ISSN: 2640-8031
Annals of Psychiatry and Treatment
Research Article       Open Access      Peer-Reviewed

Psychiatry of disasters. Organization of the work of a psychiatrist outpatient consultative reception

Shapovalova LA1, Shapovalov KА2*

1State Autonomous Health Agency of the Republic of Komi, “Consultative and Diagnostic Center of the Republic of Komi”, Syktyvkar, Republic of Komi, Russian Federation
2State Education Agency of Additional Professional Education of the Republic of Komi, “Komi Republican Institute for Development of Education”, Syktyvkar, Republic of Komi, Russian Federation
*Corresponding author: Shapovalov KА, State Education Agency of Additional Professional Education of the Republic of Komi, “Komi Republican Institute for Development of Education”, Syktyvkar, Republic of Komi, Russian Federation, E-mail: stampdu@rambler.ru
Received: 11 June, 2019 | Accepted: 18 October, 2019 | Published: 21 October, 2019
Keywords: Medical service of civil defense; Emergency situations; Qualification category; Psychiatrist; Outpatient consultation; Advisory department; Diagnostic center; Subarctic territory

Cite this as

Shapovalova LA, Shapovalov KА (2019) Psychiatry of disasters. Organization of the work of a psychiatrist outpatient consultative reception. Annals of Psychiatry and Treatment 3(1): 012-022. DOI: 10.17352/apt.000012

Introduction: The predicted increase in anthropogenic, technogenic, social, military, possible space disasters and emergencies attracts the attention of health organizers, doctors of specialists and especially psychologists and psychiatrists in connection with the need to provide assistance to the victims, as well as to develop principles, strategies and tactics, methods and means of providing timely psycho-psychiatric care.

The aim of the work: Was to justify the need for the psychiatrist to prepare an outpatient consultative reception for work in emergency situations of catastrophes, natural disasters and terrorist acts.

Materials and methods: The analysis of 5 qualification works of a psychiatrist of the highest qualification category (1997, 2002, 2008, 2013 and 2018) for the work in medical service of civil defense (MSCD) and emergence cituations (ES) as an integral part of the mandatory requirements for registration of documents when they are submitted to the Attestation Commission on the assignment of qualification medical category in psychiatry. The depth of the study was 24 years. Methodical approaches were used: system, complex, dynamic, normative, quantitative and situational. Methods of analysis included: historical, analytical and comparison. Methods were used: groupings, continuous and selective observations.

Results: The work of a psychiatrist in the structure of MSCD and ES is analyzed from the standpoint of: 1) Personal participation in the development of educational and methodological and lecture materials for the preparation of the population for action in the context of civil defense and emergencies; 2) The actions of the doctor in the workplace in a medical institution with possible “everyday” emergencies; 3) Work in the medical-nursing brigade of the civil defense system; 4) Participation in the structure of psycho-psychiatric care for the population in emergencies.

Conclusions: 1. In accordance with normative legal documents and official duties, a psychiatrist provides psychiatric assistance to the population in emergency situations and should know the organization and activities of the medical service of civil defense.

2. It is expedient to divide the work of a psychiatrist in the structure of MSCD and ES for four blocks: 1) Personal participation in the development of educational and methodological and lecture materials for preparing the population for action in the context of civil defense and emergencies; 2) The actions of a doctor in a medical institution under “everyday” emergencies; 3) Work in the medical-nursing brigade of the civil defense system; 4) Participation in the structure of psycho-psychiatric care for the population in emergencies.

3. The psychiatrist must undergo special training for successful work in the basic modules of the psychological and psychiatric service of emergency situations: 1) the Department of anonymous psychological and psychiatric help by phone; 2) an advisory visiting team of psycho-psychiatric care; 3) Department of psychological and psychiatric care; 4) Cabinet of psychological and psychiatric care.

4. Medical workers who survived ES should be treated as victims, who need comprehensive psychological and psychiatric care and careful corporate support, with a gradual return to normal workload.

5. The contingent of professional rescuers under conditions of ES is exposed to the extreme factors of the current situation and is a risk group for the development of affective spectrum disorders. They may experience psychopathological disorders of exogenous organic origin with a tendency to gradually formulate variants of psycho-organic syndrome and polysystemic psychosomatic disorders.

6. The multifaceted work of a psychiatrist in the MSCD system and ES should be a weighty additional argument in favor of a positive decision on awarding the qualification category declared by him.

Introduction

Psychiatry of emergencies (ES), catastrophes and terrorist acts is formed into an independent direction and section of disaster medicine in the last 30-40 years. Signed events for this were the large-scale accident in Eastern Europe at the Chernobyl nuclear power plant (1986), the double terrorist act with the collapse of twin sky in New York in North America (2001) and the official announcement of the threat of an atomic air strike from 30 minute readiness in the Hawaiian Islands (2018). The multivariate conditionality and clinical polymorphism of medical as well as psychological consequences of these emergencies has been established. The projected increase in anthropogenic, man-made, social, military, potential space catastrophes and emergencies is attracting the attention of health care organizers, medical specialists and, especially, psychologists and psychiatrists in connection with the need to provide assistance to victims, as well as to develop principles, strategies and tactics, methods and means of providing timely psychological and psychiatric care. Requirements for the preparation of a report for specialists with higher medical and pharmaceutical education under this item are formulated as follows: Section 9. Work in medical service of civil defense (MSCD) and ES [1]. From this it follows that a psychiatrist who prepares documents for the qualification category should have up-to-date knowledge on this issue and be engaged in this type of medical work. It follows from this that a psychiatrist who prepares documents for the qualification category should have up-to-date knowledge on this issue and constantly engaged in this type of medical work. It takes into account the effectiveness of the specialist’s activities, business and professional qualities (responsibility, exactingness, volume and level of skills, practical skills; increase of professional competence, practical use of modern medical achievements, etc.; sections of the specialty, methods, techniques that the specialist owns perfectly , unique methods, techniques, technologies, mastered by a specialist, etc.

Materials and Methods

An analysis of 5 qualifying works of a psychiatrist (1997, 2002, 2008, 2013 and 2018) was conducted for work in MSCD and ES as an integral part of the mandatory requirements for the paperwork when they are submitted to the Attestation Commission medical category in psychiatry. The depth of the study was 24 years [2-6].

