ABSTRACT
Health care organizations have been challenged by the COVID-19 pandemic since the first half of 2020. Both hospitals (especially emergency and intensive care departments) and ambulance services were overwhelmed by surging patient numbers during the 2 pandemic waves in 2020. In this study, the data of the 2016 multisite terrorist bombing attacks in Zaventem (Brussels International Airport) and Maalbeek (subway) are reviewed. It is simulated what the impact of similar attacks would be on an already challenged health care system and which COVID-19-specific measures would be favourable for the outcome. The limited access of ICU beds, operating rooms and surge capacity, as well as the number of COVID-positive victims are cardinal features challenging the medical response to mass casualty incidents of this magnitude. During the COVID-19 pandemic, disaster management is affected by the limited availability of intensive care beds and operation rooms, and the faltering reverse triage negatively influencing the response capacity. On the other hand, the impact of the COVID pandemic can also be favourable. Special concerns on a COVID-19-safe response are discussed. It must be avoided that the medical response and gathering of stranded passengers would become a superspreading event. Multisite terrorist attacks during a pandemic are possibly catastrophic for a health care system which is already beyond its limit in terms of surge capacity. COVID-19-specific recommendations for disaster management in case of terrorist attacks are provided.