50 Years of terrorism in Belgium: a review of 121 incidents in the global terrorism database.

OBJECTIVES: Belgium is not only prone to inland terrorism but also attracts terrorist factions aiming at various political, diplomatic, military, and/or religious targets. This study aimed to identify and characterize all documented terrorist attacks in Belgium reported to the Global Terrorism Database (GTD) over a period of 50 years. METHODS: The GTD was searched for all terrorist attacks in Belgium between 1970 and 2019. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. RESULTS: In 50 years, 121 incidents accounted for 80 confirmed fatalities and 498 injured people. Bombings and explosions were the most frequently identified attack type (46.3%), followed by assassination (16.5%), infrastructure damage (15.7%) and armed or unarmed assaults (14.0%). Governmental and diplomatic institutions were the most frequent target (24.0%). For those perpetrators the GTD did have enough information we saw a timely change from far left and separatist dominating the early decades to Jihadi groups in the last decade, while anti-semitic factions were active in every decade. CONCLUSION: In contrast to other studies, this study did not show an increase over time. Left-wing perpetrators dominated the eighties. In 50 years of terrorist activity in Belgium, the health care system was spared. Devastating mass casualty attacks challenging the health care system are rare in Belgium.

Are Belgian military students in medical sciences better educated in disaster medicine than their civilian colleagues?

INTRODUCTION: Historically, medical students have been deployed to care for disaster victims but may not have been properly educated to do so. A previous evaluation of senior civilian medical students in Belgium revealed that they are woefully unprepared. Based on the nature of their military training, we hypothesised that military medical students were better educated and prepared than their civilian counterparts for disasters. We evaluated the impact of military training on disaster education in medical science students. METHODS: Students completed an online survey on disaster medicine, training, and knowledge, tested using a mixed set of 10 theoretical and practical questions. The results were compared with those of a similar evaluation of senior civilian medical students. RESULTS: The response rate was 77.5%, mean age 23 years and 59% were males. Overall, 95% of military medical students received some chemical, biological, radiological and nuclear training and 22% took part in other disaster management training; 44% perceived it is absolutely necessary that disaster management should be incorporated into the regular curriculum. Self-estimated knowledge ranged from 3.75 on biological incidents to 4.55 on influenza pandemics, based on a 10-point scale. Intention to respond in case of an incident ranged from 7 in biological incidents to 7.25 in chemical incidents. The mean test score was 5.52; scores improved with educational level attained. A comparison of survey data from civilian senior medical master students revealed that, except for influenza pandemic, military students scored higher on knowledge and capability, even though only 27% of them were senior master students. Data on willingness to work are comparable between the two groups. Results of the question/case set were significantly better for the military students. CONCLUSIONS: The military background and training of these students makes them better prepared for disaster situations than their civilian counterparts.

50 Years of Terrorism against the Nuclear Industry: A Review of 91 Incidents in the Global Terrorism Database.

BACKGROUND: The on-going Russo-Ukrainian war has resulted in a renewed global interest in the safety and security of nuclear installations and the possibility of nuclear disasters caused by warfare and terrorism.The objective of this study was to identify and characterize all documented terrorist attacks against nuclear transport, nuclear facilities, and nuclear scientists as reported to the Global Terrorism Database (GTD) over a 50-year period. METHODS: The GTD was searched for all terrorist attacks against nuclear facilities, nuclear scientists, nuclear transport, and other nuclear industry-related targets in the period from 1970-2020. Analyses were performed on temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss. RESULTS: Ninety-one incidents that occurred from 1970 through 2020 were included. Incidents took place in 25 countries and nine world regions, with most (42; 46.1%) occurring in Western Europe.During these 50 years, 91 incidents resulted in 19 fatalities and 117 injuries. One perpetrator was killed during an incident and one other assailant was injured.Bombings and explosions were the most frequently identified attack type (n = 40; 44.0%), followed by facility/infrastructure damage (n = 24; 26.4%) and armed assaults and assassinations (both n = 7; 7.7%).Nuclear power plants and reactors under construction were targeted in 13 (14.3%) and eight (8.8%) incidents, respectively. Most of the attacks took place on other nuclear industry-related sites. CONCLUSION: Terrorist attacks carried out by non-state perpetrators against nuclear facilities, nuclear scientists, nuclear transport, and other nuclear industry-related targets are rare, with only 91 incidents in a 50-year period. None of the attacks resulted in radioactive fallout or environmental contamination. Most of the attacks took place outside a nuclear power plant.

