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Edit Comment Close Premium member Presentation Transcript Disaster Management – Health SectorEnvironmental Health, Medical Response and Hospital Safety Issues, Challenges and Participatory Governance : Disaster Management – Health SectorEnvironmental Health, Medical Response and Hospital Safety Issues, Challenges and Participatory Governance Dr. Anil K. Gupta Associate Professor National Institute of Disaster Management Government of India New Delhi Reported catastrophe losses in India, 1965-2001 : Reported catastrophe losses in India, 1965-2001 Catastrophe events (1970-2001) : Catastrophe events (1970-2001) All natural catastrophes worldwide 1980 – 2005, number of events : All natural catastrophes worldwide 1980 – 2005, number of events Number of Disasters by Origin: Regional Distribution, 1995–2004 (Source (base map): UNEP/DEWA/GRID-Europe.November 2004. : Number of Disasters by Origin: Regional Distribution, 1995–2004 (Source (base map): UNEP/DEWA/GRID-Europe.November 2004. DISASTERS IDENTIFIED BY High Powered Committee (HPC) : Environment? DISASTERS IDENTIFIED BY High Powered Committee (HPC) 1. Floods 2. Cyclones 3. Tornadoes 4. Hailstorm 5. Cloud Burst 6. Heat Wave and Cold Wave 7. Snow Avalanches 8. Droughts 9. Sea Erosion 10. Thunder and Lightning 11. Tsunami (Added) I. WATER AND CLIMATE RELATED DISASTERS Slide 11: Environment? 1. Landslides and Mudflows 2. Earthquakes 3. Dam Failures/ Dam Bursts 4. Mine Fires II. GEOLOGICALLY RELATED DISASTERS III. CHEMICAL, INDUSTRIAL AND NUCLEAR Chemical and Industrial Disasters Nuclear Disasters Slide 12: Environment? IV. ACCIDENT RELATED DISASTERS 1. Forest Fires 2. Urban Fires 3. Mine Flooding 4. Oil Spill 5. Major Building Collapse 6. Serial Bomb Blasts 7. Festival related disasters 8. Electrical Disasters and Fires 9. Air, Road and Rail Accidents 10. Boat Capsizing 11. Village Fire Slide 13: Environment? 1. Biological Disasters and Epidemics 2. Pest Attacks 3. Cattle Epidemics 4. Food Poisoning V. BIOLOGICALLY RELATED DISASTERS Disaster –types : Re-classified… : Disaster –types : Re-classified… Environmental (natural or man-made) Geo-hydrological Biological Chemical Fires Epidemic…. Technological & civil / sectorial Rail, Industrial (Electrical, Mechanical..), Nuclear, Road… Security threats Terrorism, sabotage, bomb blast… War Festival related – Stempede etc. Disaster terminology : Disaster terminology Hazard Risk ~ Po * Ed Vulnerability Exposure Disaster Impact Damage Loss Disaster management terminology : Disaster management terminology Prevention Control Mitigation Resilience Avoidance Resistance Tolerance Response Relief Rehabilitation Recovery Reconstruction RISK : RISK The probability of harmful consequences or expected losses (deaths, injuries, property, livelihoods, economic activity disrupted or environment damaged) resulting from interaction between natural or human-induced hazards and vulnerable conditions Risk ~ P * D P = probability of occurrence D = extent of damageability Disaster Risk Management : Disaster Risk Management ALARP : ALARP As Low As Reasonable Practicable (ALRAP) DRR ZONE BATNEEC Concept of Disaster Risk Reduction : Concept of Disaster Risk Reduction Risk Reduction: Event minimization Loss minimization Quick recovery (Resilience) Approach: Visualizing hazards Reducing vulnerability Increasing coping capacities DM Paradigm Shift : DM Paradigm Shift Response Centric Relief Centric Mitigation centric Preparedness centric Disaster Centric Hazard Centric Vulnerability Centric Environment Centric Adaptation DRR Strategy Design – Components : DRR Strategy Design – Components What is the risk hazard - event x damageability What is at risk – Life, Structures, Resources, Infrastructure Resist Resilience Avoid Tolerate Manage Programmes Direct Indirect Infused IMPACTS OF DISASTERS : IMPACTS OF DISASTERS Physical (buildings, structures, physical property, industry, roads, bridges, etc.) Environmental (water, land/soil, land-use, landscape, crops, lake/rivers / estuaries, aquaculture, forests, animals/livestock, wildlife, atmosphere, energy, etc.) Social (life, health, employment, relations, security, peace, etc.) Economic (assets, deposits, reserves, income, commerce, production, guarantee/insurance, etc.) Physical Environmental Disaster Event SOCIAL Economic Forced Migration : Forced Migration Likely effects on disaster impacts on environmental components and assets : Likely effects on disaster impacts on environmental components and assets Disaster-Environment Impact Matrix : Disaster-Environment Impact Matrix D=Direct, I=Indirect, S=Secondary, L=Less, C=Case specific Impacts of tropical cyclone land-fall and associated environmental losses : Impacts of tropical cyclone land-fall and associated environmental losses Chemical Hazard Profile : Chemical Hazard Profile Out of 602 districts in India, 263 districts have MAH units. 170 districts have clusters of more than 05 MAH units (hazardous/industrial pockets). ?Risk There are 1666 MAH units in India. Sources of Chemical Disasters : Sources of Chemical Disasters Manufacturing and Formulation Facility Material Handling and Storage Bulk Storages: Manufacturing and isolated storages (including in Ports & Docks) Storages of Small Containers: In manufacturing facilities, in isolated warehouses and godowns, and Storage of Fuels (LPG Depots etc.) Pipelines, and Transportation (road-, rail-, air- & waterways) : Chemical Disasters in general, result from – Fire Explosion Toxic release Poisoning, or Combination of the above Reactive Radioactive Corrosive Causes of Chemical Disasters Bhopal Gas Tragedy : Bhopal Gas Tragedy Worst industrial disaster in history 2,000 people died on immediate aftermath Another 13,000 died in next fifteen years 10-15 persons dying every month 520,000 diagnosed chemicals in blood causing different health complications 120,000 people still suffering from Cancer Tuberculosis Partial or complete blindness, Post traumatic stress disorders, Menstrual irregularities Rise in spontaneous abortion and stillbirth Effects of a chemical disaster on life and environmental factors : Effects of a chemical disaster on life and environmental factors Immediate impact : Immediate impact Morbidity and mortality –Including of health care staff Disruption of water supplies Disruption of sanitation Destruction of infrastructure, including health facilities Displacement of large numbers of people Social and psychological distress Disasters and Health : Disasters and Health • Injuries from the event • Environmental exposure after the event • Malnutrition after the event • Mental health consequences • Communicable disease outbreaks • Excess neo-natal mortality Phases of Disaster : Phases of Disaster Impact Phase (0-4 days) Extrication Immediate soft tissue infections Post impact Phase (4 days- 4 weeks) Airborne, foodborne, waterborne and vector diseases Recovery phase (after 4 weeks) Those with long incubation and of chronic disease, vectorborne Disasters and Deaths : Disasters and Deaths Here is another portrayal of the number of disasters over time. From 1970-2000, the number of reported natural disasters tripled. The number of people affected also increased. However, the number of deaths attributed to disasters declined. What factors may account for this decline in mortality in the face of an increase in events? Note: CRED defines a disaster as an emergency in which more than 10 people are reported killed or 100 are reported affected. This data does not include technological disasters, or human displacement related to war or outbreaks of disease. Factors for Disease Transmission After a Disaster : Factors for Disease Transmission After a Disaster Environmental considerations Endemic organisms Population characteristics Pre- event structure and public health Type and magnitude of the disaster Factors for Disease Transmission After a Disaster : Factors for Disease Transmission After a Disaster Environmental considerations Endemic organisms Population characteristics Pre- event structure and public health Type and magnitude of the disaster Environmental