The human impact of the tsunami that occurred on 26 December 2004 was enormous, with Indonesia bearing a huge proportion of the losses. The aftermath brought predictions of communicable disease outbreaks and widespread fear of epidemics. However, evidence from previous disasters due to natural hazards does not support all of these predictions. The objectives of this study were to: (1) describe the relative importance of infectious diseases and injuries as a consequence of a disaster due to natural hazards; and (2) identify key recommendations for the improvement of control and surveillance of these diseases during and after disasters.

A team from the Center for Research on the Epidemiology of Disasters visited Jakarta and Banda Aceh from 11–23 January 2005, and collected data from the Central and Provincial Ministries of Health (MOH), the World Health Organization (WHO), and a field hospital from the International Committee of the Red Cross in Banda Aceh. The epidemiological profiles of diseases before and after the tsunami were compared. Cholera, tetanus, wounds and wound infections, acute respiratory infections, malaria, and dengue were included in this analysis.

Certain diseases (e.g., cholera, malaria, dengue) are not always an immediate priority post-disaster. Rates of disaster-related health conditions requiring emergency response fell by half, and became negligible around four weeks after the precipitating events. Some conditions, such as aspiration pneumonia and tetanus, which normally are rare, require special preparedness for emergency personnel. In addition, resistant and rare pathogens are associated with disasters due to natural hazards in the tropics and require specialized knowledge for the rapid and successful treatment of related infections.

Within the first four weeks of a disaster, international humanitarian agencies in the health sector should start working with the MOH. The WHO surveillance system established immediately after the tsunami offers lessons for developing a prototype for future emergencies. Guidelines for tetanus and aspiration pneumonia should be included in disaster medicine handbooks, and humanitarian aid groups should be prepared to provide emergency obstetrics and post-natal services. Relief funding after naturally occurring disasters should consider funding sustainability. Donors should know when to stop providing emergency relief funds and transition to recovery/development strategies.

During 2005, Hurricanes Katrina and Rita struck the US Gulf Coast, displacing approximately two million people. With >250,000 evacuees in shelters, volunteers from the American Red Cross (ARC) and other nongovernmental and faith-based organizations provided services. The objective of this study was to evaluate the composition, pre-deployment training, and recognition of scenarios with outbreak potential by shelter health staff.

A rapid assessment using a 36-item questionnaire was conducted through in-person interviews with shelter health staff immediately following Hurricanes Katrina and Rita. Data were collected by sampling at shelters located throughout five ARC regions in Texas. The survey focused on: (1) public health capacity; (2) level of public health awareness among staff; (3) public health training prior to deployment; and (4) interest in technical support for public health concerns. In addition, health staff volunteers were asked to manage 11 clinical scenarios with possible public health implications.

Forty-three health staff at 24 shelters were interviewed. Nurses comprised the majority of shelter health volunteers and were present in 93% of shelters; however, there were no public health providers present as staff in any shelter. Less than one-third of shelter health staff had public health training, and only 55% had received public health information specific to managing the health needs of evacuees. Only 37% of the shelters had a systematic method for screening the healthcare needs of evacuees upon arrival. Although specific clinical scenarios involving case clusters were referred appropriately, 60% of the time, 75% of all clinical scenarios with epidemic potential did not elicit proper notification of public health authorities by shelter health staff. In contrast, clinical scenarios requiring medical attention were correctly referred >90% of the time. Greater access and support from health and public health experts was endorsed by 93% of respondents.

Public health training for sheltering operations must be enhanced and should be a required component of pre-deployment instruction. Development of a standardized shelter intake health screening instrument may facilitate assessment of needs and appropriate resource allocation. Shelter health staff did not recognize or report the majority of cases with epidemic potential to public health authorities. Direct technical support to shelter health staff for public health concerns could bridge existing gaps and assist surveillance efforts.

Emergency medical services (EMS) personnel play an integral role during the national response to a pandemic event. To help ensure their health and safety, especially during the early stages of an outbreak, knowledge and adherence with personal protective equipment (PPE) and infection control strategies will be essential.

The objective of this study was to assess the effectiveness of a multi-method, pandemic preparedness training intervention using a pre-/post-test design.

A convenience sample of 129 EMS personnel participated in a training program on pandemic preparedness. Training consisted of an educational intervention with a focus on the routes of transmission of the influenza virus, proper use of respiratory PPE, agency policies regarding infection control practices, and seasonal influenza vaccination. This was followed by a skill-based drill on respirator fit-checking and proper respirator donning and doffing procedures.

Pre-/post-test results indicate a significant increase in knowledge and behavioral intentions with respect to respirator use, vaccination with seasonal influenza vaccine, and willingness to report to duty during a pandemic.

This method was effective in increasing knowledge and compliance intentions in EMS healthcare personnel. Further research should focus on whether training results in behavior modification.

