187 - Cruise Ship Infectious Disease Outbreak

This chapter examines infectious disease outbreak on a cruise ship, including the outbreaks and handling of 2020 Sars-CoV-2 on cruise ships early in the COVID-19 pandemic.

Cyberthreats: A primer for healthcare professionals.

INTRODUCTION: Cyberattacks are one of the most widespread, damaging, and disruptive forms of action against healthcare entities. Data breaches, ransomware attacks, and other intrusions can lead to significant cost both in monetary and personal harm to those affected and may result in large payouts to cyber criminals, crashes of information technology systems, leaks of protected health and personal information, as well as fines and lawsuits. This study is a descriptive analysis of healthcare-related cyber breaches affecting 500 or more individuals in the past decade in the United States. METHODS: The publicly available U.S. breach report database was downloaded in the Microsoft Excel (Microsoft, Redmond, Washington, USA) format and searched for all reported breaches occurring between January 1, 2011 - December 31, 2021 (10 years). Breaches were subdivided by category and analyzed by states, breach submission dates, types of breach, location of breached information, entity type, and individuals affected. All subcategories were predefined by the breach report. RESULTS: There were a total of 3822 PHI breaches that affected 283,335,803 people in the United States from January 1, 2011 to December 31, 2021. Of the 3822 PHI breaches, 1593 (41.7%) were hacking/ IT related, 1055 (27.6%) were listed as unknown, 819 (21.4%) were theft related, 194 (5.1%) were loss related, 97 (2.5%) were related to improper disposal and 64 (1.7%) were listed as "others". Year 2020 saw the most breaches with 631 and California was the state with the highest number of breaches at 403. CONCLUSION: Cyberattacks and healthcare breaches are one of the most costly and disruptive situations facing healthcare today. A total of 3822 breaches affecting 283,335,803 people in the United States were recorded from January 1, 2011 to December 31, 2021. By understanding the extent of cyberthreats this will better prepare healthcare organizations and providers to mitigate, respond, and recover from these devastating attacks.

Terrorist Attacks Against COVID-19-Related Targets during the Pandemic Year 2020: A Review of 165 Incidents in the Global Terrorism Database.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic enabled a situational type of terrorism with mixed racist, anti-government, anti-science, anti-5G, and conspiracy theorist backgrounds and motives. OBJECTIVE: The objective of this study was to identify and characterize all documented COVID-19-related terrorist attacks reported to the Global Terrorism Database (GTD) in 2020. METHODS: The GTD was searched for all COVID-19-related terrorist attacks (aimed at patients, health care workers, and at all actors involved in pandemic containment response) that occurred world-wide in 2020. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. Ambiguous incidents were excluded if there was doubt about whether they were exclusively acts of terrorism. RESULTS: In total, 165 terrorist attacks were identified. With 50% of incidents, Western Europe was the most heavily hit region of the world. Nonetheless, most victims were listed in Southeast Asia (19 fatalities and seven injured). The most frequent but least lethal attack type concerned arson attacks against 5G telephone masts (105 incidents [60.9%] with only one injured). Armed assaults accounted for most fatalities, followed by assassinations. Incendiary and firearms were the most devastating weapon types. CONCLUSION: This analysis of the GTD, which identified 165 COVID-19-related terrorist attacks in 2020, demonstrates that the COVID-19 pandemic truly resulted in new threats for COVID-19 patients, aid workers, hospitals, and testing and quarantine centers. It is anticipated that vaccination centers have become a new target of COVID-19-related terrorism in 2021 and 2022.

Emergency Medical Services Preparedness in Dual Disasters: War in the Era of COVID-19 in Armenia.

