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.

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.

Not war, not terrorism, the impact of hybrid warfare on emergency medicine.

INTRODUCTION: Healthcare facilities and medical providers are not immune to aggression and threat from terrorists, criminals and rogue states. The concept of Hybrid Warfare is often described as a mix of conventional warfare, irregular warfare, terrorism, criminality and different types of other hybrid threats such as cyberattacks and drone technology. Healthcare systems can either be primary or secondary targets of hybrid warfare with potentially devastating consequences. OBJECTIVE: The aim of this paper is to serve as a primer for clinicians, researchers and emergency managers in understanding the basic aspects of hybrid warfare, how healthcare can be affected, and to provide a framework for mitigation and resilience, especially in an emergency medicine setting. Different hybrid threats and their effect on emergency medicine, and healthcare in general, is discussed. DISCUSSION: Hybrid warfare is an increasing, multimodal, threat for all segments of healthcare, particularly prehospital care and emergency medicine. Disrupting the healthcare system in a country using hybrid warfare has the ultimate aim of destabilizing organizations and society as well as directly reducing the effectiveness and capabilities of healthcare as a key strategic resource. In this aspect prehospital care and emergency medicine are main targets of aggression. CONCLUSION: Clinicians and healthcare managers of all levels should have a basic knowledge of the different components of hybrid warfare so as to mitigate effects of an attack. It is suggested that an emergency department do not aim to create totally new solutions for hybrid threats but use an all hazards approach and the available guidelines for handling generic threats. However, there must be a preparedness for the different ways hybrid warfare can play out, how the threats can be combined in synergistic ways and the potential compounding effects on healthcare and society.

Crisis standards of care in a pandemic: navigating the ethical, clinical, psychological and policy-making maelstrom.

The COVID-19 pandemic has caused clinicians at the frontlines to confront difficult decisions regarding resource allocation, treatment options and ultimately the life-saving measures that must be taken at the point of care. This article addresses the importance of enacting crisis standards of care (CSC) as a policy mechanism to facilitate the shift to population-based medicine. In times of emergencies and crises such as this pandemic, the enactment of CSC enables concrete decisions to be made by governments relating to supply chains, resource allocation and provision of care to maximize societal benefit. This shift from an individual to a population-based societal focus has profound consequences on how clinical decisions are made at the point of care. Failing to enact CSC may have psychological impacts for healthcare providers particularly related to moral distress, through an inability to fully enact individual beliefs (individually focused clinical decisions) which form their moral compass.

Emergency Physician Twitter Use in the COVID-19 Pandemic as a Potential Predictor of Impending Surge: Retrospective Observational Study.

BACKGROUND: The early conversations on social media by emergency physicians offer a window into the ongoing response to the COVID-19 pandemic. OBJECTIVE: This retrospective observational study of emergency physician Twitter use details how the health care crisis has influenced emergency physician discourse online and how this discourse may have use as a harbinger of ensuing surge. METHODS: Followers of the three main emergency physician professional organizations were identified using Twitter's application programming interface. They and their followers were included in the study if they identified explicitly as US-based emergency physicians. Statuses, or tweets, were obtained between January 4, 2020, when the new disease was first reported, and December 14, 2020, when vaccination first began. Original tweets underwent sentiment analysis using the previously validated Valence Aware Dictionary and Sentiment Reasoner (VADER) tool as well as topic modeling using latent Dirichlet allocation unsupervised machine learning. Sentiment and topic trends were then correlated with daily change in new COVID-19 cases and inpatient bed utilization. RESULTS: A total of 3463 emergency physicians produced 334,747 unique English-language tweets during the study period. Out of 3463 participants, 910 (26.3%) stated that they were in training, and 466 of 902 (51.7%) participants who provided their gender identified as men. Overall tweet volume went from a pre-March 2020 mean of 481.9 (SD 72.7) daily tweets to a mean of 1065.5 (SD 257.3) daily tweets thereafter. Parameter and topic number tuning led to 20 tweet topics, with a topic coherence of 0.49. Except for a week in June and 4 days in November, discourse was dominated by the health care system (45,570/334,747, 13.6%). Discussion of pandemic response, epidemiology, and clinical care were jointly found to moderately correlate with COVID-19 hospital bed utilization (Pearson r=0.41), as was the occurrence of "covid," "coronavirus," or "pandemic" in tweet texts (r=0.47). Momentum in COVID-19 tweets, as demonstrated by a sustained crossing of 7- and 28-day moving averages, was found to have occurred on an average of 45.0 (SD 12.7) days before peak COVID-19 hospital bed utilization across the country and in the four most contributory states. CONCLUSIONS: COVID-19 Twitter discussion among emergency physicians correlates with and may precede the rising of hospital burden. This study, therefore, begins to depict the extent to which the ongoing pandemic has affected the field of emergency medicine discourse online and suggests a potential avenue for understanding predictors of surge.