Considerations : Environmental Considerations Climate Cold- airborne Warm- waterborne Season (USA) Winter- influenza Summer- enterovirus Rainfall El Nino years increase malaria Drought-malnutrition-disease Geography Isolation from resources Endemic organisms : Endemic organisms Infectious organisms endemic to a region will be present after the disaster Agents not endemic before the event are UNLIKELY to be present after Rare disease may be more common Deliberate introduction could change this factor Endemic Organisms : Endemic Organisms Northridge Earthquake Ninefold increase in coccidiomycosis (Valley fever) from January- March 1994 Mount St. Helens Giardiasis outbreak in 1980 after increased runoff in Red Lodge, Montana from increased ash Post-Impact Phase Infections : Post-Impact Phase Infections Crush and penetrating trauma Skin and soft tissue disruption (MRSA) Muscle/tissue necrosis Toxin production disease Burns Waterborne Gastroenteritis Cholera Non-cholera dysentery Hepatitis Rare diseases Post-Impact Phase Infections : Post-Impact Phase Infections Vector borne Malaria other viral encephalitis Dengue and Yellow fever Typhus Respiratory Viral Rare disease Other Blood transfusions Recovery Phase Infections : Recovery Phase Infections These agents need a longer incubation period TB Schistosomiasis Lieshmaniasis Leptospirosis Nosocomial infections of chronic disease What effects skin and soft tissue infections? : What effects skin and soft tissue infections? Post-traumatic Care Hypoxia from pulmonary contusion, ARDS, VAP Coagulopathy Renal failure DVT/PE Ulcer disease Soft tissue infections Cellulitis Necrotizing fasciitis Post op wound infection Burn care Population Characteristics : Population Characteristics Density Displaced populations Refugee camps Age Increased elderly or children Chronic Disease Malnutrition DM, heart disease transplantation Population Characteristics : Population Characteristics Education Less responsive to disaster teams Religion Social-grouping, customs, habits Hygiene Underlying health education of public Trauma Penetrating, blunt, burns Stress Slide 71: Increasing Global Travel Rapid access to large populations Poor global security & awareness ...create the potential for simultaneous creation of large numbers of casualties Cellulitis : Cellulitis Skin infection involving the subcutaneous tissue Predisposing factors Lymphatic compromise Site of entry Obesity Dirty/contaminated wound Cellulitis- Microbiology : Cellulitis- Microbiology Streptococcus Staphylococcus (MRSA) Worse in shelters Special circumstances Water exposure Aeromonas (MMWR 2005 Sept;54(38):961 and Clin Infect Dis 2005 Nov;41(10):93) Vibrio vulnificus (MMWR 2005 Sept;54(38):961) E coli, Klebsiella, Pseudomonas (Lakartidningen 2005 Nov;102(48):3660) Myroides, Bergeyella, Sphingomonas Mucormycosis (Ann Acad Med Singapore 2005) Necrotizing Fasciitis : Necrotizing Fasciitis Fulminant destruction of tissue Systemic toxicity Very high mortality Much larger bacterial load than cellulitis Travels through fascial plain Much less inflammation from necrosis, vessel thrombosis, and bacterial factors Toxin Diseases : Toxin Diseases Tetnus Rare due to vaccination 1 Million die per year in developing world 4 clinical patterns Generalized Local Cephalic Neonatal Tetanus : Tetanus Spores of C. tetani enter the tissue Produce metalloprotease, tetanospasmin Retrograde movement into CNS Blocks neurotransmission by cleaving protein responsible for neuroexocytosis Disinhibition of motor cortex Extensive spasm Tetanus : Tetanus Needs the right factors to produce Penetrating injury with spore delivery Co-infection with other bacteria Devitalized tissue Localized ischemia Can have water contamination as part of entry (Ann Acad Med Singapore 2005;34(9):582) Waterborne disease : Waterborne disease Viral gastroenteritis Norovirus (MMWR 2005 Oct;54(40):1016) Cholera Gram negative bacterium Vibrio cholerae Severe water diarrhea with 50% mortality if untreated 190 serrotypes but only O1 and O139 cause human epidemics Bacterial model for toxin