An Epidemiological Analysis of Terrorist Attacks in the Nordic and Baltic Countries from 1970 through 2020.

BACKGROUND: Russia's annexation of Crimea in 2014, and the recent Russo-Ukrainian war that started in 2022, were triggers that radically changed the perception of security in the Nordic and Baltic countries. The on-going Russian hybrid war has resulted in a renewed global interest in the safety and security of many countries (eg, the Nordic-Baltic Eight). The prospective North Atlantic Treaty Organization (NATO) membership of Finland and Sweden may drastically change the regional military and political landscape.The objective of this study was to identify and characterize all documented terrorist attacks in this region as reported to the Global Terrorism Database (GTD) from 1970 through 2020. METHODS: The GTD was searched using the internal database functions for all terrorism incidents in the Nordic-Baltic states: Denmark, Estonia, Finland, Iceland, Latvia, Lithuania, Norway, and Sweden.Temporal factors, location, target type, attack and weapon type, perpetrator type, number of casualties, and property value loss were collated. Results were exported into an Excel spreadsheet for analysis. RESULTS: There were 298 terrorism-related incidents from 1970 through 2020. Most attacks occurred in Sweden, followed by Norway and Finland. No entries were recorded for the Baltic states prior to their independency in 1991. The 298 incidents resulted in a total of 113 fatalities and 277 injuries.Facility/infrastructure attacks were the most frequently identified attack type (35.0%), followed by bombings and explosions (30.9%). Armed assaults were responsible for 80 fatalities and 105 injuries, followed by bombings/explosions with 15 fatalities and 72 injuries. The predominant target types were immigrants and refugee shelters (64/298 incidents). In only 33.6% of the incidents, perpetrators were known. Right-wing assailants represented the largest group, accounting for 27 incidents. CONCLUSION: From 1970 through 2020, there were 298 terrorist attacks in the Nordic-Baltic Eight. Sweden accounted for 50% of incidents.The profile of terrorist attacks was very diverse, as were the perpetrators and targets. Every country had its own incident characteristics. The surge of right-wing extremism must be closely monitored.

Primary Care as Primary Target: A Review of Terrorist Attacks Against Primary Care Providers and Their Offices.

BACKGROUND: Violence against primary care providers (PCPs) has increased during the current pandemic. While some of these violent acts are not defined as terrorist events, they are intentional events with an aim to disrupt, kill, or injure. Despite their pivotal role in health care, little is known about the risk for PCPs as targets of terrorism. 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 terrorist attacks against PCPs and their offices from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary attack and weapon type, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: There were 29 terrorist attacks against PCPs and their offices from 1970-2019. The majority of attacks occurred during or after 2010. There were 58 fatalities, 52 injured, and 13 hostages. Most documented attacks took place in Pakistan, the United States, and Sri Lanka. Bombings concerned 55% of cases and 21% were hostage-takings. CONCLUSION: Although less common than attacks on other health care related targets, terrorist attacks against PCPs have occurred. The majority of attacks occurred during the last decade. Future studies are warranted to further assess the risk of terrorist attacks against PCPs: before, during, and beyond the current pandemic.

Attacks on Health Care Workers in Historical Pandemics and COVID-19.

Previous pandemics have been (mis)used for (geo)political reasons, for terrorism purposes, and in times of conflict. Coronavirus disease (COVID-19) has been no exception with populist politicians challenging the relations with China, calling it the "Chinese virus," certain state actors setting up cyberterrorist actions against health care organizations in the United States and Europe, and a reported increase of violent acts against health care workers.Aside from state-driven factors, both left- and right-wing activists and anti-vaccination activists adhering to conspiracy theories are a threat for health care organizations. Furthermore, socioeconomic, religious, and cultural factors play a role in why health care is a possible target of violence. Fear of viral pathogens, fury about financial losses due to the pandemic and governmental measures such as lockdowns, anger because of mandatory quarantines, and the disruption of burial rituals are among the reasons for people to revolt against health care providers.Here, we provide a narrative review of the impact of violence against health care workers during the COVID-19 pandemic and earlier pandemics, and suggest preventive strategies.

Terrorist Attacks against Concerts and Festivals: A Review of 146 Incidents in the Global Terrorism Database.