INTRODUCTION: Emergency Medical Services (EMS) is a critical part of Disaster Medicine and has the ability to limit morbidity and mortality in a disaster event with sufficient training and experience. Emergency systems in Armenia are in an early stage of development and there is no Emergency Medicine residency training in the country. As a result, EMS physicians are trained in a variety of specialties.Armenia is also a country prone to disasters, and recently, the Armenian EMS system was challenged by two concurrent disasters when the 2020 Nagorno-Karabakh War broke out in the midst of the SARS-CoV-2/coronavirus disease 2019 (COVID-19) pandemic. STUDY OBJECTIVE: This study aims to assess the current state of disaster preparedness of the Armenian EMS system and the effects of the simultaneous pandemic and war on EMS providers. METHODS: This was a cross-sectional study conducted by anonymous survey distributed to physicians still working in the Yerevan EMS system who provided care to war casualties and COVID-19 patients. RESULTS: Survey response rate was 70.6%. Most participants had been a physician (52.1%) or EMS physician (66.7%) for three or less years. The majority were still in residency (64.6%). Experience in battlefield medicine was limited prior to the war, with the majority reporting no experience in treating mass casualties (52.1%), wounds from explosives (52.1%), or performing surgical procedures (52.1%), and many reporting minimal to no experience in treating gunshot wounds (62.5%), severe burns (64.6%), and severe orthopedic injuries (64.6%). Participants had moderate experience in humanitarian medicine prior to war. Greater experience in battlefield medicine was found in participants with more than three years of experience as a physician (z-score -3.26; P value <.01) or as an EMS physician (z-score -2.76; P value <.01) as well as being at least 30 years old (z-score -2.11; P value = .03). Most participants felt they were personally in danger during the war at least sometimes (89.6%). CONCLUSION: Prior to the COVID-19 pandemic and simultaneous 2020 Nagorno-Karabakh War, EMS physicians in Armenia had limited training and experience in Disaster Medicine. This system, and the frontline physicians on whom it relies, was strained by the dual disaster, highlighting the need for Disaster Medicine training in all prehospital medical providers.

Health Emergency and Disaster Risk Management Workforce Development Strategies: Delphi Consensus Study.

INTRODUCTION: Health workforce development is essential for achieving the goals of an effective health system, as well as establishing national Health Emergency and Disaster Risk Management (Health EDRM). STUDY OBJECTIVE: The objective of this Delphi consensus study was to identify strategic recommendations for strengthening the workforce for Health EDRM in low- and middle-income countries (LMIC) and high-income countries (HIC). METHODS: A total of 31 international experts were asked to rate the level of importance (one being strongly unimportant to seven being strongly important) for 46 statements that contain recommendations for strengthening the workforce for Health EDRM. The experts were divided into a LMIC group and an HIC group. There were three rounds of rating, and statements that did not reach consensus (SD ≥ 1.0) proceeded to the next round for further ranking. RESULTS: In total, 44 statements from the LMIC group and 34 statements from the HIC group attained consensus and achieved high mean scores for importance (higher than five out of seven). The components of the World Health Organization (WHO) Health EDRM Framework with the highest number of recommendations were "Human Resources" (n = 15), "Planning and Coordination" (n = 7), and "Community Capacities for Health EDRM" (n = 6) in the LMIC group. "Policies, Strategies, and Legislation" (n = 7) and "Human Resources" (n = 7) were the components with the most recommendations for the HIC group. CONCLUSION: The expert panel provided a comprehensive list of important and actionable strategic recommendations on workforce development for Health EDRM.

Strengthening Emergency Department Resiliency - Resident Deployment Considerations during a Mass-Casualty Incident.

In the event of a mass-casualty incident (MCI), hospital emergency departments (EDs) may be called upon to provide care to a large number of critically ill patients. As EDs plan for MCIs, determining how to best allocate staff members can play a significant role in the success or failure of a response. In academic EDs, a group that is often overlooked during MCI planning is the resident physicians. We argue that MCI plans at academic hospitals should consider the re-deployment of emergency medicine resident physicians in non-critical hospital rotations back to the ED.