mediated disease 2 cases isolated after Katrina with minimal disease (MMWR Nov 2005) Respiratory Illness : Respiratory Illness Viral Most common cause of infectious illness after Midwest floods over past 20 years More common is shelter setting (unpublished) TB 25% mortality in camps in Africa and Asia Worsened by drought Community acquired bacterial pneumonia Mainly theoretical, no data Recent experiences : Recent experiences Meliodosis (Emerg Infect Dis 2005 Oct;11(10):1639) Necrotizing pneumonia Multidrug resistant TB (Emerg Infect Dis 2005 Oct;11(10):1591-3) Atypical mycobacterial pneumonia (Emerg Infect Dis 2005 Oct;11(10):1591-3) Vector borne disease : Vector borne disease Malaria Common after flooding (Prehospital disaster Med 2002;17(3):126) Brackish water increases Anopheles (Malar J 2005;4(1):30) Well controlled with mosquito abatement Encephalitis No documented increase in US but heavy abatement programs West Nile? CRITICAL BIOLOGICAL AGENTSCATEGORY A : CRITICAL BIOLOGICAL AGENTSCATEGORY A High priority agents that pose a threat to national security because they: can be easily disseminated or transmitted person-to-person cause high mortality, with potential for major public health impact might cause panic and social disruption require special public health preparedness CRITICAL BIOLOGICAL AGENTSCATEGORY A : CRITICAL BIOLOGICAL AGENTSCATEGORY A Variola major (smallpox) Bacillus anthracis (anthrax) Yersinia pestis (plague) Clostridium botulinum toxin (botulism) Francisella tularensis (tularemia) Filoviruses Ebola hemorrhagic fever Marburg hemorrhagic fever Arenaviruses Lassa (Lassa fever) Junin (Argentine hemorrhagic fever) and related viruses CRITICAL BIOLOGICAL AGENTSCATEGORY B : CRITICAL BIOLOGICAL AGENTSCATEGORY B Second highest priority agents that include those that: are moderately easy to disseminate cause moderate morbidity and low mortality require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance CRITICAL BIOLOGICAL AGENTSCATEGORY B : CRITICAL BIOLOGICAL AGENTSCATEGORY B Coxiella burnetti (Q fever) Brucella species (brucellosis) Burkholderia mallei (glanders) Alphaviruses Venezuelan encephalomyelitis eastern / western equine encephalomyelitis Ricin toxin from Ricinus communis (castor bean) Epsilon toxin of Clostridium perfringens Staphylococcus enterotoxin B CRITICAL BIOLOGICAL AGENTSCATEGORY B : CRITICAL BIOLOGICAL AGENTSCATEGORY B Subset of Category B agents that include pathogens that are food- or waterborne Salmonella species Shigella dysenteriae Escherichia coli O157:H7 Vibrio cholerae Cryptosporidium parvum CRITICAL BIOLOGICAL AGENTSCATEGORY C : CRITICAL BIOLOGICAL AGENTSCATEGORY C Third highest priority agents include emerging pathogens that could be engineered for mass dissemination in the future because of: availability ease of production and dissemination potential for high morbidity and mortality and major health impact Preparedness for Category C agents requires ongoing research to improve detection, diagnosis, treatment, and prevention CRITICAL BIOLOGICAL AGENTSCATEGORY C : CRITICAL BIOLOGICAL AGENTSCATEGORY C Nipah virus Hantaviruses Tickborne hemorrhagic fever viruses Tickborne encephalitis viruses Yellow fever Multidrug-resistant tuberculosis Why EPR Planning: Outbreak Detection and Response Without Preparedness : Why EPR Planning: Outbreak Detection and Response Without Preparedness Delayed Response DAY CASES Opportunity for control Late Detection First Cases Why EPR Planning: Outbreak Detection and Response Without Preparedness : Why EPR Planning: Outbreak Detection and Response Without Preparedness Rapid Response DAY CASES Early Detection Potential Cases Prevented Slide 113: Case Study: Public Health, Botswana Dec-Feb RAINFALL and Jan-May MALARIA incidence (Thomson et al, 2006; Nature) Environmental monitoring : ENV monitoring enables opportunities to mobilize more localized response >> Example in Botswana … Environmental monitoring Seasonal Forecasting : Seasonal Forecasting ….. SCF offers opportunities for planning and preparedness ……. ……..strengthen vector control