Attestation Commission of the Ministry of Labor and Social Development of the Russian Federation (Moscow), on July 4, 1997, the applicant was awarded the highest qualification category in Psychiatry, which was confirmed in December 2002 by the Certification Commission of the St. Petersburg Institute of Advanced Training of Medical Experts, April 18, 2008, March 28, 2013, and February 20, 2018 - by the Republican Attestation Commission of the Ministry of Health of the Republic of Komi (RK).

When working on the material, the following methodological approaches were used: systemic, integrated, dynamic, regulatory, quantitative and situational. Analysis methods included: historical, analytical, and comparisons. The following techniques were used for the analysis: grouping, continuous and selective observations.

The study was conducted on the basis of the State Autonomous Health Agency of the RK “Consultative and Diagnostic Center of the Republic of Komi” (SAHA RK “CDC RK”), which provides highly qualified consultative and diagnostic, specialized medical assistance to the population of the RK and the organizational and methodological guidance of the diagnostic services of health institutions of administrative entities. RK is located in the Extreme North-East of the European part of the Russian Federation (RF) and belongs to the subarctic territories. The main task of the SAHA RK “CDC RK” is to provide high-quality comprehensive diagnosis of diseases and provide highly qualified advice with the use of high-performance medical technologies on an outpatient basis, accessible to the general population. It serves patients of 20 administrative territories of the RK and part of the Arkhangelsk region. For this purpose, modern diagnostic and technical equipment is concentrated in the agency a team of qualified specialists is formed.

Results

The psychiatrist is receiving patients in working hours on schedule and should be, like any specialist from the advisory department of the SAHA RK “CDC RK”, ready for any unforeseen situations and emergency situations of anthropogenic or anthropogenic origin: turning off the light, stopping heat to the building during the winter period, fire, a terrorist call with a bomb warning and the possibility of an explosion. The work of a psychiatrist in the structure of MSCD and ES can be divided into four blocks:

1) Personal participation in the development of teaching materials and lecture materials to prepare the population for action in CD and ES;

2) The actions of the doctor in the workplace in a medical institution in case of possible “everyday” ES;

3) Work as part of the medical-nursing brigade of the CD system;

4) Participation in the structure of psychological and psychiatric assistance to the public in ES.

Formation of the scientific interests of the practitioner doctor

In the case being analyzed, the future psychiatrist was engaged in student scientific circles of the chairs of topographic anatomy and operative surgery, dermatology and venereology, and psychiatry of the Arkhangelsk State Medical Institute (ASMI), was involved in scientific research at the chair of psychiatry of the ASMI during training in clinical internship, taught at the faculty of social work of Syktyvkar State University. Therefore, in the field of scientific interests, in addition to psychiatry and the mental health of the population were: preventive medicine; methods of teaching the basics of life safety, emergency medical care for injuries and accidents, healthy lifestyles and health-saving technologies; the didactics of the subjects “Life Safety” for non-medical faculties of humanitarian and technical universities; distance and additional education, active forms of education.

In 1996, a psychiatrist co-authored a psychiatrist with a textbook prepared, which went through four editions: “Fundamentals of life safety: Safety and protection of the population in emergency situations; Self-, mutual and first aid for injuries and accidents”: a training manual. - 4th ed., Reworked and add. (Recommended by the decision of the Presidium of the Council of the Educational and Methodical Association of Russian Universities in the field of pedagogical education as a textbook for university students enrolled in the specialty 033300 “Life Safety” (09.03.2004. Protocol number 2) - Syktyvkar: KRAGSiU, 2004. - 187 pp.: Ill. The manual is presented in the Russian State Library (Moscow) in the Unified Electronic Catalog (www.rsl.ru); the Russian National Library (St. Petersburg) in the electronic catalog (www.nlr.ru); National Bi When presenting the material, the authors proceed from the position that full medical care for injuries, burns, poisonings and other types of injuries cannot be rendered without taking into account the neuropsychiatric disorders arising from injured during accidents, disasters and emergencies [7-12].

The textbook was presented at the collective stand of the “Universities of Russia” exposition at the 55th International Book Fair in Frankfurt am Main (Germany), which after graduation went to the library of the Frankfurt University (2003). The Presidium of the Council of Educational and Methodical Association in the field of pedagogical education awarded the book the “Grif textbook for students of higher educational institutions” (2004).

Scientific articles and theses of the reports of the psychiatrist on emergency situations during emergencies are published in the journals: “Alma mater (Vestnik vysshej shkoly)”-1; “OBZh. Osnovy Bezopasnosti Zhizni”-10; “Zhizn’ i Bezopasnost’”-13; “ Prepodavatel’ XXI vek”-1; “Bezopasnost’ Zhiznedeyatel’nosti”-9; “Prehospital and Disaster Medicine. The Official Journal of the World Association for Disaster and Emergency Medicine-2; “OA Alcohol”-3; “European Psychiatry. The Journal of the European Psychiatric Association”-9.

The publications dealt with issues: Classification of ES; The Unified Russian State System for the Prevention and Liquidation of ES (RSChS); Natural emergencies; Industrial accidents and disasters; Accidents involving the release of highly toxic substances (SDYaV); Modern means of mass destruction and their effects on humans; Chemical weapon; Terrorism; Civil defense organization and necessary documentation in educational institutions on CD and ES; Methods of holding the “Children’s Day in emergency situations” at school; Educational and methodical complex for the discipline “Life Safety” (for universities); First aid for injuries and accidents during ES of natural, man-made or anthropogenic origin [13-23].

Doctor’s actions in ES

The daily activities of a doctor of any specialty, including a psychiatrist, do not exclude the occurrence of ES during the working day in a hospital. Pay attention to the two most dangerous situations that require rapid response.

Procedure in case of fire

1) Immediately inform the fire brigade by phone 01. Clearly state the address of the institution, indicate the place of the fire, what is burning and whether there is a threat to people’s lives, at the same time inform your position, first name, last name;

2) Inform the head of the institution about the fire;

3) Take measures to prevent panic among patients and organize their evacuation;

4) If possible, turn off electricity, close windows and doors in areas where a fire has occurred, to prevent its spread;

5) To extinguish the fire before the fire brigade arrives with the available primary fire extinguishing agents (fire extinguisher, water, sand);

6) To organize the evacuation of property - documentation, material values;

7) to reconcile the payroll with the actual presence of evacuees from the building;

8) Ensure the protection of the property;

9) Arrange a meeting of fire departments. Informing the head of the department whether all people have been evacuated from the danger zone and in which premises people may be, whether electricity in the burning room is turned off, as well as information on the presence and storage of toxic, radioactive, narcotic and other dangerous substances and materials.