BACKGROUND: Mass gatherings are vulnerable to terrorist attacks and are considered soft targets with potential to inflict high numbers of casualties. The objective of this study was to identify and characterize all documented terrorist attacks targeted at concerts and festivals reported to the Global Terrorism Database (GTD) over a 50-year period. METHODS: The GTD was searched for all terrorist attacks against concerts and festivals that occurred world-wide from 1970 through 2019. 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. Chi-square tests were performed to evaluate trends over time and differences in attack types. RESULTS: In total, 146 terrorist attacks were identified. In addition to musical concerts, festivals included religious, cultural, community, and food festivals. With 53 incidents, South Asia was the most heavily hit region of the world, followed by the Middle East & North Africa with 25 attacks. Bombings and explosions were the most common attack types. The attacks targeted attendees, pilgrims, politicians, or police/military members who secured the concerts and festivals. CONCLUSION: This analysis of the GTD, which identified terrorist attacks aimed at concerts and festivals over a 50-year period, demonstrates that the threat is significant, and not only in world regions where terrorism is more prevalent or local conflicts are going on. The findings of this study may help to create or enhance contingency plans.

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.

Disaster health education framework for short and intermediate training in Saudi Arabia: A scoping review.

Background: Saudi Arabia has made extensive efforts to manage disasters using unique national approaches; however, challenges and obstacles concerning disaster health handling persist. The nation has a reactive strategy to disaster management with a need for increased involvement of health professionals in disaster management and improvement of healthcare facilities emergency preparedness including competency-based education training. Objective: A comprehensive and consistent approach of disaster education programs for short and intermediate training of health professionals involved in disaster responses in Saudi Arabia is still not evident. Therefore, it is vital to explore and map the current state of the disaster education framework in Saudi Arabia. Methods: The Joanna Briggs Institute approach for scoping reviews was used to assess research articles and preprints between January 2000 and September 2021 from Saudi Digital Library; PubMed, CINAHL, and Google Scholar. Five experts identified key aspects of the disaster education approach and eligibility criteria to facilitate identification of relevant articles. Results: Only five articles met the specified criteria and described two short and three intermediate courses on disaster health management in Saudi Arabia. All courses involved competency-specific training aimed at basic or foundational level and involved a range of activities and learning types. None had refresher courses within 12 months. Conclusion: The review highlights the obvious scarcity of short and intermediate term evidence-based disaster health programs in Saudi Arabia. Adoption of the education framework proposed by the authors based on international frameworks could improve the quality and consistency of the disaster education curriculum in Saudi Arabia.

Terrorist Attacks against Hospitals: World-Wide Trends and Attack Types.

BACKGROUND: Analysts have warned on multiple occasions that hospitals are potential soft targets for terrorist attacks. Such attacks will have far-reaching consequences, including decreased accessibility, possible casualties, and fear among people. The extent, incidence, and characteristics of terrorist attacks against hospitals are unknown. Therefore, the objective of this study was to identify and to characterize terrorist attacks against hospitals reported to the Global Terrorism Database (GTD) over a 50-year period. METHODS: The GTD was used to search for all terrorist attacks against hospitals from 1970-2019. Analyses were performed on temporal factors, location, attack and weapon type, and number of casualties or hostages. Chi-square tests were performed to evaluate trends over time and differences in attack types per world region. RESULTS: In total, 454 terrorist attacks against hospitals were identified in 61 different countries. Of these, 78 attacks targeted a specific person within the hospital, about one-half (52.6%) involved medical personnel. There was an increasing trend in yearly number of attacks from 2008 onwards, with a peak in 2014 (n = 41) and 2015 (n = 41). With 179 incidents, the "Middle East & North Africa" was the most heavily hit region of the world, followed by "South Asia" with 125 attacks. Bombings and explosions were the most common attack type (n = 270), followed by 77 armed assaults. Overall, there were 2,746 people injured and 1,631 fatalities. In three incidents, hospitals were identified as secondary targets (deliberate follow-up attack on a hospital after a primary incident elsewhere). CONCLUSION: This analysis of the GTD identified 454 terrorist attacks against hospitals over a 50-year period. It demonstrates that the threat is real, especially in recent years and in world regions where terrorism is prevalent. The findings of this study may help to create or further improve contingency plans for a scenario wherein the hospital becomes a target of terrorism.

