A mass-casualty incident (MCI) can occur in the periphery of a densely populated area, away from a metropolitan area. In such circumstances, the medical management of the casualties is expected to be difficult because the nearest hospital and the emergency medical services (EMS), only can offer limited resources.When coping with these types of events (i.e., limited medical capability in the nearby medical facilities), a quick response time and rational triage can have a great impact on the outcome of the victims. The objective of this study was to identify the lessons learned from the medical response to a terrorist attack that occurred on 05 December 2005, in Netanya, a small Israeli city.

Data were collected during and after the event from formal debriefings and from patient files. The data were processed using descriptive statistics and compared to those from previous events. The event is described according to Disastrous Incidents Systematic Analysis Through Components, Interactions, Results (DISAST-CIR) methodology.

Four victims and the terrorist died as a result of this suicide bombing. A total of 131 patients were evacuated (by EMS or self-evacuation) to three nearby hospitals. Due to the proximity of the event to the ambulance dispatch station, the EMS response was quick.The first evacuation took place only three minutes after the explosion. Non-urgent patients were diverted to two close-circle hospitals, allowing the nearest hospital to treat urgent patients and to receive the majority of self-evacuated patients. The nearest hospital continued to receive patients for >6 hours after the explosion, 57 of them (78%) were self-evacuated.

The distribution of casualties from the scene plays a vital role in the management of a MCI that occurs in the outskirts of a densely populated area.Non-urgent patients should be referred to a hospital close to the scene of the event, but not the closest hospital.The nearest hospital should be prepared to treat urgent casualties, as well as a large number of self-evacuated patients.

There are many patient assessment challenges in the prehospital setting, especially the estimation of external blood loss. Previous studies of experienced paramedics have demonstrated that external blood loss estimation is highly inaccurate. The objective of this study was to determine if undergraduate paramedic students could accurately estimate external blood loss on four surfaces commonly found in the prehospital environment.

This prospective, observational, blinded study used a convenience sample of undergraduate students studying at Monash University during 2006. Students were provided with four clinical vignettes using four different surfaces and varying simulated blood amounts.

Accurate estimation occurred with the vinyl simulation (100 ml), with a mean value of the estimations of 98 ml (95% Confidence Interval (CI) 84–113 ml). Carpet and concrete surfaces were both associated with large under-estimations.The carpet simulation (1,000 ml) had a mean value for the estimations of 347 ml (95% CI 320–429 ml). The concrete simulation (1,500 ml) had a mean value for the estimations of 885ml (95% CI 771–999 ml). Conversely, the clothing simulation (500 ml) emphasized over-estimation, with a mean value for the estimations of 1,253 ml (95% CI 1,093–1,414 ml). There was no relationship between increased accuracy and clinical experience, exposure, educational qualifications, or age of students.

External blood loss estimation by undergraduate paramedic students generally is too inaccurate to be of any clinical benefit. Particularly, absorbent and impermeable surfaces precipitated inaccuracies by undergraduate paramedic students.

Open-source information consists of a range of publicly available material, includingvarious periodicals, news reports, journal publications, photographs, and maps. Although intelligence agencies regularly use open source information in developing strategically important intelligence, the disaster community has yet to evaluate its use for planning or research purposes. This study examines how open-source information, in the form of Internet news reports and public access disaster databases, can be used to develop a rapid, 72-hour case report.

Open-source information was extrapolated from several news reports on a terrorist bombing that occurred in Russia on 05 December 2003, using a self-devised “data” collection sheet, and background information collected on the nature of similar disasters using three public access databases.

The bulk of health-related information was collected in the first 13 hours after the event, including casualty demographics, immediate dead, total dead, admitted, and treated-and-released. The complex and prolonged rescue of casualties was identified, as well as the presence of unexploded ordnance. This incident also was identified as the first publicly reported suicide terrorist bombing of a commuter train.

Open-source information has the potential to be a helpful tool in reconstructing a chain of events and response. However, its use must be validated further and used appropriately. Standards for collection and analysis also must be developed.

This paper is an attempt to review the advances and shortfalls in data collection and use of health data that have occurred during health emergencies in recent decades for the opening session of the Humanitarian and Health Conference at Dartmouth University in September of 2006.

Examples of various kinds of successes and failures associated with health data collection are given to highlight advances with an effort to emphasize multi-agency efforts reviewed by outside scholars.