Actions in the case of a phone call about the tab of explosives and the threat of an explosion:

1) Record the exact start time of the conversation;

2) Record the exact time of the end of the conversation;

3) In the course of the conversation, try to identify: the person of the speaker (man, woman, teenager, child, approximate age; Rate voice-loud, quiet, tall, low, sharp, pleasant, excited, deaf, other features; Accent-local, non-local, foreign, regional; Speech-fast, slow, unintelligible, distorted; Speech defects-stutters, speaks in the “nose”, lisps, lisp, other defects; Speech literacy is excellent, good, mediocre, bad, unpleasant; Talking manner-calm, angry, sensible , unreasonable, command, consistent, inconsistent, cautious, emotional, mocking, other; Sound background in the handset-the noise of vehicles, factory equipment, train, plane, animal voices, quiet voices of other people, mix of sounds, party, other; Nature of the call-urban or long-distance, from a mobile phone, recording a voice recorder, a robot.

During the conversation, if possible, get answers to the questions:

1) Where and by what phone number does this person call;

2) What specific requirements he (she) puts forward or acts as an intermediary, or represents some group of persons;

3) On what conditions he (she) or they are ready to refuse to fulfill the intended threat;

4) How and when it can be contacted;

5) Who can and should be informed about this call.

Observing confidentiality, it is necessary to urgently report the incoming call to the head doctor or the person performing his duties, and act in accordance with his instructions.

Provision of qualified medical care in the structure of the Medical and Nursing Brigade (MNB)

On the basis of the decree of the Head of the municipality “On the establishment of civil defense rescue services of the Syktyvkar municipal educational institution No. 3/769 dated March 19, 2007, a medical and nursing brigade of 4 persons, including a doctor, two nurses and a driver. The institution has created several such teams. Their tasks in the mode of daily activities include the following medical and preventive measures in the volume of the first medical aid:

1) Elimination of respiratory dysfunction (removal of blood and mucus from the upper respiratory tract, flashing the tongue, the imposition of vehicle tires for fractures of the jaws, the introduction of an air duct, the imposition of a tracheostomy);

2) Applying an occlusive dressing with open pneumothorax;

3) Artificial lung ventilation;

4) Closed heart massage;

5) The final stop of external bleeding by flashing the vessel, ligation of the vessel in the wound or throughout it;

6) Fight against shock (administration of anesthetics and cardiovascular drugs, novocaine blockades, transport immobilization, transfusion of anti-shock and plasma-substituting liquids);

7) Monitoring the effectiveness of anti-shock therapy (measuring pulse rate, blood pressure level);

8) Catheterization or suprapubic puncture of the bladder during urinary retention;

9) Dressing correction, fix immobilization;

10) Cutting off the limb hanging on the skin flap;

11) The introduction of antibacterial drugs and other means of delaying and preventing the development of infection in the wound;

12) Partial sanitization;

13) Relief of the reactive state [24-28].

The volume of first medical aid may vary depending on the conditions of the situation, the number of injured admitted, the time of their delivery, the distance to the nearest medical institutions and availability of transport for the evacuation of the affected, etc.

MNB doctor

1) Must possess modern methods of diagnosis and treatment of emergency conditions;

2) Organizes the timely and full receipt, loading of the aircraft’s personal property;

3) Ensures timely arrival of the MNB to the place of emergency;

4) Organizes the work of the MNB on the site of an emergency;

5) Ensures the interaction of MNB with medical and other formations involved in emergency response;

6) Solves the issues of evacuation of victims and escort them by a health worker;

7) Organizes special training of the personnel of the MNB and maintains its constant readiness for work in emergency situations;

8) Inform the head of the treatment-and-prophylactic institution in a timely manner about changes in his address, telephone number, or inability to stay in the MNB for any objective reason [29-31].

Disaster Psychiatry: Is a medical area that deals with theoretical and applied issues of helping victims of ES. The subject of her study is the medical-psychological and psychiatric consequences of disasters with the aim of developing the theoretical, methodological and organizational basis for the provision of psychiatric care at various stages of ES response. Disaster psychiatry is closely related to environmental psychiatry, which is a medical area that covers a wide range of biomedical research related to the study of psychological and psychopathological conditions caused (directly or indirectly) by pathogenic and sanogenic effects of environmental factors [32]. Psychiatry of accidents is also associated with extreme psychiatry, focused on the study of medical, psychological and psychiatric problems, caused by the influence of specific factors of extreme types of professional (military-professional) activities.

Virtually all persons affected by ES, regardless of the severity of the clinical picture, need first aid; First aid is necessary for 65.0% of victims with lung and up to 100.0% with severe psychogenias. 25.0% of victims with neurotic reactions, 75.0% with moderate mental disorders and 100.0% with severe, need specialized psychological and psychiatric care. The terms of treatment of these groups are different: up to 10 days with mild psychogenias and for more than 2 months for people with reactive psychosis [33-35].

The primary tasks of the psycho-psychiatric service in ES situations are:

1) Identification of victims with acute psychomotor agitation;

2) Ensuring their safety and those around them;

3) Elimination of the situation of confusion;

4) Elimination of the possibility of mass panic reactions.

From the moment of occurrence of an ES and until the appearance of the possibility of providing the necessary highly qualified specialized assistance, certain time passes. Conventionally, there are three phases in terms of the amount of assistance provided:

Phase of the isolation: Depending on the type of emergency, it can last from several minutes to several hours. During this period, the provision of assistance by representatives of the medical service is impossible for obvious reasons. Therefore, at this time, the ability and the ability to provide self-help and mutual assistance becomes crucial.

Phase of the rescue: Lasts from several hours to several days. At this time, medical care is provided by ambulance doctors and trained personnel.

Phase of the specialized medical care: Begins with the advent of the possibility of providing highly qualified medical care.

It have to admit that so far, both for the population and for the majority of people who provide assistance to victims of ES, the function of the members of the psychological and psychiatric service group in the lesion focus remains unclear. Therefore, representatives of the psycho-psychiatric service in the lesion should not only perform the functions assigned to them, but also conduct outreach work among the victims and rescuers about the role and place of the group in the overall system of care [36-38].

A representative of the psychological-psychiatric group should take part in meetings of the leaders of rescue organizations and local leaders with the affected population and their relatives in order to identify people who, because of their temporary disorders, sow panic, spread rumors and sometimes not true.

