Hajj stampede disaster, 2015: Reflections from the frontlines.

The Hajj is an annual religious mass gathering that takes place in Makkah, Saudi Arabia. The complexity of its system is multidimensional, with religious, political, cultural, security, economic, communication, operational, and logistic unique challenges. This year, yet another stampede tragedy that caused around a 1,000 deaths and severe injuries, capturing worldwide media attention and exacerbating existing political tensions across the Gulf coasts was faced. Planning is important but the planning process is more important, requiring systematic analysis based on accurate collected and targeting root cause factors. Every year, the Hajj provides us with important knowledge and experience that will help preventing such events. This will only be possible if the initiative to extract all possible lessons learned are taken. The medical and public health community in Saudi Arabia must learn from other scientific fields where much more quantitative data-driven approach to identify problems and recommending solutions.

Suicide bombing of the Mineralnye Vody Train: case study in using open-source information for open-source health intelligence.

OBJECTIVE: Open-source information consists of a range of publicly available material, including various 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Investigation of Federal Bureau of Investigation bomb-related death and injury data in the United States between 1988 and 1997.

OBJECTIVE: The study of physical injury from terrorist explosives is an increasing international area of research. However, there are few data sets to characterize the scope of injury and death from these devices. Therefore, one option is to begin evaluating statistics reported by a nontraditional public health data source, the U.S. Federal Bureau of Investigation (FBI) Bomb Data Center. METHODS: We reviewed data reported by the FBI Bomb Data Center for the years 1988-1997 and analyzed the number of bomb-related deaths and injuries and incidence of bombings. RESULTS: The FBI reported 17,579 bombings, 427 related deaths, and 4,063 injuries in the United States between 1988 and 1997. The benefits of this data are reporting of information not normally found in public health data, including type of explosive device and explosive composition. The primary limitations include lack of case comparison and unknown methods of data reporting and data collection. CONCLUSION: To completely study physical injury from explosive devices requires a systematic and comprehensive data set. The FBI data provides an interesting statistical resource to assess the scope of injury from bombs in the United States, but at the current time cannot be used for extensive epidemiological analysis.

Medical treatment of radiological casualties: current concepts.

The threat of radiologic or nuclear terrorism is increasing, yet many physicians are unfamiliar with basic treatment principles for radiologic casualties. Patients may present for care after a covert radiation exposure, requiring an elevated level of suspicion by the physician. Traditional medical and surgical triage criteria should always take precedence over radiation exposure management or decontamination. External contamination from a radioactive cloud is easily evaluated using a simple Geiger-Muller counter and decontamination accomplished by prompt removal of clothing and traditional showering. Management of surgical conditions in the presence of persistent radioactive contamination should be dealt with in a conventional manner with health physics guidance. To be most effective in the medical management of a terrorist event involving high-level radiation, physicians should understand basic manifestations of the acute radiation syndrome, the available medical countermeasures, and the psychosocial implications of radiation incidents. Health policy considerations include stockpiling strategies, effective use of risk communications, and decisionmaking for shelter-in-place versus evacuation after a radiologic incident.

Public health issues in disasters.

OBJECTIVE: This article outlines a number of important areas in which public health can contribute to making overall disaster management more effective. This article discusses health effects of some of the more important sudden impact natural disasters and potential future threats (e.g., intentional or deliberately released biologic agents) and outlines the requirements for effective emergency medical and public health response to these events. CONCLUSION: All natural disasters are unique in that each affected region of the world has different social, economic, and health backgrounds. Some similarities exist, however, among the health effects of different natural disasters, which if recognized, can ensure that health and emergency medical relief and limited resources are well managed.

Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel.