Health data, particularly surveillance data, have allowed relief workers to set priorities for life-saving humanitarian programs. The main guidelines widely utilized such as those of the US Centers for Disease Control and Prevention, Médecins sans Frontières, and the Sphere Project have considerable similarity due to the consistency of data collected in various crises. Moreover, difficult to see problems and successes have been revealed by coherent surveillance efforts. Yet, these data collection efforts can not show significant improvements in the quality of humanitarian aid in recent years. Moreover, health data often do not appear to have meaningful influence on the prioritizing of relief resources globally or on those political issues that trigger emergencies.

The field of humanitarian relief is relatively nascent. Methods for documenting basic health measures on the local level have been developed and general health priorities have been documented. Some technical improvements in monitoring still are needed but decision-making is most often limited by the lack of data rather than the problems with data. The ability of health data to influence spending global priorities, legal or political actions undertaken by international organizations, remains very limited.

The objective of this study was to estimate the burden of cancer in counties affected by Hurricane Katrina using population-based cancer registry data, and to discuss issues related to cancer patients who have been displaced by disasters.

The cancer burden was assessed in 75 counties in Louisiana, Alabama, and Mississippi that were designated by the Federal Emergency Management Agency as eligible for individual and public assistance. Data from the National Program of Cancer Registries were used to determine three-year average annual age-adjusted incidence rates and case counts during the diagnosis years 2000–2002 for Louisiana and Alabama. Expected rates and counts for the most-affected counties in Mississippi were estimated by direct, age-specific calculation using the 2000–2002 county level populations and the site-, sex-, race-, and age-specific cancer incidence rates for Louisiana.

An estimated 23,549 persons with a new diagnosis of cancer in the past year resided in the disaster-affected counties. Fifty-eight percent of the cases were cancers of the lung/bronchus, colon/rectum, female breast, and prostate. Eleven of the top 15 cancer sites by sex and black/white race in disaster counties had >50% of cases diagnosed at the regional or distant stage.

Sizable populations of persons with a recent cancer diagnosis were potentially displaced by Hurricane Katrina. Cancer patients required special attention to access records in order to confirm diagnosisand staging, minimize disruption in treatment, and ensure coverage of care. Cancer registry data can be used to provide disaster planners and clinicians with estimates of the number of cancer patients, many of whom maybe undergoing active treatment.

Tete Province, Mozambique has experienced chronic food insecurity and a dramatic fall in livestock numbers due to the cyclic problems characterized by the floods in 2000 and severe droughts in 2002 and 2003. The Province has been a beneficiary of emergency relief programs, which have assisted >22% of the population. However, these programs were not based on sound epidemiological data, and they have not established baseline data against which to assess the impact of the programs.

The objective of this study was to document mortality rates, causes of death, the prevalence of malnutrition, and the prevalence of lost pregnancies after 2.5 years of humanitarian response to the crisis.

A two-stage, 30-cluster household survey was conducted in the Cahora Bassa and Changara districts from 22 October to 08 November 2004. A total of 838 households were surveyed, with a population size of 4,688 people.

Anthropometric data were collected among children 6–59 months of age. In addition, crude mortality rates (crude mortality rates), under five mortality rates (under 5 mortality rate), causes of deaths, and prevalence of lost pregnancies were determined among the sample population. The prevalence of malnutrition was 8.0% (95% confidence interval (CI) = 6.2–9.8%) for acute malnutrition, 26.9% (95% CI = 24.0–29.9%) for being underweight, and 37.0% (95% CI = 33.8–40.2%) for chronic malnutrition. Boys were more likely to be under-weight than were girls (odds ratio (OR) = 1.34; 95% CI = 1.00, 1.82;p <0.05) after controlling for a, household size, and food aid beneficiary status. Similarly, children 30–59 months of age were significantly less likely to suffer from acute malnutrition (OR = 0.45; 95% CI = 0.26, 0.79; p <0.01) and less likely to be underweight (OR = 0.37; 95% CI = 0.27, 0.51;p <0.01) than children 6–29 months of a, after adjusting for the other, aforementioned factors. The proportion of lost pregnancies was estimated at 7.7% (95% CI = 4.5–11.0%). A total of 215 deaths were reported during the year preceding the survey. Thirty-nine (18.1%) children <5 years of age died. The CMR was 1.23/10,000/day (95% CI = 1.08–1.38), and an under 5 mortality rate was 1.03/10,000/day (95% CI = 0.71–1.35). Diarrheal diseases, malaria, tuberculosis, and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) accounted for more than two-thirds of all deaths.