It has been established that persons with stress disorders on their own rarely seek psychological and psychiatric care, so they rarely come to the attention of a psychotherapist or psychiatrist. In this regard, part of the psychiatrists (psychotherapists) should work as part of the general medical team, which performs the sorting of patients.

The modern system of providing psychological and psychiatric care allows for preventive measures aimed at reducing the likelihood of emergency consequences. It provides an opportunity to provide victims immediately after the occurrence of an ES with differentiated psychiatric and psychological assistance, as well as to carry out rehabilitation activities in a more remote period. A further condition for improving the entire system of assistance to victims and victims in emergencies should be considered targeted training of a wide range of EMERCOM specialists in the field of disaster psychiatry.

In the life of modern society is not happening exactly the same ES. Therefore, the nature of the necessary psychological and psychiatric care and its volume is always different. The amount of assistance provided, in addition to medical care, largely depends on the political and social conditions of the region and the epicenter of the ES.

The basic modules of the Psycho-Psychiatric Emergency Service are:

1) Department of psychological and psychiatric care;

2) The office of psychological and psychiatric care;

3) Advisory outreach team of psychological and psychiatric care;

4) Department of anonymous psychological and psychiatric care by telephone. Which of these units can and should be involved in each case determine the features of an ES [39-41].

Discussion

Order of the Ministry of Healthcare and Social Development of the Russian Federation of July 23, 2010 N 541n “On Approval of the Unified Qualification Reference Book of Managers, Specialists and Employees, the section” Qualification Characteristics of Health Workers’ Positions “(Registered in the Ministry of Justice of the Russian Federation on August 25, 2010 N 18247) unequivocally interprets that the doctor the psychiatrist provides psychiatric assistance to the population in emergency situations, must be aware of the organization and activities of the civil defense medical service, fire safety rules [42-44]. But in Order Ministry of Health from 04.23.2013 № 240n “On the order and timing of passage of health professionals and pharmaceutical personnel certification for qualification category” in the qualifications for the second, the first and highest category physician requirements for MSCD and ES no [45-47].

Disaster psychiatry as a science is built on the following principles

1) Integrity-determines the systematic changes at the level of the organism and the personality, which cannot be explained by the properties of any one, taken separately, system, including the central nervous system;

2) Structural-includes the natural unity of structural and functional changes at all levels of the systemic organization of the body and personality;

3) Causality-explains the causation of the features of the development of mental disorders in ES situations, phases and stages of the changes that occur, reflecting the close relationship between the factors in ES situations, the state of the organism, the personality and their reactive-adaptive capabilities;

4) Dynamism-recognizes the complexity of the system of regulation and self-regulation, the reliability and stability of the activity of functional systems in ES, the dynamic nature of the norm and pathology, their ability to develop and “self-develop”;

5) Hierarchy-explains the dependence of the relationship between physiological and mental processes, psychological and social patterns as the relations of the highest and the lowest level, when the social as the highest level includes as its basis the biological as the lowest level that is closely connected and interact with each other.

The subject of catastrophe psychiatry can be defined as the study of the influence of factors of catastrophic events on the state of mental health in various age and socio-occupational groups of the population and among members of emergency response teams; proper mental and psychosomatic disorders caused or mediated by ES factors, the establishment of their structure, patterns of development and features of clinical manifestations; methods of diagnosis, treatment, prevention and rehabilitation; forecasting and assessing the psychological and psychiatric consequences of disasters and ES; development and improvement of a unified system of psychological and psychiatric care for the population affected by an emergency situation and members of emergency response and rescue units.

Thus, the psycho-psychiatric service is a system of forces and means designed to provide psychological and psychiatric care to victims of ES and to conduct (plan and organize) activities aimed at protecting the health and maintaining the high working capacity of rescuers.

Medico-social problems of the psychiatry of disasters are determined by a significant modern multiple increase in ES, which leads to an increase in the number of people with an acute reaction to stress, as well as the number of secondary victims. Each person in conditions approaching in composition to an ES, there are various physical and mental changes in the process of adaptation. At certain stages, asthenic, depressive and intellectual-mnestic disorders arise. Features and patterns of the dynamics of these disorders, as well as indicators of autonomic reactivity, reflecting the state of the mechanisms of mental and physical adaptation to unusual conditions of life, have a decisive influence on the formation of a pathological state. In the development of mental disorders in ES, an important role is played by the level and nature of the motivations and moral and ethical qualities of the victim.

At the same time, there is an accumulation in society of individuals with prolonged disorders such as post-traumatic stress disorder and adaptation disorder. Already in the coming periods after ES, the circle of victims is expanding at the expense of relatives and close victims of disasters. Special socio-psychological problems are experienced by refugees, internally displaced persons, persons participating in emergency rescue operations. At their separate stages, structurally complex painful disorders are formed, which are distinguished by polymorphism, a combination of asthenic, psycho-vegetative, affective, psychosomatic, and pathological characterological disorders with gradual involvement of somatogenic and exogenous mechanisms of pathogenesis. Often in ES situations and disasters panic disorders occur, which take on the character of a mental epidemic [48-51].

In general, mental disorders during ES should not be viewed as an exclusively mental pathology, but as pathological forms of adaptive reactions and conditions that have a positive meaning “in terms of expanding the range of adaptive properties of the organism and the personality”.

The structure of service MSCD and ES

The department of psychological and psychiatric help by telephone in emergency situations - the “Hotline” is used to obtain information:

1) On the structure of the ES and its consequences (the presence of victims, destruction, etc);

2) On changing the social infrastructure in the epicenter of ES (metro stations are closed or open, whether other vehicles are working, whether electricity is being supplied, whether the water supply is not interrupted, etc);

3) Regarding the lists of victims and where they are sent;

4) For assistance with troubleshooting communications or other malfunctions that they believe could lead to an ES. The “hot line” provides psychological and psychiatric assistance to the population by telephone every day, around the clock, without interruption. Psycho-psychiatric assistance to the population is anonymous. The address of the hotline is not indicated in the address directories. Specialists of the department are represented as “Hotline”, “Medical and psychological assistance” or under a pseudonym.

Despite the existing system of measures, only 20%–25% of victims apply for psychological and psychiatric help in the early days of ES in its epicenter. In most cases, this is due to the lack of information about the existence of such a service, the fear that seeking psychological and psychiatric care may lead to undesirable social consequences. Regarding cases of ad hoc treatment makes it difficult for old age, the presence of physical illness, etc. An important role is played by the inability to use the injured by those medical and other services offered by the society.