Current Perspectives and Concerns Facing Hospital Evacuation: The Results of a Pilot Study and Literature Review.

OBJECTIVE: To analyze the evacuation preparedness of hospitals within the European Union (EU). METHOD: This study consisted of 2 steps. In the first step, a systematic review of the subject matter, according to the PRISMA flow diagram, was performed. Using Scopus (Elsevier, Amsterdam, Netherlands), PubMed (National Library of Medicine, Bethesda, MD), and Gothenburg University´s search engine, 11 questions were extracted from the review and were sent to representatives from 15 European Union (EU)- and non-EU countries. RESULTS: The findings indicate that there is neither a full preparedness nor a standard guideline for evacuation within the EU or other non-EU countries in this study. A major shortcoming revealed by this study is the lack of awareness of the untoward consequences of medical decision-making during an evacuation. Some countries did not respond to the questions due to the lack of relevant guidelines, instructions, or time. CONCLUSION: Hospitals are exposed to internal and external incidents and require an adequate evacuation plan. Despite many publications, reports, and conclusions on successful and unsuccessful evacuation, there is still no common guide for evacuation, and many hospitals lack the proper preparedness. There is a need for a multinational collaboration, specifically within the EU, to establish such an evacuation planning or guideline to be used mutually within the union and the international community.

The Development of Swedish Military Healthcare System: Part II-Re-evaluating the Military and Civilian Healthcare Systems in Crises Through a Dialogue and Study Among Practitioners.

INTRODUCTION: Historical changes have transformed Sweden from being an offensive to a defensive and collaborative nation with national and international engagement, allowing it to finally achieve the ground for the civilian-military collaboration and the concept of a total defense healthcare. At the same time, with the decreasing number of international and interstate conflicts, and the military's involvement in national emergencies and humanitarian disaster relief, both the need and the role of the military healthcare system within the civilian society have been challenged. The recent impact of the COVID-19 in the USA and the necessity of military involvement have led health practitioners to anticipate and re-evaluate conditions that might exceed the civilian capacity of their own countries and the need to have collaboration with the military healthcare. This study investigated both these challenges and views from practitioners regarding the benefits of such collaboration and the manner in which it would be initiated. MATERIAL AND METHOD: A primary study was conducted among responsive countries using a questionnaire created using the Nominal Group Technique. Relevant search subjects and keywords were extracted for a systematic review of the literature, according to the PRISMA model. RESULTS: The 14 countries responding to the questionnaire had either a well-developed military healthcare system or units created in collaboration with the civilian healthcare. The results from the questionnaire and the literature review indicated a need for transfer of military medical knowledge and resources in emergencies to the civilian health components, which in return, facilitated training opportunities for the military staff to maintain their skills and competencies. CONCLUSIONS: As the world witnesses a rapid change in the etiology of disasters and various crises, neither the military nor the civilian healthcare systems can address or manage the outcomes independently. There is an opportunity for both systems to develop future healthcare in collaboration. Rethinking education and training in war and conflict is indisputable. Collaborative educational initiatives in disaster medicine, public health and complex humanitarian emergencies, international humanitarian law, and the Geneva Convention, along with advanced training in competency-based skill sets, should be included in the undergraduate education of health professionals for the benefit of humanity.

Impact of lightning strikes on hospital functions.

Two regional hospitals were struck by lightning during a one-month period. The first hospital, which had 236 beds, suffered a direct strike to the building. This resulted in a direct spread of the power peak and temporary failure of the standard power supply. The principle problems, after restoring standard power supply, were with the fire alarm system and peripheral network connections in the digital radiology systems. No direct impact on the hardware could be found. Restarting the servers resolved all problems. The second hospital, which had 436 beds, had a lightning strike on the premises and mainly experienced problems due to induction. All affected installations had a cable connection from outside in one way or another. The power supplies never were endangered. The main problem was the failure of different communication systems (telephone, radio, intercom, fire alarm system). Also, the electronic entrance control went out. During the days after the lightening strike, multiple software problems became apparent, as well as failures of the network connections controlling the technical support systems. There are very few ways to prepare for induction problems. The use of fiber-optic networks can limit damage. To the knowledge of the authors, these are the first cases of lightning striking hospitals in medical literature.

Are Belgian senior medical students ready to deliver basic medical care in case of a H5N1 pandemic?