Canadian Wildfires: A Plague on Societies Well-Being, Inequities and Cohesion.

Extreme heat and wildfires have health implications for everyone; however, minority and low-income populations are disproportionately negatively affected due to generations of social inequities and discriminatory practices. Indigenous people in Canada are at a higher risk of many chronic respiratory diseases, as well as other non-communicable diseases and hospitalization, compared to the general population. These wildfires occurring during the COVID-19 pandemic have demonstrated how disruptive compounding disasters can be, putting minority populations such as First Nations, Metis, and Inuit tribes at increased risk and decreased priority. Going forward, if the necessarily proactive mitigation and preparedness steps are not undertaken, the ability to attenuate health inequity in the indigenous community by building resiliency to wildfire disasters will be significantly hampered.

An Epidemiological Analysis of Terrorism-Related Attacks in Eastern Europe from 1970 to 2019.

INTRODUCTION: Over the past five decades, Eastern Europe has seen relatively little in terms of terrorist attacks. The recent escalation of the Russo-Ukrainian conflict has, however, placed a new spotlight on the region, and new questions and concerns around war, conflict, insurgency, and terrorism are being posed. The Russian invasion and extensive combat operations, the largest in Europe since World War II, are occurring across Ukraine where there are 15 active nuclear reactors, not including the Chernobyl site, that are vulnerable to attack or sabotage. In addition, Eastern Europe has been heavily affected by COVID-19, exposing broad vulnerabilities in an otherwise fragile health care system. This raises concerns over the ability of Eastern European health care institutions to absorb surge and manage terrorist attacks or acts of violent extremism. This study provides an epidemiological description of all terrorism-related fatalities and injuries in Eastern Europe sustained from 1970 - 2019. METHOD: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorism events which occurred in Eastern Europe from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of this study. Primary weapon type, country where the incident occurred, and number of deaths and injured were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 3,901 terrorism-related events in Eastern Europe between the years 1970 and 2019, inclusive. In total, the attacks resulted in 5,391 deaths and 9,538 persons injured. Explosives were the most commonly used weapon type in 59.2% of all attacks in the region, followed by firearms in 27.6%. CONCLUSION: From 1970 through 2019, a total of 3,901 terrorist attacks occurred in Eastern Europe, inflicting 5,391 deaths and 9,538 injuries. Of those, 72.3% occurred in Russia and Ukraine. Terrorist attacks sharply declined since the peak in 2014, but there is an overall uptrend in attacks since the 1970s.

Terrorist Attacks in the Middle East: A Counter-Terrorism Medicine Analysis.

BACKGROUND: The Middle East and North Africa (MENA) region has been, like many parts of the world, a hotbed for terrorist activities. Terrorist attacks can affect both demand for and provision of health care services and often places a unique burden on first responders, hospitals, and health systems. This study aims to provide an epidemiological description of all terrorism-related attacks in the Middle East sustained from 1970-2019. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Iraq, Yemen, Turkey, Egypt, Syria, West Bank and Gaza Strip, Israel, Lebanon, Iran, Saudi Arabia, Bahrain, Jordan, Kuwait, United Arab Emirates, North Yemen, Qatar, and South Yemen from January 1, 1970 - December 31, 2019. Primary weapon type, primary target type, country where the incident occurred, and number of deaths and injuries were collated and the results analyzed. RESULTS: A total of 41,837 attacks occurred in the Middle East from 1970-2019 accounting for 24.9% of all terrorist attacks around the world. A total of 100,446 deaths were recorded with 187,447 non-fatal injuries. Fifty-six percent of all attacks in the region occurred in Iraq (23,426), 9.4% in Yemen (3,929), and 8.2% in Turkey (3,428). "Private Citizens and Properties" were targeted in 37.6% (15,735) of attacks, 15.4% (6,423) targeted "Police," 9.6% targeted "Businesses" (4,012), and 9.6% targeted "Governments" (4,001). Explosives were used in 68.4% of attacks (28,607), followed by firearms in 20.4% of attacks (8,525). CONCLUSION: Despite a decline in terrorist attacks from a peak in 2014, terrorist events remain an important cause of death and injuries around the world, particularly in the Middle East where 24.9% of historic attacks took place. While MENA countries are often clustered together by economic and academic organizations based on geographical, political, and cultural similarities, there are significant differences in terrorist events between countries within the region. This is likely a reflection of the complexities of the intricate interplay between politics, culture, security, and intelligence services unique to each country.

