection guidelines that should always be followed, as described above. ● Monitor a person’s hair, hands, pockets, dirty parts of clothes, feet and face, holding the monitor about 10 cm from the monitored surface. Instructions for health and safety during decontamination of externally-contaminated casualty in hospitals by the hospital emergency team ● Wear PPE, including respiratory protection as required. ● Change gloves and survey the hands frequently to prevent the spread of contami- nation to other sites. ● Remove patient’s clothing and place in labelled plastic bags. 6.2.2 Incident Command System for managing radiation emergencies Radiation emergencies, like chemical incidents, are also managed through an Incident Command and Control system. Table 4 shows the response teams involved in a radiation emer- gency at the scene and at the hospital. In radiation emergencies, it has been observed that local emergency services (e.g. local medical, law enforcement, fire services) have the most important role in the early response. The teams for environmental monitoring, radiological triage, decontamination, people moni- toring, dose assessment and records that operate at the scene, as well as the radiation protec- tion officer and health/medical physicist roles, are specific to a radiological emergency. Environmental monitoring team: The function of the environmental monitoring team is to carry out environmental monitoring at the site of incident to assess radiation and contamination levels. Radiological triage team: The function of the radiological triage team is to prioritize people for medical assessment, radiation measurements and decontamination procedures. 99Chapter 6. Occupational safety and health in radiation incidents Table 4. Response teams involved in a radiological emergency At the scene At the hospital Tactical Incident Command Security personnel First responders Ambulance team Security personnel Emergency medical manager Medical team Hospital emergency team Environmental monitoring team Pathology department Radiological triage team Radiation protection officer Decontamination team Health/medical physicist People monitoring team Dose assessment team Records team Ambulance team Source: TMT Handbook, Norwegian Radiation Protection Agency [64]. Figure 8. Risk zones in radiation emergencies Source: Nuclear and Radiological Emergency Guidelines, International Federation of Red Cross and Red Crescent Societies [65]. Safe zone Destination for decontaminated general population, injured and hospital patients Transition zone Lower contamination levels, area for triage, emergency medical treatment, decontamination and evacuation Hot zone High contamination area People monitoring team: The function of the people monitoring team is to monitor people for external contamination and possibly also for internal contamination. Other functionaries and teams in the Incident Command System include support functions from records, logistics and administrative teams. Role of helpers in emergency: The helpers are the members of the public who willingly and voluntarily help in response to a nuclear or radiological emergency. Helpers are provided with information about the potential exposures and impact risks and are aware that they may be exposed to radiation while helping in response to a nuclear or radiological emergency. The scene is organized into different zones based on radiation exposure levels, and accordingly various activities are performed in different zones as shown in Figure 8. The red zone is a high-contamination zone where activities should be conducted only by first responders. 100 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 6.2.3 Personal protective equipment PPE should be selected on the basis of known or anticipated contamination levels in the work area, anticipated work activity, worker health considerations, and regard for non-radiological hazards that may be present. Personnel are required to wear PPE when entering areas con- taining contamination levels above specified limits in order to prevent contamination of skin and clothing. The degree of protective clothing required depends on radiological conditions in the work area and the nature of the job (Box 6). Basic factors that determine the type and extent of protective clothing required are: ● type and form of contamination; ● levels of contamination; ● type of work being performed. 6.2.4 Decontamination Decontamination of injured persons can be carried out either in hospital or adjacent to the incident, depending on the severity of injuries. Decontamination as described in this section refers to the removal of radioactive contamination and not removal of chemical or biological materials. Box 6. Personal protective equipment appropriate to the responder’s role (In all cases PPE giving a similar level of protection must be used) a. First responders and emergency workers entering the red zone must wear: full-face respirator when non-radiological hazards are not present and the assigned protection factor (APF) is appropriate; waterproof gloves (must be abrasion-resistant); waterproof clothing (all skin and hair must be covered); waterproof shoes or boots; safety helmet; personal dosimeter (measuring instantaneous dose rate as well as cumulative dose) with alarm; personal dosimeter (film badge or thermos-luminescent dosimeter); high-visibility clothing (recommended). b. First responders and emergency workers entering the yellow zone and medical staff handling contaminated casualties must wear: surgical gloves (must be changed frequently); waterproof coveralls that cover arms, legs, neck and head; respirators; plastic shoe covers; hair cover (e.g. surgical cap); personal dosimeter (film badge or thermos-luminescent dosimeter) (recommended). c. Personnel carrying out decontamination must wear: PPE as in b, above, plus waterproof clothing (recommended). Source: TMT Handbook, Norwegian Radiation Protection Agency [64]. 101Chapter 6. Occupational safety and health in radiation incidents ● Decontamination procedures consist of removing clothing and washing the body with soap and water to eliminate most external contamination. Removal of outer clothing without washing may reduce contamination by 80-90%. ● Persons carrying out decontamination should not eat, drink or smoke and should keep hands their away from their mouth until their outer clothing has been removed and they have showered. ● At the decontamination facility, a one-way system should be established so that people in need of decontamination do not come into contact with those people who have been decontaminated. Areas for decontamination must have separate entrance and exit points. ● Contamination with radioactive materials is not immediately life-threatening. De- contamination should be carried out as soon as possible, but generally does not require the same immediacy as in the case of chemical or biological contamination, except in extreme circumstances where the radioactive contamination is sufficient to cause severe effects. ● If contamination is present on clothing, the contaminated clothing must be changed. If contamination is found on skin, the person must go through decontamination procedures. ● Contaminated or potentially contaminated items such as casualties’ clothes, dress- ings, equipment, staff clothing etc. should be bagged, labelled and stored in a secure area. 6.2.5 Occupational health surveillance of persons occupationally exposed to radiation in emergencies Article 12 of the ILO Convention No 115 states that: “All workers directly engaged in radiation work shall undergo an appropriate medical examination prior to or shortly after taking up such work and subsequently undergo further medical examinations at appropriate intervals.” Article 13 provides that circumstances shall be specified, in which, because of the nature or degree of the exposure or a combination of both, the following action shall be taken promptly: (a) the worker shall undergo an appropriate medical examination; (b) the employer shall notify the competent authority in accordance with its requirements; (c) persons competent in radiation protection shall examine the conditions in which the worker’s duties are performed; and (d) the employer shall take any necessary remedial action on the basis of the technical findings and the medical advice. In this regard, paragraph 3.76(f) of the BSS 2014 provides that employers, registrants and licensees should ensure, for all workers engaged in activities in which they are or could be subject to occupational exposure, that necessary workers’ health surveillance and health services for workers are provided. According to paragraph 3.108 of the BSS 2014, these programmes for workers’ health surveillance should be based on the general principles of occupational health and should be designed to assess the initial fitness and continuing fitness of workers for their intended task. Paragraph 27 of the ILO Radiation Protection Recommendation 1960 (No. 114) provides that, if as the result of such medical advice as is envisaged in Article 14 of the ILO Convention No 115, it is inadvisable to subject a worker to further exposure to ionizing radiations in that worker’s employment, every reasonable effort should be made to provide such a worker with suit- able alternative employment. In this respect, paragraph 3.112 of the BSS provides that employers 102 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES should make all reasonable efforts to provide workers with suitable alternative employment in circumstances for which it has been determined, either by the regulatory body or in the frame- work of the programme for workers’ health surveillance in accordance with the requirements of the BSS, that workers, for health reasons, may no longer continue in employment in which they are or could be subject to occupational exposure. In addition, it may be noted that some of the more recent occupational safety and health instruments (the Working Environment (Air Pollution, Noise and Vibration) Convention, 1977 (No. 148) and the Asbestos Convention, 1986 (No. 162)) indicate that where continued assignment to activities covered by those instruments is found to be medically inadvisable, every effort shall be made, consistent with national practice and condi- tions, to provide the worker concerned with other means of maintaining their income. Occupational exposures may arise following accidents, typically among emergency teams acting in the initial phases of an emergency response and among those conducting longer-term recovery operations. In most cases, the exposures can be controlled but it may be necessary to exceed the recognized dose limits. Emergency workers may be deliberately exposed above normal dose limits in the following situations [66]: ● while saving life or preventing serious injury; ● while undertaking actions to avert a large collective dose; ● while undertaking actions to prevent the development of catastrophic conditions. Normally such doses are limited to 0.5 Gy. Those exposed must be fully trained and must volun- teer for the operation in question. Another condition is that, before implementing planned oper- ations that are likely to result in exposures above the dose limits, the workers involved should be consulted about the planned operation, informed of the potential hazard and instructed in measures to keep exposures as low as reasonably achievable. Doses resulting from the emergency exposure should be recorded together with those from normal exposures, but in such a way as to distinguish them from doses from routine prac- tices; they should not be incorporated into the five-year cumulative total dose upon which the application of the dose limits is based. Doses resulting from exposures in emergency situations should be reported to the worker, the occupational physician and the regulatory authority. Such doses would not exclude the worker from subsequent employment involving occupational expo- sure, subject to medical approval [67]. Treatment of overexposed persons Based on International Atomic Energy Agency (IAEA) guidance [67], exposures can be divided into three categories according to dose, namely: ● doses close to or just above the dose limits; ● doses well above the dose limits but below the threshold for deterministic effects in a particular organ; ● doses at or above the threshold for deterministic effects. ● Doses close to the dose limits. Doses close to the dose limits do not normally require any special clinical investigation or therapy, and the role of the occu- pational health personnel is to counsel the overexposed worker that such an exposure is unlikely to produce adverse health effects. Such an advisory role is undertaken whether or not it is solicited by the worker. 103Chapter 6. Occupational safety and health in radiation incidents ● Doses well above the dose limits. Where the exposure is significantly higher than the dose limits but below the threshold for particular deterministic effects, the role of the occupational physician is to counsel the worker and to determine whether biological dose indicators, such as lymphocyte counts and chromo- somal aberration assays, are needed to confirm the dose estimates. A blood sample should be taken by the physician for examination and dose estimation but normally no further action is required. ● Doses at or above the threshold for deterministic effects. If the assessed ex- ternal doses for the whole body or organs are around the threshold for deter- ministic effects, therapeutic action may need to be undertaken. As a basis for this decision, the overexposed worker needs to be examined clinically and any abnormal findings or symptoms recorded. Haematological examination will need to be undertaken in order to monitor the clinical course of the overexposure. If the exposure is severe enough to lead to acute radiation syndrome, early transfer to specialized treatment facilities is essential. The occupational physician should initiate the investigations and treatment of the early symp- toms. Immediate life-threatening injuries such as fractures and burns must be treated as a priority before transfer to a specialized centre. The long-term clinical management of such highly-exposed persons would normally require the expertise available at specialized clinics. Medical record of accidental and emergency exposures. The medical record of accidental and emergency exposures should be as complete as possible. It should contain details of all exam- inations, treatment and advice given. The occupational health service should participate in the accident investigation to review the adequacy of the response. Chapter 7. Occupational safety and health hazards in natural disasters The main responsibilities of emergency workers during natural disasters include the rescue of survivors and provision of medical help, the evacuation of people from the affected area, recovery of dead bodies, prevention of further damage, clean-up work, provision of food and potable water, maintenance of a good level of hygiene to prevent the spread of epidemics, and supporting the vaccination of the population. During natural disasters, the specific risks for emergency workers may be due to the devasta- tion of the area, collapsing buildings and other structures, destruction of electrical installations, and general destruction of infrastructure and communication lines. In addition, the response may require workers to work in confined spaces, with the attendant risks of being seriously injured or trapped by debris, or attacked by aggressive animals. Natural disasters due to floods, windstorms and tsunamis are associated with the risks of drowning and the spread of waterborne and vector-borne diseases [67]. Waterborne diseases are spread when the affected population or emergency workers come into direct contact with contaminated water with high concentrations of bacteria, viruses and other microorganisms – such as when sewage enters the drinking-water supply, or when emergency workers have to work in contaminated surface water. The key waterborne infectious diseases include cholera, typhoid fever, shigellosis, E. coli infections, polio, hepatitis A, hepatitis E, rotavirus, leptospi- rosis and parasitic diseases such as schistosomiasis. After flooding or following disasters, vector-borne diseases are also a risk where field camps are erected for the care of disaster victims and where the waste management system is disturbed. Standing water serves as a breeding-site for mosquitoes, and rodents are attracted by nutrients in the waste. Diseases that are typically transmitted by mosquitoes are malaria, dengue, yellow fever, Zika virus, St. Louis encephalitis, Japanese encephalitis and West Nile fever. The faeces of rodents may contain large quantities of organisms, permitting the spread of leptospirosis. Infectious diseases that may affect emergency workers through their contact with survivors include wound infections, diseases that are transmitted by droplet infection such as tubercu- losis, gastrointestinal diseases transmitted by smear infections, and bloodborne diseases such as HIV, hepatitis B and hepatitis C. The possibility of infections associated with contact with dead bodies is highest for bloodborne diseases, gastrointestinal diseases and tuberculosis. Emergency responders such as fire-fighters and other rescue and relief workers deployed in natural disasters may be particularly at risk of respiratory and asthmatic problems. Volcanic eruptions lead to significant releases of ash and gas. Smoke is also generated in wildfires or fires occurring as secondary effects of natural disasters. Landslides and earthquakes lead to 105Chapter 7. Occupational safety and health hazards in natural disasters 106 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES excessive amounts of dust production. All these factors (ash, gas, smoke and dust) cause eye and pulmonary irritation, and in the most severe cases may lead to asphyxiation. Some of the by-products of combustion are often carcinogenic. Volcanic eruptions, vegetative fires or fires generated as secondary effects of natural disas- ters cause high heat stress, presenting the possibility of skin injuries and burns. Air pollution caused by dust from collapsed buildings, gas and ash released as a consequence of volcanic eruptions or smoke resulting from fires also make transport accidents more likely. In pre-hospital health care and in the provision of assistance to disaster victims, emergency workers face an increased risk of exposure to blood and body fluids and to needle-stick inju- ries. These expose them to a very high risk for HIV, hepatitis B and hepatitis C. In regions where tuberculosis is prevalent among the population, the possible transmission of infection when in contact with survivors or dead bodies is also a possible risk for emergency workers. Those workers who anticipate possible prolonged exposure to persons with tubercu- losis (e.g. those who expect to come into routine contact with populations in clinics, hospitals, prisons or homeless shelters) should have a tuberculin skin test (TST) or TB blood test before departure. If the reaction to the TST or TB blood test is negative, they should have a repeat test 8-10 weeks after returning. 7.1 Occupational safety and health hazards and risks due to floods Floods are the most common weather-related natural disasters and affect many countries around the world. According to a report by the United Nations Office for Disaster Risk Reduction (UNSDR), between 2005 and 2015, floods accounted for 47% of all weath- er-related disasters, causing 40% of all deaths due to such disasters, with 89% of such deaths occurring in low-income countries in Africa and Asia. Between 2005 and 2015, many nations faced major floods, including Bangladesh, China, India and Pakistan in Asia and Madagascar, Malawi, Mozambique, Rwanda, South Africa and the United Republic of Tanzania in Africa [68]. Floods can potentially increase the transmission of the following communicable diseases: ● waterborne diseases, such as typhoid fever, cholera, leptospirosis and hepatitis A; ● vector-borne diseases, such as malaria, dengue and dengue haemorrhagic fever, yellow fever, and West Nile fever. Waterborne diseases Floods cause an increased risk of infection with waterborne diseases – such as wound infec- tions, dermatitis, conjunctivitis, fungal infections and ear, nose and throat infections – con- tracted through direct contact with polluted waters. Leptospirosis, a zoonotic bacterial disease, is transmitted directly from contaminated water. Transmission occurs through contact of the skin and mucous membranes with water, damp soil, vegetation or mud contaminated with rodent urine. The occurrence of flooding after heavy rainfall facilitates the spread of the organism due to the proliferation of rodents which shed large amounts of leptospirosis-causing microbes in their urine. 