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The purpose of this document is to establish guidelines for the control of disease,
and to state plans to mitigate the diseases that are found on the job site for all
persons that will work on the site. It is also to be used to inform HMS Contractor
and Subcontractor employees of the diseases that exist in Indonesia, as well as
providing guidelines for preventing infection and transmission. This document
establishes procedures for disease mitigation for site work on the project. This
document is for the management and control of diseases endemic to the site or
that are exacerbated by conditions at the site, such as malaria, diarrhea, etc.


This procedure covers all of HMS workplaces in Indonesia, however based on a

risk assessment of the disease threat present in the location of the workplace,
which will determine the disease mitigation controls to be implemented.


Disease Vector Control: Includes spraying and fogging for insects, rodent
extermination, prompt pick-up and disposal of trash, elimination of standing
water, and other measures as may be deemed necessary to prevent the spread
of diseases



HMS is responsible to ensure its employees and its Subcontractors employees,

Visitors, and Client representatives, etc., are in a healthy, safe and
environmentally friendly work environment.

HMS has the responsibility to successfully manage the implementation of the

Disease Vector Control activities. All insecticides and rodent poisons used shall
be approved by the Indonesian Department of Health and shall be used in strict
conformance with the manufacturer's instructions and directions.


All HMS employees assigned to the site are required to:

 Complete a physical examination prior to mobilization.

 Receive vaccinations as defined by a reputable medical provider, such as
SOS, as applicable.
 Receive a briefing/orientation from the relevant medical department
regarding the disease hazards/risks such as malaria, hepatitis, dengue, bird
flu etc.

 Receive a physical examination prior to site employment and/or site

mobilization. The physical examination shall conform to the guidelines
described in Medical Examinations Procedure and shall determine the
general health, physical fitness for the job or prospective employees and
determine if they have any communicable diseases or debilitating long-term
health problems. Those personnel, whose health is not adequate for the
rigors associated with living and working in a tropical climate with
indigenous diseases, communicable diseases, and those with long-term
debilitating diseases, shall be rejected for employment/mobilization. The

examining physician shall certify each employee or perspective employee

to be fit for duty.

Each employee's Immunization Record shall contain proof of required

immunizations or exceptions allowed for health reasons whether on business or


It is HMS intent that all workers work and sleep in a mosquito free environment.
Malaria and the spread of malaria will be mitigated using the following

 All buildings will have screened windows and doors.

 Mosquito repellants will be utilized in appropriate areas.

 Land will be leveled and drained to eliminate the places where mosquitoes
can breed.
 Site medical staff will regularly inspect the site to identify and control any
mosquito breeding places. These places include:
- Buckets, cans, flower pots, barrels, etc. capable of retaining water

- Depressed areas or holes that collect and retain water

- Kitchen pipe run-off areas

- Shower units (floors must be kept dry)

- Pipe, fittings, and machines and parts that are positioned to collect

 Indonesian government approved insecticides will be used to kill

mosquitoes and larvae. A vector control insecticide plan will be developed
and used at various places and at various times to kill mosquitoes. No
environmentally unfriendly insecticides such as DDT shall be used.

 Environmentally friendly and innovative methods for mosquito control will be

studied during the design stage. These methods include the use of coconut
incubators to incubate Bacillus thuringiensis, then releasing in water to kill
mosquito larvae.

 Use of malaria prophylactic drugs will be studied to determine if they should

be administered to employees. Malaria is developing a resistance to many
drugs and many new drugs have come onto the market. This is a complex
issue that requires further study to develop an implementation plan.

 Other measures will be considered as appropriate.

The control of Japanese Encephalitis, Lymphatic Filariasis and Dengue Fever,

which are also a mosquito borne diseases, will also be a consideration in all
malaria mitigation plans.