Bioterrorism: An analysis of biological agents used in terrorist events.

BACKGROUND: The Covid19 pandemic has reignited debates and discussions around healthcare systems' biosecurity vulnerabilities and cast a spotlight on the potential weaponization of biological agents. Terrorist and violent extremist groups have already attempted to incite the intentional spread of Covid19 and to use it as an improvised form of a biological weapon. This study aims to provide an epidemiological description of all terrorism-related attacks using biological agents sustained between 1970 and 2019. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events using biological weapons between January 1, 1970 - December 31, 2019. RESULTS: 33 terrorist attacks involving biological agents were recorded between 1970 and 2019, registering 9 deaths and 806 injuries. 21 events occurred in the United States, 3 in Kenya, 2 each in both the United Kingdom and Pakistan and a single event in Japan, Columbia, Israel, Russia and Tunisia. CONCLUSION: The reported use of biological agents as a terrorist weapon is extremely rare and accounts for 0.02% of all historic terrorist attacks. Despite its apparent rarity, however, bioterrorism has the ability to inflict mass injuries unmatched by conventional weapons. Anthrax has been the most commonly used in previous bioterrorism events with the vast majority of reported attacks occurring in the United States by a single suspected perpetrator. Counter-Terrorism Medicine (CTM) and Disaster Medicine (DM) specialists need to be proactive in delivering ongoing educational sessions on biological events to first responder communities, and anticipate emerging novel biotechnology threats.

Opioid Attack and the Implications for Counter-Terrorism Medicine.

While the opioid epidemic engulfing the United States and the globe is well-documented, the potential use of powerful fentanyl derivatives as a weapon of terror is increasingly a concern. Carfentanyl, a powerful and deadly fentanyl derivative, is seeing a surge in popularity as an illegal street drug, and there is increasing congressional interest surrounding the classification of opioid derivatives under the Chemical Weapons Convention (CWC) given their potential to cause harm. The combination of the potency of opioid derivatives along with the ease of accessibility poses a potential risk of the use of these deadly agents as chemical weapons, particularly by terrorist organizations. Disaster Medicine specialists in recent years have established a sub-specialty in Counter-Terrorism Medicine (CTM) to address and research the unique terrorism-related issues relating to mitigation, preparedness, and response measures to asymmetric, multi-modality terrorist attacks.

Developing Telemedicine Curriculum Competencies for Graduate Medical Education: Outcomes of a Modified Delphi Process.

PURPOSE: Telemedical applications have only recently begun to coalesce into the field of telemedicine due to varying definitions of telemedicine and issues around reimbursement. This process has been accelerated by the COVID-19 pandemic and the ensuing expansion of telemedicine delivery. This article demonstrates the development of a set of proposed competencies for a telemedicine curriculum in graduate medical education. METHOD: A modified Delphi process was used to create a panel of competencies. This included a systematic review of the telemedicine literature through November 2019 to create an initial set of competencies, which were analyzed and edited by a focus group of experts in January 2020. Initial competencies were distributed in a series of 3 rounds of surveys to a group of 23 experts for comments and rating from April to August 2020. Competencies that obtained a score of 4.0 or greater on a 5-point Likert scale in at least 2 rounds were recommended. RESULTS: Fifty-five competencies were developed based on the systematic review. A further 32 were added by the expert group for a total of 87. After 3 rounds of surveys, 34 competencies reached the recommendation threshold. These were 10 systems-based practice competencies, 7 professionalism, 6 patient care, 4 practice-based learning and improvement, 4 interpersonal and communication skills, and 3 medical knowledge competencies. CONCLUSIONS: Half (17/34) of the competencies approved by the focus group and surveyed expert panel pertained to either systems-based practice or professionalism. Both categories exhibit more variation between telemedicine and in-person practice than other categories. The authors offer a set of proposed educational competencies that can be used in the development of curricula for a wide range of providers and are based on the best evidence and expert opinion available.