measures and prepare emergency containers with mobile treatment centers Role of Epidemiology in Disaster Management : Role of Epidemiology in Disaster Management • Identify major health problems • Determine extent of disease • Identify causes of disease and risk factors • Prioritize health interventions • Monitor health trends • Evaluate impact of health programs IFRC Pre-event resources : Pre-event resources Sanitation Primary health care and nutrition Disaster preparedness Disease surveillance Equipment and medications Transportation Roads Medical infrastructure General disaster reminders : General disaster reminders Vaccinations are the mainstay of outbreak control in many situations Dead bodies pose little to no infectious disease risk (Rev Panam Salud 2004;15(5):297-9) Early surveillance and hygiene can stem outbreaks WHY PUBLIC HEALTH ? : WHY PUBLIC HEALTH ? CHEMICAL effects immediate and obvious victims localized by time and place overt illicit immediate response first responders are police, fire, EMS BIOLOGICAL effects delayed and not obvious victims dispersed in time and place no first responders unless announced, attack identified by medical and public health personnel PUBLIC HEALTH : PUBLIC HEALTH Preparedness and prevention Detection and surveillance Diagnosis and characterization of agents Response Communication PUBLIC HEALTH : PUBLIC HEALTH Preparedness and prevention Coordinated preparedness plans Coordinated response protocols Performance standards self-assessment, simulations, exercises PUBLIC HEALTH : PUBLIC HEALTH Preparedness and prevention Detection and surveillance Diagnosis and characterization of agents Response Communication PUBLIC HEALTH : PUBLIC HEALTH Preparedness and prevention Coordinated preparedness plans Coordinated response protocols Performance standards self-assessment, simulations, exercises PUBLIC HEALTH : PUBLIC HEALTH Detection and surveillance Develop mechanisms for detecting, evaluating, and reporting suspicious events Integrate surveillance for illness and injury resulting from WMD terrorism into disease surveillance system PUBLIC HEALTH : PUBLIC HEALTH Diagnosis and characterization of agents Multilevel laboratory response network link clinical labs and public health agencies in all states, districts, territories, and selected cities and counties to CDC and other labs Transfer diagnostic technology from federal to state level CDC Rapid Response and Technology Lab PUBLIC HEALTH : PUBLIC HEALTH Response Epidemiologic investigation if requested by state health agency, CDC will deploy response teams to investigate unexplained or suspicious illness Medical treatment and prophylaxis vaccine / antibiotic stockpile and transportation Environmental decontamination PUBLIC HEALTH : PUBLIC HEALTH Communication Effective communication with the public use news media to limit panic and disruption of daily life Effective communication with health care and public health personnel coordination of activities access emergency information rapid notification and information exchange PUBLIC HEALTH : PUBLIC HEALTH Effective planning and response to a biological terrorist incident will require collaboration with national, state, and local groups and agencies including: -public health organizations -medical research centers -health-care providers and their networks -professional societies -medical examiners -emergency response units and organizations -safety and medical equipment manufacturers -Office of Emergency Management -other federal agencies ISSUES : ISSUES Existing local, regional, and national surveillance systems Adequate to detect traditional agents Inadequate to detect potential biowarfare agents Specific training for health care professionals clinical personnel will be “first responders” ISSUES : ISSUES Civilian biodefense plans are usually based on HAZMAT models Assumes responders enter a high exposure environment near the source Assumes site of exposure is separate from the health care facility Assumes no time pressure for decontamination Maximum protection is provided for a minimum