107Chapter 7. Occupational safety and health hazards in natural disasters Vector-borne diseases: Floods may lead indirectly 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 the over- flow of rivers can act as a breeding site for mosquitoes, and therefore increase the potential for exposure of the disaster-affected population and emergency workers to infections such as dengue, malaria and West Nile fever. Flooding may initially flush out mosquito breeding, but it comes back when the waters recede. The lag time is usually around 6-8 weeks before the onset of a malaria epidemic. Risks posed by dead animals and human bodies Contrary to common belief, there is no evidence that corpses pose a risk of disease “epi- demics” after natural disasters. Most agents do not survive long in the human body after death (with the exception of HIV, which can last up to 6 days) and the source of acute infections is more likely to be the survivors. Human remains pose health risks in only a few special cases that require specific precautions, such as deaths from cholera or haemorrhagic fevers [68]. However, workers who routinely handle corpses may have a risk of contracting tuberculosis, bloodborne viruses (such as hepatitis B and C and HIV), and gastrointestinal infections (such as rotavirus diarrhoea, salmonellosis, E. coli, typhoid/paratyphoid fevers, hepatitis A, shigellosis and cholera). These viruses are acquired in the following ways: ● Tuberculosis can be acquired if the bacillus is aerosolized (residual air in lungs exhaled or fluid from lungs spurted up through nose or mouth during handling of the corpse). ● Exposure to bloodborne viruses occurs as a result of direct contact with non-intact skin of the blood or body fluid, injury from bone fragments and needles, or exposure to the mucous membranes from splashing of blood or body fluid. ● Gastrointestinal infections are more common because dead bodies commonly leak faeces. Transmission occurs through direct contact with the body and soiled clothes or contaminated vehicles or equipment. Dead bodies contaminating the water supply may also cause gastrointestinal infections. The public and emergency workers alike should be duly informed not to panic, to avoid inap- propriate disposal of bodies, and to take adequate precautions in handling the dead. The other health risks posed by flooding include drowning, injuries or trauma, and hypothermia if one is trapped in floodwaters for lengthy periods. There may also be an increased risk of respiratory tract infections due to exposure to flood waters and rain. 7.2 Tropical storms, hurricanes, cyclones and typhoons Tropical storms, cyclones, hurricanes and typhoons, although named differently, describe the same type of disaster. Cyclones, hurricanes and typhoons can be predicted several days in advance. The onset is extensive and often very destructive. These disasters are usually more destructive than floods. In a sudden, brief onslaught, high winds cause major damage to infrastructure and housing, particularly fragile constructions. This is generally followed by heavy rains and floods and, in flat coastal areas, by tidal waves. 108 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES The key OSH hazards associated with tropical storms, hurricanes, cyclones and typhoons include the following: ● structural instability with risks from downed lines, live electrical equipment and other utilities (e.g. gas and water); ● noise; ● falls from height or through openings; ● asbestos, lead; ● impact to the eyes and face from flying objects; ● manual handling of materials/weights; ● discovery of unknown chemicals; ● cuts and lacerations; ● slips, trips and falls while working. 7.3 Earthquakes When an earthquake occurs in a populated area, it may cause deaths and injuries and extensive property damage. Most earthquake-related injuries result from collapsing walls, flying glass and falling objects as a result of the ground shaking, or people trying to move more than a few steps during the shaking. Much of the damage from earthquakes is predictable and preventable [69]. The main OSH hazards for emergency responders during an earthquake include the following: ● injuries resulting from structural instability, slip, trip or fall hazards from holes, protruding rebar, being struck by a falling object, fire, proximity to heavy machinery (e.g. cranes), sharp objects such as glass and debris, secondary collapse from aftershock, vibrations and explosions, and exposed, energized electrical wiring; ● exposure to hazardous chemicals and other hazardous materials (ammonia, battery acid, leaking fuel), natural gas leaks creating a flammable and toxic environment, insufficient oxygen and confined spaces/unfamiliar surroundings; ● biological hazards due to exposure to pathogens from breaks in the sanitary system and exposure to bloodborne pathogens during handling and care of the injured; ● adverse weather conditions; ● noise from equipment (generators/heavy machines); ● exposure to airborne smoke and dust (asbestos, silica, etc.). The key OSH controls for protection of emergency responders include: ● overseeing all safety and health aspects of response workers by safety/OSH personnel; ● assuring that optimal safety and injury prevention is practiced; ● investigating and documenting all response team injuries and illnesses; ● preparing and maintaining entry permits (e.g. to confined spaces, for electrical work etc.); 109Chapter 7. Occupational safety and health hazards in natural disasters ● ensuring that appropriate PPE is used; ● developing and implementing daily health and safety plans which address sanitation, hygiene, PPE, decontamination, work/rest cycles, acute medical care, and other relevant concerns; ● assessing risk for identified hazards; ● training in hazard awareness and use of PPE. 7.4 Common occupational safety and health hazards encountered during response activities following natural disasters 7.4.1 Search and rescue team operations Search and rescue is a critical activity of response to natural disasters. Major sudden-onset natural disasters – such as earthquakes, tsunamis and storms – typically damage infrastruc- ture, cause injury and sometimes massive loss of life, and trap people in debris. An immediate life-saving response is required to rescue those who are trapped and to stabilize or evacuate survivors; the difference between life and death can be a matter of hours. Initial life-saving search and rescue operations need to arrive very fast, should possess specialized skills, and often need heavy or specialized technical equipment. The operational environment where such teams work is often extremely challenging as responders have to work among debris in areas where public services and infrastructure are disrupted or destroyed. Activities undertaken by search and rescue teams and the associated health and safety hazards and risks for the emergency responders are covered comprehensively in Generic risk assess- ments [70]. In sections 2.1 on “Rescues from confined spaces” and 2.1.4 on “Collapsed struc- tures”, the publication lists key activities during search and rescue, as well as OSH hazards, risks and control measures, as described below: 1. Provision and handling of equipment to and at the scene of operations Such activities include hazards due to manual handling of equipment and the key risks include those of musculoskeletal injuries. The responders at highest risk include fire and rescue personnel. The following controls need to be in place for prevention and control of these risks: ● information, instruction and training in manual handling procedures and assessment; ● team lifting operations where appropriate; ● consideration of the type and amount of equipment required to facilitate rescue operations; ● forward logistics areas or equipment dumps that are suitably located to minimize carrying distances; ● consideration of the use of mechanical lifting aids where appropriate; ● rotation of personnel to reduce fatigue. 110 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 2. Extraction of casualties from the scene of operations Extraction of casualties from the scene also involves manual handling and use of heavy machines. The emergency responder groups at highest risk include fire and rescue personnel and other emergency workers. The key hazards include: ● manual handling activities; ● the presence of body fluids; ● the presence of sharps within medical equipment; ● agitated and distressed casualties; ● multiple casualties. The main health and safety risks include: ● musculoskeletal injuries; ● biohazard; ● contamination and infection; ● verbal and physical assault of personnel; ● prolonged and repeated exposure to traumatic situations; ● post-traumatic stress. The following controls need to be in place for the prevention and control of these risks: ● information, instruction and training in manual handling procedures and assessment; ● team lifting operations employed where appropriate; ● information, instruction and training in first aid and casualty handling procedures; ● hazardous area response team personnel/paramedics who provide clinical care and assessment; ● appropriate inoculations (e.g. tetanus, hepatitis B); ● fire and rescue authorities’ biohazard equipment and procedures; ● emergency decontamination procedures; ● consideration of the use of mechanical lifting aids/stretchers where appropriate; ● rotation of personnel to reduce fatigue; ● training/liaison with hazardous area response team/paramedic personnel; ● use of PPE; ● fire and rescue personnel not allowed to administer injections/medicines to casualties; ● rescue teams consist of at least two persons; ● provision of occupational health. 3. Accessing confined spaces A confined space is a place that is substantially enclosed (although not always entirely) and where serious injury can occur from hazardous substances or conditions within the space or 111Chapter 7. Occupational safety and health hazards in natural disasters nearby (e.g. lack of oxygen). Confined spaces or oxygen-deficient areas are commonly found in pits, sewers, tanks or areas where large quantities of gases are stored or used. Examples also include wells, storm drains, vats, boilers, silos and tunnels. Structures that have recently burned may also be oxygen-deficient. The emergency responder groups at highest risk include fire and rescue personnel and other emergency workers. The key hazards include: ● toxic and flammable vapours; ● free-flowing liquids and solids; ● oxygen deficiency or enrichment; ● extreme temperatures; ● fire or explosion. The main health and safety risks associated with work in confined spaces include: ● entrapment injuries; ● drowning; ● asphyxiation; ● heat exhaustion, heat stress; ● hypothermia; ● claustrophobia; ● inflammable or explosive gas, vapours or mists ● toxic substances. The following controls need to be in place for the prevention and control of these risks: ● fire and rescue authorities’ training and procedures for confined space operations; ● search and rescue procedures for confined space operations; ● provision and use of gas monitoring equipment; ● ventilation equipment; ● safety officers and/or designated supervisory officers oversee confined space operations; ● effective communications; ● only essential personnel allowed to enter confined spaces; ● rescue teams consist of at least two persons. 4. Breeching and breaking, space creation operations The main emergency responder group at risk include fire and rescue personnel. These activities involve the use of specialized machines, tools etc. The main hazards include the following: ● heavy dust loads; ● noise; ● vibration; 112 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● moving structural members; ● moving parts on equipment; ● flying shards/debris cast off from equipment and structural members; ● electrical hazards; ● suspended structural elements; ● irrespirable atmospheres due to the presence of hazardous materials, leaking gas and/or oxygen deficiency/enrichment. The main health and safety risks associated with breeching and breaking work include: ● respiratory distress; ● asphyxiation; ● noise-induced hearing disorders; ● inability to hear warning/evacuation signals; ● hand-arm vibration syndrome; ● secondary collapse; ● entanglement; ● cuts/contusions; ● electrocution; ● entrapment / crush injuries. The following controls need to be in place for prevention and control of these risks: ● information, instruction and training in use of specialist equipment; ● rotation of crews to reduce exposure; ● noise and vibration management systems to record exposure levels and duration; ● supervision by safety officers; ● use of building scene assessment equipment; ● liaison with on-scene specialist assistance (e.g. search and rescue teams, subject matter advisers, structural engineers); ● provision of shoring equipment; ● predetermined evacuation signal; ● fire and rescue authorities’ personal/respiratory protective equipment to consider inclusion of self-contained breathing apparatus/airline/respirators; ● monitoring equipment to locate concealed/ buried cables; ● provision and use of gas monitoring equipment. 7.4.2 Hazards and risks associated with the use of chainsaws and their control Chainsaws may be required to clear trees and bushes for rescue and response in any emer- gency situation, and especially during natural disasters. However, use of chainsaws requires safety precautions. 113Chapter 7. Occupational safety and health hazards in natural disasters Major hazards and risks with the use of chainsaws include the following: ● The blades can cause severe cuts. ● Chainsaws are heavy and can cause a back injury. ● Noise from the chainsaws can cause hearing loss. ● Chainsaws can kick back and cause an injury. ● Vibration from the chainsaw can cause numbness and injuries to muscles, nerves or tendons. ● Flying debris can cause an eye injury. The following precautions need to be taken for safe chainsaw operation, as recommended by the Health and Safety Authority of the Republic of Ireland [33]: Before starting the saw ● Check the controls, the chain brake, the chain tension, and all the bolts and handles on the chainsaw to make sure they are functioning properly. ● Ensure that the clutch cover is not broken or exposing the chain or sprocket. ● Sharpen chain teeth. ● When adding fuel to the chainsaw, ensure that the operator is at least 10 feet (3 metres) from any source of ignition. ● Start the saw on the ground with chain brake engaged, and 10 feet (3 metres) from the fuelling area. While running the saw ● Clear the area of obstacles that might interfere with cutting the tree or brush. ● Keep hands on the handles and ensure secure footing while operating the chainsaw. ● Do not cut directly overhead or between legs. ● Look up before cutting to check if loose limbs may fall from the tree. ● Be prepared for kickback. Do not cut with the tip of the saw. Keep track of where the tip is. 7.4.3 Hazards due to animal/insect bites and contact with poisonous plants during outdoor work While responding to natural disasters, emergency workers may come into contact with wild ani- mals, venomous snakes, spiders or scorpions, or insects that may pose serious risks to their health. To prevent such risks, the following protective measures are recommended by USCDC [31]: ● use of insect repellent; ● avoidance of peak exposure times/places; ● wearing of appropriate clothing that covers body parts to avoid exposure; ● use of bed nets; 114 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● treatment of clothing, bed nets and gear with insecticides such as permethrin; ● awareness of displacement of wildlife, pets and other animals (do not try to pick up snakes); ● inspection of areas before entering; ● caution as to where one places one’s hands and feet (do not put hands into holes, nests etc., and step onto rocks or logs rather than over them); ● wearing of proper foot gear and leather gloves when working in suspect areas. Response operations for natural disasters in fields and forests may expose emergency responders to contact with certain plants that pose health risks such as skin and respiratory tract allergies, or irritations in the skin and mucous membranes. Common examples of such plants include poison ivy, poison oak and poison sumac [71]. The following precautions are recommended by NIOSH to prevent these effects: ● learning to recognize poisonous plants in and around work area; ● using gloves and appropriate clothing (e.g. long pants and long-sleeved shirt); ● washing of affected areas with soap or detergent) ● use of rubbing alcohol to remove oily resin causing the reaction; ● avoidance of burning plants or brush piles that may contain poison ivy, poison oak, or poison sumac; inhaling smoke from burning plants can cause severe allergic respiratory problems. 115Chapter 8. Managing the health and safety of health workers during humanitarian response in conflict situations Chapter 8. Managing the health and safety of health workers during humanitarian response in conflict situations The health emergency workforce is made up largely of national health workers but often also includes international health-care providers striving to deliver life-saving interventions during emergencies. The most disturbing challenge for health-care providers during conflicts and emergencies is when they themselves are the victims of attacks that can be real or threatened, targeted or indiscriminate. Such attacks not only endanger health-care providers; they also deprive people affected by the emergency of urgent care when they need it most. While the consequences of such attacks are as yet largely undocumented, they are presumed to be significant – negatively affecting short- term health-care delivery as well as the longer-term health and well-being of affected popu- lations, health systems, the health workforce and, ultimately, the global public health goals. According to WHO [7], during the two-year period from January 2014 to December 2015, there were 594 reported attacks on health-care workers that resulted in 959 deaths and 1561 injuries in 19 countries with emergencies. An analysis of collected information revealed that: ● The majority of targets (63%) were health-care facilities. ● More than a quarter of targets were health-care providers (26%), and 6% of targets were health-care transport. ● 366 of the 594 attacks (62%) were reported as intentional, 116 attacks (20%) were described as unintentional, and for 112 of the attacks (19%) intentionality was not reported or was unknown or undetermined. ● Some 53% of attacks were reportedly perpetrated by state actors, 30% by non-state actors, and 17% of the perpetrators remained unknown, unreported or undetermined. 8.1 Management of occupational safety and health in health facilities during conflicts and emergencies Many factors need to be considered when addressing violence against the delivery of health care and the need for protection of the health and safety of health workers. In addition to the common health and safety risks such as locally-prevalent diseases, road accidents, thermal stress and other conditions that make emergency work dangerous, conflict presents many addi- tional OSH risks that must be addressed. The following health- and safety-related issues need to be addressed before initiating specific actions to protection of health facilities and workers: 116 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Community engagement. Gaining people’s collaboration and trust is the key for obtaining access to those in need of health care and for the safety of health workers. Emergency services should first assess and monitor how health-care workers and other emergency service providers are seen by armed groups, the authorities and other relevant groups and individuals. ● Simple signs that indicate health-care activities. Signs that indicate health-care activities should be visible. ● Communication for evacuation. Lines of communication for medical evacuations of patients must be established among medical workers, NGOs, the military and other relevant persons prior to operations and then should be maintained throughout. Local community leaders and the authorities need to be included since the evacu- ation of wounded and sick persons may not necessarily be carried out by medical workers or vehicles. ● Awareness on international humanitarian law, human rights and ethics. Health-care personnel should have a basic understanding of how international humanitarian law, human rights and ethical principles shape their rights and responsibilities in armed conflict and other emergencies. Training should be provided to them covering areas such as upholding the ethical principles of health care and facing medical dilemmas, violence management and prevention, and stress management. ● Communication with civil society leaders. It is essential to strengthen dialogue on protecting health-care services and to reach out to all leaders of civil society, including religious and community leaders, taking account of their importance in society, especially in times of conflict and crisis. 