Mass Gathering Medicine in Soccer Leagues: A Review and Creation of the SALEM Tool.

Potential risks for public health incidents, outbreaks, and casualties are inferred at association football events, especially if event organizers have not taken appropriate preventative measures. This review explores the potential risks imposed by mass gathering (MG) football events, with particular emphasis on tools and methodologies to manage the risks of football MG events. Effective planning and implementation of MGs along with the mitigation of risks related to people's health require special attention to all potential threats, especially in frequent and recurring MG events such as football leagues. The well-being of all participants can be compromised by ignoring a single risk. Healthcare systems should cooperate with all stakeholders and organizations who are involved in MG management and response. Provision of services during MG or a disaster must be performed by trained personnel or entities that have full access to available resources in accessible publicly known locations at the MG event site. Several MG assessment tools were developed worldwide; however, to adapt to the Saudi context, SALEM tool was developed to provide a guide for MG planning and assessment. SALEM assesses the risks of MG events with scores that help to categorize the risk of MG events by offering recommendations for required resources.

Potential Cross-Reactive Immunity to COVID-19 Infection in Individuals With Laboratory-Confirmed MERS-CoV Infection: A National Retrospective Cohort Study From Saudi Arabia.

BACKGROUND: A growing number of experiments have suggested potential cross-reactive immunity between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and previous human coronaviruses. We conducted the present retrospective cohort study to investigate the relationship between previous Middle East respiratory syndrome-coronavirus (MERS-CoV) infection and the risk of SARS-CoV-2 infection as well as the relationship between previous MERS-CoV and COVID-19-related hospitalization and mortality. METHODS: Starting in March 2020, we prospectively followed two groups of individuals who tested negative for COVID-19 infection. The first group had a previously confirmed MERS-CoV infection, which was compared to a control group of MERS-negative individuals. The studied cohort was then followed until November 2020 to track evidence of contracting COVID-19 infection. FINDINGS: A total of 82 (24%) MERS-positive and 260 (31%) MERS-negative individuals had COVID-19 infection. Patients in the MERS-positive group had a lower risk of COVID-19 infection than those in the MERS-negative group (Risk ratio [RR] 0.696, 95% confidence interval [CI] 0.522-0.929; p =0.014). The risk of COVID-19-related hospitalization in the MERS-positive group was significantly higher (RR 4.036, 95% CI 1.705-9.555; p =0.002). The case fatality rate (CFR) from COVID-19 was 4.9% in the MERS-positive group and 1.2% in the MERS-negative group (p =0.038). The MERS-positive group had a higher risk of death than the MERS-negative group (RR 6.222, 95% CI 1.342-28.839; p =0.019). However, the risk of mortality was similar between the two groups when death was adjusted for age (p =0.068) and age and sex (p =0.057). After controlling for all the independent variables, only healthcare worker occupation and >1 comorbidity were independent predictors of SARS-CoV-2 infection. INTERPRETATION: Individuals with previous MERS-CoV infection can exhibit a cross-reactive immune response to SARS-CoV-2 infection. Our study demonstrated that patients with MERS-CoV infection had higher risks of COVID-19-related hospitalization and death than MERS-negative individuals.

Health Workforce Development in Health Emergency and Disaster Risk Management: The Need for Evidence-Based Recommendations.

