Criteria for Deployment of the United States National Guard to Domestic Sudden-Onset Natural Disasters: A Scoping Review.

INTRODUCTION: This study is a scoping review to identify literature pertinent to the question: "What are the criteria for deployment of the United States National Guard (USNG) to domestic sudden-onset natural disasters (SODs)?" As this question relies on factors across many disciplines-legal, medical, technical, cultural-and as there is no foundational body of academic literature or unified governmental or USNG policy addressing this question, a scoping review was designed to identify the body of literature on which further research and policy decisions surrounding this question may be based. MATERIALS AND METHODS: On January 23, 2023 a modified PRISMA-ScR search was performed using an online search engine of the following databases: Academic Search Premier, Google Scholar, JSTOR, PubMed, Web of Science, and WorldCat. The inclusion criteria included the involvement of the USNG response to U.S. domestic SOD. Non-SOD results were excluded. Results from all years and of any type of literature were considered and were limited to the English language. First, titles and abstracts were screened by 2 independent reviewers. Then, a full-text review was performed by 2 independent reviewers. Finally, data were extracted from included texts by 2 independent reviewers. A third reviewer resolved any discrepancies at each stage. This study did not require approval of an institutional review board. RESULTS: Out of the 886 results identified by the original search, after the complete review process, 34 sources were relevant to the research question. Fifteen criteria for the deployment of the USNG to SODs were identified. Overwhelmed local responders, utility failure, the need for the provision of security, and the need for logistical coordination were the most commonly identified criteria. Hurricanes were the most common SOD addressed in the included literature, and most results were event reports. CONCLUSIONS: This modified PRISMA-ScR identified a foundation on which elected officials, USNG leadership, and the larger disaster response community may develop policies and disaster response plans to optimize available resources through the activation of the USNG when responding to SODs.

Analysis of Military-Civilian Patient Handoff at Vista Forge Multi-Agency Nuclear Disaster Exercise 2022.

INTRODUCTION: The leadership of Vista Forge 2022 requested evaluation of the handoff process between military assets and civilian emergency medical services (EMS) providers by the Beth Israel Deaconess Fellowship in Disaster Medicine (BIDMF). Vista Forge was a multi-agency military-civilian full-scale disaster exercise coordinated by the U.S. Military. The exercise, held in Atlanta, Georgia, simulated response to a nuclear bomb in an urban setting by military and civilian disaster teams. MATERIALS AND METHODS: BIDMF had several two-person teams who monitored handoff procedures between military assets after decontamination and civilian emergency medical services providers during the exercise evaluation. RESULTS: A verbal handoff between military and civilian entities was usually not done. Triage tags placed on mannequins before decontamination remained attached to the bodies and were sent with them to civilian hospitals. Triage tags were generic military forms without specific radiation or chemical exposure information. Not all decontamination groups had the same medical capabilities, and in a disaster it is unclear how these teams would manage medical emergencies. CONCLUSIONS: Future studies should develop a standardized handoff procedure to be used in mass casualty situations, and trial it in future multi-agency disaster exercises. Radiation specific triage tags should be considered.

Reviewing the Health Care Impacts of Attacks on Critical Infrastructure.

INTRODUCTION: Health care provision depends on reliable critical infrastructure (CI) to power equipment and to provide water for medication and sanitation. Attacks on CI limiting such functions can have a profound and prolonged influence on delivery of care. METHODS: A retrospective analysis of the Global Terrorism Database (GTD) was performed of all attacks occurring from 1970-2020. Data were filtered using the internal database search function for all events where the primary target was "Utilities," "Food or Water Supply," and "Telecommunications." For the purposes of this study, the subtype "Food Supply" was excluded. Events were collated based on year, country, region, and numbers killed and wounded. RESULTS: The GTD listed 7,813 attacks on CI, with 6,280 of those attacks targeting utilities, leading to 1,917 persons directly killed and 1,377 persons wounded. In total, there were 1,265 attacks targeting telecommunications causing 205 direct deaths and 510 wounded. Lastly, 268 attacks targeted the water supply with 318 directly killed and 261 wounded. Regionally, South America had the most attacks with 2,236, followed by Central America and the Caribbean with 1,390. Based on infrastructure type, the most attacks on utilities occurred in El Salvador (1,061), and the most attacks on telecommunications were in India (140). Peru (46) had the most attacks on its water supply. CONCLUSION: The regions with the highest number of total attacks targeting CI have historically been in South America, with more attacks against power and utilities than other infrastructure. Although the numbers of persons directly killed and wounded in these attacks were lower than with other target types, the true impacts on lack of health care delivery are not accounted for in these numbers. By understanding the pattern and scope of these attacks, Counter-Terrorism Medicine (CTM) initiatives can be created to target-harden health care-related infrastructure.