This study examined disaster preparedness, risk perception, and their association in rural hospitals in the United States. The focus of disaster preparedness largely has been centered on urban areas, in part because of the perception that more concentrated areas have an increased risk of a disastrous event. Therefore, it was hypothesized that risk perception may be a contributing factor for adequate preparedness in rural areas. This research was a component of a larger study of rural hospital preparedness. The objective of this study was to describe the perceived risk of disaster events and the status of disaster preparedness in rural hospitals. It was hypothesized that there is a positive association between risk perception and preparedness.

Secondary data analysis was conducted using the National Study of Rural Hospitals (2006–2007) from Johns Hopkins University. The study, based on a regionally stratified, random sample of rural hospitals, consisted of a mailed questionnaire and a follow-up telephone interview with each hospital's Chief Executive Officer (n = 134). A model of disaster preparedness was utilized to examine seven elements of preparedness. Risk perception was examined through seven perceived risk threats.

The results indicated that rural hospitals were moderately prepared, overall,(78% prepared on average), with higher preparedness in education/training (89%) and isolation/decontamination (91%); moderate preparedness in administration/planning (80%), communication/notification (83%), staffing/support (66%), and supplies/pharmaceuticals/laboratory support (70%); and lower preparedness in surge capacity (64%).

The respondents reported greater perceived risk from disasters due to natural hazards (79% reported moderate to high risk) and vehicular accidents (77%) than from humanmade disasters (23%). Results obtained from logistic regression models indicated that there was no statistically significant difference in the odds of a hospital being prepared overall when comparing high versus low risk perception (OR = 0.61; 95% CI = 0.26–1.44). Positive associations were identified only between higher perceived risk overall and the subcategory of education/training preparedness (OR = 1.24; 95% CI = 1.05–1.27).

Rural hospitals reported being moderately prepared in the event of a disaster with a low perception of risk for human-made disasters. Further research should be conducted to identify predictors of preparedness in rural hospitals in order to optimize readiness for potential disaster events.

Expatriate healthcare professionals frequently participate in international relief operations that are initiated in response to disasters due to natural hazards or humanitarian emergencies in low resource settings. This practice environment is significantly different from the healthcare delivery environment in the home countries of expatriate healthcare professionals. Human rights, public health, medicine, and ethics intersect in distinct ways as healthcare professionals provide care and services in communities affected by crisis.

The purpose of this study was to explore the moral experience of Canadian healthcare professionals during humanitarian relief work.

This is a qualitative study with 18 semi-structured individual interviews based on Interpretive Description methodology. There are two groups of participants: (1) 15 healthcare professionals (nine doctors, five nurses, and one midwife) with more than three months experience in humanitarian work; and (2) three individuals who have experience as human resource or field coordination officers for humanitarian, non-governmental organizations. Participants were recruited by contacting non-governmental organizations, advertisement at the global health interest group of a national medical society, word of mouth, and a snowball sampling approach in which participants identified healthcare professionals with experience practicing in humanitarian settings who might be interested in the research.

Five central themes were identified during the analysis: (1) examination of motivations and expectations; (2) the relational nature of humanitarian work; (3) attending to steep power imbalances; (4) acknowledging and confronting the limits of what is possible in a particular setting; and (5) recognition of how organizational forms and structures shape everyday moral experience.

Humanitarian relief work is a morally complex activity. Healthcare professionals who participate in humanitarian relief activities, or who are contemplating embarking on a humanitarian project, will benefit from carefully considering the moral dimensions of this work. Humanitarian organizations should address the moral experiences of healthcare professionals in staff recruitment, as they implement training prior to departure, and in supporting healthcare professionals in the field.

The threat of mass casualties caused by an unconventional terrorist attack is a challenge for the public health system, with special implications for emergency medicine, anesthesia, and intensive care. Advanced life support of patients injured by chemical or biological warfare agents requires an adequate level of personal protection. The aim of this study was to evaluate the personal protection knowledge of emergency physicians and anesthetists who would be at the frontline of the initial health response to a chemical/biological warfare agent incident.

After institutional review board approval, knowledge of personal protection measures among emergency medicine (n = 28) and anesthetics (n = 47) specialty registrars in the South Thames Region of the United Kingdom was surveyed using a standardized questionnaire. Participants were asked for the recommended level of personal protection if a chemical/biological warfare agent(s) casualty required advanced life support in the designated hospital resuscitation area.

The best awareness within both groups was regarding severe acute respiratory syndrome, and fair knowledge was found regarding anthrax, plague, Ebola, and smallpox. In both groups, knowledge about personal protection requirements against chemical warfare agents was limited. Knowledge about personal protection measures for biological agents was acceptable, but was limited for chemical warfare agents.

The results highlight the need to improve training and education regarding personal protection measures for medical first receivers.

Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills.

A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under or over-preparation.

Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22–59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91–97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52–65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96–100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20–32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26–43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23–38%); and (3) verbal ADs (75% very important vs. 54% well-prepared, difference 21%: 95% CI = 12–29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23–39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation.

There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.