8.1.1 Measures for the safety of health facilities The factors affecting the safety of health-care facilities should be considered together – including the capacity of the health-care system and infrastructure to absorb shock, the poten- tial impact of disruptions to the supply chain and the well-being of staff and patients. WHO’s Safe Hospitals Programme [72] helps to assess the safety of health facilities, particularly in the event of a natural disaster, but also in the event of violence. One of the key objectives of the programme is to protect health workers, but other objectives cover protection of patients and families, and protection of the physical integrity of hospital buildings, equipment and critical hospital systems. The international Hospital Safety Index has become a global standard and is continually being used in countries to identify actions to address identified weaknesses. The International Committee of the Red Cross in its report Protecting health care, key recom- mendations addresses violence against health-care facilities and recommends the following measures [73]: ● Contingency plan. A contingency plan should be drawn up together with a checklist of the supplies and services which are needed in order to guarantee self-sufficiency for about 10 days. It is crucial to build up a good working relationship with several suppliers, as reliance on a single source is too risky. Sufficient resources should be allocated to formulating plans and holding drills to enable the entire staff to prepare for emergencies. The facility’s contingency plans should match with existing regional or national plans. 117Chapter 8. Managing the health and safety of health workers during humanitarian response in conflict situations ● Evacuation plans and risk assessments. Fire and other risks should be monitored and all members of staff should be familiar with evacuation plans. The use of plastic film on windows and protective walls outside critical areas reduces damage from explosions. It is also essential to arrange for an alternative water supply, along with several types of power source. ● Access control. To better control access and entry, perimeter walls with control points should be erected around the entire health-care facility. Initial security screen- ing and medical triage should be clearly separated. Guards should be employed only for security duties and at control points, and not for triage. ● Early warning system. An early warning system adapted to difficult emergency situations should be put in place. ● Critical utilities located in a safe place. Locating important utilities safely will reduce their vulnerability to attack and ensure backup. ● Information communication systems, Alternative communication methods should be put in place in case normal communication channels break down. ● Other vital measures include the following: ● storing goods in secure areas, where they are protected from hazards and looting; ● using oxygen concentrators rather than cylinders; ● incinerating waste and isolating dangerous material. 8.1.2 Measures for protection of people working in health facilities ● Staff roles and responsibilities should be clarified to ensure the requisite flexibility during emergencies. ● Health-care personnel should be offered training in emergency preparedness and stress management. This training could include fire drills, risk assessment and risk management, elements of protection, negotiation, communication, managing people’s expectations, self-defence, psychological support, first aid and self-care. In addition, guidance and training should be provided on appropriate staff behaviour inside and outside the facility in order to defuse aggression. ● Health-care facilities need to protect their patients while paying due heed to the risks that may be associated with some of them. If possible, grouping patients according their affiliation should be avoided, and patients who pose a high security risk should be discharged as soon as it is feasible to do so. ● Health-care managers should consider the needs of patients’ relatives. Their con- sent should be sought before major surgical procedures, such as amputations, are performed and the relatives should, if necessary, be provided with psychosocial support. While it may sometimes be advisable to limit the number of visitors, waiting rooms should be available for patients’ relatives. ● Maintaining regular communication and good relations with the local community increases a facility’s safety and acceptance by building a sense of ownership. Per- sons in charge of a hospital or clinic should regularly try to ascertain what the local community thinks of it and whether precautionary measures are seen as barriers. 118 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES ● Engaging with the media may improve the safety of a hospital or clinic. Informing the general public and relevant actors about its services can increase the acceptance of health care thanks to an awareness that it is delivered impartially. A proactive media strategy, including guidelines on responsible behaviour on social media, should be developed, and regular contact should be established with the press to reduce tension and misunderstandings in the event of an emergency or crisis. However, the need for information-sharing must always be weighed against ethical considerations, confidentiality and the facility’s safety. ● A temporary relocation of health-care services may be the only solution if security risks become intolerable. Any temporary relocation should be planned carefully and a strategy should be worked out to guide management during the preparatory phase, as well as during the transfer of services, patients and staff. It is useful to consult local providers, authorities, community leaders, staff, patients and NGOs when setting up a temporary health-care facility. Before choosing a new location, a security and site analysis should be conducted and the following factors should be considered: community acceptance, accessibility to staff and the population, availability of quality health-care services and the presence of potential partners. 8.1.3 Management of stress during conflicts In addition to physical injuries, working in conflicts poses serious risk of stress among workers. Stress can be a form of self-protection when it is a normal and useful reaction to a given sit- uation. However, it may lead to higher and more serious levels of stress. Three kinds of severe stress are felt by people working in armed conflicts and other emergencies. They may be harmful if they are not recognized and dealt with. They are: ● basic stress, which is the result of an abrupt shift to an unfamiliar context; ● cumulative stress, which is caused by a number of factors, including concern for one’s own safety (this can build up slowly or rapidly, and is often foreseeable); ● traumatic stress, which is caused by an unexpected and violent event accompanied by a threat of physical or psychological harm to the person or to someone close to him/her. PTSD is a delayed response to acute psychological trauma. Both traumatic stress and PTSD require professional help at the earliest opportunity. The IASC guidelines on mental health and psychosocial support in emergency settings include the following actions [74]: Personal general well-being of health and other emergency workers during conflicts Providing care for the wounded and sick in armed conflicts and other emergencies can be extremely stressful. Emergency workers must take measures to secure their own well-being in order to continue to fulfil their responsibilities. With respect to general well-being, the following actions are required: ● follow local security guidelines if they exist; ● do everything to ensure your own safety; ● do not take unnecessary risks; ● be aware of changes in the context; 119Chapter 8. Managing the health and safety of health workers during humanitarian response in conflict situations ● have enough rest; ● know your limits; ● eat regularly and avoid alcohol and drugs; ● fit into the team and do not isolate yourself; ● talk to friends and colleagues about what concerns you, especially if you are feeling stressed; ● take exercise; ● pay attention to personal hygiene. 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WHO laboratory biosafety guidelines for handling specimens suspected of containing avian influenza A virus. Geneva: World Health Organization; 2005. 43. Infection prevention and control of epidemic- and pandemic- prone acute respiratory diseases in health care: WHO interim guidelines. Document WHO/CDS/EPR/2007.6. Geneva: World Health Organization; 2007. 44. Field situation: how to conduct safe and dignified burial of a patient who has died from suspected or confirmed Ebola virus disease. Geneva: World Health Organization; 2014. 45. Travel and transport risk assessment: interim guidance for public health authorities and the transport sector. Geneva: World Health Organization; 2014. 46. Dembe AE, Erickson J, Delbos R, Banks s. The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States. Occup Environ Med. 2005. 62(9):588-97. 47. 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Chemical - Biological - Radiological - Nuclear (CBRN) personal protective equip- ment selection matrix for emergency responders. Atlanta (GA): National Institute for Occupational Safety and Health; 2005. 124 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES 61. Interim guidance document. Initial clinical management of patients exposed to chemical weapons. Geneva: World Health Organization; 2014. 62. Disaster risk management for health: radiation emergencies. Geneva: World Health Organization; 2011 (http://www.who.int/hac/events/drm_fact_sheet_radiation_emergen- cies.pdf accessed 22 September 2017). 63. Radiation protection and safety of radiation sources: international basic safety standards. General Safety Requirements Part 3 (No. GSR Part 3). Vienna: International Atomic Energy Agency; 2014. 64. Rojas-Palma C, Liland A, Jerstad AN, Etherington G, Pérez MdR, Rahola T, Smith K, editors. 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Generic risk assessment (2.1 Rescues from confined spaces; 2.1.4 collapsed structures). London: The Stationary Office; 2013. 71. NIOSH Fast Facts. Protecting yourself from poisonous plants. Atlanta (GA): National Institute for Occupational Safety and Health; 2010:118. 72. Comprehensive safe hospital framework. Geneva: World Health Organization; 2015. 73. Protecting health care: key recommendations. Geneva: International Federation of Red Cross and Red Crescent Societies; 2016. 74. IASC guidelines on mental health and psychosocial support in emergency settings. Geneva: Inter-Agency Standing Committee; 2007. 125Appendix - Toolkit Appendix Toolkit TOOL Urine colour chart Heat stress is an important occupational health hazard while working outdoors, as well as indoors, with the use of personal protective clothing. The colour of the urine provides adequate information on the associated state of hydration in a rapid and easy manner and hence can prompt the emergency response worker to take adequate water and fluids as well as other pre- cautions to prevent the impacts of heat stress. The urine colour chart is a simple visual aid developed by NIOSH, USA, for monitoring hydra- tion status. The chart displays different hydration levels by using different blends of colour, ranging from pale yellow to deep amber. Although the urine chart is a good indicator of hydra- tion status for most workers with normal pale yellow to deep amber urine, urine colour can also be affected by diet, medications and illnesses or disorders, as provided in the table depicting causes of abnormal colours in urine. The urine colour chart is available in Appendix B of the document NIOSH criteria for a rec- ommended standard: occupational exposure to heat and hot environments by Jacklitsch B, Williams WJ, Musolin K, Coca A, Kim J-H and Turner N. Cincinnati (OH): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 2016-106. Weblink: https://www.cdc.gov/niosh/docs/2016-106/pdfs/2016-106.pdf, accessed 25 September 2017. TOOL Heat index The heat index, as included in the NIOSH, USA, document NIOSH criteria for a recommended standard: occupational exposure to heat and hot environments, consists of charting of temper- atures with relative humidity. It provides useful information on the likelihood of heat disorders that may occur due to long exposure to heat and/or strenuous activity, and provides risks levels in four grades of risk – extreme danger, danger, extreme caution and caution – displayed as different shades of colours. The National Oceanic and Atmospheric Administration (NOAA), USA, issues heat alerts based on the heat index values. The document/heat index includes risk levels as classified by OSHA, USA, for worksites. These risk levels may help emergency response managers to monitor weather and issue instructions for precautions and controls against heat stress. The information should be useful for emer- gency workers working in hot environments (e.g. outdoor in tropical regions during the day) as well as health-care workers working in health facilities in tropical regions. The heat index is available in Appendix C of the document NIOSH criteria for a recommended standard: occupational exposure to heat and hot environments by Jacklitsch B, Williams WJ, Musolin K, Coca A, Kim J-H and Turner N. Cincinnati (OH): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 2016-106. Weblink: https://www.cdc.gov/niosh/docs/2016-106/pdfs/2016-106.pdf, accessed 25 September 2017. 126 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES TOOL Water disinfection techniques in field The information on the traveler’s health webpage of USCDC provides comprehensive guidance on different types of water disinfection techniques, compares advantages and disadvantages of the various common methods, and guides the selection of an appropriate method. The information should be of help to emergency response workers who are deployed in remote areas for selecting and using an appropriate method of water disinfection to protect them from waterborne diseases. Weblink: https://wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel-consultation/water-disin- fection-for-travelers, accessed 35 September 2017. TOOL Safe use of ladders During response management, emergency workers may have to climb up buildings, trees, walls etc. to rescue casualties or respond to the emergency. Working in these conditions often involves the use of ladders. Such situations pose serious risks of injuries due to falls from heights. The risk of injuries due to falls increase progressively from six feet above the ground, and any work above that level would require the use of ladders. A brief guide on the safe use of ladders and stepladders by the Health and Safety Executive of the United Kingdom covers precautions to be taken when using ladders. This information should be of practical use for emergency responders in adopting safe ladder usage practices. Source: Safe use of ladders and stepladders, a brief guide. London: Health and Safety Executive; 2014. Weblink: http://www.hse.gov.uk/pubns/indg455.pdf, accessed 25 September 2014. TOOL Personal stress management during emergencies Psychological stress during emergencies is one of the major occupational health and safety hazards for emergency workers. Psychological first aid (PFA) involves humane, supportive and practical help to fellow human beings suffering serious crisis events. It gives a framework for supporting people in ways that respect their dignity, culture and abilities. PFA covers both social and psychological support. The coverage on “Caring for yourself and your colleagues” provides simple practical guidance on practical measures to prevent stress through healthy work and life habits. This information should be useful to emergency response workers during different stages of response. Source: Psychological first aid: guide for field workers. Published by the World Health Organization in collaboration with the War Trauma Foundation and World Vision International, Geneva, 2011. Weblink:http://apps.who.int/iris/bitstream/10665/44615/1/9789241548205_eng.pdf, accessed 25 September 2017. http://apps.who.int/iris/biteam/10665/44615/1/9789241548205_eng.pdf 127Appendix - Toolkit TOOL Personal preparedness checklist for emergency workers The Handbook for emergency field operations by the World Health Organization covers different aspects of emergency field operations and includes a mission readiness checklist for emer- gency staff. The checklist includes various areas such as: family welfare, banking information, business and finance, vehicle repair and maintenance, home security repairs and maintenance, transportation and communication skills, geopolitical and cultural awareness, health and WHO administrative issues. These practical areas need to be addressed by the emergency worker before deployment to the area of emergency. This should also be of great help in addressing stress before deployment. The checklist may be suitably adapted for use by administrators to monitor preparedness of their team members as well as by individual response workers. Source: Handbook for emergency field operations. Geneva: World Health Organization; 1999. Weblink: http://www.who.int/hac/techguidance/tools/7661.pdf, accessed 25 September 2017. TOOL Recognition and assessment of workplace violence in health facilities Workplace violence in health facilities is being noticed across the world. Although any facility may be affected by violence due to multiple causes, there are certain features and certain organizations, workers’ groups, workers and workplace conditions that facilitate and perpetuate violence. The document Framework guidelines for addressing workplace violence in the health sector has sections on workplace violence recognition and workplace risk assessment. The document includes information on identification of organizations at risk, vulnerable groups, characteristics of potential perpetuators and victims, and workplace situations that pose high risks of workplace violence. This information should help policy-makers, planners, administrators and managers to identify workplace characteristics, vulnerable populations and workplace conditions that may pose risks for workplace violence in the health sector. This should help them to develop appropriate and relevant policies, strategies and plans to prevent and manage workplace violence in health sector. Source: Framework guidelines for addressing workplace violence in the health sector. Joint programme on workplace violence in the health sector. Published by the International Labour Organization in collaboration with the International Council of Nurses, World Health Organization and Public Services International, 2002. Weblink: http://apps.who.int/iris/bitstream/10665/42617/1/9221134466.pdf, accessed 25 September 2017. 128 OCCUPATIONAL SAFETY AND HEALTH IN PUBLIC HEALTH EMERGENCIES TOOL Incident Command System The eTool on the Incident Command System (ICS) by OSHA, USA, is a useful web resource created to provide information about the Incident Command System and the unified command. The eTool covers different aspects of the ICS in a comprehensive manner that includes need, scope and definition, organizational structure, roles and responsibilities, safety aspects during preparedness, implementation and after incidents. The information should be useful to help emergency response planners and administrators to understand the concept of ICS in emergencies and should help in planning the occupational safety and health of emergency response workers. Weblink: https://www.fema.gov/national-incident-management-system, accessed 11 October 2017. TOOL Five keys to safer food The Five Keys to Safer Food resources (e.g. manual, poster, audiovisual presentations etc.) are developed by the World Health Organization. The information incorporates all the messages of the rules for safe food preparation under simpler headings that are more easily remembered and also provides more details on the reasoning behind the suggested measures. The core messages of the Five Keys to Safer Food are: (1) keep clean, (2) separate raw and cooked, (3) cook thoroughly, (4) keep food at safe temperatures, and (5) use safe water and raw materials. The information that is provided in the manual as well as other media (e.g. audiovisual aid, posters, pamphlets etc.) would be very helpful in disseminating food safety messages across the emergency response workforce. It should be helpful to administrators and managers in plan- ning, implementing and monitoring food safety measures during the response and to individual emergency workers in adopting safe and hygienic food-handling and preparation practices. Source: Five keys to safer food manual. Geneva: World Health Organization; 2006. Weblinks: http://apps.who.int/iris/bitstream/10665/43546/1/9789241594639_eng.pdf?ua=1, accessed 25 September 2017. Five keys to safer food (audiovisual presentation) https://www.youtube.com/watch?v=ONkKy68HEIM, accessed 25 September 2017. TOOL Online courses on health and safety in emergencies Online courses by the DisasterReady organization cover a wide range of topics on health, safety and security in emergencies. These include areas of practical importance such as mental health and psychological support – including psychological first aid, Ebola awareness, malaria matters, health care in danger, the legal framework, fire safety, basic field security etc. The courses are open to everyone and consist of short presentations in easy-to-understand language with audio-visuals. Weblink: https://www.disasterready.org/, accessed 25 September 2017. 129Appendix - Toolkit TOOL Hand hygiene resources Hand hygiene is the key element in protection against biological hazards during routine func- tioning as well as during outbreaks and emergencies. Hand hygiene should be implemented as a systematic programme consisting of the rationale for use in clinical settings, correct meth- odology, use of different hand hygiene materials, awareness among users and monitoring in the workplace. The key WHO resources on hand hygiene are noted here. These resources should be useful to emergency programme managers and responders for creating awareness of the need for hand hygiene practices during outbreaks and emergencies as well as routine working conditions. WHO guidelines on hand hygiene in health care. Geneva: World Health Organization; 2009. Weblink: http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf Hand hygiene-related videos and podcasts. Weblink: http://www.who.int/gpsc/5may/video/en/ Hand hygiene-related tools and resources. Weblink: http://www.who.int/gpsc/5may/tools/en/ WHO audio-visuals on hand hygiene. No action today, no cure tomorrow Weblink: https://www.youtube.com/watch?v=kOKeFv5VvY4 Hand washing technique Weblink: https://www.youtube.com/watch?v=3PmVJQUCm4E (All resources accessed 25 September 2017) TOOL Online training on emergency responders’ health monitoring and surveillance This educational training course, designed by USCDC, covers information on the health monitoring and surveillance framework during emergencies – referred to as the Emergency Responder Health Monitoring and Surveillance (ERHMS) system. The system includes specific recommendations and tools for all phases of a response, including the predeployment, deploy- ment and post-deployment phases. The training should be useful for officials associated with the occupational safety and health of emergency response workers (e.g. emergency managers, emergency responders, medical personnel, health and safety representatives, epidemiologists etc.). Weblink: https://emergency.cdc.gov/training/erhmscourse/index.asp, accessed 25 September 2017. International Labour Organization Route des Morillons 4 CH-1211 Geneva 22 ilo.org World Health Organization Department of Environment, Climate Change and Health 20, avenue Appia 1211 Geneva 27 Switzerland who.int/health-topics/occupational-health O ccupational safety and health in public health em ergencies ILO | W HO