Terrorist Attacks in Sub-Saharan Africa from 1970 through 2020: Analysis and Impact from a Counter-Terrorism Medicine Perspective.

BACKGROUND: Sub-Saharan Africa (SSA) has become a hotspot for global terrorism, with nearly 50% of global terror-related deaths occurring in SSA in 2021. With a large population and complex geopolitical and social climate, terrorist activity further burdens an already strained medical system. This study provides a retrospective descriptive analysis of terrorist-related activity in SSA from 1970-2020. METHODS: A retrospective analysis of the Global Terrorism Database (GTD) was performed for the region of SSA from 1970-2020. Data were filtered using the internal database search function for all events in the following countries: Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Comoros, the Democratic Republic of the Congo, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Ivory Coast, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Niger, Nigeria, People's Republic of the Congo, Republic of the Congo, Rhodesia, Rwanda, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Swaziland, Tanzania, Togo, Uganda, Zaire, Zambia, and Zimbabwe. Number of attacks, deaths, and injuries, as well as primary weapons types, country where attacks occurred, and primary target types, were collated and analyzed. RESULTS: A total 19,320 attacks were recorded, resulting in 77,565 deaths and 52,986 injuries. Firearms were the most frequent weapons used (8,745), followed by explosives (6,031), unknown (2,615), and incendiary (1,246), with all others making up the remainder (683.) Private citizens and property were the most frequently targeted entities (8,031), followed by general government facilities (2,582), police (1,854), business (1,446), military (805), diplomatic government facilities (741), and religious figures/institution (678), with all other targets making up the remainder (3,183). CONCLUSION: The majority of deaths from terrorism in SSA are the result of firearm attacks and explosions. Nigeria, Somalia, South Africa, The Democratic Republic of the Congo, and Sudan have had the largest number of attacks since 1970, and Nigeria has the largest number of people killed and injured. The health implications of terrorist attacks are often compounded by violence and pose unique challenges to governments, populations, and aid organizations. By understanding the impact and scope of terrorist activity in SSA, Counter-Terrorism Medicine (CTM) initiatives can be employed to improve health care outcomes.

Defining quality indicators for emergency care delivery: findings of an expert consensus process by emergency care practitioners in Africa.

Facility-based emergency care delivery in low-income and middle- income countries is expanding rapidly, particularly in Africa. Unfortunately, these efforts rarely include measurement of the quality or the impact of care provided, which is essential for improvement of care provision. Our aim was to determine context-appropriate quality indicators that will allow uniform and objective data collection to enhance emergency care delivery throughout Africa. We undertook a multiphase expert consensus process to identify, rank and refine quality indicators. A comprehensive review of the literature identified existing indicators; those associated with a substantial burden of disease in Africa were categorised and presented to consensus conference delegates. Participants selected indicators based on inclusion criteria and priority clinical conditions. The indicators were then presented to a group of expert clinicians via on-line survey; all meeting agreements were refined in-person by a separate panel and ranked according to validity, feasibility and value. The consensus working group selected seven conditions addressing nearly 75% of mortality in the African region to prioritise during indicator development, and the final product at the end of the multiphase study was a list of 76 indicators. This comprehensive process produced a robust set of quality indicators for emergency care that are appropriate for use in the African setting. The adaptation of a standardised set of indicators will enhance the quality of care provided and allow for comparison of system strengthening efforts and resource distribution.