number of workers / rescuers Myths and Disaster Realities : Myths and Disaster Realities Myth: Foreign medical volunteers with any kind of medical background are needed. Reality : The local population almost always covers immediate lifesaving needs. Only skills that are not available in the affected country may be needed. Few survivors owe their lives to outside teams 2) Myth: Any kind of assistance is needed, and it’s needed now! : 2) Myth: Any kind of assistance is needed, and it’s needed now! Reality: A hasty response not based on impartial evaluation only contributes to chaos Un-requested goods are inappropriate, burdensome, divert scarce resources, and more often burned than separated and inventoried Not wanted, seldom needed – used clothing, OTC, prescription drugs, or blood products; medical teams or field hospitals. 3) Myth: Epidemics and plagues are inevitable after every disaster. : 3) Myth: Epidemics and plagues are inevitable after every disaster. Reality: Epidemics rarely ever occur after a disaster Dead bodies will not lead to catastrophic outbreaks of exotic diseases Proper resumption of public health services will ensure the public’s safety Immunizations, sanitation, waste disposal, water quality, and food safety Caveat: Criminal or terror-intent disasters require special considerations Prepare and Plan to Reduce Risk : Prepare and Plan to Reduce Risk Hazard Mapping (Individual / Multihazard) Hazard-Risk and Vulnerability Assessment Modeling and simulation (e.g. flood models) Forecasting (e.g. through sharing of real-time data and information on floods, including telemetry involved in collecting data from field to national centres and beyond Early Warning Systems (e.g. weather forecasting in cyclones and tropical storms) Monitoring (e.g. Temporal image analysis, GLOF) Knowledge hub (e.g. portal giving database of equipment, responsible agencies,, evacuation plan, sharing of lessons learned and experiences etc.) Preparedness through education, communication and Information e.g. Radio, TV can be used to raise awareness and accountability of policy makers to ensure polices are drawn HRVC Analysis : HRVC Analysis Hazard identification Establish relative priorities for your hazards. Hazard Mapping Vulnerability Analysis Societal Infrastructure Environmental Economic Critical Facility Analysis Identify critical facilities categories Complete a critical facilities inventory Identify intersections of critical facilities with high-risk areas DM in India : DM in India Disaster Management Act 2005 Paradigm Shift Planned, holistic and proactive approach Role of S&T and academic inputs, and participative Disaster Management Act 2005 A Holistic and Comprehensive Approach Institutional Mechanisms at National, State & Local level Focus on Prevention, Mitigation and Preparedness Nodal agencies for monitoring andearly warning of disasters : Nodal agencies for monitoring andearly warning of disasters Forecasts / Warnings relating to major Natural Disasters are being provided by…. – India Meteorological Department (Cyclones, Floods, Drought, earthquakes) – Central Water Commission of the Ministry of Water Resources (Floods) – Geological Survey of India (Landslides) – Department of Ocean Development (Tsunami) The Disaster Management Act 2005 : The Disaster Management Act 2005 The Disaster Management Act was enacted on 23rd December,2005. The Act provides for establishment of - NDMA (National Disaster Management Authority) SDMA (State Disaster Management Authority) DDMA (District Disaster Management Authority) Act provides for constitution of Disaster Response Fund and Disaster Mitigation Fund at National, State and District level. Establishment of NIDM and NDRF. NATIONAL POLICY ON DISASTER MANAGEMENT : NATIONAL POLICY ON DISASTER MANAGEMENT The National Policy on Disaster Management has been finalized and approved by Home Minister. Inter-Ministerial consultation process has been completed. The Policy is now under consideration of NDMA. Draft Policy lays down the roadmap/direction for all Government endeavors. Nodal