CONTEXT: An increase of terror-related activities may necessitate treatment of mass casualty incidents, requiring a broadening of existing skills and knowledge of various injury mechanisms. OBJECTIVE: To characterize and compare injuries from gunshot and explosion caused by terrorist acts. METHODS: A retrospective cohort study of patients recorded in the Israeli National Trauma Registry (ITR), all due to terror-related injuries, between October 1, 2000, to June 30, 2002. The ITR records all casualty admissions to hospitals, in-hospital deaths, and transfers at 9 of the 23 trauma centers in Israel. All 6 level I trauma centers and 3 of the largest regional trauma centers in the country are included. The registry includes the majority of severe terror-related injuries. Injury diagnoses, severity scores, hospital resource utilization parameters, length of stay (LOS), survival, and disposition. RESULTS: A total of 1155 terror-related injuries: 54% by explosion, 36% gunshot wounds (GSW), and 10% by other means. This paper focused on the 2 larger patient subsets: 1033 patients injured by terror-related explosion or GSW. Seventy-one percent of the patients were male, 84% in the GSW group and 63% in the explosion group. More than half (53%) of the patients were 15 to 29 years old, 59% in the GSW group and 48% in the explosion group. GSW patients suffered higher proportions of open wounds (63% versus 53%) and fractures (42% versus 31%). Multiple body-regions injured in a single patient occurred in 62% of explosion victims versus 47% in GSW patients. GSW patients had double the proportion of moderate injuries than explosion victims. Explosion victims have a larger proportion of minor injuries on one hand and critical to fatal injuries on the other. LOS was longer than 2 weeks for 20% (22% in explosion, 18% in GSW). Fifty-one percent of the patients underwent a surgical procedure, 58% in the GSW group and 46% in explosion group. Inpatient death rate was 6.3% (65 patients), 7.8% in the GSW group compared with 5.3% in the explosion group. A larger proportion of gunshot victims died during the first day (97% versus 58%). CONCLUSIONS: GSW and injuries from explosions differ in the body region of injury, distribution of severity, LOS, intensive care unit (ICU) stay, and time of inpatient death. These findings have implications for treatment and for preparedness of hospital resources to treat patients after a terrorist attack in any region of the world. Tailored protocol for patient evaluation and initial treatment should differ between GSW and explosion victims. Hospital organization toward treating and admitting these patients should take into account the different arrival and injury patterns.

Creating a health care agenda for the Department of Homeland Security.

The challenge before us at DHS--to optimize use of our resources to create an effective health response to terrorist incidents--is formidable. After spending several weeks in Baghdad and seeing all the problems that arise in establishing a new government, I found myself thinking, "This is going to take years." Then, when I returned to the United States, Surgeon General Vice Adam. Richard Carmona, MD, MPH, almost immediately assigned me to the new Department of Homeland Security, adding that the problems it faced were probably worse than those in Baghdad. "That is impossible," I thought. "There's no way this could present a greater logistical, organizational, cultural, and administrative challenge than establishing a new government in a country with no democratic tradition in its 5,000-year history!" Within two days of my appointment to the new department, however, I recognized the accuracy of the surgeon general's statement. We will, however, work diligently toward our goals. During the next couple of years, a major DHS priority will be state and local preparedness, which includes rapid identification of epidemics, improved training, the establishment of liaisons with other first responders such as fire, rescue, law enforcement, and emergency medical services teams, and implementing state-of-the-art communication, disease alert, and reporting systems. Table 2 constitutes a checklist for bioterrorism preparedness, from a public health perspective. Local response and coordination with federal authorities and the issues inherent in these efforts are discussed in depth in the presentations that begin on the following page of this publication.

Introduction: consequences of terrorism.

Recent acts of terrorism have ranged from the dissemination of anthrax spores to intentional contamination of food to the release of chemical weapons to suicide attacks using explosives. The prediction of such events is difficult, if not impossible. The recent attacks that have generated massive numbers of injured and dead may signal the crossing of a new threshold from multi-casualty events to the use of weapons of mass destruction. Consequently, the medical and healthcare infrastructure must be able to prevent and treat illness and injury resulting from such events. Thus, a first step in improving the preparation for and responses to such events must include a sustained commitment to training physicians, nurses, identification specialists, pathologists, and other first responders. The rapid spread of SARS gives reason to believe that the distribution of such agents has potential advantages over the use of other weapons. Investments in the public health and healthcare systems provide the best defense against terrorism.

Impacto de los desastres en la salud pública / Disaster Impact on Public Health

Texto de referencia para profesionales de salud responsables de la preparación y respuesta ante un desastre y de la toma de decisiones para las poblaciones que atienden. Esta dividido en cuatro secciones: I. Analiza la naturaleza de los desastres naturales y sus efectos en la salud pública. Contiene también aspectos epidemiológicos y de salud ambiental en los desastres, control de enfermedades transmisibles, salud mental y relaciones efectivas con los medios. II y III. Proveen información acerca de las causas y los efectos de eventos tales como los terremotos, volcanes, ciclones tropicales, tornados, oleadas de calor y ambientes calurosos, ambientes fríos e inundaciones. IV. Cubre información de aquellos problemas generados por el hombre como la hambruna, contaminación del aire, desastres industriales, incendios, accidentes en reactores nucleares y emergencias complejas donde se involucren refugiados y otras poblaciones