After the resolution of an ES (after the completion of an acute reaction to stress), the hotline addresses several other problems.

1) Persons in need of correspondence support psychotherapeutic care (previously received the necessary internal psychological and psychiatric care);

2) Persons with post-traumatic stress disorder who for one reason or another do not wish (cannot) to apply for psychological and psychiatric care in person;

3) Persons who called for psychological and psychiatric help earlier through the hotline;

4) Persons with personal problems not directly related to an ES;

5) Persons for whom daily repeated conversations on the hotline turn

If necessary, the doctors of the psychological and psychiatric service of the person who called by phone should recommend visiting a psychiatrist at the place of residence, a psychiatrist (psychotherapist) in the office or a doctor of the emergency psychiatric department for ES response.

Employees of the psycho-psychiatric service, when they receive by telephone information about the intentions of a person who pose a threat to individual or public safety, should take measures to ascertain their passport data, the subscriber’s place of stay, and immediately inform the ambulance service of the district doctor. Psychiatrist, the police [39,52].

The advisory medical team of psychological and psychiatric assistance in ES is a part of the psychological and psychiatric service and is subordinated to its head

The tasks performed by the medical team are primarily determined by the specifics of assistance to victims of ES. Team members must take into account not only the required amount of assistance provided, but the nature of the ES (natural, man-made, mixed). It is known that many victims of ES during an acute reaction to stress, especially during the period when the threat of the victim’s life has passed, can cause a heroic phase, when along with the increased background mood, there is a decrease in criticism of the situation and a decrease in the sense of danger. Overestimating their abilities on their own initiative, they begin to interfere in rescue work, endangering not only their own lives, but also the lives of those around them.

With an acute reaction to stress with an external orderly behavior, there is a difficulty in concentrating attention, which in turn complicates the perception of information, its critical understanding, fixation and reproduction. All of the above imposes the need to record medical recommendations in the form of a prescription sheet (prescribed drugs, time of their administration and dose), which should be given to the injured person.

When exposed to a stress factor, along with other shifts, the vital senses of the body are suppressed - feelings of thirst and hunger, which leads to a decrease in the circulating blood volume (BCC) of the body, primarily due to a decrease in circulating plasma volume (CPV). Therefore, the doctors of the advisory team should pay special attention to the external manifestations of signs of dehydration, since the effectiveness of psychotropic drugs and the severity of adverse (unwanted) actions largely depend on the concentration of the drug in the blood plasma.

The specific features of the work of the medical team in ES also include the low reliability of objective information that is provided by relatives and friends of the victim, which is due to the fact that in case of ES, victims are often individuals who report information about the victim.

Physicians who provide psychological and psychiatric care should also consider the following: persons who have survived an ES (who have not received physical injuries), first of all, pay attention to the parameters reflecting the functioning of the body’s somatic sphere. When changes are found in the body’s basic self-regulation systems (changes in pulse rate, blood pressure, and black blood pressure), headaches, hand tremors, and other disorders that occur after an ES and are usually caused by the stressor effect, the victims first turn to internist doctors. In this regard, one of the most important tasks of providing psychological and psychiatric care in ES is to work in close contact with internist doctors and general medical teams.

Mental disabilities caused by an ES often do not correlate with the occurring ES and are not referred to psychiatrists (psychotherapists). In addition, appealability to psychiatrists (psychotherapists) in connection with ES and the resulting problems in the Russian Federation remains very low, which makes it necessary to actively identify and actively offer psychological and psychiatric assistance to victims (visiting victims at home). This is due to the fact that previously the material and moral support from close relatives, friends, work collectives, etc. was quite strong.

The emergency psychiatric medical team provides psychiatric assistance to people with mental and behavioral disorders arising from large-scale and individual events. In addition, the team provides assistance to persons with combined mental and somatic pathology; persons with somatic disorders accompanied by mental disorders. Doctors of the brigade conduct an examination of a person without his consent or without the consent of his legal representative and hospitalize in a non-voluntary manner in accordance with the legislation in force. The team also transports persons suffering from mental disorders to the relevant health care facilities or other facilities.

The department of psychological and psychiatric ES Assistance

Is essentially the main link that, outside the emergency period, carries out organizational measures aimed at minimizing their consequences. These activities include:

1) Identification of natural ES (which may occur in the service area) and institutions with an increased risk of occurrence of ES located in the service area;

2) Determination of the probable number of primary and secondary victims in an alleged ES.

The plan of interaction of the group of psychological and psychiatric care with doctors of other specialties, as well as with other specialists providing care; includes questions:

1) What will be the outpatient psychological and psychiatric care in the ES area;

2) What institutions will provide specialized assistance;

3) How will the injured be delivered to the hospital? Preliminary “temporary” calculations are carried out, which determine the time after which this or that specialized assistance will be rendered to the victim.

The person responsible for assisting with ES must determine and make calculations which drugs, in what quantity and in what form may be needed in the lesion and at later stages of care (neuroleptics, antidepressants, tranquilizers, nootropics, sleeping pills)

It also seems necessary:

1) The selection of objects that require special attention - schools, homes, hospitals, maternity hospitals;

2) Using the media to raise public awareness of the consequences of ES and the actions to be taken;

3) Coordination of work with other nongovernmental organizations involved in providing assistance in ES (church, charitable associations, volunteers).

The main purpose of the department of psychological and psychiatric care is to provide optimal assistance to those affected by ES. The department is organized (depending on the conditions on the ground) on the basis of a multidisciplinary hospital (psychiatric hospital, day hospital, mental health center).

Persons with mental disorders caused by ES are hospitalized to the department, as well as mentally ill persons who have exacerbated symptoms due to emergency situations. Sending to the office is carried out voluntarily at the request of the victim or with his consent. Doctors provide inpatient diagnostic and treatment assistance for mental disorders caused by (or aggravated) ES, carry out differential diagnostic measures in complex clinical cases and carry out an examination of the ability to work. [39. 53]

The office of psychological and psychiatric ES care

Is created to provide optimal assistance to those affected by an ES but not in need of inpatient care. Persons suffering from mental illness who have exacerbation of symptoms due to an emergency situation can also contact the office.

