In 2010, the US Food and Drug Administration (Silver Spring, Maryland USA) created the Medical Countermeasures Initiative with the mission of development and promoting medical countermeasures that would be needed to protect the nation from identified, high‐priority chemical, biological, radiological, or nuclear (CBRN) threats and emerging infectious diseases. The aim of this review was to promote regulatory science research of medical devices and to analyze how the devices can be employed in different CBRN scenarios. Triage in CBRN scenarios presents unique challenges for first responders because the effects of CBRN agents and the clinical presentations of casualties at each triage stage can vary. The uniqueness of a CBRN event can render standard patient monitoring medical device and conventional triage algorithms ineffective. Despite the challenges, there have been recent advances in CBRN triage technology that include: novel technologies; mobile medical applications (“medical apps”) for CBRN disasters; electronic triage tags, such as eTriage; diagnostic field devices, such as the Joint Biological Agent Identification System; and decision support systems, such as the Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST). Further research and medical device validation can help to advance prehospital triage technology for CBRN events.

Lansdowne K, Scully CG, Galeotti L, Schwartz S, Marcozzi D, Strauss DG. Recent Advances in Medical Device Triage Technologies for Chemical, Biological, Radiological, and Nuclear Events. Prehosp Disaster Med. 2015;30(3):1-4

A Conceptual Framework upon which the study of disasters can be organized is essential for understanding the epidemiology of disasters, as well as the interventions/responses undertaken. Application of the structure provided by the Conceptual Framework should facilitate the development of the science of Disaster Health. This Framework is based on deconstructions of the commonly used Disaster Management Cycle. The Conceptual Framework incorporates the steps that occur as a hazard progresses to a disaster. It describes an event that results from the changes in the release of energy from a hazard that may cause Structural Damages that in turn, may result in Functional Damages (decreases in levels of function) that produce needs (goods and services required). These needs can be met by the goods and services that are available during normal, day-to-day operations of the community, or the resources that are contained within the community’s Response Capacity (ie, an Emergency), or by goods and services provided from outside of the affected area (outside response capacities). Whenever the Local Response Capacity is unable to meet the needs, and the Response Capacities from areas outside of the affected community are required, a disaster occurs. All responses, whether in the Relief or Recovery phases of a disaster, are interventions that use the goods, services, and resources contained in the Response Capacity (local or outside). Responses may be directed at preventing/mitigating further deterioration in levels of functions (damage control, deaths, injuries, diseases, morbidity, and secondary events) in the affected population and filling the gaps in available services created by Structural Damages (compromise in available goods, services, and/or resources; ie, Relief Responses), or may be directed toward returning the affected community and its components to the pre-event functional state (ie, Recovery Responses). Hazard Mitigation includes interventions designed to decrease the likelihood that a hazard will cause an event, and should an event occur, that the amount of energy released will be reduced. Capacity Building consists of all interventions undertaken before an event occurs in order to increase the resilience of the community to an event related to a hazard that exists in an area-at-risk. Resilience is the combination of the Absorbing, Buffering, and Response Capacities of a community-at-risk, and is enhanced through Capacity-Building efforts. A disaster constitutes a failure of resilience.

Birnbaum ML, Daily EK, O’Rourke AP, Loretti A. Research and Evaluations of the Health Aspects of Disasters, Part II: The Disaster Health Conceptual Framework Revisited. Prehosp Disaster Med. 2015;30(5):523–538.

Although it is well known that the Great East Japan Earthquake (March 11, 2011) resulted in a large number of disaster-related deaths, it is not common knowledge that the number of disaster-related deaths continues to increase, even four years after the earthquake, in Fukushima Prefecture, where the nuclear power plant accident occurred. There has been a lack of a minute and critical analysis for the causes for this continuous increase. In this report, the causes for the increase in disaster-related deaths in Fukushima Prefecture were analyzed by aggregating and comparing multiple data released by public organizations (the Reconstruction Agency, the National Police Agency, and Fukushima Prefecture), which may also have implications for developing response strategies to other disasters. The disaster-related death rate, the dead or missing rate, and the refugee rate (the number of disaster-related deaths, dead or missing persons, and refugees per 1,000 people) in each prefecture in stricken areas, and also each city, county, town, and village in Fukushima Prefecture, were calculated and compared with each other. The populations which were used for the calculation of each death rate in the area were based on the number of dead victims who had lived in the area when the earthquake occurred, regardless of where they were at the time of their death. The disaster-related death rate was higher than the dead or missing rate in the area around a stricken nuclear power plant in Fukushima Prefecture. These areas coincide exactly with the Areas under Evacuation Orders because of unsafe radiation levels. The external and internal radiation doses of most of the victims of the Great East Japan Earthquake have appeared not to be so high to harm their health, until now. The psychological stress associated with being displaced from one’s home for a long time with an uncertain future may be the cause for these disaster-related deaths. There is an urgent need to recognize refugees’ stressful situations, which could even cause death, and to provide them with high-quality medical treatment, including care for their long-term mental health.

Tanaka R. Prolonged Living as a Refugee from the Area Around a Stricken Nuclear Power Plant Increases the Risk of Death. Prehosp Disaster Med. 2015;30(4):1-6.