Naturaleza de los desastres: Sus características generales y sus efectos en la salud pública / Disaster Nature: General Characteristics and their Effects on Public Health

Contiene datos sobre los desastres ocurridos durante el siglo XX, los diez peores del mundo durante el periodo de 1945 a 1990, los principales en cuanto a daños, número de personas afectadas y número de muertes de 1963 a 1992. Se incluye la definición de desastres, su clasificación, su impacto, y los factores que contribuyen a su ocurrencia y a su severidad. Las fases de un desastre al igual que las razones por los que se les considera un problema de salud pública están contempladas junto con una tabla que resume los efectos a corto plazo de los grandes desastres naturales. Finalmente, se listan los 10 mitos y creencias erróneas identificadas por la OPS como aquellas con las que todos los planificadores y ejecutores de desastres deben estar familiarizados con ellas

Uso de los métodos epidemiológicos en los desastres / Use of Epidemiological Methods on Disaster

Introduce el tema de la epidemiología con su definición y uso en caso de un desastre. Hace un recorrido histórico de la epidemiología de desastres y de cómo las agencias de socorro la han aceptado en la respuesta a los desastres ya que permite una mayor confianza en el manejo de la crisis y una disminución en las tasas de morbilidad y mortalidad. También, contiene una descripción de las técnicas epidemiológicas antes, durante y después del desastre. Finalmente describe los problemas y desafíos a los que se enfrentan los epidemiólogos después de un desastre, que van desde los relacionados con el ambiente político hasta los causados por los rápidos cambios en las condiciones sociales y demográficas

Vigilancia y epidemiología / Vigilance and Epidemiology

Se hace una relación entre la vigilancia en salud pública (VSP) y la epidemiología. La vigilancia en salud pública es vista como herramienta para identificar los problemas en un área determinada, establecer las prioridades para quienes toman decisiones y evaluar la efectividad de las actividades realizadas. Se encuentran definiciones de la VSP y su uso en la planeación, implementación y evaluación de los programas de salud pública. Incluye información sobre el ciclo de la vigilancia en salud pública, las características de los métodos de recolección de datos en escenarios de desastre y los pasos en la planificación del sistema de vigilancia. Se refiere también a los problemas metodológicos como la evaluación y la vigilancia post-desastre e incluye ejemplos seleccionados de estrategias y métodos que incluyen la planificación, la evaluación epidemiológica rápida, vigilancia activa que usa servicios médicos existentes y temporales, vigilancia centinela, investigación de rumores, investigaciones por conglomerados para estimar las necesidades de los servicios de salud. Finalmente incluye recomendaciones para mejorar la eficiencia de la VSP en todas las fases del desastre

Impacto de los desastres en la salud pública / Disaster Impact on Public Health

Texto de referencia para profesionales de salud responsables de la preparación y respuesta ante un desastre y de la toma de decisiones para las poblaciones que atienden. Esta dividido en cuatro secciones: I. Analiza la naturaleza de los desastres naturales y sus efectos en la salud pública. Contiene también aspectos epidemiológicos y de salud ambiental en los desastres, control de enfermedades transmisibles, salud mental y relaciones efectivas con los medios. II y III. Proveen información acerca de las causas y los efectos de eventos tales como los terremotos, volcanes, ciclones tropicales, tornados, oleadas de calor y ambientes calurosos, ambientes fríos e inundaciones. IV. Cubre información de aquellos problemas generados por el hombre como la hambruna, contaminación del aire, desastres industriales, incendios, accidentes en reactores nucleares y emergencias complejas donde se involucren refugiados y otras poblaciones

Naturaleza de los desastres : Sus características generales y sus efectos en la salud pública / Disaster Nature : General Characteristics and their Effects on Public Health

Contiene datos sobre los desastres ocurridos durante el siglo XX, los diez peores del mundo durante el periodo de 1945 a 1990, los principales en cuanto a daños, número de personas afectadas y número de muertes de 1963 a 1992. Se incluye la definición de desastres, su clasificación, su impacto, y los factores que contribuyen a su ocurrencia y a su severidad. Las fases de un desastre al igual que las razones por los que se les considera un problema de salud pública están contempladas junto con una tabla que resume los efectos a corto plazo de los grandes desastres naturales. Finalmente, se listan los 10 mitos y creencias erróneas identificadas por la OPS como aquellas con las que todos los planificadores y ejecutores de desastres deben estar familiarizados con ellas