The office is organized (depending on the conditions on the ground) on the basis of a polyclinic, a multidisciplinary hospital (psycho-neurological dispensary).

If necessary, the office staff can be nominated to provide psychological and psychiatric care in the epicenter of the ES and provide assistance both independently and as part of the brigade. If necessary, persons with mental disorders due to emergency situations are referred to institutions that provide inpatient psychological and psychiatric (psychiatric) care.

The office staff also provides psychological and psychiatric care for people with mental disorders that have arisen as a result of ES in the late stages of the disease (post-traumatic stress disorder, impaired adaptation, etc.).

Outside the ES period, the cabinet’s staff draws up an ES response plan, which is likely to occur in this region; take part in the allocation of objects that require special attention - schools, homes, hospitals, maternity hospitals; organize social groups (headquarters) of psycho-psychiatric care; participate in the exercise of medical care for victims of emergency situations; raise public awareness in matters of mental disorders arising from ES (with the involvement of the media).

The head of the office assists the head of the psycho-psychiatric service in forming a group of psychologists and psychiatrists working at the epicenter of the ES, provides information on the structure of the psychiatric service in the ES region and on the degree of its equipment, and also reports on the degree of involvement of local doctors of various specialties in Ch [39,54].

Rendering assistance to medical workersParticipants in rendering assistance to victims of ES

As experience shows, medical workers who survived ES should first of all be treated as injured, which implies the provision of necessary medical, psychological and medical assistance. Their involvement in professional activities (depending on the state) should be gradual. At first, they should be assigned specific, monosyllabic tasks that are not related to making responsible, independent decisions.

When working together with professional rescuers, the psychiatrist should take into account that in an ES, this cohort can also identify various types of mental adaptation to the current situation. Rescuers are at risk of developing affective spectrum disorders. Participants in the aftermath of emergency situations are dominated by psychopathological disorders of exogenous-organic origin with a tendency to the gradual formation of variants of the psychoorganic syndrome and polysystemic psychosomatic disorders [39, 54,55].

Conclusions

1. In accordance with normative legal documents and official duties, a psychiatrist provides psychiatric assistance to the population in emergency situations and should know the organization and activities of the medical service of civil defense.

2. It is expedient to divide the work of a psychiatrist in the structure of MSCD and ES for four blocks: 1) Personal participation in the development of educational and methodological and lecture materials for preparing the population for action in the context of civil defense and emergencies; 2) The actions of a doctor in a medical institution under “everyday” emergencies; 3) Work in the medical-nursing brigade of the civil defense system; 4) Participation in the structure of psycho-psychiatric care for the population in emergencies.

3. The psychiatrist must undergo special training for successful work in the basic modules of the psychological and psychiatric service of emergency situations: 1) the Department of anonymous psychological and psychiatric help by phone; 2) an advisory visiting team of psycho-psychiatric care; 3) Department of psychological and psychiatric care; 4) Cabinet of psychological and psychiatric care.

4. Medical workers who survived ES should be treated as victims, who need comprehensive psychological and psychiatric care and careful corporate support, with a gradual return to normal workload.

5. The contingent of professional rescuers under conditions of ES is exposed to the extreme factors of the current situation and is a risk group for the development of affective spectrum disorders. They may experience psychopathological disorders of exogenous organic origin with a tendency to gradually formulate variants of psycho-organic syndrome and polysystemic psychosomatic disorders.

6. The multifaceted work of a psychiatrist in the MSCD system and ES should be a weighty additional argument in favor of a positive decision on awarding the qualification category declared by him.

The authors express sincere love to their parents. The authors are grateful to Muratova ID, Stepanov AF, Kotova EG, Ipatko IA, Knyazeva LV, Nosov PP, Repina GV, Krtesteva-Gavrilova AG, and Mordvinkova LV, as well as to all anonymous reviewers for their support, valuable advice and helpful comments.