Knowledge of injuries of earthquake victims is important to plan relief efforts. This cross-sectional study was conducted following the 08 October 2005 earthquake in Northern Pakistan to determine the pattern of injuries sustained and their relationship with age and gender in order to identify the medical needs in an earthquake-affected zone.

The study was conducted between 13 October and 23 October 2005 at the Emergency Relief Hospital, Doraha, Mansehra. From the 1,700 patients registered in the hospital, 310 were sampled randomly for the study. Demography and details of the patients' injuries were noted by history and physical examination. Twelve cases were omitted due to incomplete data.

Of the cases, 54% were female. Children ≤10 years old formed the largest age group. Isolated bone injuries were present in 41%, soft tissue injuries in 36%, and mixed injuries in 23% of the patients.The most common bone injury was lower limb fracture (52%), while the most common non-bone injury was non-infected, soft tissue wounds on the limbs (33%). Among patients with soft tissue injuries, gangrenous wounds were present in 9%, and grossly infected wounds in 30% (20% on limbs and 10% on rest of the body).

The population injured during the earthquake showed a higher proportion of females and children ≤10 years old, and lower limb bone injuries. The data highlight the need to address orthopedic, pediatric, and women's health issues, and for logistic arrangement of relevant diagnostic and therapeutic facilities at the initial stages of relief activities after earthquakes.

Though many reports have assessed hospital emergency responses during a disaster that affected the facility's operations, relatively little work has been dedicated to identifying factors that aid or impede the recovery of such hospitals.

On 05 October 2005, Hurricane Stan triggered landslides that buried an impoverished Mayan community in Santiago Atitlán, Guatemala. The six-bed Hospitalito Atitlán also was in the landslide's path. Though opened just months earlier, the institution maintained 24-hour services until reopening in a new facility only 15 days after the landslides.

This qualitative study examined the Hospitalito Atitlán's disaster recovery using unstructured interviews with key hospital personnel and community members. Participant observation provided information about institutional and cultural dynamics affecting the hospital's recovery. Data were collected retrospectively during June–September 2006 and June 2007.

The Hospitalito's emergency responses and recovery were distinct endeavors that nonetheless overlapped in time. The initial 12 hours of disorganized emergency relief work was quickly succeeded by an organized effort by the institution to provide inpatient and clinic-based care to the few severely injured and many worried-well patients. As international aid started arriving 2–3 days post-landslide, the Hospitalito's 24-hour clinical services made it an integral organization in the comprehensive health response. Meanwhile, a subset of the Hospitalito's non-clinical staff initiated rebuilding efforts by Day 2 after the event, joined later by medical staff as outside aid allowed them to handoff clinical duties. Effective use of the Internet and conventional media promoted donations of money and supplies, which provided the raw materials used by a group determined to reopen their hospital.

Early work by a recovery-focused team coupled with a shared understanding of the Hospitalito as an institution that transcended its damaged building drove the hospital's rapid post-emergency revival. Encouraging a similar sense of mission, emulating the Hospitalito's handling of funding and material procurement, and conducting rebuilding and relief efforts in parallel may aid recovery at other health facilities.

Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs.

The available data on airmedical transport from remote MCIs are limited. The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs.

The study was retrospective and reviewed descriptive records of airmedical transports.

The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch. The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome.

The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

The large number casualties caused by the 1995 Great Hanshin and Awaji Earthquake created a massive demand for medical care. However, as area hospitals also were damaged by the earthquake, they were unable to perform their usual functions. Therefore, the care capacity was reduced greatly. Thus, the needs to: (1) transport a large number of injured and ill people out of the disaster-affected area; and (2) dispatch medical teams to perform such wide-area transfers were clear. The need for trained medical teams to provide medical assistance also was made clear after the Niigata-ken Chuetsu Earthquake in 2004. Therefore, the Japanese government decided to establish Disaster Medical Assistance Teams (DMATs), as “mobile, trained medical teams that rapidly can be deployed during the acute phase of a sudden-onset disaster”. Disaster Medical Assistance Teams have been established in much of Japan. The provision of emergency relief and medical care and the enhancement and promotion of DMATs for wide-area deployments during disasters were incorporated formally in the Basic Plan for Disaster Prevention in its July 2005 amendment.

The essential points pertaining to DMATs were summarized as a set of guidelines for DMAT deployment. These were based on the results of research funded by a Health and Labour Sciences research grant from the, Labour and Welfare (MHLW) of the Ministry of Health. The guidelines define the basic procedures for DMAT activities—for example: (1) the activities are to be based on agreements concluded between prefectures and medical institutions during non-emergency times; and (2) deployment is based on requests from disaster-affected prefectures and the basic roles of prefectures and the MHLW. The guidelines also detail DMAT activities at the disaster scene of the, support from medical institutions, and transportation assistance including “wide-area” medical transport activities, such as medical treatment in staging care units and the implementation of medical treatment onboard aircraft.

Japan's DMATs are small-scale units that are designed to be suitable for responding to the demands of acute emergencies. Further issues to be examined in relation to DMATs include expanding their application to all prefectures, and systems to facilitate continuous education and training.