Ministries :: OBJECTIVES OF POLICY : OBJECTIVES OF POLICY A holistic and pro-active approach for mitigation and preparedness will be adopted. Each Ministry/ Department of the Central/ State Government to ensure that disaster reduction elements are integrated with development planning. Promoting a culture of Prevention and Preparedness Ensuring Mitigation measures based on State-of-the-Art technology and environmental sustainability OBJECTIVES OF POLICY : Mainstreaming DM concerns into the Development Planning Process Putting in place a streamlined Institutional Techno-Legal Framework in order to create and preserve the integrity of an Enabling Regulatory Environment and a Compliance Regime OBJECTIVES OF POLICY OBJECTIVES OF POLICY : Promoting a productive partnership with the Media to create awareness and contributing towards Capacity Development Ensuring efficient Response and Relief with a caring approach towards the needs of the vulnerable sections of the Society Undertaking Reconstruction as an opportunity to build back better OBJECTIVES OF POLICY POLICY : TECHNO LEGAL FRAMEWORK : POLICY : TECHNO LEGAL FRAMEWORK Development and vigorous enforcement of Indian Codes /Standards relevant to multi hazard resistant designs and updating it on regular basis. Review of development control regulations and zoning regulations. Revision of relief codes/ manuals so as to convert them into disaster management codes/ manuals to institutionalize planning process. Slide 146: Disaster Risk Insurance Micro-finance and Micro-insurance Regulations for provision and rescheduling of loans/debts in case of disasters of severe magnitude POLICY:TECHNO- FINANCIAL FRAMEWORK POLICY : MITIGATION AND CAPABILITY BUILDING : POLICY : MITIGATION AND CAPABILITY BUILDING Detailed evaluation & retrofitting of lifeline buildings Construction of multi-purpose cyclone shelters Capacity building of all stakeholders. POLICY: PREPAREDNESS AND RESPONSE : POLICY: PREPAREDNESS AND RESPONSE Development of fully trained and equipped specialist response teams. Strengthening of civil defense set up to supplement local response and relief efforts. Development of Standard Operating Procedures by all relevant Ministries/ Departments at Central, State and District levels. POLICY: RELIEF AND REHABILITATION : POLICY: RELIEF AND REHABILITATION State Government will be advised to establish per-contract and pre-agreement arrangements for immediate mobilization f resources. Central Government will also facilitate mobilization of resources when requested by the State Governments. POLICY: HUMAN RESOURCE DEVELOPMENT : POLICY: HUMAN RESOURCE DEVELOPMENT Establishment of National centers of excellence for human resource development in areas of disaster mitigation, preparedness and response. Promotion of research and envelopment for early warning systems and prevention and mitigation of sudden onset disasters. Involvement of community civil defense volunteers, NGOs, ex-servicemen and youth organizations in all aspects of DM. Promotion of self-reliance in the community. FINANCE : FINANCE National, State, District Mitigation Fund National, State, District Response Fund Ministry or Department to make provision for fund in annual budget for disaster management activities as set out in disaster management plan During any threatening disaster situation, disaster National/State/District authority if satisfied that immediate procurement of provision or materials are necessary. inviting tenders shall be waived NATIONAL DISASTER RESPONSE AND MITIGATION FUND : NATIONAL DISASTER RESPONSE AND MITIGATION FUND National Disaster Response Fund will be constituted and funded by the Central Government, and grants may be made by any person/institution. National Disaster Mitigation Fund started for mitigation projects. The State Government shall establish Disaster Response Fund and Disaster Mitigation Fund at State and District Levels. Every Ministry/Department of Central and State shall make provision in budget for activities in DM plan. 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