7.1 Cholera

Cholera is an acute, diarrhea illness caused by bacterial infection of the

intestine. Often mild and without symptoms, the infection can at times be
severe causing diarrhea, vomiting, and leg cramps. It is contracted from
contaminated water and food, especially fish, shellfish, and raw fruits and

1. Risk:

Cholera is a health problem primarily in less-developed countries of Africa,

Asia, and Latin America. Cholera has been reported from some of the
countries of Southeast Asia, but those who follow food safety
recommendations are at virtually no risk of infection.

2. Prevention:

The most effective way to avoid infection is to consume only food that is
cooked and served hot, fruits and vegetables peeled by oneself. Consider
bottled water, beverages and ice made from boiled or chlorinated water. A
cholera vaccine is available, but the effectiveness is limited and of brief
duration. The risk to travelers taking adequate precautions is considered so
low that vaccination is not recommended, especially for infants younger
than six months and pregnant women.

3. Mitigation:

Final mitigation measures will be decided based upon the threat level in the
location. Generally, health experts recommend not using the Cholera
vaccine because of its short-term effect and side effects. The medical staff
will regularly inspect caterer’s food safety and handling practices to ensure
that all food is prepared in a sanitary manner. Any negative observations
by the medical staff will be notified to the HSEC Manager and corrected

7.2 Dengue Fever

Dengue Fever is primarily a viral infection transmitted by mosquito bites in

residential areas. The mosquitoes are most active during the day, especially
around dawn and dusk, and are frequently found in or around human
habitations. The illness is flu-like and characterized by sudden onset of, high
fever, severe headaches, joint and muscle pain, and rash. The rash appears
several days after the onset of fever.

1. Risk:

Dengue fever occurs in less developed countries of Africa, Asia, and Latin

2. Prevention:

In areas of risk, wear clothes covering most of the body, and apply insect
repellent to exposed areas of skin, The most effective repellents contain the
compound DEET (N,N-diethyl metatoluamide). They should be used only
according to directions, not on areas of the hands coming into contact with
the eyes and mouth, and sparingly on children. A spray to kill flying insects
can be used in living and sleeping areas during the evening and night.
Maintain window and door screens.

3. Mitigation:

Mitigation measures will be the same as the Malaria and Mosquito control
plan. Site HSE/ medical staff will diligently watch for cases of Dengue fever
and will take appropriate action when required.

7.3 Encephalitis

Japanese Encephalitis is a mosquito borne viral disease that occurs in rural

areas. The mosquitoes are most often found in rice growing areas and bite in
late afternoon and early evening. Although there are often no symptoms, these
can include headache, fever, and flu like reactions. In serious cases, there is a
swelling of the brain.

1. Risk:

The greatest risk is in rural areas of Southeast Asia during the rainy
season. The chance that travelers will contract the disease is regarded as

2. Prevention:

Individuals who are not vaccinated should use mosquito repellents, sleep in
well-screened quarters and use insecticide sprays in sleeping quarters.

A vaccine is available but three shots are required at days 0, 7, and 30 to

maximize the efficiency of the vaccine. The same brand of vaccine should
be used for all shots; there are different brands of the vaccine, which are
produced by different methods. A single shot has no effect. The risk of a
serious reaction to the vaccine is 0.6%, although one Australian study put
the risk at 1.04%. The risk of reaction is rising for unknown reasons. Ten
percent of the vaccines will experience systemic side effects such as fever,
headaches malaise, rash, chills, nausea, vomiting, abdominal pain, etc..
Serious immunologic reactions have been observed in some vaccines. The
vaccine efficiency is 80%, i. e. one who takes the vaccine has a 20%
chance of contracting the disease if exposed to it. Those with a history of
certain allergic disorders should not take the vaccine. Consult your
personal physician and the Centers for Disease Control and Prevention
(CDC) recommendations before taking this vaccine, the risk of a reaction,
particularly an immunologic reaction or anaphylaxis, to the vaccine may be
greater than the risk of infection for some individuals.

3. Mitigation:

Mitigation measures will form part of the Malaria and Mosquito control plan.