本指南英文版于2018年由世界卫生组织（World Health Organization）和国际 劳工局（International Labour Office）出版，指南名为： Occupational safety and health in public health emergencies:A manual for protecting health workers and responders © World Health Organization , 2018 © International Labour Office , 2018 世界卫生组织和国际劳工局授权山东省德州市疾病预防控制中心翻译出版本指南 中文版。此翻译不是由世界卫生组织和国际劳工局创建的。世界卫生组织和国际 劳工局不对此翻译的内容或准确性负责。中文版的翻译质量和对原文的忠实性由 德州市疾病预防控制中心负责。当出现中文版与英文版不一致的情况时，应将英 文版视作可靠和有约束力的版本。英文版信息如下： Occupational safety and health in public health emergencies:A manual for protecting health workers and responders Geneva: World Health Organization and International Labour Organization; 2018. Licence: CC BYNC-SA 3.0 IGO. 中文版《突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手 册》 ©德州市疾病预防控制中心, 2019 中文版译者：李发强（山东省德州市疾病预防控制中心） 免责声明. 本文为WHO《Occupational safety and health in public health emergencies:A manual for protecting health workers and responders》的 翻译件。全篇公益翻译，旨在为中国的卫生应急工作者提供技术参考，不得用作 商业目的。 中文版版权属于《突发公共卫生事件中的职业安全与健康：卫生工作者与应急人 员保护手册》，任何媒体、网站或个人转载或使用须注明出处和译者信息。 突发公共卫生事件中的 职业安全与健康 卫生工作者与应急人员保护手册 世界卫生组织（World Health Organization） 国际劳工局（International Labour Office） 2018年，日内瓦 翻译：李发强（山东省德州市疾病预防控制中心） 致谢 本手册由世界卫生组织（WHO）和国际劳工局（ILO）联合制定，集合了加 拿大不列颠哥伦比亚大学世卫组织职业卫生合作中心、马里兰大学和美国疾病预 防控制中心（CDC）/国立职业健康与安全研究所（NIOSH）的集体智慧。 本手册是在WHO公共卫生、环境和社会决定因素部门的Ivan D. Ivanov， ILO劳动行政管理、劳动监察和职业安全与卫生处的Francisco Santos- O'Connor的指导下编写的。ILO工人健康顾问Shubhendu Mudgal起草了大纲草 稿。 以下诸位为本手册提供了有价值的贡献： WHO：Benedetta Allegranzi，Sebastian Bruno， Zhanat Carr， Kenneth Carswell，Francois Cognat，Rudy J.J.M Connix， Sergey Eremin， Ivan Ivanov，Erin Maura Kenny， Meleckidzedeck Khayesi， Kazunobu Kojima，Mark van Ommeren，Adrienne May Rashford，Joana Helena Tempowski， Ju Yang； ILO：Shengli Niu，Francisco Santos-O’Connor，Yuka Ujita， Christiane Wiskow； 美国马里兰大学：Joanna Gaitens，Melissa McDiarmid，G.M. Oliver； Claire C. Caruso, Christopher Coffey, Lisa Delaney, Chad Dowell, Selcen Kilinc-Balci, Margaret； 美国CDC/NIOSH：Kitt， Leslie Nickels，Jill Shugart； 本手册获得了英国国际发展部资助的WHO区域应对方案，以及《WHO和 CDC/NIOSH关于执行WHA 60.26号决议“工人健康:全球行动计划”的合作协 定》的资助。 目录 1 突发事件中的OSH 1 1.1 OSH危害与风险管理体系探讨 1 1.2 在疫情爆发和突发事件期间雇主和工作者的权利、义务和责任 3 1.3 西非埃博拉病毒应对期间实施的健康和安全监测及监测系统概述 7 1.4 突发事件应急响应人员的健康监护 11 2 在突发事件和疫情爆发中保护职业安全和健康的策略和工具 14 2.1 国际卫生条例，2005 14 2.2 突发事件应急指挥系统 15 2.3 WHO卫生应急方案 19 2.4 职业安全健康控制 21 2.5 感染预防和控制策略 23 2.5.1 标准预防措施 23 2.5.2 预防保健场所职业性呼吸道感染 35 3 突发事件中的安全与健康风险 37 3.1 媒介传染病 37 3.2 介水传播和食源性传播疾病 38 3.3 可通过接种疫苗预防的疾病 39 3.4 热应激 39 3.5 滑倒、绊倒和跌倒 41 3.6 道路交通伤害 43 3.7 人体工效学危害 44 3.8 暴力 46 3.9 疲劳 47 3.10 疫情爆发与突发事件时的心理社会应激 50 4 传染病爆发中的职业安全与健康：临床和社区环境 57 4.1 埃博拉治疗和护理机构的职业安全与健康 58 4.2 霍乱治疗机构的职业安全与健康 59 4.3 处理感染性病原体实验室的职业安全与健康管理 60 4.4 在卫生保健环境中暴露于血液、体液和其他污染物的管理 61 4.5 在呼吸道疾病爆发期间保护卫生工作者免受急性呼吸道疾病的职业安全与健康措施 64 4.6 社区环境中应对爆发的职业安全与健康 66 4.6.1 社区工作（例如社会动员，接触者追踪，个案调查） 66 4.6.2 救护车，运送病人或尸体的车辆 66 4.6.3 尸体检验 67 4.6.4 安全且庄重的下葬 68 4.6.5 出入境站点、陆路口岸、机场和海港 70 4.6.6 航空器 71 4.6.7 船舶 72 4.6.8 出租车与公共交通工具 74 4.6.9 污水处理员工 75 4.6.10 喷洒杀虫剂以控制媒介动物的活动 76 5 化学事故中的职业安全与卫生 79 5.1 化学事故造成的突发事件 79 5.2 职业安全健康危害与化学品风险 79 5.3 化学事故中应急响应人员的职业安全与健康管理 81 5.3.1 处置化学品紧急事故的事故指挥系统 81 5.3.2 个个体护装备 84 5.3.3 应急响应人员的洗消 86 5.3.4 应急响应人员的医学观察 89 6 辐射事故中的职业安全与健康 90 6.1 辐射事故的来源与情景 90 6.2 辐射应急响应人员的职业安全健康管理 91 6.2.1 辐射应急中应急响应人员的防护指南 93 6.2.2 辐射事故应急处置指挥系统 95 6.2.3 个人防护用品 96 6.2.4 洗消 97 6.2.5 辐射应急作业人员职业健康监护 97 7 自然灾害中的职业安全与健康危害 100 7.1 洪水导致的职业安全健康危害与风险 101 7.2 热带风暴、飓风、气旋和台风 102 7.3 地震 103 7.4 自然灾害后的应急行动中常见的职业安全和健康危害 104 7.4.1 搜救队行动 104 7.4.2 链锯使用的危害和风险及其控制 107 7.4.3 户外作业中因动物/昆虫咬伤和与有毒植物接触而引起的危险 108 8 在冲突局势中的人道主义响应期间管理卫生工作者的健康和安全 110 8.1 医疗机构安全措施 111 8.2 医疗机构人员保护措施 112 8.3 冲突中的压力管理 113 参考文献 115 附录：工具箱 120 缩略语 ARD 急性呼吸道疾病 MERS- CoV 中东呼吸综合征-冠状 病毒 BSS 电离辐射防护与辐射源安全基 本标准 NGO 非政府组织 ERHMS 应急反应人员的健康监护与监 测 NIOSH 美国国立职业健康与安 全研究所 ERW 埃博拉应急工作者 OSH 职业安全与健康 EVD 埃博拉病 PEP 暴露后预防 HBV 乙型肝炎病毒 PPE 个人防护用品 HCV 丙型肝炎病毒 PTSD 创伤后应激障碍 HIV 人类免疫缺陷病毒 SARS 严重急性呼吸道综合症 IAEA 国际原子能机构 SCBA 自给式呼吸器 IASC 机构间常设委员会 UNCDF 联合国资本发展基金 IATA 国际航空运输协会 UNDP 联合国开发计划署 ICAO 国际民用航空组织 UNFPA 联合国人口基金会 ICS 事故指挥系统 UNMEER 联合国埃博拉应急特派 团 IFRC 红十字会与红新月会国际联合 会 USCDC 美国疾病预防控制中心 IHR 国际卫生条例 WFP 世界粮食计划署 ILO 国际劳工组织 WHO 世界卫生组织 IPC 感染预防与控制 介绍 WHO在其应急框架中将紧急情况定义为对大量人口或相当大比例人口的生 活和福祉产生影响、并且需要多部门的大量援助的情况【1】。必须有明确的公共卫 生后果，WHO才能启动响应。此外，根据2005年世界卫生大会通过的《国际卫 生条例》（IHR），国际关注的突发公共卫生事件的定义是：（i）通过疾病的国 际传播构成对其它国家的公共卫生危害；以及（ii）可能需要采取协调一致的国 际应对措施【2】。这些事件包括传染病的爆发、危险化学品泄漏或放射性物质泄漏 及其他情形。 在过去五十年中，世界目睹了各种各样的自然灾害、人为灾害和紧急情况。 这些紧急情况包括：在世界不同地区不时发生的传染病爆发，如严重急性呼吸系 统综合症SARS、甲型H1N1流感、埃博拉病、霍乱、寨卡病毒等；除传染病爆发 外，其他主要紧急情况包括辐射紧急情况（如切尔诺贝利、福岛）和化学紧急情 况（如博帕尔有毒气体泄漏、深水地平线漏油）。此外，世界各地发生了许多自 然灾害，如印度洋海啸，以及海地、巴基斯坦和菲律宾的地震，洪水和飓风【3】。 目前的环境、经济和政治发展和趋势表明，今后灾害的严重程度和频率都有 所增加。支持这一假设的现象包括能源使用的增加、气候变化和污染、人口增长、 工业化在全球的扩张、交通设施的扩张以及恐怖主义的日益蔓延。2015-2016年， 由于厄尔尼诺现象造成的严重干旱和相关的食品不安全、洪水、降雨和温度上升， 造成了广泛的健康威胁，包括疾病爆发、营养不良和保健服务中断【4】。 随着全球化学品生产、贸易和使用（例如农业）的增加，化学事件的全球风 险正在增加。发展中国家和经济转型国家尤其如此——他们的经济发展与化学品 生产、开采、加工和使用密切相关，预计到2050年产量将增加六倍【5】。 对此类疫情和紧急情况的处置涉及众多不同组织之间的密切协调与合作。与 这些组织有关的应急响应人员包括专业团体——其中包括消防员、警察、医疗救 援人员（护理人员、急救医疗技术人员、医生和护士）和心理学家。在重大灾害 中，还有救援人员、大型救援组织的技术人员、增援的医务人员、军人、反恐部 队、尸体处理人员、清理工人、建筑工人和众多志愿者。这些类别的工作人员中 的每一类都在应急响应方面发挥特定作用，这可能使他们在履行职责时面临各种 健康和安全危害。 近年来发生的许多事件具有很高的受伤和感染风险，在某些情况下还导致卫 生应急和其他应急工作者死亡。在SARS和中东呼吸综合征冠状病毒(MERS- CoV)爆发期间观察到了卫生工作者之间发生了感染。在西非埃博拉病毒疾病爆发 期间，受影响最严重的国家，卫生工作者的高发病率和死亡率对卫生服务【6】的整 体功能造成了严重的负面影响。 除了这些事件之外，还有许多国家正面临着人道主义危机和冲突，在这些危 机和冲突中，针对卫生机构的袭击越来越多，这种趋势令人不安。此类袭击不仅 影响卫生服务提供者的健康和安全，而且严重影响了卫生系统应对人道主义危机 的能力。根据WHO的报告，在2014年1月至2015年12月的两年期间，在19个存 在危机的国家，报道了594其针对卫生工作者的袭击事件，导致959人死亡和 1561人受伤【7】。 鉴于所有这些事件，越来越多的人认识到：为应急工作者提供更好的职业健 康与安全保护是主要的优先事项之一。 编写本手册的目的 本手册概述了在疾病爆发和其他紧急情况(如自然灾害、化学事故、紧急辐射 事件和涉及冲突的紧急情况)中，应急反应人员面临的主要OSH风险。目的是帮 助组织和工作场所更好地准备和应对这些事件。本手册特别侧重于低资源环境下 的需要，就建立系统性的良好做法和程序提供技术指导，以便:1)减少应急工作人 员的职业接触、伤害、疾病和死亡；2)减轻压力，减少恐惧；3)促进卫生保健和 其他应急工作人员的健康和福祉。 本手册主要分为三部分。第1至3章介绍在紧急情况下应对OSH的管理和技术 工具及策略。这些工具包括用于紧急情况的OSH管理系统方法、事故指挥系统 (ICS)、OSH控制和标准预防措施以及它们在紧急情况下的应用。第4至8章涉及 不同类型紧急情况下的OSH危害，例如涉及临床和社区环境应急、化学品事件、 辐射事件和自然灾害的紧急情况，以及冲突情况。附录收集了从各种来源的工具 和资源，目的是在紧急情况和爆发中就职业健康与安全的不同方面向用户提供实 际支持。 本手册适用于应急组织中负责员工职业健康安全的专家和官员。这一信息在 具有突发事件高风险的国家尤其重要，例如高传染风险的病原体(如霍乱、黄热病、 病毒性出血热)和/或自然灾害以及化学和放射事故的高风险国家。核心的目标受 众包括国家中负责实施《国际卫生条例》的机构和人员, 政府机构的卫生和劳动 部门,国际组织、非政府组织,人道主义和慈善机构、宗教组织、医院和医疗机构、 公共和私人公司、安全部队、雇主和工会组织。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 1 / 124 第一章 突发事件中的OSH 管理卫生应急工作者的OSH需要一种系统方法，包括计划、组织、实施、监 测和有序评估行动等各种管理职能。本章涵盖疫情爆发和突发事件期间与应急响 应人员OSH有关的各方面管理。 1.1 OSH危害与风险管理体系探讨 应急响应工作者的OSH管理，应作为OSH管理体系来实施，该体系与整体的 应急响应管理体系兼容或整合，包括准备、响应和恢复阶段[8]。 图1：OSH管理系统的持续改进周期 Source： OSH Management System： tool for continual improvement， International Labour Organization [9]. OSH管理体系的关键组成部分 在应急行动中，所有管理人员、团队负责人和工作者代表都需要通过ICS接 受培训，以构建突发事件和紧急情况下的OSH管理体系。这包括（如图1）： ●工作场所的OSH策略； ●ICS中，OSH的组织机构、角色和职责； ●OSH规划，包括可调动的资源（如人力资源、PPE、监测设备、药品和疫 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 2 / 124 苗)，程序和指导方针； ●监测和评价机制（例如指标、清单）。 以下是在突发事件和紧急情况期间，针对应急响应工作者的OSH管理的关键 要求： ●为所有的岗位选配合适的、有资格和技能的人员； ●培训选定的健康和安全风险评估、风险管理和风险沟通专业人员； ●在应急行动期间对OSH风险进行评估和管理； ●健康监护包括监测应急响应的实施对响应者的身体、心理和社会健康的不 利影响，以及对这些影响的管理，包括通过心理支持和咨询。 选择具有工作所需的资格和技能的合适的人员 这是任何组织的响应机制的重要一环，无论是疫情爆发还是任何其他突发事 件。该过程包括使所选人员的资格、技能和身心状况与潜在突发事件的要求相匹 配。 突发事件和应急响应期间OSH管理培训要求 培训是响应工作者应对疫情、化学和辐射事件以及自然灾害的应急行动过程 中不可或缺的一部分，以便使他们掌握知识、态度和技能，以确保采取适当的行 为以保护他们的个人健康和安全：采取这些措施他们就能保持健康和安全，从而 使得他们可以有效地开展响应行动。 所有预计可能参与疫情响应或其他突发公共卫生事件的工作者都应接受以下 培训： ●对OSH领域的危害和风险进行基本评估和管理，包括物理、化学、生物、 机械和心理社会危险因素； ●与特定突发事件或紧急情况相关的危害和风险，如感染预防和控制 （IPC），以及化学和辐射安全的基础知识； ●ICS中应急响应人员的角色和职责； ●现场人身安全； ●应急行动期间疾病、伤害和事故的报告。 此外，在响应过程中，工作者应每天获取关于对其健康和安全造成特定危害 和风险的安全工作简报和指示。每日简报等也将成为一个很好的契机：用于监测 应急救援人员的健康状况(如医疗单位、实验室和坟场、以及接触化学和辐射的工 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 3 / 124 作者)，除上述外，也可能需要培训意识和特殊技能(如使用PPE，化学和辐射洗 消过程)。 与参与突发事件和紧急情况的工作者沟通 风险沟通是响应计划的关键部分，在实施的所有阶段都是必需的。沟通是该 领域所有负责人的职责。在疫情爆发和突发事件期间与卫生和其他应急工作者进 行风险沟通的关键原则包括： ●与工作者的风险沟通应该是个体化的，面对面的，不应仅仅依靠海报和健 康教育材料； ●工作者代表应参与风险沟通； ●不应让工作者向媒体了解风险和危险情况；应与工作者讨论所有事故，并 应立即采取预防措施； ●与工作者的风险沟通应该促进形成一种无责任的文化； ●风险沟通应该是平等的，应该解决恐惧、权利和权益以及保护措施的有效 性。 心理支持和咨询 应急响应过程与高水平的压力联系在一起，这些压力会在响应实施的所有阶 段影响应急响应者。因此，心理支持的目的是在整个实施过程中及之后预防和管 理压力及其对身体、心理和社会健康的影响。 当应急响应人员返回家中时，在任务期间遇到的压力的影响不会奇迹般地消 失。保护他们免受压力的影响，需要心理救治以及专业人员的专业咨询和心理支 持。 1.2 在疫情爆发和突发事件期间雇主和工作者的权利、义务和责任 保护卫生工作者和其他应急响应人员的健康和安全，对于维持充足和有效的 人力资源以及确保应急响应和基本卫生服务的连续性至关重要。在突发事件中， 例如疫情爆发、化学品泄漏或放射性物质泄漏，工作场所风险迅速变化，雇主需 要准备好与工作者及其代表和技术专家协商，调整他们一贯的做法，以实现安全 与工作义务间合理的平衡。专栏1描述了塞拉利昂在2015年应对埃博拉疫情期间 应用的风险津贴政策。 雇主和工作者的一般权利和责任 在处理突发事件和紧急情况期间的OSH风险时，1981年职业安全与健康公 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 4 / 124 约(第155号，ILO)[10]规定了雇主的下列一般权利、义务和责任： 雇主有全面的责任，确保采取一切可行的预防和保护措施，以尽量减少职业 风险： ●雇主有责任提供OSH相关的全面信息、全面指导和必要培训，向工作者咨 询与其工作有关的OSH问题，并向主管当局（例如劳工、医疗监察机构）报告职 业伤害和疾病案件； ●雇主必须为工作者提供足够的防护服和防护设备，并对其使用进行适当的 培训，以在合理可行的范围内防范对健康产生不利影响的风险； ●下列工作者的一般权利、职责和责任适用： ●要求工作者立即向主管报告下列情况：他们有合理理由相信的、对自己的 生命或健康构成紧迫和严重危险的任何情况。在雇主采取补救行动之前，如有必 要，雇主不得要求工作者返回对生命或健康继续存在紧迫和严重危险的工作环境； ●当工作者有合理的理由相信：这会给他们的生命或健康带来紧迫的严重危 险时，他们有权脱离工作环境。工作者行使此项权利受到保护，免于承担不良后 果； ●工作者有责任遵循既定的OSH程序，避免使他人暴露于健康和安全风险， 并参加雇主提供的培训。 1981年职业安全与健康公约(第155号，ILO)中的下列一般原则也适用： ●OSH措施不要求工作者承担费用； ●雇主和工作者和/或其在工作场所的代表之间的合作，应是与工作场所相关 的预防措施的基本要素，例如通过工作者安全代表、安全和健康委员会以及提供 信息和培训方面的合作。 2002年职业病清单建议书（第194号，ILO）规定，如果通过职业暴露罹患 感染和创伤后应激障碍，则被视为职业病，受影响的工作者有权获得补偿、康复 和治疗服务。 雇主和工作者在突发事件中的权利和义务 包括卫生工作者在内的应急工作者，有提供服务的合同义务和注意义务：这 些服务可能使他们面临感染、中毒、受伤和疾病的风险。尽管有注意义务，但面 对紧急情况下工作固有的风险增大，应急工作者有权根据国情、实际情况和实践 经验，脱离工作环境——他们有合理的理由相信存在对他们的生命或健康构成紧 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 5 / 124 迫的严重威胁。 应急响应工作者的雇主有义务采取提供安全的工作条件和实施适当的OSH措 施的必要手段。 雇主有义务： ●为工作者提供充分的培训、装备和保护措施； ●为他们提供实施OSH技术的能力和知识； ●就这些工作者的工作条件、对他们的期望值及此种情况下存在的固有的风 险，提供清晰的指南； ●提供适当的心理支持，并采取促进健康行为的措施； ●对工作者提供的服务给予适当的补偿，包括意外保险、为他们及其家人提 供的保障、为感染者/致残者提供的福利待遇； ●系统地收集信息，以支持持续监测和评估OSH计划在提供保护方面的有效 性。 专栏1：塞拉利昂埃博拉病毒疫情（EVD）应对期间针对埃博拉应急工作者 （ERWs）的风险津贴政策[11] ●该政策于2015年4月1日生效，2015年11月截止，后来被EVD弹性分散津贴 政策取代。 该政策包括： ●涵盖的ERWs类别； ●风险津贴率； ●管理和更新清单的程序； ●核查和审计程序；以及 ●投诉管理。 应急响应中工作者的社会保障 根据ILO定义，社会保障是一个社会向个人和家庭提供的保护，以确保获得 医疗保健和保证收入安全，特别是在老年、失业、疾病、残疾、工伤、生育或丧 失收入能力的情况下。它涵盖所有提供福利的措施——不论是现金还是实物—— 以确保免受下列因素影响：由于疾病、残疾、生育、工伤、失业、老年或家庭成 员死亡而导致的与工作有关的收入的缺乏；无法获得医疗保健；家庭支持不足， 特别是儿童和需要赡养的成年人；普遍的贫困和社会排斥。 与突发事件和其他应急响应相关的、高于正常的风险，突出了所有工作者的 社会保障的必要性，包括移民、兼职者和自雇佣者。1952年社会保障（最低标准） 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 6 / 124 公约（第102号，ILO）就突发事件中可能适用的各种福利提供了一般性指导， 即： ●所有参与疫情和应急响应活动的工作者都应享有医疗保险和疾病津贴。另 一个优先事项是紧急医疗后送——将潜在的受感染、危险化学品或辐射的国际援 助工作者转移到能够接受适当医疗护理的地方； ●在疫情控制行动中，应向护理受感染患者的卫生工作者提供暴露后治疗； ●卫生工作者——包括医务人员、实验室工作者、安葬队和设施清洁工—— 以及参与救援和响应的应急响应人员、在响应中存在暴露于受影响人员的血液和 其他分泌物的风险，应首先接种疫苗； ●工作者在隔离、检疫期间，应当享受疾病津贴。对受隔离、检疫工作者的 经济补偿应当是主动的，这是西非埃博拉疫情应对战略的重要组成部分。为工作 者和自雇佣者提供替代收入，是确保高比例遵守隔离检疫的关键。如果在隔离检 疫期间，每日领取薪酬的工作者不能获得补偿，那么即使已经发热他们仍会坚持 工作，这样存在感染他人的风险； ●如果工作者在遵守监视、旅行限制、检疫或隔离命令的同时必须缺勤，他 们也需要受到法律保护以免遭解雇。在公共卫生当局实施检疫的情况下，雇主可 能会要求工作者继续做一些工作——也许是在远离家或检疫地点的地方。在这种 情况下，管理部门和工作者代表应就检疫期间的工资、工作时间和一般条件进行 协商。 工伤津贴 并非所有的工作者都具有相同的职业暴露风险（高传染性病原体、危险化学 品或辐射），也不是所有工作者都能获得工伤福利。个案的流行病学调查会记录 哪些职业或居住环境属于高传染性病原体、危险化学品或辐射的暴露来源。对于 那些与此类危险源密切基础的工作者，在没有流行病学调查的情况下，将其暴露 归因于职业因素可以认为是合理的。 其他疾病或症状——无论是由生物、物理、化学、心理因素或者不良的人体 工效学因素引起的——如果劳动者罹患此类疾病与应雇主的要求所从事的工作之 间有直接联系——此种联系可以通过科学的方法或其他符合国情和实践的方法确 定——则可以认定为职业病。 健康危机准备，必须包含卫生工作者支付方案和减灾规划，并作为核心要素 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 7 / 124 （专栏2）。这需要机构间协调和基于国家层面的的需求评估协议、政策和技术 指导的制定，以及质量技术援助、成本计算工具和规划框架的可用性和可及性[12]。 专栏2：埃博拉应急工作者的支付方案 联合国开发计划署（UNDP）与包括IFRC、UNCDF、UNFPA、UNMEER、 WPF，以及埃博拉应对工作者支付方案（PPERW）在内的合作伙伴，向爆发 疫情的三个国家政府提供必要的技术支持和能力援助，以确保及时向ERWs提 供奖励。具体而言，PPERW有三个主要目标：（1）通过信息管理系统加强卫 生部门人力资源规划；（2）提高现有支付平台和激励性薪酬的数字化程度； 以及（3）在几内亚和利比里亚建立联合国运营的应急支付平台。 在塞拉利昂，PPERW负责覆盖所有ERWs的78%，不仅包括医疗和卫生部门 的员工，还包括志愿工作者。 在几内亚和利比里亚，卫生部门继续监督向有工 资的政府卫生工作者支付危险津贴，PPERW仅限于监督向ERWs志愿者或现 有合作伙伴未覆盖的ERWs（约占这些国家的ERWs总数的19%）。在利比里 亚，联合国开发计划署协助向ERWs支付款项，并加强了现有的支付机制和信 息管理系统。 IFRC：红十字会与红新月会国际联合会；UNCDF：联合国资本发展基金； UNFPA：联合国人口基金会；UNMEER：联合国埃博拉应急特派团；WFP： 世界粮食计划署。 遗属福利及丧葬费用 因工伤、疾病或职业危害而死亡的工作者的家庭成员和/或家属应有权享受遗 属福利，除非这些福利已由其他社会保障计划按照可以满足要求的最低标准覆盖。 这些案件的受害者的葬礼需要由公共卫生当局组织，作为安全下葬计划的一部分。 孕产妇福利与保护 不应将孕妇部署到受影响国家，也不应让她们参与疫情爆发和应急响应相关 行动。不应许可孕妇或哺乳期工作者进入有感染传播风险的工作场所。 1.3 西非埃博拉病毒应对期间实施的健康和安全监测及监测系统概述 管理卫生工作者等应急响应工作者的OSH，对于维持应急响应、正常提供卫 生保健服务以满足社区的所有公共卫生需求而言，是至关重要的。 根据这些目标， 在2014-2015年西非的EVD疫情应对过程中，WHO建立了一个系统，以确保部 署的应急响应人员的OSH[13]。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 8 / 124 该系统包括在任务前、任务中和任务后，由WHO员工健康和福利服务部门 以及参与应急响应的WHO其他部门提供的援助和指导。该系统建立在受影响的 国家，以确保部署的工作者的OSH得到多学科小组的支持，包括卫生和安全官员、 与国家和地区一级IPC和其他专业人员密切合作。 这些小组与WHO国家办事处的工作者协调，确保部署的工作者得到全面的 上岗培训、关于国家局势的简报、关于其职能的指示、防护设备和在必要或突发 事件时联系人的联系方式。任命卫生和安全官员，帮助部署的工作者遵守指示和 程序、以便在工作期间和之后保护自己安全和健康，并监督这些措施的执行情况。 任务前 该阶段包含以下内容： 健康检查和体检： 在被抽调执行任务前，必须确保应急救援人员在身体和心理上做好准备—— 工作环境紧张、工作时间长，因此良好的健康状况和准备是很重要的。怀孕的情 况下禁止安排任务。 一旦被选中执行任务，应急工作者需要从WHO员工健康和福利部门或区域 办事处获得医疗许可。由经过认证的医师进行检查并出具健康体检报告（包括实 验室检查和预防接种），即可获得体检合格证明。 预防接种： 在EVD应对期间部署到西非的应急人员需要及时接种以下疫苗： ●黄热病（强制性）； ●白喉 - 破伤风（最好在5年内）-脊髓灰质炎 +/-百日咳； ●伤寒； ●甲型肝炎、乙型肝炎； ●脑膜炎ACYW 135（如果疫情持续则为强制性）； ●麻疹（对于1963年以后出生但未患过病者人），或2剂MMP联合疫苗 ●狂犬病（推荐）； ●霍乱（仅在某些情况下推荐，且应基于风险评估）。 疟疾的化学预防： 作为EVD爆发期间风险最高的国家，几内亚、利比里亚和塞拉利昂也是疟疾 流行区。针对蚊虫叮咬的化学预防和个人防护，对于预防疟疾和其他虫媒传染病 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 9 / 124 非常重要。因此，部署到受影响地区的应急响应工作者必须在任务前任务中和任 务后进行化学预防。这适用于所有疟疾流行的国家。 岗前培训： 在部署到现场或抵达任务国之前，应急响应工作者接受岗前培训。这种培训 是在WHO总部、区域办事处或国家办事处进行的，视出发地点和行程安排而定。 岗前培训旨在为为所有员工——不论其职务及所属机构——提供EVD简介及基本 业务指南，并提高员工对OSH关注事项的认识。培训包（名为ePROTECT）以 电子版形式在网上提供。 此外，对于那些需要从事高风险工作——例如患者护理、安全下葬或实验室 工作的应急工作者，WHO总部、区域办事处或国家办事处还将根据部署途径和 已部署工作者的报告提供额外的培训。 在部署之前，向应急响应工作者简要介绍国家局势，并向他们提供已经部署 的工作者的报告。到达后，他们又从卫生和安全官员那里得到一份更详细的简报。 简报内容包括： ●响应者的免疫状况； ●抵达时的疟疾免疫状况； ●收到的ePROTECT培训和手卫生知识； ●在部署过程中关键OSH风险和控制措施； ●提供医疗卫生用品和浸渍杀虫剂的蚊帐。 一旦确定上述规定已经就位，响应者就会被允许前往指定的任务区。 任务中 在任务期间，卫生和安全行为守则以及伙伴模式由应急人员在各自任务区实 施。此外，定期评估工作地点和住宿地点的IPC和OSH状况。 行为守则： 尤其是在疫情尚未得到控制的热点地区，且鉴于ECD等传染病的早期症状是 非特异性的，建议部署的工作者在社交和工作生活中采取以下预防措施： ●避免与他人握手、拥抱； ●会议期间与同事保持至少1m的距离； ●执行任务期间避免性生活（任何不遵循此建议者，请确保使用安全套）； ●打喷嚏或咳嗽时遵守“呼吸礼节”，如果他人不遵守，则要求其遵守； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 10 / 124 ●经常洗手，特别是在上述情形下。 伙伴模式： 伙伴模式指的是两个人（即“伙伴”）组成一个单元共同操作，一边他们可 以互相监督和帮助。在危险的活动中，伙伴常常是同行，模式的主要优点是可以 提高安全性。每个人都可以通过该模式防止对方受到伤害、或者在危急时刻拯救 对方。与独立的操作相比，这是的经验不足者可以通过与经验丰富的伙伴间密切 和频繁的接触而更快地学习。 伙伴的责任是： ●帮助创造一个舒适的环境； ●引导参观工作区域； ●作为澄清各种政策、程序和协议的来源； ●有耐心和积极地，有助于培养角色的自信心； ●回答常见问题，以减少角色混乱和不确定倾向； ●介绍同事和员工，从而协助建立更加有效、更加高效的网络； ●协助培训关键环节和程序，比如使用PPE和感染控制。 任务后 要求所有参加任务的应急响应人员在任务后举行情况汇报会，收集任务过程 的资料，以便改进行动。这些情况汇报应重点关注应急人员在任务期间的观察、 体验和学习到的内容，以及本组织如何从这些经验中获益。 此种经历——被人倾听自己的实地经验和审视组织实践——也有助于减轻个 别工作者的压力（如果存在的话）。 任务结束后，应急响应人员需要联系WHO总部、员工健康和福利部门或区 域办事处工作者，以安排任务后的情况汇报。 任务结束后的情况汇报由工作者的顾问或心理专家组织进行，重点是应急响 应人员如何应对他们在任务期间经历的压力。总结探讨他们的经历、想法和感受， 以及如何应对这一切。特别关注他们当前的精神状态，以及他们可能需要的、进 一步的、个人或家庭的或其他任何的干预需求。还包括与压力经历可能会对个人 造成的远期影响相关的教育。PTSD的诊断和治疗需要专业的心理和医疗措施， 如怀疑PTSD应寻求之。 文献 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 11 / 124 关于OSH的意见、指南已经汇编为以下主要资源： ●WHO Ebola outbreak response handbook for health and safety in the field， providing comprehensive information on elements of the surveillance and monitoring required during deployment[13]. ●Training slides on ePROTECT training covering OSH instructions， later organized as online training[14]. ●The GO Training manual covering details of the EVD response， WHO’s role， and guidance on safety and health during deployment， also available online[15]. 1.4 突发事件应急响应人员的健康监护 ICS涵盖的ERHMS系统由NIOSH设计，已成为应急响应工作者OSH管理的 有用工具。该系统已经于2010年墨西哥湾深水地平线漏油事件应急响应期间得到 了成功应用（专栏3）。ERHMS的关键组成部分概述如下[16]。 任务前 名单和资格审查： 这些都是应急响应所需要的，以便对所有应急响应人员负责。注册和认证系 统被设计为支持四个相互依赖、相互辅助的功能：（1）注册（记录每个工作者 的基本信息和证件信息）；（2）应急资格认证（根据响应者认证和教育分配认 证级别）；（3）重新验证（定期验证响应者信息）；（4）应急证件（根据认证 等级分配身份证明）。 健康检查： 任务前健康检查旨在了解身体和情绪健康的基本状况，并应解决应急工作者 的身体健康状况、情绪健康状况和免疫状态方面存在的问题。这些信息可以来自 确定是否适合上岗的初次体检，或随后的医学检查。该基本信息允许对部署后的 可能的不良健康影响做出更为明智的解释，并且在暴露信息难以获得、无法解释 或不存在时具有特殊价值。 培训： 应急人员必须经过充分认证以执行特定任务——这些任务可能需要通用的、 国家或地方层面规定的培训要求。此外，应急人员识别和避免可能的健康与安全 风险的能力，将会影响其在灾难应急期间及以后的表现、生存能力和恢复能力。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 12 / 124 任务中 现场名册： 人员的标识、职责和跟踪过程称为应急人员名册。该名册用于记录向灾区报 到并参与救灾或恢复工作的每个人。后勤团队负责收集这些信息。 健康监护与监测： 监测是指持续和系统地收集、分析、解释和传播与响应人员个体的伤害、疾 病和暴露状态相关的数据。这样就可以评估暴露的发生情况，确定响应者个体在 工作期间可能经历的暴露水平，以及评估该暴露如何影响响应者。监护是指对某 一事件作出响应的整个应急工作小组的疾病和伤害数据进行持续和系统的收集、 分析、解释和传播。这样就可以跟踪应急响应人员在响应和恢复期间的健康(疾病 和伤害)趋势。对任何事件做出响应时，都应当包含允许做出监护的机制。 响应行动记录和安全控制记录： 响应人员和志愿者在工作期间可能会接触到许多不同的化学和环境危害因素。 关于工作者暴露的准确和有用信息，是确保正确描述暴露、恰当传达风险以及提 供足够信息以制定基于证据的决策（即PPE和工作实践控制）、以保护工作者健 康和安全的关键因素。 应急响应期间，暴露和健康监护与监测数据的传播： 收集环境暴露数据、个人健康和安全监测数据以及总监测数据，事关短期与 长期保护所有参与事件的响应人员。这些信息必须与组织内、组织间以及ICS结 构内外的工作者进行交流。 任务后 外部评估： 进行外部评估，以确定响应者个体在任务期间对其工作产生不利影响的程度， 并评估工作者群体内的趋势，以识别对他人的潜在风险。所有应急人员应在复员 过程中或复员后尽快接受外部评估。 跟踪应急响应人员的健康和功能状况： 由于应急响应工作中固有的潜在健康和安全风险，响应者健康状况的事后跟 踪可能是适当的。目标是识别可能与应急响应工作相关的不良健康或功能后果 （例如暴露，疾病，伤害或残疾：包括情绪创伤），尽早干预以最大限度地提高 恢复的几率，并阻止其余工作者进一步暴露（ 即通过暴露控制或医疗处置）。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 13 / 124 经验教训和行动后评估： 最后，有必要评估在任务前、任务中和任务后阶段如何进行紧急响应，并设 法确定在每个阶段改进响应的方法。这通常通过一个称为事后报告的文件来完成。 专栏3 ERHMS在深水地平线漏油事件响应中的应用 美国墨西哥湾深水地平线漏油事件响应期间使用ERHMS的概述，包括以下内容 [17]： 任务前 •截至2010年10月，登记和认证覆盖了55，388名具有不同工作经验的员工 •对应急响应人员进行任务前医疗评估，评估其在开展应急工作前的医疗状况， 指导医疗专业人员识别需要特别注意或限制暴 露的易感人群等 •对应急响应人员进行培训，培训内容如下： •8小时急救员操作培训 •24小时职业安全与健康管理局(OSHA) Hazpower或HAZMAT技术员培训 •40小时Hazpower培训 任务中 •每周收集和整理伤害和疾病数据。此外，每周绘制热病病例的时间趋势 •对海滩清理、野生动物康复、设备洗消和废物流管理等岸上和离岸活动进行了 健康危害评估 任务后 •包括外处理评估和暴露数据分析，以及自我报告和卫生保健服务者提供的信息 •分析暴露和健康部分，包括医疗监测、监护和暴露评估、任务前基线指标和医 学检查结果的分析。基于以上分析，确定了需要健康跟踪的工作者，并探讨了长 期跟踪选项 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 14 / 124 第二章 在突发事件和疫情爆发中保护职业安全和健康的策略和工具 管理系统方法提供了在突发事件和紧急情况下管理OSH风险的总体框架。为 了在这个框架内管理风险，给出一些预防和控制OSH危险和风险的战略、工具和 手段。这些资源可以根据具体的疫情或突发事件进行调整。本章节概述“控制层 次”、ICS和感染预防控制策略。 2.1 国际卫生条例，2005 国际卫生条例（IHR）[2]是一项对196个国家具有约束力的国际法律文书， 包括WHO的所有成员国。国际卫生条例的目的是帮助国际社会预防和应对可能 跨越国界并威胁全世界人民的严重公共卫生风险。 世界卫生大会于2005年通过IHR，于2007年6月15日生效。该条例要求各国 向WHO报告某些疾病爆发和公共卫生事件。基于WHO在全球疾病监测、预警和 反应方面的独特经验，IHR确定了各国报告公共卫生事件的权利和义务，并制定 了WHO为维护全球公共卫生安全必须遵循的程序。 除了疾病病原体之外，IHR还涵盖了有毒、传染性或其他危险材料的传播风 险，这些材料可能已经(或尚未)污染，或具有潜在污染众多人口和/或大面积区域。 IHR为保护公众健康和安全而做出的下列建议和规定，也保护了医疗救援机 构： ●关于人员、行李、货物、集装箱和运输工具的建议； ●包括机场、港口和一般过境点的建议； ●主管机关的作用； ●监测和响应的核心能力要求； ●评估和通报可能构成国际关注的突发公共卫生事件的事件决策工具。 建议采取以下与医疗救援机构健康和安全相关的公共卫生措施： ●抵达和撤离时的健康措施； ●运输和运输经营者的特殊规定； ●与旅行者入境有关的健康规定； ●海事健康宣言； ●飞机总申报单的健康部分； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 15 / 124 ●船舶卫生证书。 2.2 突发事件应急指挥系统 ICS是一种标准化的现场事件管理概念，被专门设计用于允许响应者采用与 任何单个事件或多个事件的复杂性和要求相适应的集成化组织结构，而不受管辖 边界的阻碍[18]。 ICS通过建立可管理的控制范围实现集成通信和规划。ICS将应急响应划分为 五个可操作的功能，这些功能对于应急响应操作至关重要：指挥、行动、规划、 后勤、财务和管理。 图2：ICS的结构 Source： Federal Emergency Management Agency， USA [18]. 组织结构 ●最小的ICS应包含以下内容，并可根据要求进行扩展： ●指挥人员由新闻官员、安全官员和联络官员组成。他们直接向事件指挥官 报告。 ●部门层级的代表承担事件处置的主要环节（行动、规划、后勤/财务）的职 能。在级别上，部门介于分队和事件指挥官之间。 ●每个部门由逐渐变小的组织单位组成，即分部、科室、工作组、单位、任 务组、小分队，最后是单一资源。单一资源是一件装备及其人员补充，或一个固 定的工作者或小组，其工作已由主管确定，可用于处理一个事件。 ●ICS是通过识别有效应对事件所需的主要活动或功能而设计的。随着事件 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 16 / 124 变得更加复杂、困难和代价高昂，对组织管理的要求也愈加明显。