Medical care systems will be overwhelmed if a human H5N1 pandemic should occur. Several national disaster plans, including that of Belgium, focus on maximal treatment at home with senior medical students supporting frontline care. To evaluate the knowledge and preparedness of Belgian senior medical students, an e-mail survey of senior medical students (last two years of education) attending Flemish universities was conducted. A total of 243 students (30%) replied. Only 21.8% of them were aware of the possibility of being involved in this planning. A total of 77.4% estimated H5N1 to be a possible threat to national health. Seventy percent of respondents reacted positively towards the idea of being involved in implementing primary care, and only 9.5% were absolutely opposed to the idea. A total of 82.3% would care for pandemic patients if necessary, but only 41.2% would do so if these patients were children. Only 18.9% estimated themselves to be sufficiently educated regarding H5N1. Ninety-one percent were convinced that care for H5N1-influenza patients should be incorporated into their regular curriculum. Several antiviral products were reported by the students to be efficient for treating H5N1, but only 34.6% correctly chose oseltamavir and/or zanamavir and 35.4% replied "I don't know". A total of 95.5% correctly answered that the regular influenza vaccination doesn't protect against H5N1. The risk for human-to-human transmission was rated to be small by 50.6% (none 21%, high 27.6%). The human infection risk was rated to be small by 74.1% (none 1.6%, high 23%). There is a high level of willingness to participate among senior medical students. However, in the case of pediatric patients they're more reserved. It would be useful to incorporate a focused session on preparedness in the regular teaching program. A legal base for their actions should also be provided. Ethical guidelines on rights and duties in case of a pandemic should be prepared by an international, multidisciplinary group of experts.

Seizures and hyponatremia after excessive intake of diet coke.

We describe a case of epileptic seizures after a massive intake of diet coke. Apart from the hyponatremia due to water intoxication the convulsions can be potentiated by the high dose of caffeine and aspartame from the diet coke. To our knowledge this is the first report of seizures due to excessive diet coke intake.

Differential diagnosis between viral and bacterial meningitis in children.

OBJECTIVE: The differential diagnosis between viral meningitis and bacterial meningitis is often very difficult. The results of peripheral blood and spinal fluid analysis are not 100% accurate. We tried to find a useful 'bedside' decision-making tool, based on laboratory results readily available at the emergency department. METHODS: Retrospective study design. Analysis of a consecutive series of all children (age 0-15 years) admitted to the paediatric ward because of a viral or bacterial meningitis, in the period from 1997 to September 2005. RESULTS: Seventy-one children with viral and 21 with bacterial meningitis were included. Bacterial meningitis occurred at much younger ages than viral meningitis. The paediatrician decided to administer antibiotics in 41 of 71 children with viral meningitis and in all children with bacterial meningitis. We developed a 'bacterial meningitis score' based on C-reactive protein in peripheral blood, as well as glucose and protein in cerebrospinal fluid. Using this score, we could distinguish 54 of 71 patients with viral meningitis from the group with bacterial meningitis. When the dispensing of antibiotics was based on this score, only 16 patients with viral meningitis would receive antibiotics. CONCLUSION: We present a bedside bacterial meningitis score. Using this bacterial meningitis score as a decision-making tool, we would be able to avoid antibiotics in a large number of children with viral meningitis. As this gives a 100% success rate, thus guaranteeing that bacterial meningitis patients would receive the proper therapy, our bacterial meningitis score could be an accurate decision-support tool.

Are Belgian hospitals prepared for an H5N1-pandemic?

OBJECTIVE: Virulent airborne diseases can be a real burden to a nation's health system. The most recent threat is the fear of a mutation-induced H5N1-influenza pandemic. We studied whether Belgian hospitals are able to deal with H5N1-influenza infected patients in the case of a pandemic. Many patients, including children, may require artificial ventilation within 48 h after admission. METHODS: A survey aimed at determining 'availability and preparedness' was sent by e-mail to the different Belgian Emergency Departments. RESULTS AND DISCUSSION: Sixty-five hospitals were finally included. The amount of patients being potentially admitted is limited, owing to the reduced number of intensive care beds equipped with automatic ventilators. Furthermore, the number of available intensive care beds for children is still lower than for adult patients. The number of mortuary places, in the case of a catastrophe, is also insufficient. Although most hospitals set up a disaster plan on H5N1, there are only limited stocks of antiviral medication to protect the hospital staff in the acute phase. A separate triage area is only available in a limited number of hospitals. We conclude that Belgian hospitals and emergency departments are not equipped to deal with potential pandemic situations.

Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study.

BACKGROUND: The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs. OBJECTIVES: To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost-effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department. METHOD: In this Belgian prospective, double-blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result. RESULTS: The prevalence of protective anti-tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost-effective tool for patients presenting with a tetanus-prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (10.58 euros/patient with the TQS versus 11.34 euros/patient without). The benefits of the TQS use were significantly greater in patients <61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to 8.31 euros. CONCLUSION: In selected patients, the TQS is a cost-effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result.

Hospitals: Soft Target for Terrorism?

In recent years, the world has been rocked repeatedly by terrorist attacks. Arguably, the most remarkable were: the series of four coordinated suicide plane attacks on September 11, 2001 on buildings in New York, Virginia, and Pennsylvania, USA; and the recent series of two coordinated attacks in Brussels (Belgium), on March 22, 2016, involving two bombings at the departure hall of Brussels International Airport and a bombing at Maalbeek Metro Station located near the European Commission headquarters in the center of Brussels. This statement paper deals with different aspects of hospital policy and disaster response planning that interface with terrorism. Research shows that the availability of necessary equipment and facilities (eg, personal protective clothing, decontamination rooms, antidotes, and anti-viral drugs) in hospitals clearly is insufficient. Emergency teams are insufficiently prepared: adequate and repetitive training remain necessary. Unfortunately, there are many examples of health care workers and physicians or hospitals being targeted in both political or religious conflicts and wars. Many health workers were kidnapped and/or killed by insurgents of various ideology. Attacks on hospitals also could cause long-term effects: hospital units could be unavailable for a long time and replacing staff could take several months, further compounding hospital operations. Both physical and psychological (eg, posttraumatic stress disorder [PTSD]) after-effects of a terrorist attack can be detrimental to health care services. On the other hand, physicians and other hospital employees have shown to be involved in terrorism. As data show that some offenders had a previous history with the location of the terror incident, the possibility of hospitals or other health care services being targeted by insiders is discussed. The purpose of this report was to consider how past terrorist incidents can inform current hospital preparedness and disaster response planning. De Cauwer H , Somville F , Sabbe M , Mortelmans LJ . Hospitals: soft target for terrorism? Prehosp Disaster Med. 2017;32(1):94-100.

Are Dutch Hospitals Prepared for Chemical, Biological, or Radionuclear Incidents? A Survey Study.

Introduction Being one of Europe's most densely populated countries, and having multiple nuclear installations, a heavy petrochemical industry, and terrorist targets, the Netherlands is at-risk for chemical, biological, or radionuclear (CBRN) incidents. Recent world and continental events show that this threat is real and that authorities may be underprepared. Hypothesis The hypothesis of this study is that Dutch hospitals are underprepared to deal with these incidents. METHODS: A descriptive, cross-sectional study was performed. All 93 Dutch hospitals with an emergency department (ED) were sent a link to an online survey on different aspects of CBRN preparedness. Besides specific hospital information, information was obtained on the hospital's disaster planning; risk perception; and availability of decontamination units, personal protective equipment (PPE), antidotes, radiation detection, infectiologists, isolation measures, and staff training. RESULTS: Response rate was 67%. Sixty-two percent of participating hospitals were estimated to be at-risk for CBRN incidents. Only 40% had decontamination facilities and 32% had appropriate PPE available for triage and decontamination teams. Atropine was available in high doses in all hospitals, but specific antidotes that could be used for treating victims of CBRN incidents, such as hydroxycobolamine, thiosulphate, Prussian blue, Diethylenetriaminepentaacetic acid (DTPA), or pralidoxime, were less frequently available (74%, 65%, 18%, 14%, and 42%, respectively). Six percent of hospitals had radioactive detection equipment with an alarm function and 22.5% had a nuclear specialist available 24/7 in case of disasters. Infectiologists were continuously available in 60% of the hospitals. Collective isolation facilities were present in 15% of the hospitals. CONCLUSION: There is a serious lack of hospital preparedness for CBRN incidents in The Netherlands. Mortelmans LJM , Gaakeer MI , Dieltiens G , Anseeuw K , Sabbe MB . Are Dutch hospitals prepared for chemical, biological, or radionuclear incidents? A survey study. Prehosp Disaster Med. 2017;32(5):483-491.