Each of the elements described in the Conceptual Framework for disasters has a temporal designation; each has a beginning and end time. The Temporal Framework defines these elements as phases that are based on characteristics rather than on absolute times. The six temporal phases include the: (1) Pre-event; (2) Event; (3) Structural Damage; (4) Functional Damage (changes in levels of functions of the Societal Systems); (5) Relief; and (6) Recovery phases. Development is not a phase of a disaster. The use of the Temporal Framework in studying and reporting disasters allows comparisons to be made between similar phases of different disasters, regardless of the hazard involved and/or the community impacted. For research and evaluation purposes, assessments, plans, and interventions must be described in relation to the appropriate temporal phase.

Birnbaum ML, Daily EK, O’Rourke AP. Research and Evaluations of the Health Aspects of Disasters, Part III: Framework for the Temporal Phases of Disasters. Prehosp Disaster Med. 2015;30(6):628–632 .

For the purposes of research and/or evaluation, a community/society is organized into 13 Societal Systems under the umbrella of an overall Coordination and Control System. This organization facilitates descriptions of a community/society or a component of a community for assessment at any designated time across the Temporal Phases of a disaster. Such assessments provide a picture of the functional status of one or more Systems that comprise a community. Since no system operates in isolation from the other systems, information of the concomitant status of several Societal Systems is crucial to gaining a complete understanding of compromised functions, as well as the effects and side effects of any intervention directed at restoring the functional state of the affected community or risk-reduction interventions of a community-at-risk. The 13 Societal Systems include: (1) Public Health; (2) Medical Care; (3) Water and Sanitation; (4) Shelter and Clothing; (5) Food and Nutrition; (6) Energy Supply; (7) Public Works and Engineering; (8) Social Structures; (9) Logistics and Transportation; (10) Security; (11) Communications; (12) Economy; and (13) Education. Many functions and sub-functions of the Systems overlap, or share some common sub-functions with other systems. For the purposes of research/evaluation, it is necessary to assign functions and sub-functions to only one of the Societal Systems.

Birnbaum ML, Daily EK, O’Rourke AP. Research and Evaluations of the Health Aspects of Disasters, Part IV: Framework for Societal Structures: the Societal Systems. Prehosp Disaster Med. 2015;30(6):633–647.

During July through August 2014, Operation Protective Edge, a military conflict between Israel and the Hamas regime in Gaza, dramatically affected both populations. Magen David Adom (MDA), the Israeli national Emergency Medical Service (EMS) and a member of the Red Cross, faced a unique challenge during the conflict: to continue providing crucial service to the entire civilian population of Israel, which was under constant missile threat. This challenge included not only providing immediate care for routine EMS calls under missile threat, but also preparing and delivering immediate care to civilians injured in attacks on major cities, as well as small communities, in Israel. This task is a challenge for a civilian EMS agency that normally operates in a non-military environment, yet, in an instant, must enhance its capability to respond to a considerable threat to its population. During Operation Protective Edge, MDA provided care for 842 wounded civilians and utilized a significant amount of its resources. Providing EMS services for a civilian population in a mixed civilian/military scenario is a challenging task on a national level for an EMS system, especially when the threat lasts for weeks. This report describes MDA’s preparedness and operations during Operation Protective Edge, and the unique EMS challenges and dilemmas the agency faced.

Jaffe E, Wacht O, Strugo R. Operation Protective Edge – A Unique Challenge for a Civilian EMS Agency. Prehosp Disaster Med. 2015;30(5):539–542.

Event: Typhoon (high-velocity winds and flooding from storm surge/rains)

Event Onset Date: November 8, 2013

Location of Report: Tacloban, Leyte Island, Philippines

Geographic Coordinates: latitude 11°13m N, longitude 125°1m E; elevation: 3 meters

Response Dates: November 18-28, 2013

Response Type: Medical Relief (Humanitarian)

Studies of the health aspect of disasters focus either on the epidemiology of disasters to define the causes and the progression from a hazard to a disaster, or the evaluations of interventions provided during any phase of a disaster. Epidemiological disaster research studies are undertaken for the purposes of: (1) understanding the mechanisms by which hazards evolve into a disaster; (2) determining ways to mitigate the risk(s) that a specific hazard will progress into a disaster; (3) predicting the likely damages and needs of the population-at-risk for an event; and (4) identifying potential measures to increase the resilience of a community to future events. Epidemiological disaster research utilizes the Conceptual, Temporal, and Societal Frameworks to define what occurs when a hazard manifests as an event that causes a disaster. The findings from such studies should suggest interventions that could augment the absorbing, buffering, or/and response capacities to lessen the probability of similar damages occurring from the next event. Ultimately, the use of these Frameworks in studying the health aspects of a disaster will help define what to expect in a specific setting and the standards and best practices upon which education, training, competencies, performance, and professionalization will be built.

Birnbaum ML, Daily EK, O’Rourke AP. Research and Evaluations of the Health Aspects of Disasters, Part V: Epidemiological Disaster Research. Prehosp Disaster Med. 2015;30(6):648–656.