在ICS中，特 别是在更大的事件中，事件指挥官负责管理组织，而不是直接处置事件。 除命令功能外，其他所需的功能和活动包括： ●在ICS内授权和提供单独的组织级别，单独负责战术指导和资源控制； ●提供后勤支持； ●为当前和未来活动提供规划服务； ●支持事故响应所必需的成本评估、时间记录和采购控制； ●及时有效地与媒体互动，为事件处置团队、其他相关机构和公众提供信息 服务； ●在事件响应的所有环节提供安全的操作环境； ●确保援助和合作机构的需要得到满足，并确保这些机构得到有效利用。 作用和责任 ●从技术层面来说，事件指挥官不属于一般指挥人员或指挥人员的一部分。 事件指挥官负责整体事件处置，包括确保安全。 ●指挥人员被指派执行满足事件指挥官需要的职能。这些职能包括机构间联 络、事件安全管理和公共信息。设立指挥人员的职位，是为了便于对那些关键活 动（在一般人员的职责中没有明确的）分配落实责任。根据事件指挥官的要求和 指派，这些职位可能包括新闻官员、安全官员和联络官员，以及其他职位。 ●一般工作者负责ICS的事务性职能。一般工作者通常由业务、规划、后勤 和财务/行政部门组成。 安全官员： 安全官员/OSH官员的核心职责包括： ●识别和减轻危险情况； ●确保传达安全信息并提供简报； ●行使紧急权力以阻止和预防不安全的活动； ●审查有关安全影响的事故行动计划； ●指派有资格评估特殊危险的助理； ●启动对事故地区内的事故进行初步调查； ●审查和批准医疗计划； ●参与规划会议。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 17 / 124 ICS下的组织措施 ●美国联邦紧急事务管理局（FEMA）下属的应急管理研究所列出了以下措 施，作为ICS下健康和安全管理的一部分[18]： 风险评估和管理 ●对应急响应人员的保护必须遵循安全管理周期，负责应急人员保护的人员 必须时刻考虑到应急人员的OSH风险，权衡部署应急人员是否足够有益。 ●风险评估应遵循一般原则，并涵盖应急工作者可能遇到的所有可能的危险 和风险。 例如，灾害现场的风险评估必须包括评估多米诺骨牌效应是否可能（即 当前事件是否会造成进一步的损害和危险）。在寻找可能的风险时，应考虑所有 过去的事故和接近事故的意外。在此基础上制定的早期规划应预见可能的响应要 求，并应制定所有必要的预防措施。 ●必须在应急工作者的OSH风险和紧急行动可能带来的利益之间取得平衡。 员工也有责任合理照顾自己和他人，并与雇主合作；员工应在雇主的指挥和控制 下，采取明智和负责任的行动。 为了有效协调应急工作者的活动，集中领导是最合适的方式，因为它在需要 明确和快速指示的情况下运作良好。 因此，在灾害发生之前，必须查明现有装备、现有技术和人力资源、任务、 应急组织/工作队伍/工作者的作用和管理任务，并将这些任务分配给组织/工作队 伍/个人，以便尽可能有效地进行灾害控制。 工作组织 限制工作者接触：通过将现场人员的数量限制在必要的最低限度，并尽快疏 散无需继续留在现场的人员，可以减少应急工作者在现场的危险暴露。减少应急 人员和公众暴露于危险中的一种方法是建立“防护行动区”——根据与事故源的 距离和事故引起的影响强度。 工作/任务轮换：应尽可能考虑工作/任务轮换，以降低风险和过度劳累。 培训： ●必须向应急工作者提供有关风险（后果及可能性）的预防措施的知识，应 当涵盖其在专业活动中可能遇到的所有类型的职业安全与健康危害。培训应当涵 盖有害因素暴露的症状，适当的洗消程序和人工处置措施，在高度紧张或巨大压 力状态下的特殊影响，以及如何正确选择、使用、保养和维护PPE。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 18 / 124 ●应当针对不同场景下的标准操作程序进行培训。 ●对于帮助应急工作者更好地应对工作中的暴力而言，培训可能是至关重要 的。紧急医疗服务（EMS）工作者、医护人员和消防人员在履行职责过程中，比 其他工作者遭受暴力的风险更高。 预防接种： ●预防接种是一种有效的预防措施，应在工作者可能面临乙肝、介水传播疾 病（霍乱、伤寒、轮状病毒）或暴露于其他可能用于生物恐怖主义的生物制剂 （如肉毒毒素、土拉菌和天花）时提供。 个体防护装备的维护和保管： ●必须根据突发事件的类型、现场的风险，以及分配给特定应急工作者的特 定职责来选择PPE。 ●负责灾难处置或者相关应急小组工作的相关人员，必须选择额外的或特殊 的PPE。必须考虑适合性、可调节性、与其他PPE间的结合、特点和性能。 ●由于不可能进行更复杂和详细的监测，因此对于灾害现场的风险评估和监 测，往往只能通过肉眼来评估风险。 ●必须选择正确的PPE，在现场必须提供PPE，而且工作者必须熟悉PPE才 能正确使用。 ●在恐怖袭击和枪支暴力的情况下，应急工作者可能会成为“软目标”，他 们应当至少部分地获得防弹/防刺背心、安全鞋、头盔和防护服的保护。因此，在 危急情况下也应考虑为救援人员提供可能会用到的防护服，并配备在救护车上可 以经常使用。 ●标准安全设备应包括高可见度反光材料（装置如锥体和标志牌，个人防护 如背心和头盔），以及另外的警告标志和警示灯。这对于交通事故中的应急和救 援人员的安全，或在灾难和突发事件中（如部署使用起重机和挖掘机等重型机 械），以及能见度降低和夜间工作时的安全尤为重要。 ●在特定事件中可能需要使用化学毒物检测设备，气体探测器，辐射报警系 统，消防系统以及安全车辆。 ●必须提供适当的防护措施以保护皮肤和身体免受危险因素和危险物质的伤 害。例如使用经杀虫剂处理的蚊帐，以及在室内使用杀虫剂喷雾、使用酒精材质 的消毒液清洗双手以防止感染。为了保证清洁和消毒工作，使用和经常更换手套 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 19 / 124 等PPE是很重要的。 人体工效学设备： 应尽可能考虑使用符合人体工效学的设备，以减少工作者疲劳和暴露于危险 之中。在突发事件中使用符合人体工效学的设备的案例包括： ●使用移动设备运送人员（尸体）或任何必要的装备； ●在高层建筑中救人时使用电梯等工具； ●突发事件中需要长途步行时，应当将急救包放在背包里而不是手提袋中； ●为急救人员提供具备防针刺伤、减少感染风险的安全性能的注射器，并配 备针头盒、辅以专门培训。 心理准备： 工作中的心理方面的准备工作，有助于应急工作者应对工作中的情绪压力。 干预后心理帮助： 我们已经发现：紧急情况下，在部署期间和之后的社会支持，以及有机会与 同事或心理学家进行谈话和冷静讨论，可以帮助急救人员应对心理压力。但是， 如果出现创伤后应激障碍等严重的精神健康问题或持久症状，则可能需要专业帮 助。 长期护理和健康监护： ●健康监护应当同应急工作者所承担的职责相适应，并应考虑到不同危害因 素的潜在暴露， ●定期健康监护（通过强制性的年度健康体检和重大事件部署后体检）有助 于： ○评估应急工作者的身体素质（包括心肺测试）； ○检测危害因素暴露可能导致的疾病和伤害； ○早期提供必要的治疗和康复，以免工作者受到更严重的影响；以及 ○改善他们的恢复前景。 2.3 WHO卫生应急方案 WHO目前正在修订其紧急方案，目的是迅速有效地应对突发卫生事件。新 方案[19]改进了WHO在应急响应中的作用，增强了WHO的在专业技术和标准制定 方面所发挥作用的可操作性。 根据该方案，WHO正在帮助各国解决预防、准备、 应对和早期恢复的全周期风险管理。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 20 / 124 图3：WHO卫生应急方案，事件处置结构（简图） Source： WHO Health Emergencies Programme update： October 2016 [19]. 组织结构 WHO的国家办事处、区域办事处以及总部，都有一套共同的卫生应急方案 结构。这就意味着有一套统一的应急方案，包括统一的人力资源、统一的财务预 算、统一的责任机制、统一的流程/体系和统一的标准。在WHO的所有办事处， 这一构成和对结果的预期，都是一致的。 该方案由五个技术和行动单元组成，如下所示： 传染病危害处置确保为优先级的高风险的传染病危害制定战略、建立相应能 力。 国家卫生应急准备和《国际卫生条例》（2005年）确保为全部有威胁的应 急风险处置建立国家能力。 卫生应急信息和风险评估为所有重大卫生应急和事件提供及时、权威的形势 分析、风险评估和响应监测。 应急行动确保受突发事件影响的人群获得必要的、一整套的急救卫生服务。 应急核心服务确保WHO的应急行动得到迅速的和可持续的资金人员支持。 合作伙伴协调 卫生应急方案与其合作伙伴协作，在所有突发卫生事件中保护和挽救人们的 生命。危机期间，WHO与当地卫生部门和其他合作伙伴一道，确定最需要卫生 服务的领域，并协调合作伙伴共同努力，以确保这些领域获得医疗物资和人员的 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 21 / 124 保护。 WHO通过合作网络经常性地与合作伙伴开展合作，利用和协调数百个合作 伙伴机构的专业知识。主要的合作伙伴包括： 全球卫生组织集群：有300多个合作伙伴正在24个受危机影响的国家开展应 对。 紧急医疗队：WHO将来自25个国家的超过60个医疗队进行分类，以便在突 发事件发生后提供临床救治。 全球疫情警报和响应网络（GOARN）：自2000年以来，已经部署约2500名 卫生人员，以应对80个国家的130多起突发公共卫生事件。 后备伙伴：2015年，WHO的后备伙伴累计向18个国家部署了207个月的人 员支持。 机构间常设委员会（IASC）：WHO是IASC的积极参与者，机构间协调委员 会是在紧急救助协调员领导下的、应对复杂和重大突发事件的、非人道主义救援 机构间的主要机制。 国家支持 WHO卫生应急计划向各国提供以下服务： ●支持对国家的卫生应急准备情况进行评估，制定国家方案以解决能力方面 的重大不足； ●制定/促进预防和控制高风险的传染病危害的战略和能力；以及 ●监测新发的和正在进行的公共卫生事件，以对公共卫生风险进行评估、沟 通和提出行动建议。 此外，WHO正与各国和合作伙伴开展以下合作： ●确保为降低突出薄弱国家的公共卫生风险做好准备；以及 ●向正在发生突发事件的国家的受影响人口提供救命的卫生服务。 2.4 职业安全健康控制 为了管理由各种危害因素导致的健康和安全风险，需要采取措施预防和削弱 这些风险。OSH中的控制层次结构（图4）指的是控制程序的优先级别，从最有 效到效果最差[20]。其核心理念是最好首先尝试消除危险因素。如果不可能做到消 除，则应当将其控制在源头，其次是传播途径，最后才是个体层面。每种环境不 尽相同，需要对工作场所进行评估，以识别危害因素并确定控制措施。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 22 / 124 图4：OSH控制层次 Source： USA Hierarchy of controls， NIOSH [20]. 源头控制意味着消除危险或者任何使工作者面临风险的行为。这包括：实施 分级诊疗，以避免将患有高传染性风险疾病（如病毒性出血热）的患者置于传染 病救治中心以外的一般医疗机构，实验室检测中杀灭或灭活标本中的病毒，密闭 排泄物使病毒自然死亡，通过焚烧或高压灭菌破坏受污染的废弃物，以及选择危 害最小的替代方案（如口服补液治疗替代静脉给药，针刺抽取血液样本替代静脉 切开术）。 传播途径控制是指在危险源和工作者之间构筑屏障的工程和制度控制。例如， 在预防针刺伤害和相关血源性病原体暴露方面，设计安全的设备要比培训个人安 全使用针头更加有效。高传染性疾病如EVD和其他病毒性出血热的工程控制，包 括实验室的层流箱、临床护理的负压室和封闭（气泡）床，以及用于降低刺伤风 险的无针静脉系统。此外，必须提供安全的水和卫生服务，以确保有足够的水用 于卫生措施和正确处理排泄物。 管理控制旨在防止危险行为，包括：培训工作者采用安全的工作方法，确定 更安全的工作实践、标准操作制度和程序，以及对进入高风险工作场所进行限制。 关于政策和程序的培训，穿脱个人防护装备以及检疫和隔离程序，是防止高传染 性疾病（如EVD和其他病毒性出血热）传播的行政措施的实例。分诊是分类的过 程。在诸如霍乱和EVD等专门治疗单位中，分诊是一项重要的管理控制措施，可 防止患者和医务人员感染、传播。另一种形式是对处于危险中的工作者进行健康 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 23 / 124 监护，以便在早期阶段（此阶段疾病更容易治疗）发现职业危害的任何不利健康 影响（例如通过监测工作者的发热或其他传染病的早期症状）。 个体层面的控制是控制层次中效果最差的。包括：使用PPE（包括不透水防 护服或套装，如果套装不放水，还应当穿戴防水围裙）；双层手套；呼吸防护器； 遮挡颈部、面部的防护罩；护目镜、防护眼镜或面罩；带鞋套的靴子或防水鞋。 此外，还需要进行针对PPE磨损、清理、储存和维护的适当的培训，以确保实现 最高水平的防护。通常情况下应当佩戴上文推荐的PPE，但是应当针对特定任务 实施风险评估，以便为工作者选用最合适的PPE。评估工作中的适应性体格检查 的目的，是确定哪些可能因暴露于职业危害而加重或恶化的健康状况。在西非疫 情爆发应对中，在该领域获得优质医疗服务的机会非常有限。因此，必须进行体 检以确保工作适应性，以避免工作者在受疫情影响的国家部署期间，因既往健康 问题而出现任何并发症。 然而，在高传染性的疾病疫情爆发期间，使用PPE或者其他管理控制措施， 是保护医护人员健康和安全的最直接的措施之一。 2.5 感染预防和控制策略 IPC策略也涉及到控制的层次结构。管理控制是感染预防策略的最重要的组 成部分，包括实施和促进IPC预防措施和安全的患者护理实践。环境和工程控制 有助于减少与医疗保健相关的某些病原体的传播，但安全行为是关键。最后一个 控制层次结构是PPE。 管理控制提供政策和标准操作规程，以防止传染源暴露和传播给易感者。其 中包括：组织支持IPC和管理疫情；组织服务；合理使用现有供应和加强IPC基础 设施的政策；卫生工作者的教育；医护单位的风险评估；早期发现的患者分类； 患者安置和报告；患者分流；分区；专人作业；限制进入隔离设施；限制来访者； 环境清洁程序；布草和废物管理；减少静脉注射的程序。 工程与环境控制包括：配有适用于隔离患者个人使用的厕所/卫生设施的隔离 室；物理屏障；通风；安装并使用针具容器；洗手设施，以及功能适用、便于使 用的洗手液分配容器；相应数量的便桶；安全的针具；安全的水和卫生服务，包 括非现场处置污水和医疗废物。 2.5.1 标准预防措施 标准预防措施旨在降低已知或未知来源的血源性疾病或病原体的传播风险， 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 24 / 124 是感染预防控制措施的基本级别，至少应用于所有患者的护理中[21]。 手卫生是标准预防措施的主要组成部分，是预防与卫生保健相关的病原体传 播的最有效方法之一。除了手卫生外，PPE的使用还应依照风险评估结果，以及 预期的血液和体液或病原体暴露水平。 “手卫生五个时刻”由WHO制定，定义了卫生工作者应该进行手卫生的关键 时刻。临床护理环境中需要进行手卫生的情况包括： 1、接触患者之前：保护患者免受医护人员手上的有害细菌污染，并在某些 情况下防止外源性感染。 ●接近患者、接触患者之前清洁双手 2、洁净/无菌操作之前：保护患者免受有害细菌感染，包括其自身携带的和 外源性进入的细菌。 ●在进入对患者有感染风险的关键部位（如粘膜、非完整皮肤、侵入性医疗 设备）之前，必须立即清洁双手。 3、体液暴露风险后：保护医护人员免遭来自患者的有害细菌侵袭或感染， 保护医疗环境免受细菌传播的影响。 ●一旦涉及体液暴露风险的任务结束后（以及摘除手套后），立即清洁双手。 4、接触患者后：保护医护人员免遭来自患者的细菌侵袭，保护医疗环境免 受细菌传播的影响。 ●接触患者后、离开患者身边时清洁双手。 5、接触患者周围环境后：保护医护人员免遭来自患者周围表面/物体的细菌 侵袭，保护医疗环境免受细菌传播的影响。 ●离开患者周围环境时（未接触患者、接触任意物体或家具后）清洁双手。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 25 / 124 图5：手卫生五个时刻 Source： World Health Organization [21] 简易技术： ●洗手（40～60秒）：沾湿手并涂上肥皂；擦拭表面各处；洗手并用一次性 毛巾彻底擦干；用毛巾关闭水龙头。 ●擦手（20～30秒）：涂抹足量的消毒产品覆盖手表面各处；反复摩擦直至 干燥。 手卫生及医用手套的使用： ●使用手套并不能取代清洁手部的要求。 ●无论使用手套的指证如何，必须在适当时清洁手卫生。 ●出现要求戴手套的指证，应先取下手套清洁手卫生。 ●每次操作结束后丢弃手套并清洁双手（手套可能携带细菌）。 ●仅在依据标准和接触预防措施指示时戴手套，否则手套会成为细菌传播的 主要隐患。 防止针刺伤和其他血源性暴露 使用控制层次结构 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 26 / 124 根据WHO注射和相关程序最佳实践[22]的建议，按照有效性顺序（最有效排 第一）给出了防止针刺伤和其他血源性暴露的控制等级。 消除危险：从工作区域彻底清除危险隐患是最有效的控制危险的方法，应优 先使用此法。例如：在可能的情况下去除利器、针头（例如使用喷射器替代针头 和注射器，或使用无针头静脉内输液系统），消除所有不必要的注射行为，去掉 所有可有可无的锐器（如毛巾夹）。 工程控制：用于隔离或排除工作场所的危险。例如：锐器处理容器；如有可 能，在所有操作中使用针头保护装置（使用后立即收回、护套或针头钝化设备）。 管理控制：这些措施（例如标准操作程序）旨在控制危险暴露。例如：分配 资源以证明对卫生工作者安全的承诺；建立针刺伤害预防机制；制定暴露控制方 案；清除所有不安全的设备；以及对安全设备使用的持续的培训。 工作实践控制：这些控制措施旨在改变工作者的行为以减少职业危害。例如： 不要再次扣上针头；将锐器容器放置在视线水平及手臂可及范围内；锐器容器满 3/4时应密封弃用；在开始操作之前建立安全处理和处置锐器设备的方法。 个人防护用品 个人防护用品的水平，与消除危险、工程控制、管理控制和工作实践控制相 同，属于控制层次结构的第五个部分。使用和处理PPE对减少暴露而言至关重要。 政策和程序应详细说明为每项工作选择PPE、PPE的位置，以及如何使用PPE的 培训（包括穿戴、洗消、脱去PPE，以及处置或储存的程序）。此外，培训包含 强调“伙伴系统”，在穿戴、使用、脱去中互助协作、互相审查，有助于更加成 功地使用PPE。 选择PPE：PPE使用要求的选择因素包括供应储备、尺寸、适合性、防护等 级、舒适性、设计和使用经验。例如，手套的选择是基于暴露类型。非乳胶手套 用于预防传染病，而耐化学品手套用于预防化学品。其他考虑包括提供各种尺寸 和制造商的PPE，使其适合和舒适，这可能是正确使用的关键因素。 手套： 必须按照标准和接触预防措施配戴手套： ●无论使用手套的指证如何，必须在适当时清洁手卫生。 ●当开展涉及粘膜或血液的侵入性操作(如外科手术、阴道分娩、介入放射学 手术、心血管介入手术、全肠外营养和化疗药物)时，应使用无菌手套。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 27 / 124 ●当可能接触血液、体液、分泌物、排泄物和明显被体液污染的物品时，应 使用检查手套。 ○存在直接接触患者的风险的情况包括：接触血液、粘膜和不完整的皮肤， 以及可能存在高度传染性和风险的生物材料；疾病流行或紧急情况；静脉插管和 取出；抽血；终止静脉注射；盆腔和阴道检查；以及抽吸气管导管的非封闭系统。 ○存在间接接触患者风险的情况包括：倾倒呕吐物、清洁处理器械、处理废 物和清理体液溢出。 ●如果没有接触血液、体液或被污染环境的可能性，除了接触预防措施外， 不建议使用手套。 ●存在直接接触患者的情况还包括：测量血压、体温和脉搏；进行皮下和肌 肉注射；为患者沐浴更衣；转运患者；护理眼睛和耳朵（无分泌物）；以及在没 有血液渗出的情况下进行任何血管线操作。 ○存在间接接触患者的情况还包括：使用电话；写病历；给予口服药；分发 或收集患者餐盘；取出并更换病床布草；放置无创通气设备和氧气插管；以及移 动患者的家具。 面部防护（眼、鼻、口）： 在可能产生血液、体液、分泌物和排泄物的飞溅或喷溅的操作中，应戴上外 科或手术面罩和眼睛保护装置（眼罩、护目镜）或面罩，以保护眼睛、鼻子和口 腔的粘膜。还应穿戴鞋/靴套、罩衣和围裙。 防护服和工作服： 在可能引起血液、体液、分泌物或排泄物飞溅或喷溅的操作中，应穿上防护 服和工作服以保护皮肤，防止污染衣物。弄脏的防护服或工作服应尽快脱掉，并 进行手卫生。 呼吸防护设备： 呼吸防护设备保护工作者免于空气传播的危害因素。 ●呼吸防护设备有两种类型：空气过滤式和供气式。呼吸防护设备也可分为 紧配合式或松配合式。存在吸入危险时，应使用N95或防护系数较高的呼吸防护 设备。紧配合式呼吸防护设备包含在呼吸防护设备和使用者面部和/或颈部之间的 紧密密封。 ●如果呼吸防护设备的密封件泄漏，污染的空气将被吸入面罩并可以吸入。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 28 / 124 因此，杜绝任何干扰呼吸防护设备密封的物体（如面部毛发，耳环，头巾，假发 和面部穿孔）。松配合式呼吸恢复设备不依赖于与面部的紧密密封来提供保护， 因此无需进行适合性测试。 ●必须对工作者进行医学检查，并按与拟采用的呼吸防护设备（相同品牌、 型号、样式和尺寸）进行适合性测试。进行适合性测试目的是确保呼吸防护设备 的面罩与面部匹配。在第一次使用之前，必须对呼吸防护设备进行适合性测试。 应至少每12个月进行一次重新测试，以确保呼吸防护设备仍然适用。此外，如果 手术或体重增加导致面部特征发生变化，则需要重新进行适合性测试。 ●每次佩戴时，佩戴者都要进行密封性检查，确定呼吸防护设备是否正确固 定在面部或需要重新调整。 ●普通口罩或外科手术口罩不是呼吸防护设备，不能保护使用者免于空气传 播风险。 穿脱个人防护用品 为了更加有效的使用PPE保护卫生工作者，必须遵循标准的穿脱程序。 穿PPE： 防护服： ●完全覆盖躯干部（从颈部至膝盖，手臂至手腕末端），环绕背部。 ●在颈后和腰后系住。用胶带固定。 口罩或呼吸防护设备： ●在头部和颈部中间固定系带或松紧带。 ●将可调节的系带置于鼻梁上。 ●贴合脸部和下巴。 ●进行适合性测试。 护目镜或面罩： ●佩戴于面部和眼睛上，并调整到合适位置。 手套： ●延伸至防护服腕部。 脱PPE： 手套： ●手套外层已被污染！ 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 29 / 124 ●用戴着手套的手抓住手套外层、脱掉。 ●用戴手套的手抓住脱下的手套。 ●将未戴手套的手指滑到戴手套的手腕处。 ●脱掉第二只手套。 ●将手套丢弃至废物容器中。 护目镜或面罩： ●护目镜或面罩外层已被污染！ ●如需摘除，请抓住头带或耳带操作。 ●放入指定的容器中进行再处理或丢弃在废物容器中。 防护服： ●防护服正面和袖子已被污染！ ●解开领带。 ●剥离颈部和肩部，仅接触内层。 ●将防护服翻出。 ●折叠或卷成一捆并丢弃。 面罩或呼吸防护设备： ●面罩/呼吸呼吸防护设备前面被污染，请勿触摸！ ●抓住底部，然后抓住顶部系带或松紧带并将其取下。 ●丢弃在废物容器中。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 30 / 124 图6：穿PPE Source： World Health Organization [13] 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 31 / 124 其他预防措施（基于传播方式） 在确保维持标准预防措施的同时，采取其他预防措施（基于传播方式）。 WHO在卫生机构感染控制实用指南[23]中所述的其他预防措施包括空气传播预防 措施、飞沫传播预防措施和接触传播预防措施。 空气传播预防措施： 空气传播预防措施旨在减少那些通过空气途径传播的疾病。小于5微米的飞 沫核（飞沫蒸发后）散布在空气中时，就会发生空气传播。这些飞沫核可以在空 气中悬浮一段时间。飞沫是飞沫的残留物，悬浮在空气中时会干燥并产生1～5微 米的颗粒，这些颗粒可以长时间悬浮于空气中（特别适于尘埃粒子结合时）。 通过这种方式传播的疾病包括开放性/活动性肺结核(TB)、麻疹、水痘、肺 鼠疫和肺炎型出血热。 需要采取以下预防措施： ●执行标准预防措施。 ●将患者置于有可监测的负压气流的单独房间中（通常称为“负压室”）。 ●空气在排放到室外或循环到医疗机构的其他区域之前，应进行特殊过滤。 ●保持关门状态。 ●任何进入房间的人都必须佩戴专门的、高效过滤颗粒物的（如N95）呼吸 防护设备。 ●限制患者的活动和转运（仅满足基本目的要求）。 ●如有必要转运，患者应佩戴外科口罩、减少飞沫核扩散。 ●取得工程部门支持，以确保维持气流负压。 飞沫传播预防措施： 通过这种途径传播的疾病包括肺炎、百日咳、白喉、B型流感、腮腺炎和脑 膜炎。当易感者的鼻粘膜、口腔粘膜或结膜与大颗粒飞沫（大于5微米）充分接 触时，就会发生飞沫传播。在咳嗽、打喷嚏、说话或医护人员进行气管抽吸等手 术时，感染者通常会产生飞沫。 需要采取以下预防措施： ●执行标准预防措施。 ●将患者置于单独房间（或与另一名感染相同病原体患者置于同一房间）。 ●在距患者1～2米范围内工作时请戴口罩。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 32 / 124 ●如需转运，请给患者佩戴外科口罩。 ●预防飞沫传播，无需特殊的空气处理和通风措施。 接触传播预防措施： 通过这种途径传播的疾病包括多种耐药微生物的定植或感染、肠道感染和皮 肤感染。 需要采取以下预防措施： ●执行标准预防措施。 ●将患者置于单独房间（或与另一名感染相同病原体患者置于同一房间）。 ●安置患者时请考虑疾病的流行病学和患者的群体性。 ●进入房间时戴上干净的非灭菌手套。 ●如果预期与患者、环境表面或患者房间内的物品有密切接触，进入房间时 应穿一件干净、非灭菌的防护服。 ●限制患者离开病房和转运。转运患者仅满足基本目的要求。如果需要转运， 应采取预防措施，尽量减少运输风险。 环境清洁 ●日常清洁对于确保医院环境清洁无尘至关重要。许多微生物通常存在于 “可见污垢”中，常规清洁有助于清除这些污垢。 ●不接触患者的行政办公区域，需要常规的家政清洁。 ●大多数患者的护理区域都应该用湿拖把清洁。 ●不建议干扫。使用中性洗涤剂溶液可以改善情节质量。热水（80℃）是一 种很有用处且有效的清洁剂。 ●除了寻找潜在的爆发源外，不推荐对环境进行细菌学检测。 ●任何明显受到血液或体液污染的区域，应立即用洗涤剂和水清洗。 ●隔离室和其他有已知传染性疾病患者的区域应至少每天使用洗涤剂/消毒剂 进行清洁。 ●所有水平表面和所有卫生间区域应每天清洁。 衣物洗涤 布草： 布草管理的基本原则如下： ●在交接布草区域，将用过的布草装在合适的包装中。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 33 / 124 ●将沾有人体组织或其他液体的布草至于合适的、不透水包装中，并在运输 中安全密封，避免血液、体液、分泌物或排泄物溢出或滴落。 ●在适当区域整理布草，而不要在患者护理区域清洗或分拣。 ●尽可能轻地翻动布草，避免产生病原微生物气溶胶。 ●干净的布草与脏衣物分开，单独运输/存放。 ●用热水（70-80℃）和洗涤剂清洗用过的布草（床单、棉毯子），最好在 干衣机或阳光下干燥。（建议医院使用大型洗衣机/烘干机） ●布草供应到手术室前应进行高压灭菌。 ●用温水清洗羊毛毯、在阳光下晒干，或低温下用烘干机烘干，或干洗。 床品： ●带塑料罩的床垫和枕头应当用中性洗涤剂擦拭。 ●没有塑料罩的床垫如果被液体污染，应当使用蒸汽清洁。如果无法做到， 应在确保足够的人员和环境防护的情况下采取手动清洗消除污染。 ●清洗枕头依照上述标准洗涤程序，如果被体液污染则可以干洗。 仪器和设备的后处理 对仪器设备的有效的后处理包括以下环节： ●仪器设备使用后立即清洁，清除所有有机物和化学品，以及 ●消毒（通过加热，水洗，或化学消毒剂），或 ●灭菌。 患者护理设备： ●处理沾染血液、体液、分泌物、排泄物等的设备时，应防止皮肤和粘膜暴 露、衣物污染，以及避免将病原体转移给其他患者或环境。 ●可重复使用的设备应在与其他患者共用前进行适当的清洁、消毒和再处理。 用过的个人防护用品： WHO卫生机构感染控制实用指南[23]给出了用过的PPE的一些处置措施建议 （见表1）。 表1：用过的PPE的处置 设备/用品 标准程序 备注 N95或标准手术口罩 一次性使用 根据卫生机构指南，丢 弃于适当的废物袋。 HEPA（P100）面罩 仅使用一次性过滤器 分离过滤器与面罩，丢弃过滤器。 使用洗涤剂和水清洗面罩，晾干，再用 根据卫生机构指南，将 过滤器丢弃于适当的废 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 34 / 124 70%酒精消毒，然后再使用。 物袋。 眼罩、护目镜、面罩 建议使用一次性产品 如需重复使用，请用洗涤剂和水清洗，晾 干，再用70%酒精消毒或1%次氯酸盐溶液 浸泡20分钟，然后洗净。 如果是一次性的，根据 卫生机构指南，丢弃于 适当的废物袋。 防护服 建议使用一次性防护 服 如需重复使用，按照卫生机构污染布草指 南清洗，如：用热水(70-80℃)洗涤（如有 可能），或 清水中加0.5%漂白粉浸泡30分钟，再用洗 涤剂和水洗去漂白剂。 如果是一次性的，根据 卫生机构指南，丢弃于 适当的废物袋。 如重复使用，宜用烘干 机或阳光下晒干。 围裙 建议使用一次性围裙 如需重复使用，使用洗涤剂和水清洗面 罩，晾干，再用70%酒精消毒。 如果是一次性的，根据 卫生机构指南，丢弃于 适当的废物袋。 帽子和鞋套 推荐使用一次性产品 如需重复使用，按照卫生机构污染布草指 南清洗，如：用热水(70-80℃)洗涤（如有 可能），或 清水中加0.5%漂白粉浸泡30分钟，再用洗 涤剂和水洗去漂白剂。 如果是一次性的，根据 卫生机构指南，丢弃于 适当的废物袋。 如重复使用，宜用烘干 机或阳光下晒干。 手套 仅一次性使用 根据卫生机构指南，丢 弃于适当的废物袋。 靴子（可重复使用） 用洗涤剂和水清洗，晾干，再用70%酒精 消毒。 医疗废物处置 医院的废弃物是潜在的病原微生物储存库，需要恰当、安全和可靠的处置。 与感染相关的主要风险是被血液污染的锐器。应有一名或多名人员负责废物收集、 处理、储存，以及处置的组织管理。废物处置应与感染控制小组协调运作。 WHO在其卫生机构废物安全处置指南[24]中列出了以下医疗废物处置步骤： ●产生 ●隔离/分拣 ●储存 ●运输 ●处理和处置 医疗废物处置原则： 医疗废物的安全处置，包含一个基于监管要求的系统方法，以及可及的处理/ 处置资源。关键要素包括机构管理人员的如下活动： ●基于对当前形势的评估，制定废物处置方案，并将废物产量降至最低。 ●将临床废物（感染性）与非临床废物分开存放于专门容器中。 ●使用专用运输工具转运废物。 ●划定限制进入的专门区域存放废物。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 35 / 124 ●将锐器集中存放于锐器容器中。锐器容器应为塑料或金属材质，有可关闭 的盖子。应有适当的标签或标识：如临床废物（感染性）生物危害标志。 ●储存区域标识以生物危害标志。 ●确保运输需隔离废物的小车/推车不得作为他用，并应定期清理。 ●划定处理或最终处理前废弃物的存放区域。 ●必须根据国家法规和WHO指南处置危险废物和临床/感染性废物。这可能 包含将感染性废物运送至集中式废物处理设施，或现场处置废物。 2.5.2 预防卫生机构职业性呼吸道感染 为防止通过飞沫传播的所有呼吸道感染（包括流感、脑膜炎球菌性脑膜炎） 在卫生机构环境中传播，应在与潜在感染者接触的第一步就采取以下感染控制措 施。这些措施应作为标准预防措施的一部分纳入感染控制实践。 1、警示标识 应在门诊机构入口（如急诊科、诊所、门诊部）以适当语言设置醒目的警示 标识，提醒患者和陪同人员（如家人、朋友），在医护人员首次接诊登记时就告 知其呼吸道感染的症状，并遵守呼吸道卫生/咳嗽礼节。 必须采取以下措施，以防止咳嗽造成的感染传播： ●应避免与患者密切接触。 ●患病时呆在家中。 ●咳嗽或打喷嚏时用纸巾遮住口鼻。 ●经常洗手，用肥皂和温水洗手60秒。如果没有肥皂和水，就用酒精洗手。 ●避免接触他人的眼、鼻、口。 ●养成其他良好的卫生习惯 2、呼吸道卫生/咳嗽礼节 对于所有具有呼吸道感染症状和体征者，建议采取以下控制呼吸道分泌物的 措施： ●咳嗽或打喷嚏时用纸巾遮住口鼻。 ●将用过的纸巾丢弃到最近的垃圾桶。 ●如果没有纸巾，咳嗽或打喷嚏时应对着上衣袖而不是你的手。 ●接触呼吸道分泌物以及受污染的物品/物料后，应进行手卫生（如，用非抗 菌的肥皂和水洗手，酒精洗手，或消毒液洗手）。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 36 / 124 卫生机构应确保在患者和来访者等候区提供呼吸道卫生/咳嗽礼节用材料。 ●提供纸巾和非接触式容器（便于处理用过的纸巾）。 ●提供位置便利的酒精洗手液分配器；如果有水池，确保洗手用品（如肥皂、 一次性手巾）始终可用。 3、有呼吸道症状者，隔离并戴口罩 在社区呼吸道感染增加活跃期间（如工作环境和医疗机构就诊者中主诉呼吸 道症状者增多）为咳嗽者提供口罩。手术口罩（带耳带）或外科口罩（带系带） 可用于阻滞呼吸道分泌物（无需使用N95或以上呼吸防护设备）。在空间和椅子 可用性允许的情况下，鼓励咳嗽者在公共等候区域就座时距离他人至少三英尺。 有些机构可能会发现，全年执行此建议在后勤上会更简便。 4、飞沫预防措施 建议卫生保健人员在检查有呼吸道感染症状的患者时，特别是在发热的情况 下，除了标准预防措施外，还要遵守飞沫预防措施（即进行密切接触时戴上外科 口罩或手术口罩）。应保持这些预防措施，直至明确病因并非需要此类预防措施 的传染源。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 37 / 124 第三章 突发事件中的安全与健康风险 由于高感染率和高病死率，微生物感染是迄今为止疫情应对和准备工作者主 要的职业健康问题。然而，在热带和亚热带气候条件下，应急人员也有可能暴露 于常见的地方病，如疟疾、伤寒、霍乱、甲型和乙型肝炎、艾滋病毒/艾滋病、肺 结核、介水和食源性感染以及其他传染病。 除了高度传染性的病原体之外，其他危害因素也可能进一步危及应急人员和 卫生工作者的健康。地方病、心理社会压力、疲劳和暴力尤其会降低卫生保健和 应急响应工作者的工作能力，妨碍IPC措施的有效性。 来自世界各地的短期的外籍工作者和志愿者是应急响应人员的重要组成部分。 他们的医疗、安全和保障、住宿、与当地工作者和社区的关系，以及适应受影响 国家的气候和社会文化背景也可能具有挑战性。这就要求采取综合性、多学科的 方法来保护疫情爆发和应急响应工作者的健康、安全和福利，包括OSH、IPC、 应急响应、后勤和社会福利方面采取的措施。本节介绍了几乎所有类型的突发事 件和紧急情况中不同程度发生的危险，及其预防和控制措施的信息。 3.1 媒介传染病 受高传染性病原体如霍乱、黄热病和病毒性出血热（例如埃博拉病毒或马尔 堡病毒）影响的国家，也常流行疟疾、登革热和其他媒介传染病。疟疾引起发热 并且早期阶段类似于病毒性出血热如EVD，可能导致在专门的治疗机构中被错误 分类并隔离。对疟疾的化学预防，以及提高警惕、在白天和夜间针对蚊子及其他 媒介生物采取个人防护，对于预防媒介传染病很重要。 部署在存在地方性疟疾等媒介传染病高流行的区域的工作者，应采取以下预 防措施： ●穿长袖衣服。 ●日夜使用驱蚊剂。 ●睡觉时用浸泡杀虫剂的蚊帐。 ●按照医务人员建议，在部署前后进行疟疾化学预防。 ●注意风险、潜伏期、延迟发病的可能性，以及主要症状（发热加流感样症 状、腹泻）。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 38 / 124 ●如果在进入有疟疾风险的地区1周或更长时间后出现发热，以及在离开风 险地区后3个月内（或更短，或稍后）出现发热，应立即寻求诊断和治疗。 ●按照医务人员建议，携带疟疾治疗备用药物。 3.2 介水传播和食源性传播疾病 应急响应人员需要在偏远地区和艰苦条件下工作，在这些地区可能无法获得 安全的食品和水；他们住宿时可能涉及到使用来自当地可用的水源的饮用水、烹 饪当地的食品。WHO在其饮用水水质准则[25]中提出如下旅行者建议，防止不安 全的水源带来的危害和风险： ●如果水质无法保证，请务必避免饮用或使用不安全的水（即使刷牙时）。 ●避免饮用/食用未经消毒的蔬果汁，以及未经处理的水制成的冰。 ●避免用不安全的水清洗或制备沙拉或其他未煮熟的食品。 ●饮用煮沸、过滤和/或用氯或碘处理过并存放在干净容器中的水。 ●仅食用知晓满足饮用水水质的冰。 ●饮用已知安全的瓶装水，密封防伪包装的碳酸饮料（水和苏打水），巴氏 杀菌/罐装果汁和巴氏杀菌牛奶。 ●喝煮开并存放于干净容器中的咖啡和茶。 食品安全 在食品安全指南[26]中，WHO规定了“食品安全五大要点”，涵盖了以下食 品准备到供应的所涉及的食品安全领域，以保持食品的质量与安全： 保持食品制备区清洁：虽然大多数微生物不致病，但有害微生物广泛存在于 土壤、水、动物和人中。这些微生物通过手、抹布和器具（尤其是砧板）携带， 轻微接触就会将其转移至食品，引起食源性疾病。因此，厨房和储藏区必须采取 手卫生、环境卫生和病虫害防治。 生熟食品分开：生食（特别是肉类、家禽和海鲜及其汁液）可能含有有害微 生物，可能在食品制备和储存过程中转移到其他食品上。 为防止这种情况发生， 应将生肉、家禽和海鲜与其他食品分开，并应使用单独的设备和器具（如刀具和 砧板）。食品应储存在容器中，以避免原料和预制食品接触。 彻底烹饪食品：恰当的烹饪可以杀死几乎所有的有害微生物。研究表明，在 70℃下烹饪食品有助于确保食用安全。特别需要注意的食品包括肉末、烤肉、带 骨的大肉块和整只家禽。因此必须彻底做熟食品，尤其是肉类、家禽、鸡蛋和海 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 39 / 124 鲜。如果熟食需要重新加热，也必须彻底做熟。汤和炖菜等食品需要煮沸以确保 达到70℃，对于肉类和家禽，应确保汤汁澄清而不是粉红色。 在安全的温度保存食品：如在室温下储存食品，微生物会快速繁殖。将食品 保存在低于5℃或高于60℃，可以是微生物生长减缓或停止。烹饪好的食品在室 温下保存不宜超过2小时。所有熟食和易变质食品最好在5℃以下冷藏。即使是冰 箱中的食品也不应长期保存，冷冻食品在烹饪前应在室温下解冻。熟食应保持滚 烫，最好在食用前保持在60℃以上。 使用安全的水和原材料：原材料包括水和冰，可能被有害微生物和化学品污 染。破损和霉变食物中可能会产生化学毒物。注意选择原材料以及采取简单的措 施（如洗涤和去皮）可以降低风险。必须使用安全的水，或通过煮沸或氯片/溶液 安全处理后的水，应选择新鲜、有益健康的食品，应使用巴氏杀菌牛奶，必须彻 底清洗水果和蔬菜，尤其是生吃的水果和蔬菜。包装食品不得超过有效期[26]。 3.3 可通过接种疫苗预防的疾病 对可通过接种疫苗预防的疾病，免疫接种是保护卫生工作者和应急响应人员 免受高传染性疾病危害的最有价值的保护措施之一。部署在高流行地区的工作者， 应及时了解部署地区需要接种疫苗的情况。 WHO在其网站上归纳总结了针对各种可通过接种疫苗预防疾病的卫生工作 者免疫接种指南[27]。 例如，对于部署在西非埃博拉应对行动中的应急人员，WHO建议在部署前 针对下列疾病接种疫苗[28]： ●黄热病（强制性）； ●白喉-破伤风（最好五年内），脊髓灰质炎，百日咳； ●伤寒； ●甲型肝炎和乙型肝炎； ●脑膜炎ACYW 135（如疫情持续，则强制性）； ●麻疹（1963年出生后未患麻疹者），或2剂麻疹腮腺炎风疹疫苗 （MMR）； ●狂犬病； ●霍乱（根据风险评估在有限情况下推荐的疫苗）。 3.4 热应激 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 40 / 124 暴露于极端高温环境，或在炎热环境中工作的应急工作者，可能面临热应激 的风险。暴露于极端高温下会导致职业病和伤害。热应激会导致中暑、热衰竭、 热痉挛或热皮疹。高温也会增加工作者受伤的风险，因为可能会导致手心出汗、 护目镜起雾和头晕。意外接触热表面或蒸汽也可能导致烫伤。 自然灾害、化学和放射性事件以及疫情爆发期间，应急响应工作通常涉及由 于在户外阳光下工作而导致的长时间热暴露。此外，灾害、野火及其他与火灾相 关的应急工作，应对火灾的应急救援人员可能会直接受到影响（如烧伤）。 建议使用的PPE为覆盖全身或大部分身体/皮肤表面的半透性和不透性材料， 如消防队员和专业治疗机构的卫生工作者所要求的那样，这样可以防止热量和汗 水进入。这限制了身体通过蒸发进行降温的保护机制，反而促进了热量储留和体 温升高。在室外炎热潮湿环境中，以及缺乏电力和空调的环境中，这种情况更为 复杂。 美国疾病预防控制中心（USCDC）[29]建议采取以下管理和工作实践措施来 预防和控制热应激及其影响： ●适应环境的时间：对于热点地区的新工作者，在炎热环境条件下的工作暴 露时间应在7-14天内逐渐增加，以减少与热有关的疾病的风险并提高安全工作的 能力。 如果无法做到这一点，那些对气候不熟悉的工作者应该做一些较短的班次， 直到他们的身体适应高温。 对气候不熟悉的工作者，第一天应安排进行不超过通 常工作班次的20%，每增加一天不超过20%。有既往在此气候下工作经验的工作 者，第1天应安排不超过正常工作班次的50%，第2天60%，第3天80%和第4天 100%。 ●强化所有工作者的意识：工作者要能够识别与热有关疾病的症状。这些疾 病包括一系列的健康影响，随着严重程度增加，范围从热皮疹、热晕厥（昏厥）、 热衰竭和横纹肌溶解导致的热衰竭——需要紧急医疗救治以防止器官损伤（如大 脑、心脏、肾脏、肝脏或肌肉）以及死亡。与热有关疾病的相关严重风险，以及 在炎热环境中工作时丧失工作能力或受到伤害的风险的增加，使所有工作者、同 事和主管认识到热相关疾病的症状和体征变得非常重要。 ●伙伴模式：当工作者发现自己或他人出现与热有关的疾病的迹象或体征时， 应通过伙伴模式立即通知主管人员。应指示同伴定期向其同事伙伴询问其感受， 并在必要时与同事一起撤离工作区域。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 41 / 124 ●限制暴露时间：对于在专业治疗机构工作且穿着全套PPE的工作者，休息 前的工作时间最长不超过1小时。在室外炎热环境下的工作，如果可能的话须在 早上和晚上进行，以避免高温暴露。 ●休息时间：应为工作者提供足够的休息时间和恢复/乘凉区域。 ●获得饮用水：在休息/恢复期间，工作者应能轻松获得足够的凉水（即10- 15℃或50-59℉）和电解质补充液或口服补液盐。 ●监测水合状态：工作者应当监测其尿量和颜色，以及饮水量，以维持水合 状态。 ●应急程序：应当为出现热相关症状的工作者制定应急程序，包括考虑为受 到严重影响的有症状者提供冷水浴。 ●整体舒适性：通过在工作日和非工作日鼓励充足的睡眠、饮食和饮水，以 及限制使用酒精、含咖啡因产品和安眠药，提高工作者的整体舒适性，预防热应 激的影响。 3.5 滑倒、绊倒和跌倒 由滑倒、绊倒和跌到所致的事故/事件可以造成伤痛，并在突发事件和紧急情 况下造成宝贵的人力资源的损失。此外，天气和其他条件以及对工作的紧急要求 也可能导致此类事件，这是造成卫生机构工作者严重伤害的主要原因之一。 美国疾病预防控制中心在《医护人员预防滑倒、绊倒和跌倒》中列举的导致 滑倒、绊倒和跌倒的主要原因如下[30]： ●地板上的污物（水、油脂、油、液体、食物）：地板上的污物是导致医疗 机构滑倒、绊倒和跌倒事故的主要原因。水、油脂和其他液体会使得人行道表面 变得光滑。 ●排水不畅（管道和排水管）：水管和排水管布置不当会导致液体溅到人行 道，而排水管堵塞会造成水倒流到地板上。 ●路面不平整：维护不当、不平整的地面，突出的构造，孔洞，岩石，树枝 及其他碎片，可能导致工作者跌倒，绊倒，滑倒或摔倒。 ●天气状况（雨、冰和雪）：雨水、冰雪会导致员工滑倒。 ●照明不足：存在照明不足造成危险的公共区域包括停车场、储藏室、走廊、 楼梯间，以及设施内外的人行通道。 ●梯子/梯凳使用不当：用于高空作业的梯子/梯凳，如果使用不当，可能会 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 42 / 124 导致危险状况。 ●绊倒风险（杂物，包括松散的绳索，软管，电线，医用管线）：杂物可能 在存储区、工作区、走廊和人行道上堆积，可能导致滑倒、绊倒或跌倒事故。暴 露在地板上的、摊开在人行道上、缠绕在工作场所附近的绳索，可能会绊到员工 的脚，导致摔倒事故。 与滑倒、绊倒和跌倒有关的人为因素 人为因素表示与环境相关的人的行为方式。可能影响滑倒或绊倒风险的人为 因素包括： ●沟通：是否正确理解安全说明、标志和标签； ●疲劳：疲劳会影响执行任务的能力； ●个性：人们队指示的不同反应（例如，有些人选择无视，有些人会冒险）； ●能力：要求某人做超出其能力范围的事情（如缺乏培训）； ●行为：人们如何行动（例如，匆忙赶路，抄近路）； ●感知：接受周围环境信息的能力（如分神）。 某些活动会影响滑倒和绊倒。例如： ●搬运/提升：人们可能看不到地面上的危险，而且一旦失去平衡就更有可能 跌到。 ●推/拉：需要更强的抓地力，而且可能看不到地面上的危险。 ●快跑：如果一个人快速跑动，则需要更强的抓地力，且对危险的反应时间 也更少。 ●分神：如果一个人的注意力被吸引到附近的某物或某人身上，则不太可能 看到地面上的危险。 欧洲职业安全健康局（EU-OSHA）[31]建议采取以下预防措施： ●良好的内务管理：糟糕的内务管理，以及普遍的不整洁，是滑倒和绊倒的 主要原因。保持工作环境干净整洁、楼层和出入通道畅通无阻。定期清理避免垃 圾堆积。 ●清洁和维护：定期清洁和维护可将风险降至最低。应定期清除垃圾，保持 工作区域清洁。清洁方法和设备必须适合被处理的表面。在清洁和维护工作期间， 注意不要产生新的滑倒和绊倒危险。 ●照明：确保照明水平、灯的功能和位置处于良好状态，确保所有楼层区域 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 43 / 124 照明均匀，所有潜在危险（如障碍物和溢出物）清晰可见。照明水平需要允许安 全通行。室外工作场所必须有足够的照明，这可能需要额外的照明灯。 ●行走路面：应定期检查地板等表面是否损坏，必要时进行维护。潜在的滑 倒和绊倒危险包括洞和裂缝，室内地毯和垫子松动。地板表面任何位置都应适合 进行的工作（例如，可能需要耐生产过程中使用的油和化学品）。对现有地板进 行涂层或化学处理可以提高其防滑性能。地板应该保持干净。 ●溢出：溢出物应立即用适当的清洁方法进行清理（可能需要进行化学处 理）。警告标志应指明地面潮湿处，并应给出替代路线。 ●障碍物：在可能的情况下，应移除障碍物以防止发生绊倒。如果无法排除 障碍，则应使用适当的路障和/或警告通知。 ●拖曳电缆：设备的位置应确保电缆不会穿过行人路线。应使用电缆盖将电 缆牢牢固定在表面上。 ●鞋：工人需要有适合其工作环境的鞋，考虑到工作类型、地板表面、典型 地板条件和鞋底的防滑性能。 ●室外工作场所：室外工作场所的布置必须使滑倒和绊倒的风险最小化（例 如，在结冰条件下采取防滑措施和使用合适的鞋子）。 3.6 道路交通伤害 突发事件和应急响应需要大量使用车辆进行公路运输，从自行车、摩托车到 重型卡车，既要快速转运响应者，也要快速运输材料和物资。社会动员和暴露追 踪活动可能需要经常使用自行车和摩托车。在突发事件应急响应期间，很难获得 足够的医疗保健，即使是轻微的道路交通伤害也可能产生重大后果。此外，许多 热带国家的气候条件导致连续数月的大雨，冲毁道路，使运输极其困难和危险。 约90%的道路交通伤亡发生在低收入和中等收入国家，但这些国家仅占世界 注册车辆的54%[32]。政府、决策者、规划者、雇主、社区和个人可以采取的、 以改善驾驶员的职业健康和安全、并确保安全的工作场所交通系统的实际步骤包 括：管理超速、控制饮酒和驾驶、使用安全带和头盔、避免长时间驾驶或长时间 工作、避免在驾驶时使用手机，确保道路设计安全，确保车辆安全，确保优质的 事故后照料，以及执行道路安全法规。 在突发事件或其他紧急情况下，一个安全高效的运输系统尤为重要。安全运 输系统所需的关键要素包括： 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 44 / 124 道路和交通基础设施 ●道路和路径是确定的，最好在道路中间设置一个单向系统，在道路中间设 置隔离带，以分隔向相反方向行驶的车流。 ●道路应当消除或尽可能减少倒车的要求。 ●通过适当维护保持路面状况良好。 ●在指定位置安装减速器，特别是学校、医院、市场和其他繁忙场所附近。 ●设置人行横道。 车辆 ●选购和部署车辆时，应当考虑车辆选择标准，如良好的驾驶员操作方式/视 野。 ●车辆保持良好状态，特别注意轮胎、制动器、喇叭和车灯。 ●提供倒车辅助装置，如倒车喇叭和后视镜。 规章 ●根据法规要求为车辆设置限速。 ●通过适当停车来控制倒车。 ●司机应取得适当的驾驶执照。 ●装载重物时，驾驶员处于安全位置。 ●开车时禁止使用手机。 ●司机和乘客必须使用安全带。 ●建立用于记录和调查事故的事故报告系统，以预防事故发生。 人 ●通过定期的驾驶能力和健康测试，雇佣和监控合格的驾驶员。 ●要求司机必须保持限速。 ●行人必须知晓并使用指定的人行道。 此外，定期保养车辆和确保司机身体健康，对预防道路交通事故是必不可少 的。 3.7 人体工效学危害 在突发事件和应急响应期间开展的活动，会造成或加剧一些人体工效学方面 的危害。这些危害可能会导致伤痛和残疾，妨碍响应的有效开展。本文讨论了一 些人体工效学方面的危害，以及降低风险的措施。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 45 / 124 人工搬运：在地震、火灾、飓风和海啸等灾害中，救援和响应行动涉及到在 被破坏的建筑物中搜寻伤者和死者。必须移动重物和障碍物，并将尸体搬出并运 送至医疗机构。这些活动使工人有背部受伤的危险。应尽量减少手动移动重物。 强迫姿势：在几乎所有突发事件中，尤其是在地震和建筑物倒塌中，弯腰和 肢体扭曲是现场响应者背部和其他肌肉骨骼损伤的重要危险因素。同样，在疫情 应对期间，在社区和医疗机构内处置尸体和患者，经常弯腰和跪在地垫上给患者 用药、喂食和打扫卫生，使卫生工作者处于异常的身体紧张状态。强迫姿势会导 致急性背部受伤，并会显著降低工作能力和工作效率。 预防和控制突发事件和突发事件中人体工程学危害的措施可能包括： ●使用背包替代手提包：对于长途和复杂地形上的急救，以及其他应急物资 的运输，使用背包可能有助于减少人体工效学压力。 ●尽可能将患者安置在病床上：“霍乱病床”，也称为“霍乱摇床”，是一 个中间有洞的木托盘。 它被设计成适当的高度，以便医护人员不必弯腰提供护理。 防水板放置在托盘上，而孔则允许将容器置于凳子上、直接放置在床下方。 粪便 等排泄物和呕吐物被收集到水桶中。这样的床比医护人员弯腰治疗躺在地垫上的 患者更可取。 ●提供足够大的工作空间：高风险区和低风险区之间的员工更衣室应足够大， 并配备足够的设备，以允许多人同时消毒和更衣(若员工人数较多，则应可容纳 4-6人)。 ●床距：床与床之间布置足够的空间很重要。在不可分割的病房中，床之间 应有足够的空间（2米或6.5英尺），以便工作者不受妨碍地工作。 ●使用机械辅助设备（如担架或轮椅进行提升和运输）：在突发事件和应急 响应期间，尤其是在最初阶段，通常没有用于移动物品的提升设备或装置。但是， 应努力避免用手提升和移动患者或暴露者。所有不能行走的患者或暴露者，包括 儿童，应使用担架转运，如果没有担架，则应使用床单转运。转运人员时，应至 少有两名响应人员。 ●安全的手动操作：在没有担架的情况下移动人体，至少要有四个人，如果 有可能，应该有六个人。在运送患者的车辆中，至少保持一个担架清洁和随时可 用，以及一个担架可供检伤分类/移动人员使用，这一点很重要。 ●台阶和/或坡道的使用：台阶或坡道可安装在救护车或运输车辆的后部，供 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 46 / 124 无需协助即可移动的患者使用，并便于运输材料。 ●提前规划任务：应仔细规划任务以避免紧张。 减少人体工效学压力，以及 应对所需的任务和资源的提前干预计划尤为重要。 例如，由于感觉输入的改变、 灵活性的降低以及对更容易疲劳，佩戴全套PPE执行任务可能是困难的。 3.8 暴力 紧急情况下可能会发生暴力事件。高传染性疾病、化学品和辐射泄漏导致的 高死亡率，加之其发病和症状的不可测这一特性，可能会引起恐慌，进而导致暴 力事件。传染病情形下，对致病因子的存在可能会有质疑，进而促使一些人怀疑 医护人员的意图。不信认可能转化为敌意和暴力，可以针对医护人员及其他直接 与患者及其家人打交道的人。从事安葬的工作者也面临风险。同样，在自然灾害 期间，由于人员伤亡、丧失生计以及儿童和老人遭受痛苦所导致的社区情绪，可 能以针对应急工作者的暴力行为的方式表现出来。 针对应急工作者的暴力，可以是肢体也可以是语言凌辱的形式，可以发生在 工作场所内部或之外。肢体暴力（包括性侵、死亡）可能导致心理和/或身体伤害。 心理暴力包括羞辱和歧视，可以采取辱骂、欺凌和威胁的形式。性骚扰也可能以 身体和心理两种形式出现。 下列情况下可能会遇到导致暴力的社区敌意： ●出于安全和感染控制的原因，感染控制专家打破了传统习俗（照顾生病的 家庭成员，下葬等）； ●社区误解或质疑疾病的存在，医护人员被视为是在感染他们而不是帮助他 们。 例如，在应对EVD疫情期间，在几内亚的一个乡村，一个由8名医护人员、 记者和政界人士组成的小组，在一次旨在向社区普及埃博拉知识的外联访问中被 杀。 疫情爆发和应急响应情况下预防暴力的策略 以下策略有助于动员和提高家庭、社区对疫情和应急干预的认识，减少敌意 和潜在暴力： ●通过提供适合当地文化的教育活动，可以维持与家庭和社区的良好沟通。 这种运动可以从评估影响疾病反应的社会和文化问题开始，并且可以由当地人提 供。然而，必须考虑到针对通信者的凌辱和安全问题。让社区领导参与是很重要 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 47 / 124 的，因为他们可以通过减少有害谣言和鼓励家庭采取安全措施来安抚社区。 ●让社区有机会表达他们的关切并提供反馈，有利于确保应急响应措施被接 受。接受社区参与的方法，应该根据可用资源来决定。 ●与患者或受害者家属建立良好的关系取决于沟通。家属们重视对这个人或 死者所发生的事情以及原因作出清晰易懂的解释。这有助于防止误解和敌意。 ●为了在不妨碍安全的前提下尊重传统习俗，应对小组必须对影响疫情爆发 或流行的文化传统有一个良好的理解。应鼓励传统习俗和做法——只要这些习俗 和做法能由受过培训的工作者或与他们一起安全地实施。例如，安葬队必须以庄 严和尊重的方式对待遗体。 ●家庭依传统照料患者，且需要与患者保持持续沟通。家庭成员如果接触患 者则应佩戴PPE。 保护应急工作者免遭暴力侵害 ●监测和评估社区的接受程度或敌意程度，对于确保社区工作者不会处于不 安全状况至关重要。 ●工作者应保持团队合作，未经同意不得进入房屋。 ●驾驶员应始终留在附近，并监控工作者的活动，以确保在需要快速撤离时 能够方便地转移。 ●协议可以帮助员工对自己的工作感到自信和安全。随着有关疾病传播的理 念和行为的变化，应定期评估社区接受程度。 ●必须与部署到农村地区的卫生保健小组保持可靠的通信（通过无线电或其 他方式）。 ●有专人留在车内，监控团队活动，并向无线电操作人员汇报所有事件。 ●团队应当避免穿着全套PPE进入村庄。穿着常服，有助于流程更加人性化， 便于村民接受。在向社区清楚、透明地解释流程后，可以戴上全套防护装备。 人身安全与安保措施 参与疫情爆发和应急响应的工作者需要意识到犯罪和暴力事件高发的可能性。 强烈建议进行部署前安全培训。 3.9 疲劳 与典型的每周工作40小时相比，应急响应工作者通常工作时间更长，班次更 多。 延长工作时间可能会增加工伤和事故的风险，并可能导致健康状况不佳。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 48 / 124 有证据表明，每天工作超过12小时与受伤风险增加37%有关[33]。繁重的工作量、 不利的环境条件(例如不完善或受损的基础设施、有害物质和碎片、清贫的生活条 件)、通勤时间长，以及对工作者个人的要求，都可能加重繁重工作带来的疲劳和 压力。 为了应对这些挑战，应急响应组织需要制定自己的疲劳管理程序，以适应特 定的事件。组织需要评估他们在响应过程中预期进行的活动类型，评估可能执行 这些活动的条件，确定响应地点通常存在的可能导致疲劳的风险因素，制定针对 这些风险因素的控制措施，并制定评估时间表，以便评估控制措施的有效性。 疲劳风险因素 ●许多因素可能导致疲劳风险增加，降低警觉性和作业能力，以及增加工作 场所错误操作、危险暴露和伤害的风险。制定管理工人疲劳的策略和程序时应考 虑的风险因素包括： ●工作时间长； ●睡眠不足或碎片化（连续睡眠少于7～8小时）； ●倒班/轮班/夜班； ●白天睡觉； ●睡眠不足无法弥补； ●休息时间匮乏或受限； ●身心要求高的工作； ●暴露于高温和其他极端环境； ●暴露于生物、化学和物理危害因素（特别是特征不明显时）； ●工作要求使用PPE； ●限制使用娱乐/健身设备； ●暴露于心理压力因素（如与患者或死者密切接触）； ●不熟悉的工作环境和/或工作任务/操作； ●临时或集体生活条件（可能造成心理压力，导致睡眠不足或碎片化）； ●获得营养膳食的机会有限； ●到达工作现场的通勤时间。 疲劳风险评估应考虑以下因素： ●组织中不同作业的工作时间、班次、轮班和休息时间； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 49 / 124 ●应急人员可能遇到的各种情况（例如正常活动中断的程度，基础设施状况， 人口流离失所，紧张局势，工作场所安全）； ●在工作期间为工作者提供的住宿的性质（例如酒店/汽车旅馆，拖车，帐篷； 饮食服务或快餐；卫生设施；休闲的机会）； ●在行动中执行的各种类型的工作，考虑到未来行动中执行任务可能发生的 变化； ●管理及行政支持职能及服务(例如合同、财务支持、文件支持)； ●工作者经历过及可能在今后事件中经历的压力情况类型（例如接触尸体或 严重病患、严重破坏、无家可归的受害者、孤儿）。 预防疲劳的策略 NIOSH在美国建议采取以下战略措施，以防止在响应情况下出现疲劳[34]： ●定期休息：每天至少安排连续10小时的受保护休息时间，以获得7～8小时 的睡眠。休息和充分的日常恢复睡眠是防止持续作业中过度疲劳的最佳保护措施。 只安排较短的下班时间（如4～5小时）可加剧长工作时间的疲劳。 ●工间休息：在高强度工作中，频繁的短暂休息（例如每1～2小时一次）比 几次较长的休息能更有效地抵抗疲劳。用餐时安排更长的休息时间。 ●轮班时长：通常可以接受每周5×8小时或4×10小时。根据不同的工作量， 每天12小时工作制也可能是允许的（必须穿插更频繁的工间休息）。晚间和夜班， 较短的班次（如8小时）要比更长的班次更容易承受。由于夜间困倦和白天睡眠 不足，夜班工作更容易使人疲劳。 ●工作量：结核班次长度审视对工作的要求。12小时班次更适合较轻松的任 务（如办公室）。较短的班次时长有助于消除注意力高度集中或情绪紧张压抑的 工作、体力劳动、极端环境或暴露于其他健康或安全危险中造成的疲劳。 ●休息日：连续5个8小时或4个10小时班次后应计划安排1～2个休息日。连 续3个12小时班次后应考虑安排2个休息日。 疲劳控制措施 在应急响应期间预防和减少工作者疲劳的具体措施包括： ●教育：提供有关疲劳的体征、症状和健康影响的信息，以及部署准备阶段 的培训。该程序应涉及用于向工作者教育/告知的程序。 ●提前规划：规划应包含下列要素： 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 50 / 124 ○事件动员的应急计划，确定谁做什么、何时做（例如，高级事件处置团队 的角色）； ○对管理疲劳至关重要的支持服务； ○将经过专门培训和全面医学检查的人员分配至相应岗位的政策，以及在必 要时提供PPE的政策； ○考虑额外的医疗需求（例如特殊的疫苗接种），以及检查工作者进出的一 般程序，以便在整个事件过程中跟踪工作者的位置； ○营地/现场安全，以及确保工作者提前做好计划（例如，准备好行装，安排 好儿童照料、宠物照料和账单支付的替代方案）； ●工作时间和休息时间：在作业的每个阶段制定有关部署持续时间、工作时 间、工作班次和休息时间的政策。包括提前规定联系工作数天后的休息时间（例 如，24小时内最少休息10小时，并在连续工作时尽可能多安排休息时间；连续工 作14天应安排休息48小时）。尽快调整到有规律的工作时间，以便工作者自己安 排休息时间。描述如何管理和执行本政策（例如，制定规定，以确保有足够的经 过适当培训和经医学检查有资格的人员可供部署）。 ●运输：了解所使用的运输方式的范围。包括各种选项，以反映工人将面临 的各种情况。认识到长时间工作可能导致工作者和驾驶员受损伤。 ●生活条件：描述住宿选择的范围（例如商业酒店/汽车旅馆，拖车，帐篷 区），以及提供膳食，隐私，安静的睡眠区域，卫生设施，安全保障，洗衣设施， 病媒控制和疟疾预防的选项。 ●疗养规定：建立锻炼和娱乐的机会，认识到这些机会有助于维持工作者的 能力。 ●医疗服务：描述可提供的医疗、心理健康和压力管理服务。 3.10 疫情爆发与突发事件时的心理社会应激 应对疫情爆发和突发事件的工作者可能会面对诸多应激源。应激是指心理反 应，通常包括忧虑、焦虑、感觉不堪重负，或抑郁感/不适感。这些感觉通常伴随 着身体疼痛等躯体症状。并非所有应激都有问题；某种程度的应激有助于人们在 充满挑战的情况下保持安全并且能够很好地工作。然而，这种应激反应往往变得 过大，尤其是在诸如突发事件等长期逆境情况下，并且可能导致一种长期的应激 状态，在这种状态下，人感到不堪重负或无法应对。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 51 / 124 在面对困难时，压力过大以及出现与之相关的问题是很正常的，这并不意味 着人们软弱、无能或者不称职。可能的情形是，他们如此投入的工作以至于没有 时间照顾自己。生活中的其他问题，如家庭问题、缺乏社会支持、健康问题或其 他不确定性，会使工作压力更难处理。 如果个人和团队或组织实施了诸多策略，其中一些策略易于实施，则可以将 工作压力维持在可控水平。这对于个体以及他们想要帮助的人都有好处，因为自 我照顾有助于更有效地履行自己的角色，而不太可能出现承受过大的压力以至于 需要请假。本节讲阐述这些策略。 在部署期间可能有许多应激源，与突发事件的类型、可用的资源或可能存在 的不确定性/条件受限相关。应激源可能包括： ●担心自己或家人和同事的健康，可能罹患致命疾病，或者受到化学品或辐 射的影响（特别是在死亡率高的地区，或存在迅速恶化或症状明显的疾病如病毒 性出血热的地区）； ●与工作有关的压力，如有限的时间，长时间按照严格的OSH程序执行任务， 或者与不同文化和学科背景的大团队沟通； ●体力劳动，沉重的装备（如PPE），常伴有热应激、脱水和疲劳； ●缺乏基本的个人安全防护装备； ●对高风险地区工作者的污名化，可能会导致家庭或社区回避，甚至面临暴 力； ●缺乏社会支持或社交网络； ●既定的安全规程，与照顾或支持个体的愿望之间的紧张关系（例如，确保 安全的下葬方法，隔离和实施不接触策略）； ●对可能有关联的文化信仰系统理解有限（例如，不理解或不接受某些人为 什么要遵循可能增加感染风险的葬俗）； ●难以维持自我保健活动，如运动、良好的饮食习惯、充足的休息； ●履行职责和帮助他人的愿望，尽管已经数月未领取报酬。 部署后可能导致应激的因素包括： ●与响应过程中看到的不良事件和人间惨剧有关的记忆； ●担心长期接触化学品、传染病或辐射可能带来的影响； ●部署后难以重新适应生活。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 52 / 124 在紧急情况下，人对压力所作出的反应有不同方式。可能会出现行为变化， 如活动水平或工作表现的变化，增加某些作为应对方式的物质的使用，或放松、 保持平静、易怒的能力变化。还可伴有一系列身体反应（可能有其他原因），例 如胃病、体重变化、疲劳、头痛，或其他原因不明的疼痛。心理变化可能包括紧 张性增强、情绪低落、没有积极性、焦虑或抑郁，以及相关的行为变化，如经常 哭闹、孤立或难以接受帮助。 多数情况下，通过良好的组织和管理支持，可以控制与工作相关的应激。然 而，在某些情况下，人们可能出现精神健康状况的症状，这可能与高压环境有关。 如果卫生工作者要求进行评估，或其功能和承担若干任务的能力受到的损害，则 应当考虑对此类问题进行评估。 创伤后应激障碍：在人道主义紧急情况下，人们在经历极端应激后，通常会 产生广泛的心理反应或症状，对大多数人来说，这些症状是暂时的。 当一组特定的、特征性的症状（再体验、回避、警惕性增高）在潜在的创伤 事件后持续一个月以上，此人可能发展为创伤后应激障碍（PTSD）。 PTSD患者的症状通常与中度抑郁症患者非常相似(如睡眠质量差、情绪低 落)。可能需要有资格的卫生工作者进行评估，以确定PTSD症状，包括再体验、 回避和难以入睡或难以保持睡眠。 职业倦怠：职业倦怠通常用来指由于长期的压力和超负荷工作而导致的长期 的疲惫和对工作兴趣的下降。特别是在那些积极主动、敬业并参与其所从事的工 作的个体中，尤其如此。对实现高目标和期望的渴望，可能与身体、情绪和精神 疲惫形成对比，导致无法实现目标。 某些人——例如有精神健康病史者、存在持续的个人严重应激源的人（如本 人疾病、家人疾病、家庭暴力史、贫困或失业风险），或社会网络支持不足者， 或暴露于极端压力或潜在创伤性事件者——在部署后出现压力水平削弱或精神健 康问题的风险会增加。 预防和管理工作相关的应激 部署救援人员的组织应制定以下领域的政策： ●部署前和部署后，对工作者应对预期应激源的能力进行筛查和评估； ●适当的作业前准备和应激管理培训； ●定期监测现场工作者的反应； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 53 / 124 ●持续培训和支持，协助工作者处理日常的应激源； ●在发生严重或创伤性事件或异常/意外的严重应激源后，对工作者和团队提 供具体和文化上适当的支持； ●在任务或合同结束时，为工作者提供切实可行的、情感和文化上适当的支 持； ●对在部署期间受到压力、创伤或疾病影响的工作者的持续支持。 预防工作场所压力的措施 基于团队的实践 ●良好的沟通：缓解压力最好的方法之一就是提供尽可能多的高质量的信息， 使工作者感受到知情权，并给他们可控的感觉。 ●与工作者共享最新信息：信息共享对缓解压力非常重要。应建立一种机制， 使有关风险、传播方式和症状的信息清晰流动，并为工作者提供保护措施。信息 还应与社区共享，并应定期更新。特别重要的是，如果他们的一个同事生病了， 应及时通知医护人员。单位主管应尽快召集员工，给员工提问、表达关心和提出 建议的机会。医护人员不应当通过谣传听说某位同事病倒，也不应该怀疑这是怎 么回事。 ●表达关切和质疑的场合：工作者有一个可以提问和表达对自身和同事健康 风险关切的场合，这一点尤为重要。应注意确保人们健康状况的保密性。例如， 管理者可以向团队传达同事不舒服但不处于危急状态，而不泄露健康问题的细节。 ●多学科团队会议：至少每周一次，直接护理人员、供应主管、清洁工和其 他参与响应的多学科团队应当会面以交流问题。可以是每个小组主管的会议。会 议的目的是明确关注点，包括员工福利，并共同制定解决问题的策略。 ●检查表和伙伴模式：医护人员必须评估和了解自己的优势、劣势和局限， 包括识别压力和倦怠的迹象。应说明协助个人应付机制的一般措施。对于医护人 员来说，有机会以保密方式注册他们的问题和投诉也很重要，但这种方式可以最 大限度地提高这些问题确实得到解决的可能性。伙伴模式是一种有用的方式，可 以提供心理支持，是一种监测压力和倦怠的好方法。 ●心理急救：在《心理急救（PFA）现场工作者指南》 [35]中，WHO描述了 这种方法的关键特征，有助于其在现场情况中的应用。PFA： ○在不侵扰的前提下，提供实际的关怀和支持； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 54 / 124 ○评估需求和关注； ○协助人们满足基本需求（例如食物，水和信息）； ○聆听倾诉，但不强迫交谈； ○安慰受助者，帮助他们感到平静； ○帮助受助者获得信息，服务和社会支持； ○保护受助者免受进一步的伤害。 ●减少污名化行动：由于公众意识到医护人员通过职业接触感染EVD等疾病 的风险更高，医护人员常常受到污名化和社会孤立。甚至连医护人员的家庭也被 朋友和熟人污名化和回避。因此，全面的公共教育运动应该解决由于公众对传染 或感染的潜在过度恐惧、以及其他普遍持有的信念而造成的对医护人员的社会污 名化和排斥。重要的是，行动应鼓励公众重视在前线抗击流行病的男女们的作用， 使工作者为他们的所作所为感到自豪。这些行动可以作为疫情爆发社会动员计划 的一部分来组织。 ●运用幽默和参与性的技巧：这些可以促进对话、创新解决方案和态度的积 极变化。参与式剧场等方法通过在参与者之间建立一种纽带感，已被用于医护人 员以解决工作场所欺凌问题。创造性的技巧也可以通过促进幽默来驱散恐惧。 组织文化 ●应当践行团队建设技术，包括促进沟通和冲突管理。组织文化应该对其他 人敏感，因为当地工作者的家庭可能会受到爆发的影响。 ●精神卫生专业人员应与所有在事件发生后1～3个月内幸存下来的国内和国 际工作者(包括翻译、司机、志愿者等)联系。专业人士应评估幸存者的功能和感 受，评估他们的精神健康状况(如抑郁症、PTSD、药物使用)，并将那些存在长 期没有痊愈的严重问题的患者转临床治疗。 个人实践 ●规范的休息时间：管理者需要熟悉并向员工传达健康和安全的做法和程序， 包括在工作日需要充足的休整和工间休息。 ●基本需求：管理者需要确保有机会促进身体健康，包括锻炼，并且工作者 可以保持健康的饮食习惯。 ●心理支持：应该提供一个场所，让医护人员能够秘密地分担恐惧和担忧。 在压力特别大的时候，比如团队成员去世的时候，心理学家应该能够去现场。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 55 / 124 ●组织和现场管理者的角色示范：管理人员应成为其监督的工作者的角色示 范，并应以展示如何减轻压力的方式（例如，适当休息、减压练习和放松练习） 进行自我管理。最重要的是，现场管理者必须确保满足工作者的基本需求，提供 防护设备，重视工作者，并感谢工作者的努力。 应急响应不同阶段的应急管理措施 在应急响应情况下应激管理指南中，美国卫生和公众服务部建议应急管理人 员在应急响应的不同阶段实施以下措施[36]： 危机前的压力最小化 ●确保工作者熟悉整个应急响应系统以及关键团队（包括他们自己）在其中 的角色和职责。 ●明确权利和责任的范围，通过消除谁向谁汇报的困惑，使压力最小化。 ●定期提供压力管理技巧培训。 ●制定机构疏散方案并定期演练。 ●提供持续培训，确保工作者完全熟悉安全程序和政策。 ●制定指导方针，帮助工作者为部署做好准备。 ●为每位工作者保留一份最新的家庭成员联系方式清单。 减少危机期间的压力 ●明确各个角色定义，并在情况有变时重新评估。 ●每次换班时，提供工作环境、安全程序和所需安全设备的现状简报。 ●将没有经验的工作者与有经验的老手搭配。伙伴模式是提供支持、监控压 力和加强安全程序的有效方法。确保外联人员双人进入社区。 ●该模式还有助于为初始阶段承受压力的人提供PFA。 ●将工作者从高压力岗位轮换到低压力岗位。 ●发起、鼓励和监控工间休息，尤其是涉及伤亡事件的情况下。在长时间的 事件中，采取更长的休息和休假，并尽快缩短周末工作时间。 ●建立使工作者与现场和公众视线隔离的休息区。在较长时间的行动中，建 立一个能让响应人员淋浴、吃饭、换衣服和睡觉的区域。 ●为直接受事件影响的工作者实施灵活的日程安排。这有助于工作者平衡家 庭和工作职责。 ●监控和管理如下工作环境、交通运输和生活条件： 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 56 / 124 ○必要时提供PPE，以防护噪声、粉尘和烟雾。 ○通过使用防护服、适当补水和经常休息来缓解极端温度的影响。 ○确保照明充足、可调节且工作状态良好。 ○在存在危险区域的设施或场所为工作者提供安全保障。 ○为处于危险环境的工作者提供移动电话。确保工作者知道出现问题时该打 给谁。 危机后的压力最小化 ●允许经历个人创伤或损失的工作者休假。安排这些人重返组织时，应首先 分配给他们一些要求不高的工作。 ●制定方案，为工人提供免去苛刻的附加条件咨询，以便他们能够处理自己 经历中的情感方面的问题。 ●组织离职面谈，帮助员工正确看待他们的经历，审视他们所看到的、做过 的、想过的和感觉到的。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 57 / 124 第四章 传染病爆发中的职业安全与健康：临床和社区环境 许多热带国家的气候有利于各种疾病爆发的发展和传播，特别是那些无法在 寒冬季节存活且在雨季繁殖的病媒生物。宿主、微生物和环境之间的相互作用决 定了传染病的发展和传播，随着旅行、全球化和人口增长，特别是在缺乏公共卫 生准备和应对能力的国家，传染病的发展和传播变得更重、更快。这些感染可能 传播并导致可能成为国际关注的突发公共卫生事件。根据《国际卫生条例》，下 列事件可能构成国际关注的突发公共卫生事件： ●下列疾病病例不寻常或不可预料，且可能造成严重的公共卫生影响，应当 通报：天花，脊灰野病毒感染，人类流感新亚型，SARS。 ●涉及下列疾病的事件应始终应用该规则，因为已经证明它们能够造成严重 的公共卫生影响并迅速在国际上传播：霍乱、肺鼠疫、黄热病、病毒性出血热 （埃博拉、拉沙热、马尔堡病毒）、西尼罗热、其他特定国家或地区关注的疾病 （如登革热、裂谷热、脑膜炎球菌病）。 ●任何可能引发国际公共卫生关注的事件，包括不明原因或来源的事件，以 及涉及上述内容以外的事件或疾病。这样的事例包括自然发生或以其他方式发生 的、已经污染或可能污染人群和/或大面积区域的有毒、传染性或其他危险物质扩 散的危险事件。 大量卫生工作者积极参与处置此类疫情(专栏4)。包括来自紧急医疗队的急救 人员，应急部门和专业治疗机构、以及直接参与受影响社区的救援、运输、急救、 紧急护理和治疗的实验室的医护人员。 在应对传染病爆发时，预防和控制医护人员的职业性感染，需要OSH和感染 控制专家、机构管理层和一线医护人员代表以及其他人员密切配合，评估风险， 收集已发生的潜在暴露的数据，并提出预防建议。当几个雇主或组织使用相同的 设施、工作场所或程序时，他们需要密切合作，以确保所有工人（包括外籍工人 和国内工人、正规工人和分包商）都受到平等和有效的保护，免遭感染、职业伤 病。 专栏4西非埃博拉疫情爆发期间，医护人员及其他工作者的OSH风险和影响 史无前例的EVD爆发给医护人员和其他行业的工作者带来了严重的健康风险。根 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 58 / 124 据WHO在2014年1月1日至2015年3月31日期间的初步报告[6]，卫生工作者中有 815例确诊和疑似病例被登记在VHF数据库中，其中塞拉利昂328例、利比里亚 288例、几内亚199例。卫生工作者占同时期所有确诊和疑似病例（所有年龄 组）的3.9%（815/20955）.除了最初几个月报告病例很少外，卫生工作者感染 占所有月度病例数的比例在2014年7月到达顶峰，之后有所下降。从2017年7月 的12%降至2015年2月的1%，体现出预防干预措施的有效性。 在EVD广泛和剧烈传播的国家，职业性暴露和社区或居住性暴露很难区分，特别 是在与家庭成员和社区保持日常接触的本地工作者中。除医护人员外，其他存在 风险的工作者还包括清洁工、实验室工作者、传统治疗师、传统助产士、殡葬工 作者、家庭护工和宗教领袖。存在疑似患者暴露风险的工作者包括接触者追踪人 员（包括公共卫生和社区工作者）、出入境口岸查验人员以及旅游从业者（即航 空、地面运输和传播）。在受埃博拉影响的社区，出租车司机、安全部门（保 安，警察和士兵）、性工作者和处理废物的工人也面临风险。 4.1 埃博拉治疗和护理机构的职业安全与健康 为确保患者和医护人员安全，接收患者的机构必须建立以下OSH制度： ●机构需要设计在绿区（污染最轻区域）和红区（污染最重区域）之间进行 最佳隔离，且单向流动（始终由绿区到红区，绝不逆行）。在某些情况下（例如 偏远农村地区或较大的埃博拉治疗机构）也可能存在一个或多个“风险最低”区 域，例如办公室或工作者生活区，这里可能穿着常服和鞋子。这些区域必须完全 用栅栏隔开，与绿区和红区隔离。 ●患者、工作者和来访者应该有单独的入口。这一区域应允许步行或乘救护 车到达的患者直接进入，消除与工作者或其他患者区域的任何相互影响。救护车 到达区域附近必须有足够的空间进行救护车消毒。 ●工作者入口必须允许在到达时进行筛查，并应提供直接进入更衣室的通道。 工作者在进入埃博拉治疗中心前必须换上工作服和靴子。这个区域应该有安全的 存放工作者衣物和财物的地方。 ●分诊区应足够大，允许患者之间有一米的距离，至少有一个洗手台，提供 防晒和防雨，并有专用厕所。此外，应为患者陪同人员提供一个户外等候区，并 应包括上述因素。 ●使用PPE在控制层次结构中最明显。然而，这种控制是最薄弱的，不能依 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 59 / 124 赖它作为一种独立的一级预防策略。PPE在未感染者和传染源之间提供物理屏障。 这种保护包括但不限于手套、防护服、口罩、面部和眼部防护以及呼吸防护。 ●PPE使用的有效性和适当性，依赖于使用者对规程的遵守，因此是最容易 被打折扣的控制措施。只注重个人防护用品的供应和使用，而不考虑工程和管理 控制，结果造成对卫生保健环境中所有人（包括工作者）的保护不够理想。 感染预防与控制 在所有医疗机构中，为预防和控制高传染性疾病（如EVD和其他病毒性出血 热），需要在为所有患者提供护理时强化和谨慎应用标准预防措施，无论其出现 的症状和体征如何。这些IPC措施包括[37]： ●手卫生； ●适当使用PPE的风险评估； ●安全注射及预防因针头及其他锐器造成的伤害； ●清洁和消毒患者环境及护理设备； ●洗衣和废物处置； ●呼吸道卫生。 4.2 霍乱治疗机构的职业安全与健康 霍乱治疗机构（CTU）是专门的治疗机构，用来开展霍乱和介水传播疾病病 例的临床处置。CTU医护人员的防护策略与埃博拉治疗机构所用的类似，包括以 下内容： ●分类； ●隔离患者； ●消毒； ●洗手； ●PPE。 CTU包含以下4个部门，负责预防患者与医护人员间的感染[38]： ●筛选和观察； ●住院治疗； ●口服补液治疗的康复室； ●中性区（厨房、材料仓库等）。 表2给出了CTU感染预防和控制的主要卫生规则。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 60 / 124 表2：CTU卫生规则 传播方式 基本规则 其他推荐规则 人 仅限患者+一名家属家属+一名工作者 单向人流（即仅从清洁区到污染区） 每名患者不超过一名护理人 员 水 安全用水（加氯浓度依具体用途确定） 需求量大（每人每天至少10升） 理想情况下每位患者每天50 升 手 安全供水的洗手台 用水和肥皂洗手 -照料患者前后 -如厕后 -做饭或吃饭前 -离开住院病房后 修建和清洁指甲 食物 熟食 不应让医护人员处理水和食物 由CTU而不是家庭来供应食 物 衣物和床品 根据指南，用适当的含氯消毒液清洗衣物和床 品 如果没有氯消毒剂，用肥皂 清洗衣物并在日光下晒干 环境污染 （粪便和废 物） 确保机构有专用厕所 定期用适当的含氯消毒液消毒水桶、污染表面 和厕所 使用医疗废物焚烧炉 厕所应设置在距离水井或地 表水源至少100米外 特制霍乱床（霍乱摇床） 尸体 单独的停尸房 尸体消毒 确定安全的下葬方式 尽快处理尸体 4.3 处理感染性病原体实验室的职业安全与健康管理 WHO实验室生物安全手册[39]涵盖了不同类型实验室不同级别的生物安全要 求。此外，WHO在关于处理高传染性样本（例如禽流感）的指南中建议，应采 取以下措施保护实验室工作者的健康和安全[40]： ●制定综合安全政策（包括安全手册）和支持执行该政策的方案，这项职责 通常由研究所或实验室的主任或负责人承担。实验室安全也是所有管理人员和实 验室工作者的责任，每一位工作者都要对自己和同事的安全负责。 ●良好的微生物技术是实验室安全的基础。使用安全设备，结合良好的程序 和做法，将有助于减少处理生物安全危害所涉及的风险。 ●应始终遵循标准预防措施；从患者处获取样本时，无论何种情况下都应使 用防护措施（防护服、手套）。除了这些标准预防措施外，还应保护眼睛。 ●基本控制——生物安全2级（BSL2）——操作和程序应是处理样本的最低 要求。 ●应遵循良好的实验室规范。禁止在实验室工作区域内进食、饮酒、吸烟、 使用化妆品和接触隐形眼镜。 ●在实验室中处理和加工样品，以及进行诊断测试时，应穿戴PPE（防护服、 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 61 / 124 手套、护目镜）。 ●所有的技术程序都应尽量减少气溶胶和飞沫的形成。 ●所有可能会导致感染性材料飞溅、产生飞沫或气溶胶的操作（如离心、研 磨、混合、剧烈震荡或摇匀、超声波消解，打开内部压力可能与外部压力不同的 感染性材料容器），都应使用生物安全柜或其他物理防护装置。 ●应限制皮下注射和注射器的使用。不得将其作为移液装置的替代品，也不 得用于肠外注射或吸入实验动物体液以外的任何其他用途。严禁用嘴吸移液管。 ●应有适当且方便的生物危害容器来处理受污染的材料。 ●在任何潜在危险物质泄漏后，以及在工作日结束时，必须对工作表面进行 消毒。一般来说，新制备的漂白剂溶液适用于处理有生物危害的溢出物。 ●必须经常洗手，特别是在处理感染性物质和动物之后、离开实验室工作区 域之前、以及进食之前。 ●离开实验室前必须脱下PPE。 4.4 在卫生保健环境中暴露于血液、体液和其他污染物的管理 未采取防护措施的情况下，将粘膜和皮肤暴露于疑似或确诊患者的体液、受 污染的物体和死者的尸体应视为高风险的暴露事件。在大多数情况下，这类事件 包括：在脱下PPE时接触未受保护的皮肤，护理患者时受锐器伤，以及暴露于受 感染的人或受污染的物体。应报告和调查与血液、呕吐物和其他身体分泌物等感 染性物质有关的暴露事件[41]。 如果此类事件涉及诸如埃博拉病毒、马尔堡病毒和其他病毒性出血热等高传 染性疾病的病例，医护人员和其他工作者应采取以下行动： ●立即和安全地停止任何当前任务，并离开照料患者和工作的场所。 ●按照适当程序小心脱下PPE。脱下PPE期间的暴露可能是危险的，并可能 导致病毒性出血热（如EVD）的职业性传播。 ●脱下PPE后，立即用肥皂和自来水或生理盐水清洗受影响的皮肤表面或受 伤部位，至少15分钟。相应的，用大量的水或洗眼液冲洗粘膜(如结膜)。不要使 用含氯消毒液或其他消毒剂。 ●立即向当地协调员报告事件。这对时间很敏感，应在医护人员离开患者护 理机构时立即执行。 ●应对暴露者进行医学评估，同时考虑其他潜在的血源性暴露（如HIV、乙 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 62 / 124 肝和丙肝），并应接受后续护理，包括事件发生后连续21天（即EVD最长潜伏期） 每天两次监测体温。对于暴露后21天内发热者，立即咨询传染病专家。 ●疑似被感染的工作者应被隔离并且得到照料，直至确诊为阴性。 ●必须对家人、朋友、同事和其他可能通过与感染的医护人员密切接触而暴 露于EVD等病毒性出血热的人进行接触者追踪和随访。 ●按照ILO的职业病目录，与感染源存在职业接触的人感染埃博拉病毒、马 尔堡病毒等病毒性出血热，应被视为职业病。 暴露后预防 目前WHO基于科学证据的暴露后预防（PEP）建议包括： ●应尽早（最好在72小时内）向所有有可能感染HIV的人提供PEP。 ●适应性评估应尽可能基于HIV的来源状况，并考虑当地的流行病学的背景 值和流行状况。 ●可能需要PEP的暴露包括：消化道外或粘膜暴露（性接触，以及溅到眼、 鼻或口腔）。以下体液暴露会带来HIV感染的风险：血液、带血的唾液、母乳、 生殖器分泌物、脑脊液、羊水、直肠液、腹腔液、滑膜液、心包液或胸膜液。 ●无需PEP的暴露包括：暴露者已经是HIV阳性，确认暴露源为HIV阴性， 以及暴露于不构成重大风险的体液（如眼泪、无血的唾液、尿液、汗液）。 ●虽然理想情况下应在72小时内提供PEP，但在此期间人们可能无法获得相 关服务。PEP提供者应考虑向暴露超72小时者提供其他必要的干预措施和转诊服 务。 ●在一些HIV感染率背景值高或已知HIV感染高风险的环境，所有暴露都应 考虑采取PEP而无需进行风险评估。 ●如上所述的体液具有很高的HIV感染风险，但这个清单并非详尽无遗，所 有病例都应进行临床评估，并由业务人员做出关于暴露是否构成重大风险的决定。 评估 需要对暴露者、暴露过程中的条件和暴露源的状态进行如下评估： ●暴露的临床评估； ●HIV PEP适应性评估； ●尽可能对暴露者和暴露源进行艾滋病毒检测； ●皮肤破损或受伤时提供急救。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 63 / 124 咨询和支持 这些都是为了让患者做好调查、治疗和随访的准备，包括药物治疗的潜在副 作用。需要涵盖以下要素： ●HIV风险； ●HIV PEP的风险和益处； ●副作用； ●如需PEP，则加强依从性咨询； ●性侵案件的具体支持。 处方 包括选择和开始使用适当的药物治疗，并必须包括： ●暴露后尽早启动PEP； ●建议服用28天适合的抗逆转录病毒药物处方； ●药品信息； ●评估潜在的并发症和可能的药物相互作用。 随访 随访是PEP的重要组成部分，包括： ●暴露后3个月的HIV检测； ●如果可能的话，联系HIV治疗； ●提供适当的预防干预措施。 实现这些目标的步骤包括： ●立即提供急救。 ●评估潜在的HIV或其他血源性感染的暴露情况。 ●检测暴露源的HIV、乙肝、丙肝感染情况。 ●为暴露的卫生工作者提供检测，并提供咨询和护理转诊。 ●为医护人员和患者保密。 ●确保后续检测和临床评估。 ●必要提供PEP及咨询。 ●分析暴露案例以改进实践。 ●建立索赔程序。 其他可能发生暴露的疾病的处置（如乙肝和丙肝）： 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 64 / 124 ●大多数暴露病例中，HBV和HCV传播风险高于HIV，特别是在医疗环境中。 ●评估既往乙肝疫苗接种情况，如果需要，应根据适龄的国家免疫规划提供 疫苗接种。 ●暴露后段时间使用乙肝免疫球蛋白可提供被动免疫保护，对于未接种乙肝 疫苗或未全程接种乙肝疫苗者，可以考虑作为疫苗接种的补充免疫措施。 ●应根据WHO指南提供HCV筛查。应提供丙肝感染风险的咨询，并应在发 生血清学变化时转诊至专业医疗机构。 4.5 在呼吸道疾病爆发期间保护卫生工作者免受急性呼吸道疾病的职业安全与健 康措施 WHO卫生保健中易发生流行及大流行的急性呼吸道疾病感染预防与控制临 时指南[43]建议采取以下措施保护卫生工作者免受急性呼吸道疾病（ARDs）的侵 害： 其爆发和流行可能构成国际关注的突发公共卫生事件的ARDs可能包括： ●严重急性呼吸系统综合症（SARS）； ●新型流感病毒导致的人类感染； ●可能对公众健康产生巨大影响新型ARD。 严重急性呼吸系统综合症：SARS由SARS冠状病毒（SARS-CoV）引起， 可感染动物和人类。 SARS的人间传播主要通过飞沫或接触发生，尽管在短距离 内可能发生通过各种尺寸的传染性呼吸气溶胶的传播。 新型流感病毒导致的人类感染：甲型禽流感病毒通常感染禽类，但有时也能 感染其他动物和人类，并与人类聚集性病例有关。与人类感染相关性最高的毒株 是H5N1。 可能对公众健康产生巨大影响新型ARD：历史上传染病一直在人群和地区间 传播，很可能会继续确认新发的传染病。许多传染病都有动物宿主，在某些情况 下可以感染人类。 保护医护人员免受ARDS伤害的理由包括： ●在季节性流感或流感大流行爆发期间，卫生工作者可以通过在社区或医疗 机构暴露而感染流感（不一定是由于接触患者）。一旦感染，他们就可以成为将 病毒传播给其他工作者和患者的毒源，而这些患者发生与ARD相关并发症的风险 更高。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 65 / 124 ●虽然季节性流感疫苗不能预防新型流感病毒，例如禽流感，但它将有助于 防止与季节性人类流感同时感染，从而减少误诊和不必要的缺勤。 ●理论上讲，季节性流感的预防，还将使已免疫的医护人员体内出现人流感 病毒和新型流感病毒重组的可能性降到最低。 ●为有潜在问题的ARD患者提供护理的医护人员可能会接触到这些病原体， 并应根据需要进行监测和支持。 针对卫生机构管理人员的建议 ●尽可能给医护人员接种季节性流感疫苗，并监测疫苗的使用。 ●对于有潜在急性呼吸窘迫综合征（ARDS）并发症（如孕妇、免疫缺陷者、 心肺或呼吸系统疾病患者）风险的高危医护人员，应了解医疗风险，并提供不涉 及为ARD患者提供护理的工作任务。 对医疗机构处置有潜在问题的ARDs患者的特别建议包括： ●对那些护理过ARDs患者的医护人员，进行接触者追踪、登记并保存。 ●建立医护人员流感样病例监测系统。患有流感样疾病的医护人员应排除在 高危单位之外(例如新生儿重症监护室)。 ●建立医护人员健康状况监测系统，特别是向潜在ARDs患者提供护理的医 护人员，由出现症状的医护人员进行自我报告。 ●如果当地政策建议采取抗病毒药物预防措施，卫生机构管理人员应建立一 个体系，为暴露于潜在ARDs患者的医护人员提供抗病毒预防。必要时，主管部 门应与公共卫生官员联系，根据当地的指南，协助为潜在ARDs患者提供护理的 医护人员获得足够的预防用品。 ●应确保医护人员(特别是那些照顾潜在ARDs患者的工作者)及时获得新开发 的疫苗，以防止潜在的ARDs获得性感染。 ●应制定必要的方法，为保健工作者提供额外的支持（如情感和家庭支持）。 为已知或疑似感染潜在ARDs患者提供护理的医护人员的建议： ●将医护人员组织成照顾指定患者的小组，并定期检查医护人员体温（例如 在每个工作班次之前）；在最后一次可能接触到潜在ARD患者后7～10天内，监 测流感样症状（咳嗽、喉咙痛、呼吸困难）。 ●如果体温超过38℃，或出现流感样症状，应立即限制医护人员与他人的接 触，停止工作，隔离在公共区域之外，并通知感染控制/职业卫生小组（和/或其 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 66 / 124 医护人员），说明他们有症状，并接触过潜在ARD患者。 4.6 社区环境中应对疫情爆发的职业安全与健康 对疫情的应急响应包括由不同组织（本地的和国际的）采取的行动。响应措 施包括受影响威胁的国家政府和地方当局、社会民间、私营机构、非政府组织、 多边组织、国际金融机构以及来自不同国家的机构。相应措施的战略目标是控制 疫情爆发、治疗受感染者、确保基本服务、保持稳定并防止其他国家爆发疫情。 除了EVD和霍乱等专门治疗单位外，这些活动还在不同的护理环境中进行，包括 家庭、医疗机构、空运、海运和公路运输，以及入境口岸。 除卫生机构的医护人 员外，其他类别的工作者也有很高的感染风险。 本节描述了在最典型的社区环境中应对疫情防止职业感染的要求，在这样的 环境中响应活动对应急响应者造成OSH风险和危害。 4.6.1 社区工作（例如社会动员，接触者追踪，个案调查） 社区工作，例如病例检测、接触者追踪和社会动员，与未被发现的病例接触 的风险很高，并且对卫生工作者造成高度的职业健康的感染风险。 因此，进行此 类工作必须始终采取以下保障措施： ●在社交动员活动和访谈期间应避免握手和任何其他社交性接触。 ●提供可用的PPE，如不透水防护服，面罩，护目镜，检查用手套，靴子以 及手卫生产品（最好是酒精材质的手消毒液）。 ●即使看似未患病，响应者和受访者也应保持一米（约3英尺）以上的距离。 ●应避免任何与受访者和环境的身体接触。 ●当采取这些预防措施并访问无症状个体时（如无发热、腹泻、出血或呕 吐），PPE不是必需的。 ●在与疑似病例或可能受污染的环境接触后，以及离开在社区中进行接触者 追踪和病例搜索的访谈地点时，进行手卫生。 4.6.2 救护车，运送患者或尸体的车辆 转运患有高传染性疾病患者的人，存在通过接触患者体液而暴露的风险。那 些运送死于高传染性疾病患者尸体的人也处于危险之中。清洁和消毒车辆也存在 感染风险。 应采取以下控制措施： ●与疑似或确诊病例有直接身体接触的响应人员（例如帮助患者进入救护车， 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 67 / 124 在运输过程中为患者提供护理）应使用适当的PPE。 ●如果患者无呕吐或出血，且无腹泻，PPE应至少包含手套、面罩和防护服。 ●如果患者呕吐、出血或腹泻，或处理尸体，PPE应始终穿着包含戴手套的 连体工作服或全面防护，包括N95口罩，不透水防护服（或防护服外罩防渗围 裙），眼睛防护（护目镜或面罩），以及带鞋套的靴子/不透气的鞋。 ●咳嗽患者应佩戴口罩。 ●尸体装车前，应先将尸体置于双层塑料袋中。用合适的消毒剂（如0.5%含 氯消毒剂）擦拭每个裹尸袋外表面，然后密封并贴上高传染性物质的标签。 ●在帮助呕吐、出血或腹泻的患者，或转运尸体后，必须更换并安全处置 PPE。 ●应根据WHO的指示和示意图佩戴并小心地脱下PPE。脱下PPE时，应注意 避免污染的物品（如手套、防护服）与面部任何部位（如眼、鼻或口）或不完整 的皮肤接触。 ●PPE应置于高传染性物质的废弃物容器或塑料袋中处理。 ●在接触患者的血液和体液、接触受污染的表面/物品/设备以及脱下PPE后， 急救人员应使用酒精材质的手消毒液或肥皂和水进行手卫生。 ●驾驶或乘坐车辆的人员不需要PPE，前提是驾驶员或乘员不会接触任何患 者或陪同患者的任何人，也不会协助装载或处理尸体。 ●救护车和其他用于运送患者的车辆应定期（至少一天一次）用合规的洗涤 剂/消毒剂（如0.5%含氯消毒剂）进行洗消。如果表面被血液或体液污染，应立 即洗消。 ●救护车和其他用于运送患者的车辆，应始终配备手套、面罩和全套PPE、 酒精材质的手消毒液、垃圾袋、尸袋、水箱、湿巾、洗涤剂和消毒剂。救护人员 应接受培训以确保这一点，并接受使用呼吸器所需的适合性测试。 4.6.3 尸体检验 对疑似因传染病（如霍乱、埃博拉病毒或马尔堡病）死亡的患者遗体进行尸 检，应仅限于必要的评估，并应由受过培训的人员进行[37]。进行尸检时需要采取 以下预防措施： ●任何尸检决定，应咨询IPC工作者。 ●对此类患者遗体的尸检应仅限于必要的评估，并应由受过培训的人员进行。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 68 / 124 ●检查遗体的人员应穿戴全套PPE。 ●此外，对已知或疑似出血热或其他急性呼吸道疾病病例进行尸检的人员， 应佩戴防颗粒物呼吸器（例如FFP2，或EN认证的等效产品，或美国NIOSH认证 的N95），或动力式空气净化呼吸器（PAPR）。 ●脱下PPE时，避免被污染的手套或设备与脸部（如眼、鼻或口）间的任何 接触。 ●脱下PPE后应立即进行手卫生。 ●将样品置于标识明确的非玻璃防漏容器中，并直接运送到指定的样品处理 区域。 ●运输前，应使用有效的消毒剂彻底消毒样品容器的所有外表面。 ●送去处理的组织或体液应小心至于标识明确的密封容器中，以便焚化。 4.6.4 安全且庄重的下葬 尸体带来的危害 尸体处置工作者、喷雾人员、技术主管，以及家庭和社区联络工作者，通过 直接接触尸体、衣物、被褥或其他表面/物体上的体液而面临暴露风险。其他风险 因素包括佩戴全套PPE户外工作的热应激、家庭和社区成员的暴力、人工作业负 荷（尸体和棺木）的人体工程学问题，以及处理人类遗骸和目睹人类痛苦的心理 困扰。 霍乱、埃博拉病毒或马尔堡病毒等高传染性疾病死者的尸体具有高度传染性， 需要由经过适当培训和装备的特别小组埋葬。按照WHO的建议[44]，安全埋葬包 括以下12个步骤： 1：出发前，团队组成及消毒剂的准备 2：组装所有必要的设备 3：到达患者的家中：与家人一起准备葬礼并评估风险 4：穿戴好PPE 5：将尸体放入尸袋 6：将尸袋放入棺木（文化上适宜的位置） 7：净化家庭环境 8：脱下PPE，处理废弃物，保持手卫生 9：把棺木或尸袋运到墓地 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 69 / 124 10：埋葬在墓地：把棺木或尸袋放入坟墓 11：埋葬在墓地：让社区参与祈祷，因为这样可以消除紧张，提供一个和平 的时间 12：返回医院或团队驻地。 埋葬队应包括7名成员：4名尸体处置人员(佩戴全套PPE)、1名喷雾人员(佩 戴全套PPE)、1名技术主管(不佩戴PPE)和1名与家人和社区互动的人员(不佩戴 PPE)。团队还应使用裹尸袋、消毒剂和运输工具。 需要装备的基本材料包括： ●手卫生：酒精材质的手消毒液（推荐）或干净的自来水、肥皂和毛巾（推 荐）或0.05%的含氯消毒液（当上述选项不可用时）。 ●PPE：一副一次性手套（非灭菌，左右手）、一副加厚手套、一次性工作 服（如Tyvec防护服）、不透水塑料围裙、面部防护（护目镜和面罩）、鞋（建 议使用橡胶靴，如果没有橡胶靴，则使用防刺穿鞋底的鞋和一次性套鞋）。 ●废弃物处置：消毒剂、一个手动喷雾器（0.05%含氯消毒液）、一个背负 式喷雾器（0.5%含氯消毒液）、防漏、防锐器刺穿容器。 IPC处置埃博拉等高传染性疾病死者遗体的建议包括[44]： ●只有经过培训的人员才能在爆发期间处理遗体。 ●在处理死于埃博拉病毒或马尔堡病毒的尸体时，医护人员、家属和安葬队 必须遵守卫生保健中的标准预防措施。包括：在处理可疑或确诊的出血热病例的 尸体时使用全套PPE，遵守手卫生指南，以及接触受感染血液、体液和材料的标 准预防措施，尤其是溅到表面时。 处理遗体的工作应尽量减少。原则上应遵守下列建议，但可能需要作出一些 调整，以顾及文化和宗教方面的考虑： ●应在戴手套前和脱下PPE后立即进行手卫生。 ●堵塞自然孔洞。将尸体置于双层袋中，用合适的消毒剂（如0.5%含氯消毒 剂）擦拭每一个裹尸袋表面，密封并贴上高传染性物质标签，立即将尸体转移至 太平间。 ●应在收集尸体场所放置PPE，在收集尸体、将尸体放入裹尸袋、将裹尸袋 放入棺木的过程中应佩戴PPE。只有当裹尸袋被安放于棺木中是才能且迅速脱下 PPE。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 70 / 124 ●不应对遗体进行喷洒、清洗或防腐处理。不鼓励任何在准备“干净的葬礼” 时清洗遗体的做法。 ●收集遗体车辆驾乘人员无需PPE，前提是驾乘人员不处理疑似或确诊出血 热死者遗体。 ●棺木搬运工必须佩戴加厚手套。 ●再用密封、不透水漏材料包裹后，应尽可能将遗体置于棺木内并及时掩埋。 ●强烈建议根据当地风俗确定此类遇难者墓葬。 安葬过程对家庭和社区来说是一个非常敏感的问题，可能成为麻烦甚至公开 冲突的根源。因此，在开始任何程序之前，家庭必须充分了解有尊严的埋葬程序 及其尊重死者的宗教和个人权利。确保在开始安葬前已得到家人的正式同意。在 取得家庭正式同意之前不得下葬。 应该使用担架来搬运遗体。 团队应有足够人数，以便至少有四个人可以搬运 遗体。 应合理组织工作，以便在没有PPE和适当补水的情况下进行休息。 4.6.5 出入境站点、陆路口岸、机场和海港 机场、海港和陆路出入境口岸工作者提供的服务包括：文件控制、国际旅客 体温扫描和健康评估，以及行李、包裹、集装箱、运输工具、货物和邮包的处理。 口岸工作者的危险因素包括与国际旅行者的体液、受污染的表面和衣物的接触[45]。 ●应为进行旅客查验的工作者提供与其任务的风险评估相对应的PPE。PPE 应至少包含一次性手套。工作者应避免接触旅客，并应尽量保持1米或3.2英尺的 安全距离。 ●工作者应使用肥皂和水，或酒精材质的手消毒液进行手卫生。 ●对患病或可疑旅客进行健康评估的医疗或公共卫生人员应配备PPE，包括 一次性手套、长袖不透水防护服、面罩、眼部保护装置（即面罩或护目镜）和带 鞋套的不透气的鞋或胶靴。穿着长袖不透水防护服时，面罩、眼部防护和防水围 裙很重要，尤其是当有血液或体液飞溅的风险时（如患者呕吐、出血或腹泻）。 ●出入境查验工作者在处理疑似病例时，应接受正确使用PPE和感染控制的 培训，并且必须使用肥皂和自来水，或酒精材质的手消毒液和一次性毛巾进行手 卫生。 ●出入境人员，包括货物装卸人员，不应处理明显被血液或体液污染的包裹。 4.6.6 航空器 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 71 / 124 疑似或确诊高传染性疾病病例乘坐飞机去往遥远的地区或国家，对于控制病 原体向未受疾病影响的地区或国家的传播，提出了巨大的挑战。在这种情况下， 机场地面人员和机组人员必须接受适当的培训，并且应根据国际民用航空组织 （ICAO）的指导方针在航班上提供用于处置病例/联系的医疗和通用预防工具包。 在进出港时，机组应遵循国际航空运输协会（IATA）关于航班上传染病管理的 标准操作程序，提供以下指导[46]： 在航空器上处置入境的疑似传染病病例 ●根据IATA指南，“疑似病例”的定义包括与下列一种或多种症状相关的 发热（温度38℃ /100℉或更高）：明显不适、持续咳嗽、呼吸困难、持续腹泻、 持续呕吐，皮疹、瘀斑或出血，无先前损伤和近期发作的意识障碍。 ●机组人员发现机上有疑似传染病病例的，应当通知航线空管人员，由航线 空管人员通知目的地机场空管人员。所传达的信息应包括诸如航班号、出发地、 目的地、预计到达时间、机上人数和疑似病例数等细节。目的地空管人员应根据 当地安排，将个案通知公共卫生当局。飞机抵达前的时间可能会让公共卫生当局 进行“远程风险评估”，通常是通过航空公司运营控制中心或地对空医疗顾问进 行间接评估。积极的风险评估可能决定是否需要某种公共卫生应对措施，并将允 许在飞机抵达前、在当地应对计划中采取措施，从而尽量减少延误。由公共卫生 当局处置的疑似传染病个案对旅客及/或飞机造成的最大延误基准应为一小时。 在飞机上，应根据IATA建议的操作程序立即考虑以下措施： ●尽可能与其他乘客保持距离。将其他乘客安置在距离患病乘客较远的位置。 最好将患病乘客至于厕所附近，以供其专用。 ●如出现呼吸道症状（例如咳嗽或打喷嚏），用医用口罩（如果可以接受） 遮住患者口鼻。如不接受口罩，应为患者提供纸巾，并要求其在咳嗽或打喷嚏时 捂住口鼻，并在随后进行手卫生。 ●为患病乘客提供一个用于处理用过的纸巾的塑料袋；如果感到恶心或呕吐， 则提供一个晕机袋。 ●将污染物品（用过的纸巾、口罩、布草、枕头、毯子、座椅口袋等）存放 在生物危害袋中（如果有）；如果没有，使用密封的塑料袋并贴上“生物危害” 标签。 ●尽可能限制与乘客的接触。只应有一名（或两名，如果患者需要更多帮助） 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 72 / 124 机组人员照顾患者，最好只安排已与该乘客接触过的机组人员。该机组人员或与 患病乘客直接接触的任何人都应使用通行的预防措施。应佩戴手套，且脱下手套 后应进行手卫生。 ●指导机组人员进行手卫生，如果手明显受到污染、与患病乘客或其个人物 品或任何可能被患病乘客的血液或体液污染的物体/表面进行任何直接接触之后， 以及在脱下手套之后，用酒精材质的手消毒液搓手20～30秒，或用肥皂和水洗手 40～60秒。如果戴手套的手受到了体液的明显污染（如呕吐物），应立即在患者 所在位置摘下手套并立即进行手卫生。专门协助患病乘客的机组人员在处理患者， 以及在必要时进行航班清洁作业时，应当使用适当的PPE。 ●医护人员应在航班抵达时评估机上其他乘客和机组人员的传播可能性。在 大多数情况下，症状可能由疟疾等疾病，或流感等轻微疾病引起[47]。 ●如果调查结论是这名乘客的症状与传染病相符，而且曾有受影响国家暴露 的既往史，那么，如果乘客和机组人员曾与体液或严重污染的物体直接接触，他 们可能面临风险。应考虑根据接近指示病例的情况采取下列流行病学措施： 报告直接接触的乘客和机组人员 为了收集这些信息，应从航空公司获取航班上重大事件的任何记录。报告与 指示病例直接身体接触的同机旅客和机组人员，以及坐在指示病例旁边的乘客 （侧面、前面或后面，包括过道对面），进行暴露追踪。 清洁受污染的飞机 如果在离开飞机后怀疑或诊断出该病例，清洁指示病例所在部位和座位的工 作者也应进行暴露追踪。应评估通过暴露追踪识别的乘客、机组人员和清洁人员 的具体暴露水平。对于高风险水平的暴露者，应在最长的潜伏期内（例如，病毒 性出血热如EVD为21天）持续被动自我监测体温（如，仅在感觉发热时才监测体 温）和症状，或主动自我监测（例如，每天定期测量两次体温）。 4.6.7 船舶 IHR海事健康申报模板包含的问题，涵盖以下症状，这些症状是怀疑存在传 染性疾病的依据： （a）发热，持续数天或伴有（i）虚脱；（ii）意识模糊；（iii）腺体肿胀； （iv）黄疸；（v）咳嗽或呼吸急促；（vi）异常出血；或（vii）麻痹。 （b）发热或不发热：（i）任何急性皮疹或斑疹；（ii）严重呕吐（晕船除 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 73 / 124 外）；（iii）严重腹泻；或（iv）反复痉挛。 船员的主要风险是接触乘客或船员的体液，或接触被体液污染的表面和衣物。 主要控制措施如下： ●与乘客或船员保持安全距离（1米或3.2英尺）；佩戴手套处理文件。 ●避免接触物品，以及接触可能污染体液的表面和衣物。经常进行手卫生。 ●确保船长、医生或被指派处置船上卫生问题的船员充分了解且接受了培训， 了解EVD等病毒性出血热的风险，以及船员应采取的预防措施和保护措施，以防 止他们感染病毒性出血热。 ●机组成员应遵循WHO旅行和运输风险评估：公共卫生当局和运输部门临 时指南中的建议[45]。 船舶运营者指南 如果乘客在船上出现与病毒性出血热相关的症状，例如EVD（发热，虚脱， 肌肉疼痛，头痛，咽喉痛，呕吐，腹泻，出血），必须采取以下预防措施： ●保持受影响人员舱室门关闭；如果做不到，请置其于船上的隔离室。 ●为拟照顾患者、进入患者舱室或隔离室的人员提供有关病毒性出血热如 EVD的风险的信息。 ●登记所有进入机舱或隔离室的人员；除非诊断测试报告为阴性，否则应将 所有人员视为接触。 ●确保进入舱室或隔离室为受影响人员提供护理或清洁舱室的卫生工作者使 用以下PPE： ○非灭菌检查手套或外科手套；清洁人员最好使用加厚橡胶手套； ○当与受感染者密切接触和/或预期会接触血液或体液时，一次性长袖不透水 防护服覆盖衣物和暴露的皮肤，医用面罩和眼睛保护装置（眼睛、护目镜或面 罩）；如不可行，应在不透气防护服外罩防渗围裙。 ○橡胶靴或带套鞋的不透气、防刺穿和防液体渗漏的鞋； ○在离开舱室或隔离室之前，应脱下PPE，以避免接触被污染的物品和面部 任何区域。 ●任何照料被隔离者的人员，在下列情形应用酒精材质的手消毒液搓手20～ 30秒，或用肥皂和水洗手40～60秒：手明显受到污染，戴上手套前，与受影响 乘客或其个人物品或任何可能被其血液或体液污染的物体/表面直接接触后，以及 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 74 / 124 移除PPE后[49]。 WHO在船舶上预防和控制诸如H1NI1流感等急性呼吸道疾病的指南包括以 下内容[50]： ●如果船舶上已经出现或者还在陆续出现有流感样症状的旅客，船舶运营者 应尽力将下船的患病或疑似患病旅客同即将登船的旅客隔离开来，可能需要使用 单独的大厅来防止人间传播。如果两组乘客必须共用同一区域，则应在下船后和 到达前进行有效的清洁。 ●如果成员国要求并且在船上可以做到，船舶运营者可以指定一名医务人员 或经过培训的船员负责基本的卫生预防控制措施以及医疗急救，例如： ○在全体船员中开展主动监测（发现病例），以在发现流感样病例后发现新 病例，并对监测活动进行监督； ○提高旅客和船员对2009年H1N1流感的症状和体征、感染的并发症以及感 染控制措施（如手卫生和社交、咳嗽礼仪等）的认识程度； ○督促践行手卫生和咳嗽礼仪； ○及时、恰当地收集病例监测数据，并在必要和可能时，每天向船舶运营者 报告； ○每天检查乘客和船员的医疗日志数据，以评估疾病趋势，并提醒船长调查 和控制疫情的必要性。 4.6.8 出租车与公共交通工具 在高传染性疾病（如流感、EVD、马尔堡病毒等）感染高发的国家，出租车 司机（面包车、轿车、摩托车）存在咳嗽和/或打喷嚏或体液暴露的风险，尤其是 司机协助乘客上车时。放置在座椅或车辆其他表面的被体液污染的衣物或物品也 可能导致传播。 控制措施包括：询问乘客近期有关疾病或就诊的问题，并观察乘客是否有体 征或症状（如出血、在没有帮助的情况下无法站立或移动），确定疑似或确诊埃 博拉患者。不要接触疑似或确诊埃博拉患者及其物品。尽快用漂白剂对车辆进行 洗消。洗消车辆的工作者应当佩戴全套PPE。 社会动员，教育社区明白出租车或公共交通工具不应用于转运有病毒性出血 热症状和体征（如EVD）的患者。相反，应该联系医护人员，使用私人车辆将患 者送到医疗机构。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 75 / 124 在病毒性出血热广泛且急剧传播的地区，应建议出租车司机： ●在汽车前后座之间设置隔板； ●避免与乘客握手； ●经常用水和肥皂或酒精进行手卫生，尤其是接触被血液和体液污染的表面 或物品后，即使佩戴手套也应如此； ●用塑料薄膜遮盖后座，如果被血液和体液污染，应立即更换并弃之于密封 废物袋中（这样做时应佩戴手套）； ●携带酒精材质的手消毒液，手套，废物袋，湿巾和消毒剂； ●如果驾驶员接触过疑似病毒性出血热患者，如EVD（与患者或其血液或体 液有身体接触），应立即向医疗机构/当局求助。 4.6.9 污水处理员工 在感染者的粪便和尿液（排泄物）中可以发现病原微生物，如埃博拉病毒、 霍乱弧菌和钩端螺旋体。直接接触排泄物的污水处理员工应采取预防措施，包括 手卫生和佩戴个人防护装备。包括医疗机构中的污水处理员工，运输废物的员工， 污水处理厂和专业接收处理单位以及受影响社区废水的污水处理厂的员工。 废弃物处理员工的基本卫生实践 ●在处理生活垃圾或污水时，避免吸烟、咀嚼烟草或口香糖。 ●用洁净干燥的绷带包扎创面和伤口。 ●如人类排泄物或污水意外溅入眼睛，用安全的水轻轻冲洗。 ●佩戴防水手套，以免割伤或接触人类排泄物或污水。 ●在工作场所和转运垃圾或污水时穿胶靴，离开工作场所前脱下胶靴和工作 服。 ●每天用0.05%含氯消毒液（1份家用漂白剂和100份水）清洁受污染的工作 服。 ●遵循手卫生程序。 ●吃饭前请脱去被污染的工作服，并在远离人类排泄物和污水处理活动的指 定区域用餐。 工作者处理污水、废水时应使用的PPE包括： ●防护面罩或防溅面罩，保护口鼻免受人类排泄物或污水飞溅； ●护目镜，保护眼睛免受人类排泄物或污水飞溅； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 76 / 124 ●防水工作服； ●防水手套； ●橡胶靴。 4.6.10 喷洒杀虫剂以控制媒介动物的活动 在媒介传播疾病（如登革热\黄热病和疟疾）爆发的情况下，病媒控制活动 可能是应急响应的关键组成部分。在洪水、海啸和飓风后，以及为受灾害影响的 社区提供临时住所的营地的部分日常活动，也可能需要病媒控制。蚊虫控制方法 包括空间喷洒杀虫剂，施用杀幼虫剂，以及某些情况下室内长效喷洒杀虫剂（用 于特定室内表面，如墙壁或家具下）。 在打开容器、混合和装上喷雾溶液、用手提或车载设备喷洒杀虫剂、清洗和 维护喷雾设备以及处理空容器时，病媒控制工作者接触杀虫剂。浓缩杀虫剂的溢 出、溅出和泄漏可导致意外暴露。 WHO在其关于寨卡病毒爆发期间保护杀虫剂喷雾工人的临时指南中建议采 取如下措施[51]： ●规划制定保护措施，例如确定有关农药采购、使用和应用技术的国家相关 法规、有关成分及其潜在健康影响的信息，并通过全球统一的风险沟通系统提供 信息[52]； ●保护操作人员的健康和安全，例如提供防护设备（覆盖手臂和腿的棉质工 作服，耐化学品橡胶防护手套，宽边帽，防化学品护目镜或面罩，橡胶靴和耳 罩）； ●以尽量减少操作人员和居民暴露的方式喷洒杀虫剂； ●对工作者进行安全使用杀虫剂的强制培训； ●严格的个人卫生，如定期清洗更换衣服和清洁设备； ●按照制造商标签的建议，在安全的地方储存和处置杀虫剂； ●为喷雾操作人员提供医学观察； ●处置使用杀虫剂导致的急性中毒，如暴露后尽快急救和眼睛、皮肤洗消 （清洗），以及治疗（无特异性治疗方法，对症治疗，以及阻止进一步吸收）。 施用杀虫剂时的措施应包括： ●关于保护工人健康和安全工作实践措施的每日简报； ●禁止在使用杀虫剂和杀幼虫剂期间吸烟、饮食； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 77 / 124 ●使用恰当的PPE； ●使用正确的设备维护程序，确保喷洒过程中不会发生泄漏； ●喷洒设备在运行25小时后重新调整、全面保养或更换； ●使用半封闭式自动稀释机进行水稀释喷雾。 PPE的选择取决于与不同任务相关的OSH风险。PPE必须符合国家有关农药 使用的规定，并且必须考虑制造商的建议。 处理和喷洒杀虫剂时使用的个人防护设备 在处理浓缩杀虫剂产品，倒出、混合或准备喷雾液体，以及灌装设备时： ●覆盖手臂和腿的棉质工作服（每个工人每天应提供两套，以便在潮湿时更 换）； ●耐化学品橡胶防护手套； ●宽边帽； ●防化学品护目镜或面罩； ●橡胶靴。 除上述规定外，当用手持设备和手动操作车载雾化器进行喷洒时，应佩戴空 气净化式半面罩呼吸器（带有机蒸气滤毒罐），并结合使用气溶胶和颗粒物的过 滤器，如N95、R95或P95过滤器（呼吸器过滤器必须按照制造商的说明定期更 换），以及在使用高噪声雾器时佩戴耳罩。 施用微生物杀幼虫剂及生长调节剂时： ●工作服； ●橡胶手套； ●处理颗粒状制剂时使用防尘口罩。 杀虫剂的储存和处理 所有用于空间喷洒或杀灭幼虫活动的杀虫剂都应储存在安全的地方，并符合 制造商标签的建议。喷雾或杀幼虫后，未用完的稀释杀虫剂不得留在喷雾设备中， 不得储存。未使用的稀释杀虫剂、空容器和空袋应按照国家指导方针、法规和制 造商的建议进行处理。空容器应使用溶剂(如煤油、柴油、水)冲洗三次，且处置 前不得使用。在适当情况下，冲洗液可用于制备后续的喷雾液，或按照国家指南 进行处理。 洗消 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 78 / 124 ●脱掉所有受污染的衣物以阻止进一步吸收。然后用肥皂清洗受影响的皮肤， 并用大量水冲洗。如果眼睛被污染，用手轻轻扒开眼睑，用干净的自来水冲洗几 分钟。应注意避免一只眼睛流出的水流入另一只眼睛。 ●暴露后应尽快进行皮肤和眼睛洗消。洗消后应立即就医。对于该产品在全 球协调系统信息中发现的不同杀虫剂类型，需要采取具体措施。 作业前检查 ●所有操作人员都应进行初步健康评估，以确定是否有使用特定杀虫剂的禁 忌症。 ●初步健康评估应包括体格检查，病史，职业史，综合代谢（血糖，电解质 和液体平衡，肾和肝功能），基础胆碱酯酶RBC /血浆测试（针对使用有机磷酸 酯和氨基甲酸酯的人）和 肺功能检查（对于需要佩戴呼吸器的人）。 ●使用有机磷酸酯和氨基甲酸酯可能会诱发已存在的消化性溃疡、支气管哮 喘、贫血、中枢神经系统退行性疾病、慢性结肠炎、精神病（病史，或有证据表 明可能有），以及使用胆碱酯酶抑制药物的重症肌无力和青光眼等疾病的并发症。 医学观察 ●必须作出安排，以确保任何暴露者能够便捷地向主管报告任何症状，主管 随后会通知医务人员。特别指出，应注意任何与特定杀虫剂中毒的公认症状和体 征无关的异常疾病，并向有关卫生当局报告。 ●应实施监测，以检测暴露者的任何轻微的神经系统影响，例如丧失理解书 面材料和集中注意力的能力。除临床监测外，还可以进行定量生化检测，以定期 在作业前和作业期间评估暴露程度。 ●杀虫剂职业暴露造成的作业人员和其他人员的及慢性中毒，应当向依照国 家法律法规规定办理职业病和工伤登记以及赔偿的主管当局报告。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 79 / 124 第五章 化学事故中的职业安全与卫生 5.1 化学事故造成的突发事件 不同规模和后果的化学事故在世界上大多数地区都是很常见的。可能源于技 术事故、自然灾害或蓄意行为。化学事故可能涉及化学品泄漏到环境中（例如爆 炸、密封失效或非法倾倒），也可能涉及食品、饮料或药品等产品的掺假或污染。 本章适用于化学物质泄漏到环境中。表3提供了一些案例。 2000年至2009年间，全世界报告了近3200起技术事故，约10万人死亡， 150多万人受到影响。这些化学事件涉及因爆炸和泄漏、自然灾害、有毒废物倾 倒、冲突和恐怖主义而导致的化工厂泄漏化学品。表3列出了一些近年来发生的 重大化学事故案例。 5.2 职业安全健康危害与化学品风险 WHO化学品事故的公共卫生管理手册将化学事故定义为“化学品从其容器 中意外失控释放”。 化学性公共卫生事件被定义为“两名或更多的公众暴露 (或 受暴露威胁) 于一种化学物”[56]。化学事故可能是在有限的时间内迅速释放化学 物质的突发事件，也可能是持续数天甚至数年的慢性事件。 重大工业事故可由大量蒸汽或易燃气体爆炸、火灾或有毒物质泄漏引起。工 厂常见有毒物质包括氯、氨、硫酸、氯化氢、光气和硫化氢。例如，1984年12 月，印度博帕尔一家化工厂发生安全阀和其他安全控制装置故障后，一股有毒的 异氰酸甲酯气体从工厂泄漏到空气中。通过管道或铁路、公路和水路运输气体时， 也可能发生化学泄漏。 化学事故以多种方式影响人们，包括： ●化学品的毒性影响； ●火灾影响； ●爆炸的影响。 表3：近年来重大化学事故案例 年份 地点 事件描述 后果 2003 中国，高 桥 天然气井井喷释放出大量硫化氢 243人死亡，9000人中毒，64000 人被撤离 2006 科特迪瓦 在阿比让市倾倒有毒废物 10人死亡，数千人生病 2006 中国 工厂爆炸火灾，向松花江（跨 境）排放100吨废物 5人死亡，数百万人数天缺乏饮水 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 80 / 124 2008 中国 牛奶和婴儿配方奶粉被掺入三聚 氰胺 约30万名婴儿和5万名儿童住院， 600名儿童死于肾结石和其他肾脏疾 病 2010 尼日利亚 使用简陋的产生粉尘的工艺，在 普遍含铅的区域进行非正规的金 矿开采导致铅中毒 超过400名儿童中毒死亡，许多社区 受到影响 2010 匈牙利 铅厂污泥池突发泄漏，污染物排 放到附近村庄和多瑙河（跨境） 储存的污泥腐蚀造成至少9人死亡， 150人受伤 2010 美国 墨西哥湾深水地平线钻井平台爆 炸 爆炸造成11人死亡，卫生工作者、 其他工作者、居住在海岸线附近的 志愿者轻伤及其他健康影响，可能 产生长期影响[53] 2012 韩国 龟尾一家化工厂8吨氟化氢泄漏 5人死亡，至少18人受伤，当地居民 被疏散，农作物被毁，宣布设立特 别灾区[54] Source： International Health Regulations 2005， WHO， 2008 [55] 化学品的毒性效应 化学物质通过皮肤、眼睛、肺或消化道进入人体。吸收受到化学物质性质、 暴露途径和时间以及人的年龄等因素影响(儿童吸收的比例大于成人)。环境条件， 如温度，也可以通过改变化学物质的物理状态来影响吸收。在紧急情况下，最可 能的暴露途径是吸入、皮肤和眼睛接触。通过肺的吸收通常是快速的，而皮肤吸 收较慢。 暴露的影响由化学品的毒性、到达目标组织的吸收量以及影响易感性的因素 决定，例如年龄、一般健康状况、遗传因素(如代谢快或慢者)以及伴随暴露于其 他化学品的因素。短时间暴露在高浓度环境中可能足以导致毒性作用。当暴露时 间延长且剂量率较低时，可能由总累积剂量导致毒性作用。 毒性作用可以是局部的（例如皮肤、眼睛或呼吸道的灼伤或水泡），如腐蚀 性物质、刺激性气体和一些有机溶剂导致的。或者可能是全身性的影响（例如铅、 汞、有机磷杀虫剂或氰化物）。有些作用（例如眼睛和呼吸道刺激或中枢神经系 统抑制）可在暴露的数分钟或数小时内发生，如神经毒剂中毒。其他影响（例如 先天性畸形或癌症）可能需要数月或数年才能出现。 气体泄漏的毒性作用 根据对健康的影响，气体可分为刺激性或窒息性。刺激性气体具有腐蚀性， 即会对皮肤和粘膜等上皮组织造成伤害，并导致呼吸道炎症反应。例如氨、氯和 硫氧化物。窒息性气体是干扰身体的氧气供应和利用的气体。化学窒息是通过阻 止血液中的氧气运输(如一氧化碳)或抑制细胞呼吸(如氰化氢)而导致死亡。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 81 / 124 火灾中的化学物暴露 火灾对生命的主要威胁包括热损伤、热应激、有毒气体和缺氧。根据燃烧的 物质，烟雾可能是许多危险化学品的复杂混合物。典型的成分包括烟尘、一氧化 碳、二氧化碳、二氧化硫、氮氧化物、氯化氢、苯酚、甲醛、异氰酸酯、苯等。 一氧化碳是大多数火灾的重要因素。氰化氢是在涉及聚氨酯、尼龙、丝绸和羊毛 的火灾中形成的。在发生爆炸的情况下，化学物质和压力效应的突然释放会导致 人身伤害以及与火灾相关的化学和其他效应。 化学烧伤 化学烧伤可由许多物质引起，如强酸、碱、下水道清洁剂、有机溶剂和汽油。 在某些情况下，疼痛和发红可能会在暴露后数小时出现。这种损伤可能比皮肤上 的烧伤更严重。例如氟化氢，如果不及时治疗，烧伤初期可能表现轻微，但可能 发展为皮肤全层烧伤[57]。 国际化学品安全卡（ICSC）数据库[58]是WHO、ILO与欧洲委员会（EC）合 作的一项成果，可在线获取，并提供有关化学品的基本健康和安全信息。 5.3 化学事故中应急响应人员的职业安全与健康管理 本节介绍了化学事故响应的一些基本原则。强调了可能出现化学品暴露的应 急响应人员的作用，以及应采取的保护措施。 5.3.1 处置化学品紧急事故的事故指挥系统 对化学事故有组织的反应，通常通过事故指挥控制中心进行管理。在化学紧 急情况下，事故指挥的职能包括确保执行以下任务： ●情况评估； ●抢救人员； ●从危险区域疏散人员； ●建立安全和保护范围； ●通过设立隔离区和允许进入区，进入危险区域仅限于必要和授权的工作者； ●遵守个人防护准则； ●处置火灾等常规威胁； ●部署其他团队，如监测和洗消。 事故现场的分区 为了管理诸如化学品泄漏之类的化学事故，可以在事故现场周围建立一系列 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 82 / 124 区域以控制进入并建立用于控制污染的通道。 通常会分为三个区域： ●红色，热区或禁区：这是有活动的或疑似化学物质泄漏的区域。 该区域应 延伸足够远，以防止污染该区域外的人员和材料。这里可以进行非常有限的活动 （例如控制泄漏和救援受害者的任务）。该区域不提供洗消或患者护理。 人员应 穿全套防化学PPE。 ●黄色，温区或污染减少区：可能存在、不存在活动泄漏，但化学品浓度将 低于热区。应急人员仍需要化学防护。受害者、应急响应人员和设备通常在该区 域和冷区间的分界处进行洗消。存在二次污染的风险。 ●绿色或冷区：无污染。在进入该区域之前，必须对受污染的受害者、应急 人员和设备进行洗消。该区域包含所有处置化学事故的行政职能（如指挥部和救 护车）。 图7：化学事故现场分区 Source： Adopted from WHO mannual： the public health management of chemical incidents.Geneva： World Health Organization； 2009. [56] 控制进入，即仅限授权的人员进入不同区域，是控制污染物波及应急响应者 的重要措施。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 83 / 124 红区和黄区应急响应人员应遵循的安全工作实践 红区和黄区应急响应人员应做到： ●尽量减少从事救生或早期监测等必要活动的暴露时间； ●避免与表面或潜在污染材料的不必要的接触； ●使用自然通风以减少暴露（例如，在气体泄漏的情况下，应将化学物质释 放的位置设置在下风向）； ●确保强制洗消； ●对暴露的体征和症状进行撤出后评估。 联合国人道主义事务协调办公室(UN OCHA)为应急响应人员开展危险物质 作业提供了指南[59]。 在向受污染地点投入救援资源之前，应考虑以下事项： ●应根据危险/风险评估和现场调查进行风险分析。 ●各小组应评估与救援幸存受害者和运出死者有关的风险。 ●各小组还应考虑邻近地区的其他搜索和救援优先事项。 一般而言，在评估疑似受污染的现场时，应采取以下策略： ●确保安全接近，通常从上风向，发生液体泄漏时从上坡处。 ●确保指挥和控制措施清晰明确，且在场人员都完全理解。 ●设法确定污染物（使用联合国编号，危险品或危险货物代码）。 ●评估潜在危害并尽可能减少环境污染。 ●如果可能，寻求协助（专家建议，补充资源）。 ●尽可能保护现场以确保其他人员安全。 ●始终做最坏打算，直至证实并非如此。 装备和人员都需要洗消。因此，应考虑避免此区域过度投放队伍能力。每当 使用防护服或设备时，都需要考虑洗消策略。 在任何工作现场进行搜救行动时，各小组应考虑以下问题，并在行动期间实 施监测制度： ●氧气含量； ●物质或周围大气的可燃性； ●毒性水平； ●爆炸范围； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 84 / 124 ●辐射监测。 下列考虑事项可能影响是否进行搜救行动的决定： ●狭小空间的情况：如果危险可轻易隔离或减轻，且执行了相关处置，则此 情况可视为已处理，行动继续。 ●接近受困者所需时间：指接触到第一个受困者的估计所需时间。减轻危害、 破拆地板、墙壁、屋顶等，支撑和加固救生通道和相关毗邻结构所需时间应包括 在内。 ●特定场所信息：应特别注意并监测特定类型目标的危险，尤其是那些涉及 核能、放射性元素、特殊军事设施、化工厂和生物制品工厂或仓库。 ●洗消：需要周密计划以确保队伍具备为队员及搜索犬提供适当洗消的程序。 在开展检测和监控时应考虑以下内容： ●行动现场侦检与监测应由队伍中指定的危险品专家完成，并开展以下工作： ●确定每个指定建筑物的安全边界； ●确定每个指定建筑物的无污染进入点； ●制定计划以备行动中遇到需要监测的未知狭小空间或潜在空间； ●设立洗消点——包括妥善处理洗消废液； ●确保指定工具和装备的洗消，包括防护服； ●确保指定交通工具的洗消。 5.3.2 个体防护装备 处理受污染受害者/患者的医疗机构的应急人员和工作者，可能通过直接接触 患者皮肤或衣服上的化学品、或吸入或粘膜接触蒸汽危害而暴露于有毒化学品。 因此，这些人员应配备适当的PPE，并接受使用培训。PPE的水平取决于可能的 暴露程度和相关化学品的毒性。暴露的可能性越大，或相关化学品的毒性越严重， 所需的化学防护等级就越高。例如，参与控制化学品泄漏或救援暴露受害者（例 如在红区工作）的人员可能需要最高级别的化学品保护。处理有限皮肤暴露和吸 入化学品的患者的医护人员，可能只需要围裙和手套。在决定适当级别的PPE时， 必须平衡对毒性的充分保护的需求，以避免操作要求较高的设备时可能带来的困 难和不适。 PPE防护等级 根据所提供的防护等级，美国OSHA将化学紧急情况下应急响应者使用的 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 85 / 124 PPE分为四类[60]。 A级防护：当需要最高水平的呼吸、皮肤、眼睛和粘膜防护时，应选择A级 防护。典型的A级防护套装包含： ●正压（压力需求式）、自给式呼吸器（SCBA）或带逃生SCBA的正压供 气式呼吸器； ●全密封化学防护服； ●手套，内层，耐化学腐蚀； ●手套，外层，耐化学腐蚀； ●防护靴，耐化学腐蚀，钢制靴头和靴筒（取决于防护靴结构，可以穿在防 护靴上方或下方）。 B级防护：当需要最高级别的呼吸防护，但皮肤和眼睛防护需要的级别较低 时，应选择B级防护。B级防护是进入初始现场的最低等级，直至通过通过监测、 取样和其他可靠的分析方法进一步识别和定义了危害，并直至采用了与这些结果 相对应的设备。典型的B级防护套装包含： ●正压（压力需求式）、自给式呼吸器（SCBA）或带逃生SCBA的正压供 气式呼吸器； ●化学防护服（工作服和长袖夹克，连体工作服，连帽两件套式化学防护服， 一次性化学防护服）； ●手套，内层，耐化学腐蚀； ●手套，外层，耐化学腐蚀； ●防护靴，耐化学腐蚀，钢制靴头和靴筒。 C级防护：已知空气中物质的类型、浓度检测结果，满足使用空气净化式呼 吸防护器的标准，不太可能出现皮肤和眼睛暴露时，应选择C级防护。必须动态 进行空气检测。典型的C级防护套装包含： ●全面罩或半面罩、空气净化式呼吸防护器； ●化学防护服（连体工作服，连帽两件套式化学防护服，化学防护罩衣和围 裙，一次性化学防护服）； ●手套，外层，耐化学腐蚀； ●手套，内层，耐化学腐蚀； ●防护靴，耐化学腐蚀，钢制靴头和靴筒。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 86 / 124 D级防护：D级防护主要是工作服，仅用于有害污染。只包含工作服和安全 鞋/靴子。其他PPE（如手套类型等）根据实际情况确定。不得用于任何有呼吸道 或皮肤暴露风险的场所使用。针对暴露风险，丁腈或丁基橡胶要比乳胶手套更适 用。此外，化学防护服也是适用的。如果没有，也可以使用防水的工作服或防护 服，并定期更换。 标准的医用和外科口罩不能保护粘膜免受有毒蒸气的影响。需要空气净化式 呼吸防护器，例如装有活性炭过滤器或SCBA的呼吸器。SCBA需要适当的培训、 安全和适合性测试，并且只能由使用者佩戴有限的时间。 5.3.3 应急响应人员的洗消 应急响应人员在工作过程中受到化学品污染的，应当首先进行洗消；并且在 离开黄区、接受治疗或者离开工作岗位前进行洗消。迅速和有效的洗消对防止有 关化学品的急性和长期毒性影响至关重要。洗消的基本装备见专栏5。保护他人 (例如同事和家人)免受二次污染也很重要。 洗消通常是通过物理方法去除化学物，或在某些有限的情况下通过化学灭活 来实现。脱掉被污染的衣物通常可以去除大量的化学物。洗消方法大致可以分为 湿法（用肥皂和水洗掉化学物）和干法（用吸收性材料吸收或擦掉化学物）。粘 性或油性的化学物很难用单一方法去除。 在医疗机构中构建一个洗消单元 WHO化学武器暴露患者临床管理临时指南[61]涵盖了如下与医疗机构中洗消 有关的方面： ●应在指定区域进行洗消，并提供清洁材料，如水、肥皂和海绵。洗消区应 明确标明接收受污染人员的区域（预洗消区）和进行洗消的区域。此外，“洁净 区”是指人员可以着便装并在必要时可以接受治疗的区域。只能单向移动，从预 洗消区到洗消区再到洁净区。 ●洗消区包含未知种类和数量的危险物质，以及可能存在受污染的受害者、 设备或废弃物。有理由预计，这个区域的工作者可能会暴露于受污染的受害者及 其财物、设备或废弃物。该区域包括但不限于：对可能受污染的受害者进行初步 检伤分类和/或进行医疗稳定的区域、受害者的预洗消等候(阶段)区、实际洗消区 和洗消后受害者观察区。该区域通常终止于急诊室入口。在其他文件中，该区域 有时被称为“温区”。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 87 / 124 ●洗消后区域被认为未受污染。预计设备和人员不会在该区域受到污染。在 接受污染受害者的医院，医院洗消后区域包括急诊室（除非受到污染）。该区域 有时也称为“冷区”。 ●不允许怀孕的医务人员在预洗消区和洗消区工作。 在工作周期结束时，身体健康者自行进行洗消 如果穿着化学防护服，应急人员必须先清洗PPE再脱去：使用肥皂、水和软 刷，从头部开始，一直到脚，直到去除污染。PPE应该通过向下滚动(从头到脚) 来脱去，而不是将其拉过头部。SCBA应在其他PPE被脱去后再移除。脱下后， 所有PPE应放置于贴有标签且耐用的聚乙烯袋内。然后，此人应沐浴，注意用肥 皂水清洗所有区域，包括皮肤褶皱，然后穿上干净的衣服。 其他类型的PPE应小心拆卸，同样避免将物品拉过头顶。衣服应放置于贴有 标签且耐用的聚乙烯袋内，以便日后清洗或作为危险废物处置——视相关化学品 而定。此人应沐浴，注意用肥皂水清洗所有区域，包括皮肤褶皱，然后穿上干净 的衣服。 受污染/伤残人员的洗消 如果应急响应人员因污染或外伤而致残，必须由其他人使用以下程序对其进 行洗消： ●洗消应在进入医疗机构之前进行。 ●应小心脱下衣物，以免污染未暴露区域。如有必要，应割开衣物。 ●洗消应由经过适当培训、佩戴适当PPE的应急人员进行和监督。 ●干法或湿法的使用应适应当地资源和情况。有关漂洗—擦拭—漂洗技术的 信息见下文。 ●洗消可能需要伴随其他活动，如检伤分类和医疗复苏。 ●污染的材料和衣物应视为危险化学品废物来安全处置。 采用漂洗—擦拭—漂洗技术进行应急洗消 程序的关键步骤如下： 1、皮肤上的任何液体都应该用干净的吸水材料（如伤口敷料）吸干。轻轻 擦掉任何固体物质（如粉末）。 2、受影响区域应轻轻冲洗或用肥皂水清洗（开放性伤口使用0.9%生理盐 水），以稀释污染物并去除微粒。从面部开始一直到脚趾，特别注意皮肤褶皱、 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 88 / 124 指甲、耳朵和头发。用0.9%的生理盐水充分冲洗眼睛，因为只使用少量可以促进 某些化学物质的扩散和吸收。 3、受影响的区域应用海绵、软毛刷或毛巾轻轻擦拭，以去除有机化学品和 石化产品（溶于热水）。必须定期更换海绵和毛巾。 4、受影响的区域应冲洗干净，清洁后用一次性毛巾轻轻擦干。 ○应记录暴露人员的以下信息： 人员详情（如姓名、年龄、性别、地址、病史）； 化学品暴露的方式； 暴露时间（哪一天暴露？以及暴露持续时间）； 暴露途径（即空气、土壤或水）； 症状，包括其病程进展情况； 采集的样本（如生物标志物）； 提示和已提供的处置措施。 专栏5化学品应急洗消的基本装备 •剪刀 •桶（5-10升容量） •海绵、软刷（用于洗衣服） •清洁水源（最好是温水）、冲洗软管、盐水溶液（用于冲洗伤口、眼睛和其他 粘膜），如有可能，蒸馏水 •液体洗涤剂、洗涤液、不含护发素的洗发水 •一次性毛巾、干布 •大塑料袋（用于衣物和双层包装） •小透明塑料袋 •识别/分类标签/标识，笔 •坚固的容器（用于设备洗消） •替换衣物或床单、毯子 •担架 Source： Interim clinical management of patients exposed to chemical weapons： interim guidance document [61]. 5.3.4 应急响应人员的医学观察 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 89 / 124 由于化学品对健康具有急性和长期毒性作用，因此所有应急响应者在整个部 署过程中都必须接受医学观察。 这需要以下要素： ●应在部署前进行详细的体检，以确定部署的适合性，包括检查呼吸系统以 评估使用呼吸器的适合性。 ●在部署期间，应尽可能多地收集有关工作性质和危险类型、工作持续时间、 工作环境中化学品暴露浓度、污染事件和健康危害效应（如果有）的信息。 ●响应后，立即开展部署后的医疗检查，侧重于部署期间的暴露，包括心理 评估。此后，根据部署期间的暴露类型，可定期检查应急人员。 ●在部署周期内，无论何时，如有需要，都应对所有暴露者进行医疗救治。 对于复杂的全身系统性中毒，治疗可能需要咨询临床毒理学家，在某些情况下， 还需要在三级医院使用解毒剂。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 90 / 124 第六章 辐射事故中的职业安全与健康 与涉及其他危险物质（如化学品）的事件相比，核与辐射事故很少发生。然 而，尽管发生频率较低，但是在地方、国家和国际各层面，对核与辐射事故的公 众关注度和政治参与度仍然很高。此外，随着对国际恐怖主义的认识的提高，对 放射性和核材料的潜在恶意使用的担忧也在增加，可以设想各种辐射和核场景。 涉及核装置的重大事故包括1957年英国温斯克尔事故、1979年美国三里岛 事故、1986年乌克兰切尔诺贝利事故、1999年日本东海村事故以及2011年日本 福岛事故。涉及放射源的重大辐射照射事故包括2010年印度新德里公众接触废弃 放射源、2005年智利职业事故以及2004年法国埃皮纳勒过度医疗照射[62]。 因此，核与辐射突发事件的规模和类型，可以从孤立的职业或医疗人员个人 过度照射，到全球范围的重大灾难。无论事故规模或原因如何，有一点是共同的， 即对人类健康的影响。因此IHR包含了放射性危害。 6.1 辐射事故的来源与场景 辐射突发事件是指由于辐射源的辐射暴露而存在或被认为存在危险的紧急情 况，可能包括以下内容（注1）： ●辐射暴露的医学症状； ●危险放射源丢失或被盗； ●公众放射性污染/暴露； ●涉及放射性材料运输的紧急情况； ●检测到高辐射水平； ●存在放射性分散装置（RDD）。 放射源广泛应用于工业、医学和科研等各个领域，因此，辐射突发事件可能 发生在任何地方。 任何放射源，都有可能通过以下内部或外部途径造成照射剂量： 外部途径：个体可能会暴露于环境中放射性物质的照射： ●直接来自放射源、或沉积在地面或其他表面的放射性物质； ●放射性物质在大气中以气态或蒸气形式扩散。 内部途径：个体可以通过以下途径暴露于体内的放射性物质的照射： ●吸入大气中的放射性物质（来自事故，或地面沉积物再次扬起）； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 91 / 124 ●摄入受放射性物质污染的食物/水； ●通过皮肤或开放性伤口吸收放射性污染。 辐射对健康的影响包括以下一种或多种： ●短期影响，如皮肤烧伤或大剂量照射下的急性放射性综合征； ●长期影响，如剂量超过100 msv时报告的某些类型癌症的风险增加； ●即使很少或没有辐射暴露，也会产生心理影响。 注1：此处原有IAEA链接，但已失效。 6.2 辐射应急响应人员的职业安全健康管理 国际电离辐射防护和辐射源安全的基本安全标准（BSS）[63]将应急照射情况 定义为由于事故、恶意行为或任何其他意外事件的结果所引起的照射情况，这种 照射情况需要立即采取行动，以避免或减轻不利后果。在出现应急暴露情况之前， 必须考虑预防措施和缓解措施。然而，一旦出现应急暴露情况，只有采取防护行 动才能减少暴露。 在紧急情况下，每一项具体的防护行动(在应急准备和响应计划中加以阐述) 可单独执行，整个战略需要考虑所有照射途径的最优化，以确保残留剂量减至合 理可行的最低水平（注2）。当超过与参考水平兼容的防护策略中使用的通用标 准时，应实施优化的防护策略，以提供快速行动。在缺乏详细的辐射信息的情况 下，通常需要采取此类措施，这些信息通常与辐射源处于受控状态的计划照射情 况有关。在紧急情况下，应选择参考水平在ICRP（国际放射防护委员会）2007 年建议书（第103号出版物）中建议的20～100mSv的范围（或，如有可能，低 于该范围）（注3）。 应急和现有暴露情况下的职业照射应遵守现有的操作和程序安排，包括评估、 监测、参与和培训。个体照射应执行最优化，并有适当的参考水平范围。根据当 前情况，这些参考水平可能大于适用于预计暴露情况剂量限值的建议值。在应急 或现有暴露情况下，参考水平代表剂量或风险水平，高于该水平时，认为不适宜 允许预计的暴露发生，因此应规划和优化防护措施。最首要的意图是不超过或保 持在这些水平。 考虑到现实的情况，在紧急情况下，短时间内且受到优化的防护的较高暴露 水平，可能是必要且恰当的。由于可以实现减少暴露，因此这些水平预计不会持 续很长时间。 随着补充信息的出现，一些对放射源和暴露情况的控制措施得到实 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 92 / 124 现。ICRP的相关建议旨在防止组织损伤，目标是考虑经济和社会因素将所有剂量 降低到可合理实现的低水平。 在核和辐射应急响应等特殊情况下，如果有可能受到超过50mSv（一年内工 人的职业剂量限值）的剂量，应急工作者应知情且可以自愿采取行动。唯一适用 的情况如下（BSS 4.17）： ●除以下情况外，不得要求任何应急人员从事50mSv的应急活动： a）为抢救生命或防止重大伤亡； b）在为避免大的集体剂量而采取行动时；或 c）采取措施以阻止发展为灾难性状况。 ●在这种情况下进行干预时，为了避免对健康的确定性效应，应尽一切合理 努力使工作者的剂量保持在单年最大剂量限值的两倍以下，但救生行动除外（应 尽一切努力使剂量保持在单年最大剂量限值的10倍以下）。此外，只有在对他人 的益处明显大于其自身风险时，工作者才可以从事剂量可能接近或超过10倍最大 单年剂量限值的活动。 ●响应组织和雇主必须确保采取可能致使所受剂量超过50mSv的行动的应急 工作者自愿地采取行动；确保事先让他们清楚和全面地了解所涉的健康危险，以 及可利用的防护措施；并确保尽可能在可能需要他们采取的行动方面对他们进行 培训。 ●从事应急干预的工作者，除了注册者或许可证持有者外，还可能包括辅助 人员，如警察、消防员、医务人员、疏散车辆的司机和乘务员。 ●应急预案中，应对符合上述要求的人员的法定职责作出明确规定。 根据BSS，必须在优化防护策略的基础上提前进行应急准备和响应计划，防 护策略可以根据具体情况由若干具体行动组成。 根据1960年辐射防护公约（第115号，ILO）的要求（该公约适用于所有涉 及工人暴露于电离辐射的活动，包括应急工作者），为了救援物品（不管是高价 值的抑或是一般的）而让工作者发生特殊的暴露（因为不涉及工作者暴露的替代 干预技术将涉及过度的费用）是不合理的。因此，有必要在批准授权过程中审查 和管理与重大潜在风险相关的活动，并确定适当的资源，制定应急预案，以尽量 减少或消除工作者的风险。 根据1960年辐射防护建议书（第114号，ILO）的要求，应尽可能保存每名 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 93 / 124 工作者在工作过程中受到的所有剂量的完整记录，以便在雇佣时考虑其累积剂量。 2014年BBS第3.83（d）概括为：必须向雇主、注册者或许可证持有者提供关于 其过去和现在所从事的 相关工作的信息，以确保其自身和其他人有效而全面的防 护和安全。 一旦应急作业结束，其他活动（源回收、清理、废物处理等）应在辐射顾问 监督下遵守职业辐射防护指南。 ●应采取一切合理措施评估和记录参与应急干预的工作者所接受的剂量。应 将受到的剂量和由此产生的健康风险告知相关工作者。 ●通常情况下，工作者不必因应急照射情况接受的剂量而被排除进一步的职 业照射。但是，如果工作者接受紧急照射的剂量超过单年最大剂量限值的10倍或 工作者有要求的，则应在进一步暴露之前获得符合要求的医疗建议。 ICRP2007年建议书（第103号出版物）指出，在应急暴露情况的后期进行 修复和恢复性操作的工作者应被视为职业暴露工作者，并应根据常规职业辐射防 护标准进行防护，且其暴露不应超过ICRP推荐的职业剂量限值。从事工厂和建筑 物维修或放射性废物处置活动等工作的工作者，或为现场和周围区域的净化承担 辅助措施的工人，应遵循BSS第3条所述的计划暴露情况下职业暴露的有关规定。 注2：残留剂量指预期在防护行动终止（或已决定不实施防护行动）之后未来将产生的剂量。 注3：ICRP2007年建议书（第103号出版物）给出三个分级用于选择参考水平：1、剂量限 值或参考水平达到1mSv，个人暴露于此放射源的辐射中几乎没有任何益处，但是总体而言 对全社会有益。2、如果个人暴露于不受控制的放射源的辐射中，或者减少剂量的行动将造 成不相称的破坏，则将使用20～100mSv的参考水平。3、短时间或一年内超过100mSv的剂 量被视为不可接受的，除非明确说明是在与应急人员暴露相关的情况下。 6.2.1 辐射应急中应急响应人员的防护指南 根据辐射防护的基本原则，在辐射紧急情况下，应急人员应始终遵循的一般 准则包括（注4）： ●应鼓励意识到自己怀孕或正在母乳喂养的女工立即通知雇主，并应将其排 除在应急任务之外。 ●避免接触可疑的放射性物品。 ●确保在内部警戒区内时，您具有可辨识性，且处于受控体系中。 ●仅在潜在危险放射源附近执行救生和其他关键任务。 ●尽量减少在可疑危险放射性材料/源10米范围内的时间。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 94 / 124 ●在涉及潜在危险放射源的火灾或爆炸发生100米范围内，避免吸烟，或使 用可用的呼吸防护设备（针对响应人员）。 ●双手远离口腔，在洗手和洗脸之前不要吸烟、吃饭或喝水（避免误食）。 ●尽快更衣和淋浴。 ●处理或运输受污染人员时，使用常规屏蔽方法（标准预防措施），如外科 手套和口罩。 ●对可能受到严重污染或暴露的工作者（如核心警戒区内的工作者）应进行 放射性污染监测。如果不能立即进行监测，应尽快淋浴和更衣。 ●可能需要对潜在暴露和/或污染人员进行医学评估，以确定其后续医疗处置。 因此，参与辐射紧急情况的人员应进行登记。 ●应急监测部门通常使用的γ剂量率测量仪器（包括辐射报警仪）无法检测 所有类型放射性材料的危险水平。只有经过培训且配备适当装备的辐射评估人员 才能对辐射危害进行全面评估。因此，在辐射评估人员评估危险并提供具体建议 前，应始终遵循人员防护指南。 γ剂量率已知时应遵循： ●遵循上面列出的应始终遵循的指南。 ●如果特定区域的环境剂量率大于100mSv/h：仅执行抢救生命的行动。将 总停留时间限制在30分钟以内。 ●除非辐射评估员指示，否则不要进入环境剂量率大于1000mSv/h的区域。 佩戴直读式剂量率仪时应遵循： ●遵循上面列出的应始终遵循的指南。 ●遵循《辐射应急第一响应者手册》（维也纳：国际原子能机构；2006年） 中规定的“应急工作者返回指南”。 在对响应者和公众进行监测期间，针对应急监测人员的健康和安全说明 ●在离洗消区较近的环境剂量率低于0.3Sv/h的区域设置监测位置。 ●尽量使用手套和防护服。定期换手套。 ●遵循上述人员防护原则。 ●手持检测器距离待测表面约10cm，监测个体的头发、手、口袋、衣物被 污染部分、脚和脸。 由医院急救团队在医院内为受外部污染的伤病员洗消时的健康及安全指引 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 95 / 124 ●穿戴PPE，包括呼吸防护用品。 ●更换手套，经常检查双手，防止污染扩散到其他部位。 ●脱下病人衣物，放入贴有标签的塑料袋中。 