Sustainable Effectiveness of Applying Trauma Team Activation in Managing Trauma Patients in the Emergency Department.

OBJECTIVE: To determine long term effectiveness of trauma team activation criteria by measuring emergency department length of stay (EDLOS) and 28-day mortality. MATERIAL AND METHOD: A 3-year retrospective cohort study conducted in adult trauma patients who met one of the trauma team activation criteria (shock, penetrating torso injury, post traumatic arrest, respiratory rate of less than 12 or more than 30, and pulse rate of more than 120). Specific demographic data, physiologic parameters, EDLOS, injury severity score (ISS), and 28-day mortality were prospectively recorded into the Trauma Registry database. Multiple logistic regression analysis was used to determine factors affecting mortality. The Institutional Review Board approval was obtained prior to undertaking the project. RESULTS: Two hundred eighty two patients with a mean age of35.1 years old were eligible. The median ISS was 25 (range, 13-30). The median EDLOS was 85 minutes (range, 50-135) and the 28-day mortality rate was 46.5%. The mean age was 31.7 years in the survival group and 38.7 years in the fatal group (p = 0.001). The median ISS was 17 in the survival group and 26 in the fatal group (p = 0.000) and the median EDLOS was 110 minutes in the survival group and 82 minutes in the fatal group (p = 0.034). When compared to data prior to the TTA application, the median time of EDLOS improvedsustainably from 184 to 85 minutes (p = 0.000) and the mortality rate decreased from 66.7% to 46.5% (p = 0.057). The parameters affecting patient mortality were older age, high ISS, and shorter EDLOS. CONCLUSION: Trauma team activation criteria significantly improved acute trauma care in the emergency department and decreased mortality.

Pediatric disaster preparedness curriculum across emergency medicine residencies.

OBJECTIVE: To assess pediatric disaster medicine (PDM) instruction in emergency medicine (EM) residency programs and to identify barriers to integrating these skills into EM training. METHODS: National survey study of United States EM Residency Program Directors (PDs) and Assistant PDs during the 2021-2022 academic year. RESULTS: Of the 186 EM residency programs identified, a total of 24 responses were recorded with a response rate of 12.9 percent. Importance of training was rated 5.79 (standard deviation 2.51) using the Likert scale ranging from 1 to 10. Out of 24 programs, 17 (70.8 percent) do not have any PDM training as part of residency training. Live drill, simulation, and tabletop were identified as most effective methods to deliver PDM training with the Likert scale score of 4.78, 4.6, and 4.47, respectively. Senior trainees' level of -knowledge/skills with family reunification (Likert 2.09/5; chemical-biological-radiological-nuclear explosive 2.95/5) and mass casualty preparation of the emergency department (3.3/5) as assessed by the respondents. The main barrier to education included logistics, eg, space and costs (Likert 3.7/5), lack of didactic time (3.7/5), and limited faculty knowledge, skill, or experience (3.3/5). CONCLUSION: PDM training is lacking and requires standardization. This study highlights the opportunity for the creation of a model for EM resident education in PDM.

Time Series Analysis of Congestive Heart Failure Discharges in Florida (USA) Post Tropical Cyclones.

OBJECTIVES: The aim of this study was to analyze congestive heart failure (CHF) discharges in Florida (USA) post tropical cyclones from 2007 through 2017. METHODS: This was a retrospective longitudinal time series analysis of hospital CHF quarterly discharges across Florida using the Healthcare Cost and Utilization Project (HCUP) database. The autoregressive integrated moving average (ARIMA) model was used with correlated seasonal regressor variables such as cyclone frequency, maximum cyclone wind speed, average temperature, and reports of influenza-like illness (ILI). RESULTS: A total of 3,372,993 patients were identified, with average age in each quarter ranging 72.2 to 73.9 years and overall mortality ranging 4.3% to 6.4%. The CHF discharges within each year peaked from October through December and nadired from April through June with an increasing overall time trend. Significant correlation was found between CHF discharge and the average temperature (P <.001), with approximately 331.8 less CHF discharges (SE = 91.7) per degree of increase in temperature. However, no significant correlation was found between CHF discharges and frequency of cyclones, the maximum wind speed, and reported ILI. CONCLUSIONS: This study suggests that with the current methods and the HCUP dataset, there is no significant increase in overall CHF discharges in Florida as a result of recent previous cyclone occurrences.

Disasters in the Northern Triangle: A Descriptive Analysis Using the EM-DAT Database 1902-2022.