The Sendai Framework for Disaster Risk Reduction 2015-2030 placed human health at the centre of disaster risk reduction, calling for the global community to enhance local and national health emergency and disaster risk management (Health EDRM). The Health EDRM Framework, published in 2019, describes the functions required for comprehensive disaster risk management across prevention, preparedness, readiness, response, and recovery to improve the resilience and health security of communities, countries, and health systems. Evidence-based Health EDRM workforce development is vital. However, there are still significant gaps in the evidence identifying common competencies for training and education programmes, and the clarification of strategies for workforce retention, motivation, deployment, and coordination. Initiated in June 2020, this project includes literature reviews, case studies, and an expert consensus (modified Delphi) study. Literature reviews in English, Japanese, and Chinese aim to identify research gaps and explore core competencies for Health EDRM workforce training. Thirteen Health EDRM related case studies from six WHO regions will illustrate best practices (and pitfalls) and inform the consensus study. Consensus will be sought from global experts in emergency and disaster medicine, nursing, public health and related disciplines. Recommendations for developing effective health workforce strategies for low- and middle-income countries and high-income countries will then be disseminated.

50 Years of Mass-Fatality Terrorist Attacks: A Retrospective Study of Target Demographics, Modalities, and Injury Patterns to Better Inform Future Counter-Terrorism Medicine Preparedness and Response.

BACKGROUND: Terrorism-related deaths have fallen year after year since peaking in 2014, and whilst the coronavirus disease 2019 (COVID-19) pandemic has disrupted terrorist organizations capacity to conduct attacks and limited their potential targets, counter-terrorism experts believe this is a short-term phenomenon with serious concerns of an escalation of violence and events in the near future. This study aims to provide an epidemiological analysis of all terrorism-related mass-fatality events (>100 fatalities) sustained between 1970-2019, including historical attack strategies, modalities used, and target selection, to better inform health care responders on the injury types they are likely to encounter. METHODS: The Global Terrorism Database (GTD) was searched for all attacks between the years 1970-2019. Attacks met inclusion criteria if they fulfilled the three terrorism-related criteria as set by the GTD codebook. Ambiguous events were excluded. State-sponsored terrorist events do not meet the codebook's definition, and as such, are excluded from the study. Data analysis and subsequent discussions were focused on events causing 100+ fatal injuries (FI). RESULTS: In total, 168,003 events were recorded between the years 1970-2019. Of these, 85,225 (50.73%) events recorded no FI; 67,356 (40.10%) events recorded 1-10 FI; 5,791 (3.45%) events recorded 11-50 FI; 405 (0.24%) events recorded 51-100 FI; 149 (0.09%) events recorded over 100 FI; and 9,077 (5.40%) events recorded unknown number of FI.Also, 96,905 events recorded no non-fatal injuries (NFI); 47,425 events recorded 1-10 NFI; 8,313 events recorded 11-50 NFI; 867 events recorded 51-100 NFI; 360 events recorded over 100 NFI; and 14,130 events recorded unknown number of NFI. Private citizens and property were the primary targets in 67 of the 149 high-FI events (100+ FI). Of the 149 events recording 100+ FI, 46 (30.87%) were attributed to bombings/explosions as the primary attack modality, 43 (28.86%) were armed assaults, 23 (15.44%) hostage incidents, two (1.34%) were facility/infrastructure attacks (incendiary), one (0.67%) was an unarmed assault, seven (4.70%) had unknown modalities, and 27 (18.12%) were mixed modality attacks. CONCLUSIONS: The most common attack modality causing 100+ FI was the use of bombs and explosions (30.87%), followed by armed assaults (28.86%). Private citizens and properties (44.97%) were most commonly targeted, followed by government (6.04%), businesses (5.37%), police (4.70%), and airports and aircrafts (4.70%). These data will be useful for the development of training programs in Counter-Terrorism Medicine (CTM), a rapidly emerging Disaster Medicine sub-specialty.