  1. Appendix No. 3 to the Administrative Regulations for the provision of a state service for the assignment of a qualification category to specialists engaged in medical and pharmaceutical activities in the territory of the Komi Republic in accordance with the procedure established by the authorized federal executive body.
  2. Shapovalova LA (1997) Organization of the work of a specialized psychiatric bureau for medical and social expertise in 1994-1996. Syktyvkar.
  3. Shapovalova LA (2002) Attestation materials of a doctor-psychotherapist of the Republican Center for Socio-Psychological, Medical Rehabilitation of Former Servicemen and Disabled. Syktyvkar.
  4. Shapovalova LA (2007) About the work of the psychiatrist of the consultative department of the state health care institution Consultative and Diagnostic Center of the Republic of Komi in 2005-2007. Syktyvkar.
  5. Shapovalova LA (2012) An analysis of the work of a psychiatrist-consultant of the state autonomous public health institution of the Republic of Komi Consultative and Diagnostic Center of the Republic of Komi in 2010-2012. Syktyvkar.
  6. Shapovalova LA (2018) An analysis of the work of a psychiatrist at the advisory office of the State Autonomous Healthcare Institution of the Republic of Komi Consultative and Diagnostic Center of the Republic of Komi in 2015-2017. Syktyvkar.
  7. Shapovalov KA, Shapovalova LA (2015) Bases of didactics of an educational theme. Training of the population to first-aid treatment at thermal defeats, electric, thermal and beam burns, freezing injuries in the conditions of emergency situations. Bezopasnos’t Zhiznedeyate’lnosti 172: 67-72. Link: http://bit.ly/2MYeUoT
  8. Shapovalov КА, Shapovalova LA (2015) Methodological approaches to teaching academic theme "Wounds" of subject. First aid for injuries suffered during accidents, catasthrophes and natural disasters for humanitarian and technical universities. 19th World Congress for Disaster and Emergency Medicine 21-24.
  9. Shapovalov КА, Shapovalova LA. (2015) The Author's Program of Subject "First Aid for Traumas in Accidents and Natural Disasters" for Non-medical Faculties of Humanities and Technical Universities. 19th World Congress for Disaster and Emergency Medicine, Cape Town, South Africa: Abstracts 634.
  10. Shapovalov KA, Shapovalova LA (2016) Basics of Didactics of Theme "Closed Damages" of Training Module the First (Pre-Medical Emergency) Assistance for Traumas Suffered During Accidents, Catastrophes and Natural Disasters of Subject "Life Safety" for Humanitarian and Technical Universities. Bezopasnost' Zhiznedeyatel'nosti 182: 56-64. Link: http://bit.ly/2VY9mPi
  11. Niculina TI, Shapovalov KA, Shapovalova LA (2016) Additional professional training program of teachers of educational institutions providing first emergency aid to victims. Syktyvkar, Komi Republican Institute for Educational Development. (In Russian)
  12. Shapovalov KA, Shapovalova LA (2016) Basics of Didactics of Theme "Bleeding" of Training Module the First (Pre-Medical Emergency) Assistance for Traumas Suffered During Accidents, Catastrophes and Natural Disasters of Subject "Life Safety" for Humanitarian and Technical Universities. Bezopasnost' Zhiznedeyatel'nosti 184: 51-61. Link: http://bit.ly/2Mx2TaW
  13. Shapovalov KA, Shapovalova LA (2016) Bases of Didactics of Theme "Fractures" of Educational Module the First (Pre-Medical Emergency) Assistance for Injuries Suffered During Accidents, Catastrophes and Natural Disasters of Subject "Safety" for Humanitarian and Technical Universities. Bezopasnost' Zhiznedeyatel'nosti 187: 54-61. Link: http://bit.ly/32ES908
  14. Shapovalov KA, Shapovalova LA (2017) Additional Professonal Training Program of Distance Learning Course First Aid for Injuries and Accidents. Syktyvkar, Komi Republican Institute for Educational Development.
  15. Shapovalov KA, Shapovalova LA (2017) Bases of Didactics of Theme "Damage to the Head, Neck and Spinal Column" of Educational Module "The First (Pre-Medical Emergency) Assistance for Traumas Suffered During Accidents, Catastrophes and Natural Disasters" of Subject "Life Safety" for Humanitarian and Technical Universities. Bezopasnost' Zhiznedeyatel'nosti 196: 54-64. Link: http://bit.ly/2pDc68V
  16. Shapovalov KA, Shapovalova LA (2017) First Aid for Wounds to Victims of Accidents, Catastrophes and Natural Disasters. Geneva, World Health Organization 4: 1-20.
  17. Shapovalov KA, Shapovalova LA (2017) First Aid for Head, Neck and Spine Injuries to Victims of Accidents, Catastrophes and Natural Disasters. Geneva, World Health Organization 4: 1-47.
  18. Shapovalov КА, Shapovalova LA (2017) Methodological approaches to teaching academic theme "Burns" subject First aid for injuries suffered during accidents for humanitarian and technical universities. WCICT 2017 WOUND CARE From Innovations to Clinical Trials.
  19. Shapovalov КА, Shapovalova LA (2017) Organization of emergency care at occupational wounds to members of vessel’s crews on ships of the Northern water’s basin. WCICT 2017 WOUND CARE From Innovations to Clinical Trials.
  20. Shapovalov KA, Shapovalova LA (2017) Author's Program of Subject. Fundamentals of a Healthy Lifestyle for Non-Medical Faculties of Humanitarian and Technical Universities. // ICSS 2017 International Conference on Social Sciences & Interdisciplinary Studies.
  21. Shapovalov KA, Shapovalova LA (2017) The Author's Training Program and Methodical Complex Basics of a Healthy Life Style for the Prevention of Traumatism of Members of Vessel`s Crew. GPC 2017 2nd International Conference on General Practice & Primary Care.
  22. Shapovalov KA, Shapovalova LA (2005) Educational-methodical complex on discipline "Safety" (for universities). OBZH. Osnovi Bezopasnosti Zhizni 33-38.
  23. Shapovalov KA, Shapovalova LA (2005) Educational-methodical complex on discipline "Safety" (for universities). The End. OBZH. Osnovi Bezopasnosti Zhizni 35-39.
  24. Federal Law No. 28-FZ of February 12, 1998 "On Civil Defense".
  25. Order of the Ministry of Health of the Russian Federation of 24.10.2002, № 325 "On psychological and psychiatric assistance in emergency situations."
  26. FZ-No.68 of December 21, 1994 on Protection of the Population and Territories from Emergencies of Natural and Technogenic Character.
  27. Decree of the Head of the Komi Republic No. 97 of October 13, 2008 on approval of the Regulations on the organization and conduct of civil defense in the Komi Republic.
  28. The Decree of the Government of the Republic of Komi No. 481 of December 28, 2010 On maintaining civil defense forces and facilities in the Komi Republic in constant readiness.
  29. Resolution of the Government of the Republic of Komi No. 121 dated July 27, 2004 On the Komi Republican Subsystem of the Unified State System for Preventing and Eliminating Emergency Situations.
  30. The order of the Ministry of Health of the Republic of Komi No 177 of 25.09.1997 Questions of the service of medicine of catastrophes. (In Russian)31. Order of the Ministry of Health of the RK 37/184 of 20.07.2001 on approval of the Regulations on the Service of Medicine of Disasters of the Ministry of Health of the RK.
  31. Order of the Ministry of Health of the RK 37/184 of 20.07.2001 on approval of the Regulations on the Service of Medicine of Disasters of the Ministry of Health of the RK.