7.4 Hepatitis A

Hepatitis A is a viral infection of the liver transmitted by contact with fecal matter
through person-to-person contact; from contaminated water, ice, or shellfish; or
from fruits and uncooked vegetables contaminated during handling. Symptoms
may include fever, fatigue, loss of appetite, nausea, dark urine, jaundice,
vomiting, aches and pains, and light stools.

1. Risk:

Less developed countries and especially rural regions are the areas of
greatest risk.

2. Prevention:

Possibly contaminated food and water should be avoided. Boiling or

cooking to 85 degrees C for one minute inactivates the virus.

3. Mitigation:

All employees shall be vaccinated prior to arrival at the job site unless they
have a health reason not to be vaccinated. A vaccine became available in
1992. Since antibodies induced by the vaccine are not detectable until 2
weeks after administration, travelers should be vaccinated 4 weeks before
departure if possible. A booster dose given 6-24 months later is
recommended. This schedule is expected to provide at least 10 years
protection. In the case of emergency travel to a high-risk area, a dose of
immunoglobulin (0.02 ml/kg), where this product is still available, may be
given with the first dose of vaccine. A combination hepatitis A/typhoid
vaccine is available for those exposed to waterborne diseases. The vaccine
is administered as a single dose, a minimum of 4 weeks before departure,
and confers high levels of protection against both diseases. A second dose
of hepatitis A vaccine is needed 6-12 months later and boosters of typhoid
vaccine should be given at 3-yearly intervals.

7.5 Hepatitis B

Hepatitis B is a viral infection of the liver. It is transmitted primarily through

exchange between individuals of blood or bodily fluids containing blood. Such
behaviors include heterosexual or homosexual contact or sharing needles or
drug paraphernalia.

Unscreened or improperly screened blood or blood products may also transmit

the virus. Often there are no symptoms, but when these occur they are similar
to those for hepatitis A.

1. Risk:

The areas of greatest risk include sub-Saharan Africa, Southeast and East
Asia. Hepatitis B rates are high in Southeast Asia. Use of unsterilized
medical instruments or contact with potentially infected people who have
open skin lesions may increase the risk in areas with high rates of Hepatitis

2. Prevention:

Sexual abstinence with unknown partners is strongly suggested. Even the

use of contraceptives does not provide a 100% guarantee against possible
infection. If injections are required, ensure that the needles and syringes
used are being taken from sealed factory wrappers.

3. Mitigation:

Hepatitis B is the only sexually transmitted disease for which a vaccine is

available. Vaccination is recommended for those individuals who are
sexually active.

7.6 Hepatitis C

Hepatitis C is caused by a virus (HCV) which is a favivirus. The virus is

acquired through person-to-person transmission by parenteral routes. Before
screening for HCV became available, infection was mainly transmitted by
transfusion of contaminated blood or blood products. Nowadays transmission
frequently occurs through use of contaminated needles, syringes and other
instruments used for injections and other skin-piercing procedures. Sexual
transmission of hepatitis C occurs rarely. There is no insect vector or animal
reservoir for HCV.

Most HCV infections are asymptomatic. In cases where infection leads to

clinical hepatitis, the onset of symptoms is usually gradual, with anorexia,
abdominal discomfort, nausea and vomiting, followed by the development of
jaundice in some cases (less commonly than in hepatitis B). Most clinically
affected patients will develop a long-lasting chronic infection, which may lead to
cirrhosis and/or liver cancer.

The virus is distributed worldwide, with regional differences in levels of


1. Risk:

Persons are at risk if they practice unsafe behavior involving the use of
contaminated needles or syringes for injection, acupuncture, piercing or
tattooing. An accident or medical emergency requiring blood transfusion
that has not been screened for HCV is a risk. Persons engaged in
humanitarian relief activities may be exposed to infected blood or other
body fluids in health care settings.

2. Prophylaxis:


3. Precautions:

Adopt safe sexual practices and avoid the use of any potentially
contaminated instruments for injection or other skin-piercing activity.