The observed CMR in Tete Province, Mozambique is three times higher than the baseline rate for sub-Saharan Africa and 1.4 times higher than the CMR cut-off point used to define excess mortality in emergencies.The current humanitarian response in Tete Province would benefit from an improved alignment of food aid programming in conjunction with diarrheal disease control, HIV/AIDS, and malaria prevention and treatment programs. The impact of the food programs would be improved if mutually acceptable food aid program objectives, verifiable indicators relevant to each objective, and beneficiary targets and selection criteria are developed. Periodic re-assessments and evaluations of the impact of the program and evidenced-based decision-making urgently are needed to avert a chronic dependency on food aid.

Hurricane Ivan, a strong category-3 hurricane, struck Grenada on 07 September 2004 and devastated the country. Grenada is a small, developing country, whose socio-economic environment and health service is typical of most countries located within the Caribbean hurricane belt. Previous reports describing the consequences of hurricanes on health-related issues have focused mainly on the experience of wealthier countries.

The objective of this study was to document the types of patients and medical problems faced by a hospital surgical service as a result of a forceful hurricane in a developing country and to help surgical divisions in developing countries prepare for strong hurricanes.

This is a retrospective study using medical records from the surgical ward of the Grenada General Hospital. Patients admitted to the surgical ward during the month following Ivan were assessed with respect to diagnosis, age, gender, and length of hospitalization. The patients admitted during the same period the previous year were used as a control group.

The effects of the hurricane included a significant increase in the proportion of patients seen for diabetic feet, gunshot wounds, and infections due to wounds. The median length of the treatment time increased by 25%. In 2004, the total number of patients was 185 and in 2003, there were 167 patients admitted.

The results of this study indicate that preparations for future hurricanes should include securing the capacity to handle the increased needs for hospital care, and ensuring that stocks of medicines, such as insulin and antibiotics, are sufficient, properly stored, and easily available to patients (e.g., by storing medicine at hurricane shelters equipped with generators and cold storage facilities). Diabetics should be instructed to use proper footwear to reduce the risk of cuts from debris.

Due to more than a decade of armed conflict and civil unrest, Chechnya is among the regions most affected by landmines and unexploded ordnance worldwide.

The study was performed to assess the magnitude of injuries and deaths due to landmines and unexploded ordnance in Chechnya between 1994 and 2005 and to describe epidemiologic patterns and risk factors for these events.

Surveillance data that included 3,021 civilian non-combatants injured by landmines and unexploded ordnance in Chechnya during 1994–2005 were analyzed. Local non-governmental organizations in collaboration with the United Nations Children's Fund conducted victim data collection using trained staff to interview victims or their families. Surveillance data were used to describe injury trends, victim demographics, injury types, risk behaviors, and types of explosives related to landmine and unexploded ordnance events.

The largest number of injuries occurred in 2000 (716, injury rate 6.6 per 10,000) and 2001 (640, injury rate 5.9 per 10,000). One-quarter of all victims were younger than 18 years, and 19% were females. The case-fatality rate was 23%. Approximately 40% of victims were injured by landmines, 30% by unexploded ordnance, and 7% by booby traps. A large proportion of children and adults were injured while traveling or performing activities of economic necessity; 29% of children were injured while tampering with explosives or playing in a contaminated area. The proportion of victims with lower limb amputations was similar among children and adults (14% and 17%, respectively), whereas the proportion of victims with upper limb amputations was three times higher in children than in adults (12% and 4%, respectively). Most accidents that occurred while the victim was traveling or performing activities of economic necessity were caused by landmines, while most accidents that occurred while the victim was playing near an explosive device or tampering with it were caused by unexploded ordnance.

Civilians in Chechnya experienced the highest rates of injury from landmines and unexploded ordnance ever documented, 10 times higher than injury rates reported from such highly affected countries as Afghanistan, Angola, or Cambodia. Urgent efforts to identify, mark, and clear mined areas and/or areas contaminated with unexploded ordnance are needed to prevent further civilian injuries and deaths.

The coordination and integration of mental health agencies' plans into disaster responses is a critical step for ensuring effective response to all-hazard emergencies.