INTRODUCTION: Since 1902, disasters in the Northern Triangle of Central America, which consists of the countries Guatemala, Honduras, and El Salvador, have caused over one-hundred-thousand deaths, affected millions of people, and caused tens of billions of dollars in damages. Understanding the nature and frequency of these events will allow stakeholders to decrease both the acute damages and the long-term deleterious consequences of disasters. STUDY OBJECTIVE: This study provides a descriptive analysis of all disasters recorded in the Emergency Events Database (EM-DAT) affecting Guatemala, Honduras, and El Salvador from 1902-2022. METHODS: Data were collected and analyzed from the EM-DAT, which categorizes disasters by frequency, severity, financial cost, distribution by country, burden of death, number of people affected, financial cost by country, and type of disasters most prevalent in each country. Results are presented as absolute numbers and as a percentage of the overall disaster burden. These trends are then graphed over the time period of the database. RESULTS: The EM-DAT recorded 359 disasters in the Northern Triangle from 1902 through 2022. Meteorologic events (floods and storms) were the most common types of disaster (44%), followed by transport accidents (13%). Meteorologic events and earthquakes were the most severe, as measured by deaths (62%), people affected (60%), and financial cost (86%). Guatemala had the greatest number of disasters (45%), deaths (68%), and affected people (52%). The financial costs of the disasters were evenly distributed between the three countries. CONCLUSION: Meteorologic disasters are the most common and most severe type of disaster in the Northern Triangle. Earthquakes and transport accidents are also common. As climate change causes more severe storms in the region, disasters are likely to increase in severity as well. Governments and aid organizations should develop disaster preparedness and mitigation strategies to lessen the catastrophic effects of future disasters. Missing data limit the conclusions of this study to general trends.

Terrorism-Related Attacks in East Asia from 1970 through 2020.

AIM: This study aims to analyze and describe terrorism-related attacks in East Asia from 1970 through 2020. BACKGROUND: East Asia consists of South Korea, North Korea, Singapore, Hong Kong, China, Japan, Taiwan, and Macao. According to the Global Terrorism Index (GTI) 2022, the impact of terrorism in East Asia is very low. However, the assassination of former Japanese Prime Minister Shinzo Abe on July 8, 2022 demonstrates that East Asia is not safe from terrorist attacks. This descriptive analysis of terrorist attacks in East Asia will help first responders, Emergency Medical Services (EMS), hospital-based medical providers, and policymakers establish a more refined hazard vulnerability assessment (HVA) framework and develop a Counter-Terrorism Medicine (CTM) mitigation, preparedness, response, and recovery plan. METHODS: This is a descriptive observational study drawing data from the Global Terrorism Database (GTD) from January 1, 1970 through December 31, 2020. Epidemiology outcomes included primary weapon type, primary target type, the country where the incident occurred, and the number of total deaths and injured collected. Data from 2021 were not yet available at the time of this study. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 779 terrorism-related events in East Asia from 1970 through 2020. In total, the attacks resulted in 1,123 deaths and 9,061 persons injured. The greatest number of attacks (371; 47.63%) occurred in Japan and the second most occurred in China (268; 34.4%). Explosives were the most used primary weapon type (308; 39.54%) in the region, followed by incendiary devices (260; 33.38%). Terrorist attacks drastically diminished from their peak of 92 in 1990, but there were additional peaks of 88 in 1996, 18 in 2000, 20 in 2008, and 36 attacks in 2014. CONCLUSIONS: A total of 779 terrorist attacks occurred from 1970 through 2020 in East Asia, resulting in 1,123 deaths and 9,061 injuries. Of those, 82.03% attacks occurred in Japan and China. Terrorist attacks drastically diminished since their peak in 1996, but there is an overall uptrend in attacks since 1999.

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.

Hybrid warfare and counter-terrorism medicine.

INTRODUCTION: March 9, 2022. An airstrike by Russian forces destroying a maternity hospital in Mariupol, Ukraine. The image of a severely injured pregnant woman covered in blood being stretchered away against the backdrop of destroyed buildings. Mutterings of the use of chemical weapons. This paper is a primer for healthcare personnel and health systems on hybrid warfare and counter-terrorism medicine. DISCUSSION: While recent events and images arising from conflicts around the world represent a cruel hallmark in today's history, attacks against healthcare facilities and innocent civilians are not new and continue to be perpetrated around the world. In war, the Geneva Convention protects civilians and healthcare institutions from harm but when war crimes are being committed and civilians knowingly targeted, parallels from a healthcare perspective can be drawn with terrorism events. Increasingly, civilian institutions and in particular the healthcare sector, are drawn into such conflicts and understanding the health system impact of hybrid warfare and other asymmetrical attack methods is of great importance. CONCLUSION: The field of Counter-Terrorism Medicine (CTM) explores the healthcare impacts of intentional, man-made attacks and much recent research and discussions around this topic are extremely relevant and applicable not just to the ongoing hybrid war in Ukraine, but to today's threat climate all around us.