4. Mitigation:

Mitigation measures will be predominantly through educational programs

7.7 Malaria

Malaria is a serious parasitic infection transmitted to humans by infected female

Anopheles mosquitoes. They bite at night from dusk to dawn. Symptoms
include fever and flu-like reactions to chills, general aches, and fatigue. If left

untreated, Malaria can cause anemia, jaundice, kidney failure, coma, and
death. Of the several strains of the parasite called Plasmodium that causes the
disease, P. Plasmodium is the most dangerous, accounting for almost all of the
reported deaths of U.S. civilians. The others are P. vivax, P. ovale, and P.

1. Risk:

Malaria is a health problem in tropical areas of the Americas, Africa, Asia,

and Oceania. Urban and coastal areas of Peninsular Indonesia and
Sarawak are free of the risk of Malaria. There is a risk of Malaria
throughout rural (hinterland) areas of peninsular Indonesia and in
Kalimantan and West Papua.

2. Prevention:

There are a number of drugs that provide protection against infection, but
effectiveness varies from region to region. Some Malarial strains have
developed resistance to specific drugs.

Chloroquine combined with Proguanil (trade name Paludrine) is the most

widely used. Rare side effects include upset stomach, headache, dizziness,
blurred vision, and itching but these do not require discontinuation of use.

Mefloquine (Trade name Larium) is the most recommended prophylactic. It

is the most effective anti-malarial prophylactic drug known, being 95%
effective, although Larium resistant malaria strains have appeared in
Thailand and Burma. Side effects can include gastrointestinal
disturbances, dizziness, and neuropsychotic adverse events. A British
Medical Journal reports that there is a 0.7% chance that persons taking the
drug will have a serious neuropsychotic adverse event. Other studies
indicate the range is 0.2 to 0.4%. It should not be used by individuals with a
history of epilepsy, psychiatric disorder, pregnant or breast feeding women,
or those with hypersensitivity to the drug. WHO maps show Northern Irian

Jawa to contain Methfloquine resistant Malaria.

There are other drugs available, to be taken in regular dosages as

prescribed by a physician, some in conjunction with others. Two drugs with
fewer side effects than Larium for some persons are Malarone and
Doxycycline (generic name). Malarone has been recommended for
pregnant women. No drug is 100% effective and no drug is free of side
effects for all persons. Persons are strongly advised to consult their
personal physician before taking malaria prophylactics.

Routine precautions against insect bites should also be taken, such as use
of repellents and clothing covering most of the body. Persons in Malarial
areas should be constantly alert for mosquitoes as they go about their
business. They should be aware of surroundings and report any places
where mosquitoes can breed:

- Old tires filled with water

- Buckets, cans, flower pots, barrels, etc. capable of retaining water

- Depressed areas or holes that collect and retain water

- Kitchen pipe run-off areas

- Shower unit (floors must be kept dry)

"Knock down" sprays or "Bug bombs" and mosquito coils cannot be relied
on to provide permanent control. They are immediate, but only temporary
control methods.

If taken Malaria prophylaxis shall be continued for a period, the time

depends on the drug, after return from Indonesia. Additionally, personnel
should immediately contact a physician if any flu-like symptoms appear
within three months after return.

3. Mitigation:

Mitigation measures will be decided upon during the design phase. A WHO
recognized consultant and several other experts have already been
contacted and are prepared to prepare reports and give advice during the
design phase.

7.8 Poliomyelitis

Poliomyelitis is a viral disease transmitted by person-to-person contact. It

causes muscle atrophy and in extreme cases paralysis, most frequently in the

1. Risk:

Although largely eradicated in developed countries since development of

vaccines, polio persists in the temperate zones in much of Africa and Asia.
The highest incidence of infection is in the age range of 5 to 10 years,
although the disease can be contracted at any age.

2. Prevention:

Vaccination with either of the two vaccines in current use is recommended

before going to countries in areas of risk. Persons who have previously
received a primary series may need additional vaccine doses before going
to areas with an increased risk of exposure.