注4：http：//www- pub.iaea.org/MTCD/Publications/PDF/EPR_FirstResponder_web.pdf， accessed 12 October 2017. 6.2.2 辐射事故应急处置指挥系统 与化学事故类似，辐射应急也通过事故指挥控制系统进行处置。表4显示了 在现场和医院参与辐射应急的响应团队。据观察，在辐射紧急情况下，本地的应 急服务（例如当地医疗、执法、消防救援）在早期响应中起到了最重要的作用。 环境监测、辐射检伤分类、洗消、人员监测、剂量评估和现场操作记录团队， 以及辐射防护官员和卫生/医学物理学家角色，都是专门针对辐射紧急情况的。 环境监测团队：其职能是在事故现场进行环境监测，以评估辐射和污染水平。 辐射检伤分类团队：其职能是评估医疗措施、辐射测量和洗消程序的优先级。 人员监测团队：其职能是监控人员是否受到表面污染，可能还包括内部污染。 事故指挥系统中的其他工作者和团队包括记录、后勤和行政团队的支持职能。 志愿者在紧急情况下的作用：志愿者指的是自愿协助应对核或辐射紧急情况 的公众。向志愿者提供有关潜在暴露和影响风险的信息，并告知其协助应对核或 辐射紧急情况可能会导致辐射暴露。 如图8所示，根据辐射暴露水平将现场划分为不同区域，并在不同区域开展 相应的活动。红区是高污染区，只有第一响应者才能进入开展行动。 表4：参与辐射应急事件的响应团队 现场 医院 事件作战指挥部 安保人员 第一响应者 急救团队 安保人员 应急医疗处置 医疗团队 医院应急团队 环境监测团队 病理科 辐射检伤分类团队 辐射防护官员 洗消团队 卫生/医学物理学家 人员监测团队 剂量评估团队 记录团队 急救团队 Source： TMT Handbook， Norwegian Radiation Protection Agency [64]. 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 96 / 124 图8：辐射应急风险分区 Source： Nuclear and Radiological Emergency Guidelines， International Federation of Red Cross and Red Crescent Societies [65]. 6.2.3 个人防护用品 应根据工作区域的已知或预期的污染水平、计划的作业活动、工作者健康考 虑以及可能存在的非放射性危害来选择PPE。当进入污染水平超过规定限值的区 域时，要求人员穿戴PPE，以防止皮肤和衣物受到污染。所需防护服的级别取决 于工作区域的辐射状况和工作性质（专栏6）。确定所需防护服类型和级别的基 本因素有： ●污染类型和形式； ●污染程度； ●正在执行的工作类型。 专栏6适合响应者角色的PPE （在所有情况下，必须使用具有类似防护等级的PPE） a.进入红区的急救人员和应急人员必须佩戴： 全面型呼吸防护器：当不存在非放射性危害时，且额定的防护因子（APF）适 用； 防水手套（必须耐磨）； 防水服（必须覆盖所有皮肤和头发）； 防水鞋或靴子； 安全帽； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 97 / 124 个人剂量报警仪（测量瞬时剂量率和累积剂量）； 个人剂量计（胶片剂量计或热释光剂量计）； 高能见度服装（推荐）。 b.进入黄区的急救人员和处理受污染人员的医务人员必须佩戴： 外科手套（必须经常更换）； 覆盖手臂、腿、脖子和头部的防水工作服； 呼吸防护器； 塑料鞋套； 头套（如手术帽）； 个人剂量计（胶片剂量计或热释光剂量计）（推荐）。 c.进行洗消的人员必须佩戴： 上文b所示的PPE，以及 防水工作服（推荐）。 Source： TMT Handbook， Norwegian Radiation Protection Agency [64]. 6.2.4 洗消 根据伤情，可在医院或现场附近进行伤员洗消。本节所述洗消，指的是去除 放射性污染，而非化学性或生物材料污染。 ●洗消程序包括脱去衣服、用肥皂和水清洗身体以消除大部分表面污染。不 清洗的情况下脱去外层衣物，可以减少80%～90%的污染。 ●洗消人员不得进食、饮水或吸烟，并应保持双手远离口腔，直到脱掉外衣 并淋浴。 ●应在洗消设备处建立单向通道，避免待洗消者与已洗消者接触。洗消区必 须有单独的入口和出口。 ●放射性物质污染不会立即危及生命。应尽快洗消，但一般不要求与化学或 生物污染一样的即时性，除非在放射性污染足以造成严重影响的极端情况下。 ●如果衣物有污染，必须更衣。如果发现皮肤污染，则必须执行洗消程序。 ●受污染或可能受污染的物品，如伤员的衣服、敷料、设备、工作者的衣服 等，应装袋、贴标签并存放在安全区域。 6.2.5 辐射应急作业人员职业健康监护 ILO第115号公约第12条规定：“所有直接从事放射性工作的工人在着手此 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 98 / 124 种工作前或开始后不久均应作适当体格检查，此后每隔一定时期还应进行体格检 查。”第13条规定了一种情形，由于暴露的性质或程度或两者兼有而必须立即采 取下列行动：（a）工人应作适当体格检查；（b）雇主应根据要求通报主管当局； （c）主管辐射防范的人员应检查工人履行职责的条件；（d）雇主应根据技术调 查结果和医嘱采取任何必要的补救措施。2014年BSS第3.76（f）段对这方面的 规定：雇主、注册者和许可证持有者必须确保为从事受到或可能受到职业照射的 活动的所有工作者提供必要的健康监护和医疗服务。依据2014年BSS第3.108， 工作者的健康监护计划必须基于职业保健的一般原则，旨在评估工作中开始从事 预期任务的胜任程度和继续从事预期任务的胜任程度。 1960年辐射防护建议书（第114号，ILO）第27条建议，医嘱认为一名工人 在其正常工作中不宜进一步暴露于电离辐射时，应作出一切合理努力为该工人调 换适当的工作。在这方面，BSS第3.112规定，在由监管机构确定或在工作者健 康监督计划框架内确定工作者因健康原因可能不再继续从事他们受到或可能受到 职业照射的工作情况下，雇主必须尽一切合理的努力，向这些工作者提供合适的 替代工作。此外还应该注意到，一些更近的OSH文书（1977年工作环境（空气 污染，噪音和振动）公约（第148号，ILO）和1986年石棉公约（第162号， ILO））也表明：继续分配这些文书所涵盖的活动在医学上是不可取的，应根据 国家实践和条件作出一切努力，向有关工人提供其他维持收入的手段。 职业暴露可能发生在事故之后，通常发生在应急响应初始阶段的应急团队， 以及进行长期修复作业的团队中。在大多数情况下，可以控制暴露，但可能需要 超过公认的剂量限值。在下列情况下，急救人员可能会故意暴露在高于正常剂量 限值的环境中[66]： ●为抢救生命或防止重大伤亡； ●在为避免大的集体剂量而采取行动时； ●采取措施以阻止发展为灾难性状况。 通常此类剂量限值为0.5Gy。暴露在外的人员必须接受全面培训，并且必须 自愿参加相关操作。另一个条件是，在实施可能导致暴露超过剂量限值的作业计 划之前，应就作业咨询相关工人，告知潜在危险，并指导他们采取可行的措施将 暴露保持在合理的最低水平。 应将应急照射所产生的剂量与常规照射所产生的剂量一起记录下来，但应以 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 99 / 124 区别于常规剂量的方式记录下来；不应将这些剂量纳入适用剂量限值所依据的五 年累积总剂量中。在应急暴露情况下造成的剂量应向工人、职业医生和管理当局 报告。工作者不必因这些剂量而被排除进一步的职业照射，但须得到医疗许可[67]。 治疗过度暴露者 根据国际原子能机构（IAEA）的指南[67]，根据剂量可将暴露分为三类，即： ●接近或略高于剂量限值； ●远高于剂量限值但低于特定器官确定性效应的阈值； ●等于或高于确定性效应的阈值。 ○接近剂量限值的，通常不需要任何特殊的临床检查或治疗。职业卫生人员 的作用是建议过度暴露的工作者，这样的暴露不可能产生有害的健康影响。无论 工作者是否要求，都应承担此类咨询职责。 ○如果暴露剂量明显高于剂量限值但低于特定确定性效应的阈值，职业医师 的作用是为工作者提供咨询，并确定是否需要检测生物剂量指标（如淋巴细胞计 数和染色体畸变分析）来确认剂量估算。 医生应采集血样进行检查和剂量估算， 但通常不需要采取进一步措施。 ○如果全身或器官的评估外照射剂量接近确定性效应的临界值，则可能需要 采取治疗措施。作为这一决定的基础，过度暴露的工人需要进行临床检查，并记 录任何异常的发现或症状。为了监测过度暴露的病程，需要进行血液学检查。如 果暴露的严重程度足以导致急性放射综合症，有必要尽早转院至专科医院。 职业医师应开始对早期症状的调查和治疗。在转院至专科医院前，必须优先 处理立即危及生命的伤害如骨折和烧伤。对此类高暴露人群的长期临床管理通常 需要专业医院提供的专业知识。 意外和应急暴露的医疗记录应尽可能完整。应包含所有检查、治疗和建议的 细节。职业卫生监测部门应参与事故调查，以审查响应的适当性。 第七章 自然灾害中的职业安全与健康危害 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 100 / 124 在自然灾害期间，应急人员的主要职责包括：营救幸存者和提供医疗救助、 疏散受影响地区的人员、掩埋尸体、防止进一步破坏、清理工作、提供食物和饮 用水、维护可以良好预防传染病传播的卫生水平，并支持人群接种。 在自然灾害中，应急人员面临的具体风险可能是该地区的破坏、建筑物和其 他结构的倒塌、电气设施的破坏以及基础设施和通信线路的全面破坏。此外，应 对措施可能要求工作者在密闭空间内工作，伴随着严重受伤或被碎片困住或被攻 击性动物攻击的风险。 洪水、风暴和海啸造成的自然灾害，与溺水风险以及介水传播疾病和媒介传 播疾病的传播有关[67]。当受影响人群或应急人员直接接触含有高浓度细菌、病毒 和其他微生物的疫水时，例如当污水进入饮用水供应系统时，或当急救人员工作 时必须接触受污染的地表水，介水传播疾病就会传播。介水传播的传染病主要包 括霍乱、伤寒、志贺氏菌病、大肠杆菌感染、脊髓灰质炎、甲肝、戊肝、轮状病 毒感染、钩端螺旋体病和血吸虫病等寄生虫病。 洪水或灾害后，如果建立露营地照顾灾民，且废弃物处置系统被破坏，媒介 传播疾病也是一种风险。死水是蚊子的孳生地，而垃圾中的食物会吸引啮齿动物。 通常由蚊子传播的疾病有疟疾、登革热、黄热病、寨卡病毒、圣路易斯脑炎、日 本脑炎和西尼罗热。啮齿类动物的粪便可能含有大量的有机体，从而导致钩端螺 旋体病的传播。 可能通过与幸存者接触而影响急救人员的传染病包括伤口感染、由飞沫传播 感染的疾病（如肺结核）、由涂片传播感染的胃肠道疾病，以及由血液传播的疾 病（如HIV、乙型肝炎和丙型肝炎）。血源性疾病、胃肠道疾病和肺结核的感染 可能性最高。 在自然灾害中部署的消防员和其他救援人员等应急救援人员可能特别容易出 现呼吸道疾病和哮喘。火山爆发导致灰烬和气体的大量释放。在野火或火灾中也 会产生烟雾，这是自然灾害的次生影响。山体滑坡和地震导致产生大量的粉尘。 所有这些因素（灰尘、气体、烟雾和粉尘）都会引起眼睛和肺部的刺激，在最严 重的情况下还可能会导致窒息。一些燃烧的副产物通常具有致癌性。 火山爆发、森林火灾或自然灾害的次生影响导致的火灾会导致高度热应激， 从而引起皮肤灼伤和烧伤。倒塌建筑物产生的灰尘、火山爆发释放的气体和灰烬 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 101 / 124 或火灾产生的烟雾造成的空气污染，也使交通事故的可能性增大。 在院前医疗救治和向灾民提供援助方面，急救人员面临着血液和体液暴露， 以及针刺伤害的风险增加，这些都使他们面临着非常高的HIV、乙型肝炎和丙型 肝炎风险。 7.1 洪水导致的职业安全健康危害与风险 洪水是最常见的与天气有关的自然灾害，并影响到世界各地的许多国家。根 据联合国减灾办公室（UNSDR）的报告，2005年至2015年间，洪水占所有气象 灾害的47%，造成40%的灾害死亡，其中89%发生在非洲和亚洲的低收入国家。 2005年至2015年间，许多国家面临严重洪灾，包括亚洲的孟加拉国、中国，印 度和巴基斯坦，以及非洲的马达加斯加、马拉维、莫桑比克、卢旺达、南非和坦 桑尼亚[68]。 洪水可能会增加以下传染病的传播： ●介水传播疾病，如伤寒、霍乱、钩端螺旋体病和甲型肝炎； ●媒介传播疾病，如疟疾、登革热和登革出血热、黄热病和西尼罗热。 介水传播疾病 洪水导致介水传播疾病感染的风险增加：例如伤口感染、皮炎、结膜炎、真 菌感染以及耳鼻喉感染，通过直接接触疫水而感染。 钩端螺旋体病是一种人畜共 患的细菌性疾病，直接经疫水传播。通过皮肤和粘膜暴露于水、潮湿的土壤、植 被或被啮齿动物尿液污染的泥浆而发生传播。在强降雨之后洪水的发生，促进了 由于啮齿动物的繁殖而导致的病原体的扩散，这些啮齿动物在其尿液中释放了大 量导致钩端螺旋体病的微生物。 媒介传播疾病 洪水可能通过扩大病媒栖息地的数量和范围，间接导致媒介传播疾病的增加。 暴雨或河水泛滥造成的积水可能成为蚊子的滋生地，因此增加了受灾人口和应急 救援人员接触登革热、疟疾和西尼罗热等传染病的可能性。洪水一开始可能会破 坏蚊子的繁殖，但当洪水退去时，蚊子卷土重来。延迟时间通常在疟疾流行开始 前6-8周左右。 动物和遇难者尸体造成的风险 与人们的普遍看法相反，没有证据表明尸体在自然灾害后会引起疾病“大流 行”。大多数病原体在人死后不会在人体内存活很长时间（除了HIV，它可以存 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 102 / 124 活6天），而急性感染的源头更有可能是幸存者。只有少数特殊情况下需要采取 特殊预防措施，如霍乱或出血热导致的死亡，人类尸体才构成健康风险[68]。 然而，经常处理尸体的工作者可能有感染肺结核、血源性病毒（如乙肝、丙 肝和HIV）和胃肠道感染（如轮状病毒腹泻、沙门氏菌病、大肠杆菌、伤寒/副伤 寒发热、甲肝、志贺氏菌病和霍乱）的风险。这些病原体通过以下方式获得： ●如果结核杆菌被气溶胶化（在处理尸体的过程中，肺部的残余空气被挤出， 或肺部的液体通过鼻子或嘴巴喷出），就可能获得肺结核。 ●血源性病毒暴露是由于直接接触血液或体液（通过破损皮肤、碎骨片和针 头造成的伤害，或血液或体液溅到粘膜）造成的。 ●胃肠道感染更常见，因为尸体通常会漏出粪便。通过直接接触尸体、脏衣 服或受污染的车辆或设备进行传播。尸体污染水源也可能导致胃肠道感染。 应及时通知公众和应急人员不要惊慌，避免不当处置尸体，并在处理尸体时 采取适当的预防措施。 洪水造成的其他健康风险包括溺水、受伤或精神创伤，以及长时间困在洪水 中的低体温。暴露在洪水和雨水中也可能增加呼吸道感染的风险。 7.2 热带风暴、飓风、气旋和台风 热带风暴、气旋、飓风和台风虽然名称不同，但描述的是同一类型的灾害。 气旋、飓风和台风可以提前几天预报。发生范围广泛，往往具有很强的破坏 性。这些灾难通常比洪水更具破坏性。在突然的短暂的袭击中，大风对基础设施 和房屋造成了重大破坏，尤其是脆弱的建筑。随后通常会有暴雨和洪水，在沿海 平坦地区还会有大浪。 与热带风暴、飓风、气旋和台风有关的主要OSH危害包括： ●结构不稳定，有倒塌线路、带电电气设备和其他公用设施(如煤气和水)的 风险； ●噪音； ●从高处坠落或从洞口坠落； ●石棉、铅； ●飞行物体撞击眼睛和面部； ●手动搬运物料/重物； ●未知化学物质； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 103 / 124 ●割伤； ●工作时滑倒、绊倒、跌倒。 7.3 地震 当人口稠密地区发生地震时，可能会造成人员伤亡和财产损失。 大多数与地 震有关的伤害是由于地面晃动造成的墙壁倒塌、飞溅的玻璃和坠落的物体，或者 是人们在摇晃时试图移动所造成的。地震造成的大部分破坏是可预测和可预防的 [69]。 地震期间应急响应人员的主要OSH危害包括： ●因结构不稳定、孔洞、突出钢筋、坠落物撞击、火灾、接近重型机械(如起 重机)、玻璃和碎片等尖锐物体、余震、振动和爆炸造成的二次坍塌以及裸露的带 电电线而造成的损伤； ●接触危险化学品和其他危险物质(氨、蓄电池酸、燃料泄漏)、天然气泄漏 造成的易燃、有毒环境、氧气不足、密闭空间/陌生环境； ●在处理和护理伤者过程中，由于接触病原体（来自被破坏的卫生系统）、 血源性病原体而造成的生物危害； ●恶劣天气条件； ●设备(发电机/重型机械)噪音； ●暴露于空气中的烟尘(石棉、二氧化硅等)。 用于保护应急响应人员的主要OSH控制措施包括： ●由安全/OSH人员全面监督响应工作者安全和健康方面； ●确保实施最佳的安全和伤害预防措施； ●调查和记录所有响应团队的伤害和疾病； ●准备和持续使用进入许可证（例如进入密闭空间、进行电气作业等）； ●确保使用适当的PPE； ●制定和实施日常健康和安全计划，解决环境卫生、个人卫生、PPE、洗消、 工作/休息周期、紧急医疗护理和其他相关问题； ●评估已被识别的危害的风险； ●危险意识和PPE使用的培训。 7.4 自然灾害后的应急行动中常见的职业安全和健康危害 7.4.1 搜救队行动 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 104 / 124 搜救是应对自然灾害的重要活动。 突如其来的突发性自然灾害如地震、海啸 和风暴，通常会破坏基础设施，造成伤害，有时还会造成大量人员伤亡，并使人 被困废墟。需要立即作出挽救生命的反应，以拯救被困人员并稳定或疏散幸存者， 生与死的区别可能是几个小时。 最初的搜救和救援行动需要快速到达，应具备专 业技能，并且往往需要重型或专业的技术设备。这些团队工作的工作环境往往极 具挑战性，因为响应者必须在公共服务和基础设施遭到破坏或损毁的地区的废墟 中工作。 通用风险评估（英国消防救援服务操作指南的一部分，译者注）全面介绍了 搜救对开展的活动、与之相关的健康和安全危害以及应急响应人员面临的风险[70]。 在第2.1密闭空间救援和第2.1.4倒塌建筑中，指南列出了搜救过程中的关键活动， 以及OSH危害、风险和控制措施，如下所述： 1、向作业现场提供和操作设备 这些活动包括因手动操作设备而产生的危险，主要危险包括肌肉骨骼损伤。 最危险的响应人员包括消防员和救援人员。 为预防和控制这些风险，需要采取以下控制措施： ●相关手动操作程序的信息、指导和培训，以及评估； ●适当情况下集体实施提升作业； ●考虑有助于救援行动所需的设备类型和数量； ●适当布置前方物流区或设备堆场的位置，以尽量缩短运输距离； ●适当时考虑使用机械起重辅助设备； ●人员轮换以减轻疲劳。 2、从作业现场救出伤亡人员 从现场救出伤亡人员还涉及人力作业和使用重型机械。风险最高的包括消防 员、救援人员以及其他应急工作者。主要危害包括： ●人力作业活动； ●体液的存在； ●医疗设备内有锋利物； ●激动和痛苦的伤员； ●重大伤亡。 主要健康和安全风险包括： 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 105 / 124 ●肌肉骨骼损伤； ●生物危害； ●污染和感染； ●对人员的语言和人身攻击； ●长期和反复暴露于创伤性环境中； ●创伤后应激。 为预防和控制这些风险，需要采取以下控制措施： ●相关手动操作程序的信息、指导和培训； ●适当情况下集体实施提升作业； ●急救和伤亡处理程序的信息、指导和培训； ●提供临床护理和评估的危险区域响应团队人员/护理人员； ●适当的接种（如破伤风、乙型肝炎）； ●消防和救援机构的生物危害控制设备和程序； ●应急洗消程序； ●考虑在适当情况下使用机械起重辅助设备/担架； ●人员轮换以减轻疲劳； ●与危险区域响应小组/医护人员的培训/联络； ●使用PPE； ●不允许消防和救援人员给伤员注射/用药； ●救援队伍至少由两人组成； ●提供职业健康服务。 3、进入密闭空间 密闭空间是指实质上是封闭的（虽然并不总是完全封闭），并且由于空间内 或附近的危险物质或条件（例如缺氧）可能造成严重伤害的区域。密闭空间或缺 氧区域通常见于坑、污水渠、储罐，或储存或使用大量气体的地方。还包括水井、 雨水渠、大桶、锅炉、筒仓和隧道。最近燃烧过的建筑物也可能是缺氧的。 风险最高的包括消防员和救援人员以及其他应急工作者。主要危害包括： ●有毒和易燃蒸气； ●流动的液体和固体（如流沙，译者注）； ●缺氧或窒息； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 106 / 124 ●极端温度； ●火灾或爆炸。 与密闭空间作业相关的主要健康和安全风险包括： ●误入受伤； ●溺水； ●窒息； ●中暑、热应激； ●体温过低； ●幽闭恐惧症； ●易燃或爆炸性气体、蒸汽或烟雾； ●有毒物质。 需要采取以下控制措施来预防和控制这些风险： ●消防和救援当局对密闭空间作业的培训和程序； ●密闭空间作业的搜救程序； ●提供和使用气体监测设备； ●通风设备； ●安全官员和/或指定的监督人员监督密闭空间的作业； ●有效沟通； ●只允许必要的人员进入密闭空间； ●救援队至少由两人组成。 4.开凿和破拆，打开空间的操作 面临风险的主要包括消防员和救援人员。 这些活动涉及使用专门的设备、工具等。主要危害包括： ●高浓度粉尘； ●噪音； ●振动； ●移动结构件； ●设备上的运动部件； ●从设备和结构件上脱落的碎屑/碎片； ●电气危害； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 107 / 124 ●摇摇欲坠的结构件； ●由于存在有害物质、气体泄漏和/或缺氧/富氧而无法呼吸的空气。 与开凿和破拆作业相关的主要健康和安全风险包括： ●呼吸窘迫； ●窒息； ●噪声性听力障碍； ●无法听到警告/疏散信号； ●手臂振动综合征； ●二次坍塌； ●被缠住； ●割伤/挫伤； ●触电死亡； ●夹伤/挤压伤。 需要采取以下控制措施来预防和控制这些风险： ●使用专业设备的信息，指导和培训； ●轮换工作者以减少暴露； ●噪声和振动管理系统，以记录暴露水平和持续时间； ●安全人员的监督； ●使用建筑物场景评估设备； ●现场专家协助联络（例如搜救队，主要学科顾问，结构工程师）； ●提供支撑设备； ●预定疏散信号； ●消防和救援当局的个人/呼吸防护设备，考虑包括自给式呼吸器/供气管/呼 吸器； ●监控设备，以找到隐藏/埋设的电缆； ●提供和使用气体监测设备。 7.4.2 链锯使用的危害和风险及其控制 在各种紧急情况下，特别是在自然灾害期间，可能需要链锯清理树木和灌木 丛以进行救援和响应。但是，使用链锯需要采取安全预防措施。 使用链锯的主要危险和风险包括： 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 108 / 124 ●刀片会导致严重割伤。 ●链锯很重，可能会导致背部受伤。 ●链锯噪音可能导致听力损失。 ●链锯可能会反弹并造成伤害。 ●链锯的振动会导致肌肉、神经或肌腱麻木和受伤。 ●飞溅碎片可能导致眼睛受伤。 根据爱尔兰卫生和安全管理局的建议，需要采取以下预防措施，以实现链锯 安全操作[33]： 切割前 ●检查控制装置、链条制动器、链条张力器以及链锯上的所有螺栓和把手， 确保它们正常工作。 ●确保离合器盖没有破损或露出链条或齿轮。 ●磨链齿。 ●添加链锯燃料时，确保操作者距离任何点火源至少10英尺(3米)。 ●在链条制动器接合的情况下，在距加油区域10英尺（3米）的地方启动链 锯。 切割时 ●清除可能妨碍砍伐树木或灌木的障碍物区域。 ●操作链锯时，手放在把手上，确保支点稳固。 ●不要直接从头顶或两腿之间切割。 ●切割前要抬头检查松动的树枝是否可能从树上掉下来。 ●做好回扣准备。不要用锯尖切割。紧盯尖端的位置。 7.4.3 户外作业中因动物/昆虫咬伤和与有毒植物接触而引起的风险 在应对自然灾害时，应急工作者可能会接触到野生动物、毒蛇、蜘蛛或蝎子 或昆虫，可能对其健康构成严重威胁。为防止此类风险，美国CDC建议采取以下 保护措施[31]： ●使用驱虫剂； ●避免暴露的高峰时间/地点； ●穿着适当的衣服，覆盖身体部位，以避免暴露； ●使用蚊帐； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 109 / 124 ●用氯菊酯等杀虫剂处理衣物、蚊帐和用具； ●意识到野生动物、宠物等动物的流离失所(切勿试图捡起蛇)； ●进入前对区域进行检查； ●注意手和脚的位置(不要把手伸进洞、窝等，踩在石头或木头上而不是扶在 上面)； ●在可疑区域工作时，应穿戴适当的鞋套和皮手套。 野外和森林中的自然灾害响应行动，可能使应急响应人员接触到某些具有健 康风险的植物，如皮肤和呼吸道过敏，或皮肤和粘膜过敏。常见的此类植物例如 毒常春藤、毒橡树和毒漆树[71]。NIOSH建议以下预防措施以防止这些影响： ●学习识别工作区域及其周围的有毒植物； ●使用手套和合适的衣服（如长裤和长袖衬衫）； ●用肥皂或清洁剂清洗受影响区域） ●用酒精擦拭去除引起反应的油性树脂； ●避免焚烧可能含有毒常春藤、毒橡木或毒漆树的植物或灌木丛；吸入燃烧 植物的烟雾可导致严重的过敏性呼吸问题。 第八章 在冲突局势中的人道主义响应期间管理卫生工作者的健康和安全 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 110 / 124 卫生应急人员主要由本国卫生工作者组成，但通常还包括努力在紧急情况下 提供挽救生命的干预措施的国际医护人员。在冲突和紧急情况期间，医护人员面 临的最令人不安的挑战是，他们自己是真正或受到威胁、有针对性或无差别攻击 的受害者。 这种攻击不仅危及医护人员，而且也剥夺了受紧急医疗影响的人在最需要紧 急护理时候的权利。虽然此类攻击的后果迄今为止基本上是未记录在案的，但它 们被认为是重大的——对短期卫生保健的提供以及受影响人群、卫生系统、卫生 工作者的长期健康和福祉产生负面影响，最终影响全球所有公共卫生目标。 根据WHO的报告[7]，在2014年1月至2015年12月的两年间，有594起针对 医护人员的袭击报告，导致19个紧急情况国家的959人死亡、1561人受伤。对收 集到的信息的分析表明： ●大多数目标（63%）是医疗机构。 ●超过1/4的目标是医护人员（26%），6%的目标是医疗服务。 ●594次攻击中有366次（62%）被报告为蓄意，116次攻击（20%）被描 述为无意，并且112次攻击（19%）没有报告蓄意或未知/未确定。 ●据报道，约有53%的攻击是由国家行为者实施的，30%是由非国家行为者 实施的，17%的肇事者仍未知、未报告或未确定。 冲突和紧急情况下医疗机构的职业安全健康管理 在解决针对提供医疗保健的暴力问题以及保护卫生工作者健康和安全的必要 性时，需要考虑许多因素。除了常见的健康和安全风险，如当地流行的疾病、道 路交通事故、热应激和其他使应急工作变得危险的情况，冲突还会带来许多必须 解决的、额外的职业安全与卫生风险。 在采取保护卫生机构和工人的具体行动之前，需要解决以下与健康和安全相 关的问题： ●社区参与。获得人们的协作和信任是确保医疗保健和卫生工作者安全的关 键。紧急服务应首先评估和监测武装团体、当局和其他相关团体和个人如何看待 卫生保健工作者和其他应急服务提供者。 ●表明卫生保健活动的简单标志。标志应清晰可见。 ●疏散通讯。在作业之前必须在医务人员、非政府组织、军队和其他相关人 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 111 / 124 员之间建立医疗后送的通信线路，然后应在整个过程中进行维护。医疗后送工作 需要涵盖当地社区领导和当局。受救助者和病人转运不一定由医务人员或车辆执 行。 ●对国际人道主义法、人权和道德的认识。医护人员人员应大致了解国际人 道主义法、人权和道德原则如何在武装冲突和其他紧急情况下塑造其权利和责任。 应向他们提供培训，包括坚持医疗道德原则、面临医疗困境、暴力处置和预防以 及压力管理等领域。 ●与民间社会领袖沟通。 必须加强关于保护保健服务的对话，并与包括宗教 和社区领导人在内的所有民间社会领导人接触，同时考虑到他们在社会中的重要 性，特别是在冲突和危机时期。 8.1 医疗机构安全措施 影响医疗机构安全的因素应一并考虑，包括医疗系统和基础设施抗冲击的能 力、供应链被打断的潜在影响以及工作者和患者的福祉。 WHO安全医院方案[72]有助于评估卫生设施的安全性，特别是在发生自然灾 害以及暴力事件时。该计划的一个关键目标是保护卫生工作者，但其他目标包括 保护患者及家庭、保护医院建筑、设备和关键医院系统的物理完整性。国际医院 安全指数已成为一项全球标准，各国不断采用该指数来确定解决已查明弱点的行 动。 红十字国际委员会在其保护卫生保健的报告中，提出了针对暴力侵害医疗机 构的主要建议，并建议采取以下措施[73]： ●应急计划。应制定应急计划和所需补给和服务的清单，以确保自给自足约 10天。与多家供应商建立良好的工作关系至关重要，因为依赖单一来源的风险太 大。应为制定计划和举行演练分配足够的资源，使全体员工做好应急准备。该机 构的应急计划应与现有的区域或国家计划相匹配。 ●疏散计划和风险评估。应监控火灾和其他风险，所有员工应熟悉疏散计划。 在关键区域外的窗户和防护墙上使用塑料薄膜可以减少爆炸造成的损坏。此外还 必须安排备用水源和不同来源的供电。 ●访问控制。为了更好地控制出入口，应在整个医疗设施周围修建带控制点 的围墙。初步的安全检查和检伤分类应明确分开。警卫只能用于安全工作和控制 点，不能用于检伤分类。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 112 / 124 ●预警系统。应建立适应紧急情况的预警系统。 ●关键设施置于安全位置。安全放置重要的公用设施有助于降低其受到攻击 的脆弱性，并确保备份。 ●通信系统，在正常通信渠道中断的情况下，应采取其他通信方式。 ●其他重要措施包括： ○将物资存放在安全区域，保护货物免受危险和抢劫劫掠； ○使用制氧机而不是气瓶； ○焚烧废物和隔离危险物质。 8.2 医疗机构人员保护措施 ●应明确员工的角色和责任，以确保在紧急情况下具有必要的灵活性。 ●应向医护人员提供应急准备和压力管理方面的培训。这种培训可以包括消 防演习、风险评估和风险管理、防护要点、谈判、沟通、管理人们的预期、自卫、 心理支持、急救和自我保健。此外，应就工作者在设施内外的适当行为提供指导 和培训，以化解侵犯行为。 ●卫生保健设施需要保护患者，同时适当注意其中患者可能存在的风险。如 有可能应避免根据隶属关系对患者进行分组。具有高安全风险的患者，在可行的 情况下应尽快出院。 ●医疗主管应考虑患者家属的要求。在进行截肢等重大外科手术之前，应征 得他们的同意，必要时应向家属提供心理社会支持。虽然有时建议限制探访人数， 但应为病人家属提供等候室。 ●保持定期的沟通和与当地社区的良好关系，通过建立一种归属感来提高设 施的安全性和可接受性。医院或诊所的负责人应定期尝试确定当地社区对此的看 法，以及预防措施是否被视为障碍。 ●与媒体接触可以提高医院或诊所的安全性。向公众和相关行动者通报其服 务可以提高对卫生保健的接受程度：这要归功于认识到卫生保健是公平提供的。 应制定积极主动的媒体战略，包括社会媒体负责任行为准则，并与媒体建立定期 联系，以减少紧急情况或危机时的紧张和误解。然而，信息共享的必要性必须始 终与伦理考虑、保密性和设施的安全性相权衡。 ●如果安全风险变得不可容忍，临时搬迁医疗服务可能是唯一的解决方案。 在准备阶段以及服务、患者和员工转移期间，应仔细规划所有临时迁移措施，并 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 113 / 124 制定策略指导管理。在建立临时医疗设施时，咨询当地提供者、当局、社区领导、 工作者、病人和非政府组织是很有用的。在选择新地点之前，应进行安全和现场 分析，并考虑以下因素：社区接受度、工作者和人口的可达性、优质医疗服务的 可用性以及潜在合作伙伴的存在。 8.3 冲突中的压力管理 除了人身伤害之外，在冲突中工作也会给工作者带来严重的压力风险。当压 力对特定情况是一种正常的、有用的反应时，它可能是一种自我保护的形式。但 是，它可能会导致更高、更严重的压力水平。在武装冲突和其他紧急情况下工作 的人会感受到三种严重的压力。如果不被识别和处理，它们可能是有害的。包括： ●基础压力，这是突然转入陌生环境的结果； ●累积压力，由多个因素引起，包括对自身安全的担忧（这可能缓慢或快速 增加，并且通常是可预见的）； ●创伤性压力，由意外和暴力事件引起，并伴有对此人或其附近的人造成身 体或心理伤害的威胁。PTSD是对急性心理创伤的延迟反应。创伤应激和PTSD 都需要尽早获得专业帮助。 IASC关于紧急情况下心理健康和心理社会支持的指南包括以下行动[74]： 冲突期间健康和其他应急工作者的个人一般福利 在武装冲突和其他紧急情况下，为伤者和病人提供照顾可能是非常有压力的。 应急工作者必须采取措施保障自身的健康，以继续履行其职责。就一般福利而言， 需要采取以下行动： ●遵守当地安全指南（如有）； ●尽一切努力确保自己的安全； ●不承担不必要的风险； ●注意环境的变化； ●充分休息； ●了解自己的极限； ●定期进食，避免饮酒和吸毒； ●融入团队，不要孤立自己； ●与朋友和同事谈论你所关心的事情，尤其是当你感到压力时； ●锻炼身体； 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 114 / 124 ●注意个人卫生。 预防和管理心理健康和社会心理健康问题的最低响应计划 该计划应包括以下内容： ●确保制定具体计划，在特定紧急情况下保护和改善应急人员的福祉。 ●为应急工作者的工作和应急环境做好准备。 ●改善健康的工作环境。 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Geneva： International Federation of Red Cross and Red Crescent Societies； 2016. 74. IASC guidelines on mental health and psychosocial support in emergency settings.Geneva： Inter-Agency Standing Committee； 2007. 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 119 / 124 附录：工具箱 尿液颜色表 对于户外作业和室内穿戴个人防护服工作，热应激是一种重要的职业健康危害。尿液的颜色 以快速和简单的方式提供了有关水合状态的充分信息，因此可以促使应急响应工作者摄入足 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 120 / 124 够的水和液体，并采取其他预防措施，以防止热应激的影响。 尿液颜色表是美国NIOSH开发的一种简单的视觉辅助工具，用于监测水合状态。图表显示了 不同颜色混合物的不同水合水平，从淡黄色到深琥珀色不等。尽管对大多数尿呈正常淡黄色 至深琥珀色的工作者来说，尿液颜色表是一个很好的水合状态指标，但根据描述尿液颜色异 常原因的表格，尿液颜色也可能受到饮食、药物和疾病或功能失调的影响。 参见：Appendix B of the document NIOSH criteria for a recommended standard： occupational exposure to heat and hot environments by Jacklitsch B，Williams WJ， Musolin K， Coca A， Kim J-H and Turner N. Cincinnati (OH)： U.S. Department of Health and Human Services， Centers for Disease Control and Prevention， National Institute for Occupational Safety and Health， DHHS (NIOSH) Publication 2016-106. Weblink： https：//www.cdc.gov/niosh/docs/2016-106/pdfs/2016-106.pdf， accessed 25 September 2017. 热指数 NIOSH的热指数记录了NIOSH推荐标准的原则：职业暴露于高温和热环境，包括绘制包含相 对湿度的温度图表。它提供了关于长时间暴露在高温和/或剧烈活动中可能发生的热应激的可 能性的有用信息，并提供了四个风险等级：极度危险、危险、极度小心和谨慎，以不同颜色 显示。美国国家海洋和大气管理局（NOAA）根据热指数发布高温警报。 热指数包含美国OSHA定义的工作场所风险等级。这些风险等级可以帮助应急管理人员监测 天气并发布预防措施和控制热应激的说明。这些信息对于在炎热环境中工作的应急工作者 （例如白天在热带地区户外作业）以及在热带地区的医疗机构工作的医务人员非常有用。 参见：Appendix C of the document NIOSH criteria for a recommended standard： occupational exposure to heat and hot environments by Jacklitsch B， Williams WJ， Musolin K， Coca A， Kim J-H and Turner N. Cincinnati (OH)： U.S. Department of Health and Human Services， Centers for Disease Control and Prevention， National Institute for Occupational Safety and Health， DHHS (NIOSH) Publication 2016-106. Weblink： https：//www.cdc.gov/niosh/docs/2016-106/pdfs/2016-106.pdf， accessed 25 September 2017. 现场水消毒技术 美国CDC旅行者健康网页上的信息为不同类型的水消毒技术提供了全面的指导，比较了各种 常用方法的优缺点，并指导如何选择合适的方法。 该信息应有助于部署在偏远地区的应急响应工作者选择和使用适当的水消毒方法，以保护他 们免受介水传播疾病的侵害。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 121 / 124 Weblink： https：//wwwnc.cdc.gov/travel/yellowbook/2016/the-pre-travel- consultation/water-disinfection-for-travelers， accessed 35 September 2017. 安全使用梯子 在应急处置过程中，应急工作组可能不得不爬上建筑物、树木、墙壁等来救援伤员或应对紧 急情况。在这些条件下工作通常涉及使用梯子。这种情况会造成因高处跌落而受伤的严重风 险。坠落造成的伤害风险从地面以上6英尺处逐渐增加，任何超过该高度的工作都需要使用 梯子。 英国健康与安全执行局关于安全使用梯子和梯子的简要指南涵盖了使用梯子时应采取的预防 措施。这些信息对于应急安全阶梯使用实践的应急响应者应具有实际用途。 参见：Safe use of ladders and stepladders， a brief guide. London： Health and Safety Executive；2014. Weblink： http：//www.hse.gov.uk/pubns/indg455.pdf， accessed 25 September 2014. 紧急情况下的个人压力管理 紧急情况下的心理压力是应急工作者的主要职业健康和安全危害之一。心理急救（PFA）涉 及对遭受严重危机事件的人进行人道的、支持性的和实际的帮助。它提供了一个框架，以尊 重他们的尊严、文化和能力的方式给与支持。PFA涵盖社会和心理支持。 “关心自己和同事”的报道为通过健康的工作和生活习惯预防压力的实际措施提供了简单实 用的指导。在不同的响应阶段，此信息应该是对应急响应工作者有用的。 参见：Psychological first aid： guide for field workers. Published by the World Health Organization in collaboration with the War Trauma Foundation and World Vision International， Geneva， 2011. Weblink：http： //apps.who.int/iris/bitstream/10665/44615/1/9789241548205_eng.pdf， accessed 25 September 2017. http：//apps.who.int/iris/biteam/10665/44615/1/9789241548205_eng.pdf 应急工作者个人准备检查表 WHO现场应急操作手册涵盖了现场应急操作的不同方面，并包括应急人员的任务准备清单。 检查表包括各种领域，如：家庭福利、银行信息、商业和金融、车辆维修和维护、家庭安全 维修和维护、交通和通信能力、地缘政治和文化意识、卫生和WHO行政问题。 在部署到紧急区域之前，应急人员需要解决这些实际问题。这对解决部署前的压力也有很大 帮助。检查表可以适当调整，以供管理者使用，以监控其团队成员以及单个响应人员的准备 情况。 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 122 / 124 参见：Handbook for emergency field operations. Geneva： World Health Organization； 1999. Weblink： http：//www.who.int/hac/techguidance/tools/7661.pdf， accessed 25 September 2017. 医疗机构工作场所暴力的识别和评估 世界各地都在关注医疗机构中的工作场所暴力。尽管任何机构可能因多种原因受到暴力影响， 但仍有某些特征，以及某些组织、工人团体、工作者和工作场所条件，这些特征有助于滋生 暴力并使暴力持续存在。卫生部门处理工作场所暴力问题的文件框架指南中有关于工作场所 暴力识别和工作场所风险评估的章节。该文件包括有关识别存在风险的组织、弱势群体、潜 在长期者和受害者的特征，以及对工作场所暴力造成高风险的工作场所情况的信息。 这些信息应有助于政策制定者、规划者、领导者和管理者确定可能对卫生部门工作场所暴力 构成风险的工作场所特征、弱势群体和工作场所条件。这应有助于他们制定适当的相关政策、 战略和计划，以预防和管理卫生部门的工作场所暴力。 参见：Framework guidelines for addressing workplace violence in the health sector. Joint programme on workplace violence in the health sector. Published by the International Labour Organization in collaboration with the International Council of Nurses， World Health Organization and Public Services International， 2002. Weblink： http：//apps.who.int/iris/bitstream/10665/42617/1/9221134466.pdf， accessed 25 September 2017. 事故指挥系统 美国OSHA的事故指挥系统（ICS）上的eTool是一个有用的Web资源，用于提供有关ICS和 统一命令的信息。eTool以全面的方式涵盖了ICS的不同方面，包括需求、范围和定义、组织 结构、角色和责任、准备、实施和事故后的安全方面。 该信息应有助于帮助应急响应规划人员和管理人员了解紧急情况下ICS的概念，并有助于规 划应急响应工作者的职业安全与健康。 Weblink： https： //training.fema.gov/emiweb/is/icsresource/assets/reviewmaterials.pdf， accessed 11 October 2017. 食品安全五大要点 食品安全五大要点资源（如手册、海报、视听资源等）由WHO制作。这些信息将《安全食品 制备规则》的所有信息纳入了更容易记住的简单标题下，并提供了建议措施背后的理由的更 多细节。食品安全五大要点核心信息是：（1）保持清洁，（2）生熟分开，（3）彻底烹饪， （4）在安全的温度保存食物，以及（5）使用安全的水和原材料。 手册中提供的信息以及其他媒体（如视听辅助、海报、小册子等）将有助于在应急响应工作 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 123 / 124 者中传播食品安全信息。应有助于领导者和管理者在应对过程中规划、实施和监测食品安全 措施，并有助于个别应急工作者采取安全、卫生的食品处理和制备做法。 参见：Five keys to safer food manual. Geneva： World Health Organization； 2006. Weblinks： http： //apps.who.int/iris/bitstream/10665/43546/1/9789241594639_eng.pdf?ua=1， accessed 25 September 2017. Five keys to safer food (audiovisual presentation) https：//www.youtube.com/watch?v=ONkKy68HEIM， accessed 25 September 2017. 紧急情况下的健康与安全在线课程 DisasterReady组织的在线课程涵盖了一系列关于紧急情况下的健康、安全和安保的主题。 这些领域包括具有现实重要性的领域，如心理健康和心理支持——包括心理急救、埃博拉认 识、疟疾问题、危机中的医疗保健、法律框架、消防安全、基本现场安全等。 课程面向所有人开放，由简单易懂的语言和音频视频组成。 Weblink： https：//www.disasterready.org/， accessed 25 September 2017. 手卫生资源 手卫生是在日常工作以及突发事件和紧急情况下防止生物危害的关键要素。手卫生应作为一 个系统性方案实施，该方案应包括在临床环境中使用的基本原理、正确的方法、使用不同的 手卫生材料、使用者之间的意识以及工作场所的监测。 这里给出WHO现有的核心卫生资源。这些资源应有助于应急方案管理人员和应急人员认识到： 在暴发和紧急情况以及常规工作条件下需要手卫生做法。 WHO guidelines on hand hygiene in health care. Geneva： World Health Organization； 2009. Weblink： http： //apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf Hand hygiene-related videos and podcasts. Weblink： http：//www.who.int/gpsc/5may/video/en/ Hand hygiene-related tools and resources. Weblink： http：//www.who.int/gpsc/5may/tools/en/ WHO audio-visuals on hand hygiene. No action today， no cure tomorrow Weblink： https：//www.youtube.com/watch?v=kOKeFv5VvY4 Hand washing technique Weblink： https：//www.youtube.com/watch?v=3PmVJQUCm4E 突发公共卫生事件中的职业安全与健康：卫生工作者与应急人员保护手册 124 / 124 (All resources accessed 25 September 2017) 应急响应人员健康监护在线培训 本培训课程由美国CDC设计，涵盖紧急情况下的健康监护和监测框架信息，称为应急响应者 健康监护和监测（ERHMS）系统。该系统包括针对响应所有阶段（包括部署前、部署中和 部署后）的特定建议和工具。 培训应适用于与应急工作者的职业安全和健康相关的人员（如应急管理人员、应急响应人员、 医务人员、健康和安全代表、流行病学家等）。 Weblink： https：//emergency.cdc.gov/training/erhmscourse/index.asp， accessed 25 September 2017.