In order to remedy the current lack of integration of mental health into emergency preparedness training, researchers must assess mental health emergency preparedness training needs. To date, no recognized assessment exists.The current study addresses this need by qualitatively surveying public health and allied health professionals regarding mental health preparedness in Kansas.

Participants included 144 professionals from public health and allied fields, all of whom attended one of seven training presentations on mental health preparedness. Following each presentation, participants provided written responses to nine qualitative questions about preparedness and mental health preparedness needs, as well as demographic information, and a program evaluation. Survey questions addressed perceptions of bioterrorism and mental health preparedness, perceptions about resource and training needs, as well as coordination of preparedness efforts.

Overall, few respondents indicated that they felt their county or community was prepared to respond to an attack. Respondents felt less prepared for mental health issues than they did for preparedness issues in general. The largest proportion of respondents reported that they would look to a community mental health center or the state health department for mental health preparedness information. Most respondents recognized the helpfulness of interagency coordination for mental health preparedness, and reported a willingness to take an active role in coordination.

The current study provides important data about the gaps regarding mental health preparedness in Kansas.This study demonstrates the present lack of preparedness and the need for coordination to reach an appropriate level of mental health preparedness for the state.These findings are the first step to implementing effective distribution of information and training.

In December 2003, the residents of Bam, Iran experienced an earthquake that measured 6.6 on the Richter scale and destroyed more than 90% of the city.

The purpose of this study was to assess the status of the rescue, evacuation, and transportation of the casualties during the early stages following the earthquake.

A cross-sectional study of 185 casualties who were transferred to and hospitalized in the university hospital during the first week period following the earthquake was conducted. Information regarding different places of settlement after being removed from the rubble, initial medical care, and the means of transportation was obtained by reviewing medical records and interviewing the victims.

The mean value of the duration of times taken for the first rescuers to reach the scene and remove the casualties from the rubble was 1.7 ±2.7 and 0.9 ±1.1 hours, respectively. Sixty-nine (37.7%) of the patients stayed within the area immediately surrounding their home for average times of 8 ±10 hours. The majority of casualties (57.6%) were transferred manually to a first place of settlement; 45.8% were taken to a second place of settlement using blankets. Of the patients studied, 159 (85.9%) did not receive any basic medical care at the first place and intravenous fluid therapy was the most common treatment provided for 24 (13%) patients at the second place of settlement. Patients received medical care at the first place of settlement for a mean time of 16.8 ±13.5 hours after escaping the rubble.

These findings indicate that the emergency medical service system in Bam was destroyed and not able to respond adequately. In order to reduce the negative effects of such disasters in the future, there is an essential need for a comprehensive disaster management plan and improvement of hospital structures, healthcare facilities, and communication between the different governmental departments for better coordination and planning.

In recent years, the perceived threat of chemical terrorism has increased. It is hoped that teaching civilians how to behave during a chemical incident will decrease the number of “worried well” patients at hospitals, reduce secondary contamination, and increase compliance with the instructions of emergency services. The governments of the United Kingdom and Israel sent booklets to every household in their respective countries. In Israel, the civilian population was issued chemical personal protective equipment (chemical personal protective equipment).

The effectiveness of these public education programs was assessed using a scenario-based questionnaire that was distributed to 100 respondents in Birmingham, UK and Jerusalem, Israel. Respondents were asked how they would behave in three deliberate chemical release scenarios and how they would seek information and help.

Only 33% of the UK respondents and 22% of the Israeli respondents recalled reading the government booklets. When asked what they would do after being contaminated in a deliberate release, approximately half of the respondents ranked seeking medical care at a hospital as the most appropriate action.

The preferred sources of information in the wake of a chemical strike were (in descending order): radio, television, and the Internet. Approximately half of the respondents would call emergency services for information. Forty-one percent of the UK respondents and 33% of Israeli respondents stated that they either would call or go to the nearest hospital to seek information.

The public information campaigns in both countries have had a limited impact. Many citizens claimed they would self-present to the nearest hospital following a chemical attack rather than waiting for the emergency services. A similar response was witnessed in the Sarin attacks in Tokyo and the 1991 Scud missile attacks in Israel.

Current UK doctrine mandates that specialist decontamination teams be deployed to the scene of a chemical release. However, this takes >1 hour, and it requires at least 30 minutes to don hospital chemical personal protective equipment. Therefore, it is imperative that hospitals are equipped to cope with unannounced self-presenters after a chemical attack. This requires chemical personal protective equipment and protocols that are easier to use.