3. Mitigation:

All employees will be vaccinated prior to arriving at the job site unless there
is a valid health reason for not having a vaccination.

7.9 Schistosomiasis

Schistosomiasis is an infection that develops after the larvae of a flatworm have

penetrated the skin. The larvae can penetrate unbroken skin. Contact occurs

in bathing, wading, or swimming in contaminated fresh water. Water treated

with chlorine or iodine is usually safe. Salt water poses no risk.

1. Risk:

Infection can be widespread in less developed countries in tropical regions.

Travelers to Southeast Asia are at risk of infection.

2. Prevention:

Swimming in fresh water in rural areas should be avoided. Bath water

should be utilized that is supplied from a municipal water source or treated
with chlorine or iodine as done for drinking water. Immediate and vigorous
towel drying or application of rubbing alcohol to the exposed areas may
reduce risk of infection.

3. Mitigation:

Mitigation measures will be through an educational program.

7.10 Diarrhea

Diarrhea is contracted from contaminated food or water, usually from fecal

matter, due to poor sanitation. Symptoms are frequent loose bowel
movements, nausea, bloating, fever, and malaise. An attack usually runs its
course in three to seven days, the body having developed immunity.

1. Risk:

Diarrhea is a health problem throughout the world, but is most prevalent in

less developed countries.

2. Prevention:

There is no vaccine. Prescription medications that restrict bowel movement

are available but not recommended for casual use. Raw as well as cooked
foods that may have been improperly handled, seafood, unpasteurized
dairy products, and ice should be avoided. Drink bottled beverages and hot

tea or coffee. Water supplied from a municipal water source treated with
chlorine is recommended. Several commercial products are available over
the counter in tablet form at pharmacies if desired.

3. Mitigation:

The Site Medical staff will regularly inspect the catering facilities for sanitary
conditions. Unsanitary conditions will be immediately corrected. For
individuals the preferred treatment is to let the infection run its course.
Intake of liquids to prevent dehydration, salts, and mild foods helps. If
dehydration occurs, solutions such as the World Health Organization Oral
Rehydration Salts (ORS), available in pharmacies in almost all developing
countries, will help restore lost fluids. Follow instructions. Prescription
medications can restrict bowel activity but can cause complications. They
should not be used by individuals with high fever or blood in their stools. In
severe cases, antimicrobial drugs may shorten the length of illness. They
should be taken under supervision of a physician.

Afflicted persons should seek medical attention if diarrhea is severe,

bloody, or does not resolve within a few days, or if it is accompanied by
fever and chills.

7.11 Tuberculosis

Tuberculosis is transmitted through the air by bacteria from infected individuals,

usually by coughing, which releases tubercle bacilli secretions from the lungs.
It can also be transmitted in unpasteurized milk products.

1. Risk:

Tuberculosis is on the rise as a serious health problem, particularly in

Indonesia. To become infected, a person usually would have to spend a
long time in a closed environment where the air was contaminated by

another person with untreated tuberculosis. There is virtually no danger of

transmission by objects that are touched or food other than milk products.

2. Prevention:

Those who anticipate possible prolonged exposure to tuberculosis should

have a tuberculin skin test before departure. If the reaction is negative,
they should have a repeat test upon returning home. If it is positive,
treatment may be indicated. Persons who previously tested positive are
unlikely to be infected.

3. Mitigation:

All employees will be examined for Tuberculosis prior to arriving at the site.
Those with active Tuberculosis will be denied employment.

7.12 Typhoid Fever

Typhoid Fever is a bacterial infection transmitted through contaminated food

and water, or directly between individuals. Symptoms include fever,
headaches, tiredness, loss of appetite and constipation.

1. Risk:
Less developed countries in Asia, Africa, and Latin America are areas of
greatest risk.
2. Prevention:

Currently available vaccines are not 100% effective, making it advisable

that basic precautions be taken. Drinking bottled water or utilizing water
from a treated municipal water source is recommended. Eating only
thoroughly cooked food also lowers the risk of infection.