  32. Semke VYа (2007) Sostoyanie psihicheskogo zdorov'ya naseleniya Vostochnogo Zabajkal'ya. Sostoyanie psihicheskogo zdorov'ya naseleniya Vostochnoj Sibiri. Materialy mezhregional'noj nauchno-prakticheskoj konferencii, posvyashchennoj 50-letiyu kafedry psihiatrii, narkologii i medicinskoj psihologii CHitinskoj gosudarstvennoj medicinskoj akademii (Chita , 20 -21 sentyabrya 2007 g.) / Pod nauchnoj redakciej akademika RAMN V. Ya. Semke, professora N. V. Govorina. Tomsk, Chita, 2007: 5-8.
  33. Provision of psychological and psychiatric assistance to victims in emergency situations. Methodical recommendations N2002/144.
  34. Order of the Ministry of Health and Social Development of the Russian Federation of 23.07.2010 N 541n On approval of the Unified Qualification Reference Book for the positions of managers, specialists and employees, section Qualification characteristics of the positions of employees in the healthcare (Registered in the Ministry of Justice of the Russian Federation on 08/25/2010 No. 18247).
  35. Order of the Ministry of Health No. 240n of 23.04.2013 On the Order and the timing of the passage of medical personnel and pharmaceutical workers attestation to obtain a qualification category. (Registered with the Ministry of Justice of the Russian Federation on July 5, 2013).
  36. Shapovalova LA, Shapovalov КА (2016) Outpatient Consulting Care of Psychiatrist on Population of SubArctic territory. RC Psych International Congress.
  37. Shapovalova LA, Shapovalov КА (2016) Features of work of psychiatrist of Regional consultative diagnostic center of Subarctic Territory. Independent Psychiatric Journal III: 68-74 83-84. Link: http://bit.ly/33SBCWf
  38. Shapovalova LA, Shapovalov KA (2016) Questions of the Organization and Results of the Work of Psychiatrist of Advisory Department of the Regional Diagnostic Center of Sub-Arctic Territory with Low Population Density. Geneva, World Health Organization, Pubrights 12:1-25
  39. Kokhanov VP, Krasnov VN (2008) Psychiatry of catastrophes and emergency situations (theory and practice). Moscow: Practical medicine, 2008.
  40. Shapovalov К, Shapovalova L (2017) EV0534 Demographic Characteristics of the Cohort of Patients, Receiving Outpatient Psychiatric Help in Regional Medical Consultative and Diagnostic Center of Sub-Arctic Territory. European Psychiatry the Journal of the European Psychiatric Association: EPA 2017 25th European Congress of Psychiatry. 41:578. Link: http://bit.ly/33S2d6a
  41. Shapovalov К, Shapovalova L (2017) EV0535 Structure of Psychic Sphere Pathology of Patients of the Regional Medical Consultative and Diagnostic Center of Sub-Arctic Territory. European Psychiatry: The Journal of the European Psychiatric Association. EPA 2017 25th European Congress of Psychiatry. Florence, Italy. 41: 578-579. Link: http://bit.ly/31yLJhA
  42. Shapovalova L, Shapovalov К (2018) Training of Psychiatrist of Regional Diagnostic Center of Subarctic Territory for Work in Emergency Situations of Catastrophes and Natural Disasters. Scientific Program Sc23 Innovations in Policy and Planning Health. Short Communications 23: Migration and Depression and Emotional Status of Stroke Survivors, and Their Daily Activities and Validation of A Widely-Used Depression Scale 27-Feb-2018 16:15 16:45. Wpa 2018 World Psychiatric Assosiations Tematic Congress “Innovation in Psychiatry: Effective Interventions for Health & Society”. Melburne, Australia.
  43. Shapovalova L, Shapovalov К (2018) EV0364 EV0364 Features pathology newly diagnosed by a psychiatrist at the reception of the regional advisory diagnostic center of subarctic territory. European Psychiatry the Journal of the European Psychiatric Association: EPA 2018 26th European Congress of Psychiatry. Nice, France. Abstracts of the 26th European Congress of Psychiatry. 48: 569. Link: http://bit.ly/2BGg6Z7
  44. Shapovalova L, Shapovalov К (2018) EV0828 Pathology of the psychic sphere in patients with epilepsy, revealed by psychiatrist of the regional consultative center of the Subarctic territory. European Psychiatry the Journal of the European Psychiatric Association: EPA 2018 26th European Congress of Psychiatry. Nice, France. Abstracts of the 26th European Congress of Psychiatry 48: 718-719. Link: http://bit.ly/2BGg6Z7
  45. Shapovalov K, Shapovalova L (2018) EV0940 Scientific research as an integral part of the work of a psychiatrist leading an outpatient consultation in the regional diagnostic center of the subarctic territory. European Psychiatry the Journal of the European Psychiatric Association: EPA 2018 26th European Congress of Psychiatry. Nice, France. Abstracts of the 26th European Congress of Psychiatry 48: 755-756. Link: http://bit.ly/2BGg6Z7
  46. Shapovalova L, Shapovalov К (2019) E-PV0120 Alcoholic fetal syndrome as obligatory part of lecture on prevention of alcohol use of module "Fundamentals healthy lifestyle" for students of humanitarian and technical universities. EPA. European Psychiatry. The Journal of the European Psychiatric Association. Abstracts of the 27th European Congress of Psychiatry. Warsaw, Poland. 52: 482-483. Link: http://bit.ly/2JaynBE
  47. Shapovalova L, Shapovalov К (2019) E-PV0324 "Psychiatry of catastrophes" in the daily work of an outpatient psychiatrist. EPA. European Psychiatry. The Journal of the European Psychiatric Association. Abstracts of the 27th European Congress of Psychiatry. Warsaw, Poland. 56: 546. Link: http://bit.ly/2JaynBE
  48. Shapovalova L, Shapovalov К (2019) E-PV0342 Organizational and methodological work in the practice of psychiatric outpatient consultative reception. EPA. European Psychiatry. The Journal of the European Psychiatric Association. Abstracts of the 27th European Congress of Psychiatry. Warsaw, Poland. 56: 552. Link: http://bit.ly/2JaynBE
  49. Shapovalova L, Shapovalov К (2019) E-PV0437 Characteristics of mental health of patients of outpatient reception of psychiatrist. EPA. European Psychiatry. The Journal of the European Psychiatric Association. Abstracts of the 27th European Congress of Psychiatry. Warsaw, Poland. 56: 582-583. Link: http://bit.ly/2JaynBE  
  50. Shapovalova LA, Shapovalov KA (2019) Organizational and methodological work in the structure of the practice of a psychiatrist consultative outpatient admission. Geneva. World Health Organization. 4: 1-28.
  51. Shapovalova LA, Shapovalov KA (2019) The structure of the mental incidence of patients of psychiatrist consultative outpatient admission. Geneva. World Health Organization. 4: 1-26.
  52. Shapovalova LA, Shapovalov KA (2018) Organizational and methodical work as an integral part of the qualification category of a psychiatrist of consultative department of the regional diagnostic center of the subarctic territory. Mental Health. 3-11.
  53. Shapovalova LA, Shapovalov КА (2018) Characteristics of the pathology of the mental sphere of a contingent of patients on an outpatient visit to a psychiatrist of the consultative and diagnostic center of the subarctic territory. Psychiatry Psychotherapy Clinical Psychology 515-533. Link: https://bit.ly/2MyKtqA
  54. Shapovalova LA, Shapovalov КА (2018) The work of the medical service of civil defense and emergency situations as an integral part of the qualification category of a psychiatrist. Psychiatry 4: 40-52.
  55. Shapovalova LA, Shapovalov KA (2019) Fundamentals of disaster psychiatry in the structure of the work of a psychiatrist in an outpatient consultation. Geneva. World Health Organization 6: 1-28.
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