3. Mitigation:

All employees will be required to have a vaccination prior to arriving at the

site unless there is a valid health reason for not having a vaccination.

7.13 Yellow Fever

Yellow fever is a viral disease transmitted to humans by a mosquito bite. The

mosquitoes are most active during evening hours. Symptoms range from fever,
chills, headache, and vomiting to jaundice, internal bleeding, and kidney failure.
There is no specific drug that exists to treat an infection of Yellow Fever;
therefore, prevention is important.
1. Risk:

There is no risk of becoming infected with yellow fever while traveling in

Indonesia, if you are traveling from an infected area in Africa or South
America you must prove that you have had a yellow fever vaccination
before entering Indonesia.

2. Prevention:
There is an effective vaccine against yellow fever. A one-dose injection
may be administered to adults and children older than nine months. Very
young infants are more susceptible to serious adverse reactions. The
vaccine is administered at designated centers, usually local health
departments. If an individual is at continued risk, a booster is needed every
10 years. Persons severely allergic to eggs, used in the production of the
vaccine, should not be vaccinated. The vaccine is not recommended for
pregnant women or persons whose immune systems are not functioning

3. Mitigation:

At present there is no reported risk. If a risk exists all employees will be

required to have a vaccination prior to arriving at the site unless there is a
valid health reason for not having a vaccination.

7.14 Lymphatic Filariasis

Lymphatic Filariasis is a parasitic disease caused by microscopic, thread-like

worms. The adult worms only live in the human lymph system. The lymph
system maintains your body’s fluid balance and fights infections.

1. Risk:
The disease spreads from person to person by mosquito bites. When a
mosquito bites a person who has lymphatic filariasis, microscopic worms
circulating in the person’s blood enter and infect the mosquito. If the
infected mosquito bites you, you can get lymphatic filariasis. The
microscopic worms pass from the mosquito through your skin, and travel to
your lymph vessels. In your lymph vessels they grow into adults. An adult
worm lives for about 7 years. The adult worms mate and release millions of
microscopic worms into your blood. Once you have the worms in your
blood when a mosquito bites you, you can give the infection to others
through mosquitoes.
2. Symptoms:

At first, most people don’t know they have lymphatic filariasis. They usually
don’t feel any symptoms until after the adult worms die. The disease
usually is not life threatening, but it can permanently damage your lymph
system and kidneys. Because your lymph system does not work right, fluid
collects and causes swelling in the arms, breast, legs, and, for men, the
genital area. The name for this swelling is lymphedema (limf-ah-DE-ma).
The entire leg, arm, or genital area may swell to several times its normal

size. Also, the swelling and the decreased function of the lymph system
make it difficult for your body to fight germs and infections. You will have
more bacterial infections in your skin and lymph system. This causes
hardening and thickening of the skin, which is called elephantiasis (el-ah-

3. Mitigation:
Same as malaria control.


The heat and humidity in Indonesia can affect some visitors who may not be
accustomed to such conditions in their home country. Persons gradually
become accustomed to the climate, but may want to initially avoid strenuous
activity and instead take things more slowly than usual, to avoid heat
exhaustion. Remember to wear a hat when outside in the sun for any duration,
and drink plenty of water to avoid dehydration.

Immunizations for such childhood diseases as measles, mumps, rubella

(NEVIR Vaccine), diphtheria, tetanus, pertussis (DTP Vaccine), and polio
should be current before relocating to Indonesia. Mitigation measures for
persons who have never received these vaccinations will be decided during the
design phase.
Persons should be vigilant for snakes, centipedes and avoid any you may
encounter. Dangerous animals and insects will be covered in one or more
toolbox sessions.

Persons should wash hands frequently and keep them away from your eyes and
mouth. Proper personal hygiene will be covered in one or more toolbox


Anyone who has an occasion to be seen by a physician any time up to one year
after return should advise him/her that they have been to Indonesia. No post-
employment physicals are planned except for necessary occupational health