Public Health Responses to CBRN Terrorism in the Middle East and North Africa.

OBJECTIVE: Escalating global challenges (such as disasters, conflict, and climate change) underline the importance of addressing Chemical, Biological, Radiological, and Nuclear (CBRN) terrorism for sustainable public health strategies. This study aims to provide a comprehensive epidemiological analysis of CBRN incidents in the Middle East and North Africa (MENA) region, emphasizing the necessity of sustainable responses to safeguard healthcare infrastructures. METHOD: Utilizing a retrospective approach, this research analyzes data from the Global Terrorism Database (GTD) covering the period from 2003 to 2020. The study focuses on examining the frequency, characteristics, and consequences of CBRN incidents in the MENA region to identify patterns and trends that pose significant challenges to public health systems. RESULTS: The analysis revealed a significant clustering of CBRN incidents in Iraq and Syria, with a predominant involvement of chemical agents. These findings indicate the extensive impact of CBRN terrorism on healthcare infrastructures, highlighting the challenges in providing immediate health responses and the necessity for long-term recovery strategies. CONCLUSIONS: The study underscores the need for improved healthcare preparedness, robust emergency response systems, and the development of sustainable public health policies. Advocating for international collaboration, the research contributes to the strategic adaptation of healthcare systems to mitigate the impacts of CBRN terrorism, ensuring preparedness for future incidents in the MENA region and beyond.

Unleashing the global potential of public health: A framework for future pandemic response.

Public health emergencies, especially pandemics, need to be managed globally, and on several levels, emphasizing the importance of leadership, communication, and synchronization of measures, data, and management plans in contrast to the management of the Coronavirus-19 pandemic, which illustrated diverse strategies employed by various nations. This paper aims to review and discuss whether globalized diseases in a globalized world should be managed by globalized public health. Using a systematic literature search, followed by a non-systematic literature review, selected studies were grouped into topics, and analyzed, using content analysis to enhance the conclusive results. The results present a roadmap towards a re-envisioned framework highlighting key areas of focus: data-driven decision-making, robust technology infrastructure, global cooperation, and ongoing public health education, as part of a coordinated global response. This article reveals the weaknesses of current pandemic management systems and recommends new steps to further strengthen the management of future pandemics.

Care in emergencies and disasters: Can it be person-centered?

OBJECTIVES: While person-/patient-centered care aims to influence policymakers' rules and regulations to improve the care of individuals worldwide, exploration of the concept in the context of disaster and public health emergencies as an alternative ethical approach is lacking. This study aims to provide a nuanced understanding of the advantages and challenges of diverse ethical approaches in emergencies, to improve patient care. METHODS: A survey, created after several rounds of Delphi methodology, with 22 statements, was applied to 39 participants from nine different countries. The questionnaire's results, including participants' comments, were analyzed. RESULTS: The results show that practitioners chose to use a combination of diverse ethical approaches in managing victims of disasters and public health emergencies. CONCLUSION: The selection of an approach is context- and situation-dependent and seems to primarily respond to the nature of underlying etiology, creating a possibility to use diverse approaches to offer individualized care on a later occasion and when a flexible surge capacity is available. PRACTICE IMPLICATIONS: The outcomes of this study will enhance the future ethical discussion in person/patient-centered care during situations with limited resources and help to develop necessary ethical and educational guidelines.

The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards.

BACKGROUND: Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims. METHODS: Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared. RESULTS: TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel. CONCLUSIONS: The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.

Supporting the Frontlines: A Scoping Review Addressing the Health Challenges of Military Personnel and Veterans.

(1) Background: Military personnel and veterans meet unique health challenges that stem from the complex interplay of their service experiences, the nature of warfare, and their interactions with both military and civilian healthcare systems. This study aims to examine the myriad of injuries and medical conditions specific to this population, encompassing physical and psychological traumas. (2) Methods: A scoping review (systematic search and non-systematic review) was performed to evaluate the current landscape of military healthcare. (3) Results: A significant change in the injury profile over time is identified, linked to shifts in combat strategies and the integration of advanced technologies in warfare. Environmental exposures to diverse chemical or natural agents further complicate the health of service members. Additionally, the stressors they face, ranging from routine stress to traumatic experiences, lead to various mental health challenges. A major concern is the gap in healthcare accessibility and quality, worsened by challenges in the civilian healthcare system's capacity to address these unique needs and the military healthcare system's limitations. (4) Conclusions: This review underscores the need for holistic, integrated approaches to care, rigorous research, and targeted interventions to better serve the health needs of military personnel and veterans.

The Use of Prehospital Intensive Care Units in Emergencies-A Scoping Review.

BACKGROUND: Amidst a rising tide of trauma-related emergencies, emergency departments worldwide grapple with the challenges of overcrowding and prolonged patient wait times. Addressing these challenges, the integration of prehospital intensive care units has appeared as a promising solution, streamlining trauma care and enhancing patient safety. Nevertheless, the feasibility of such an initiative becomes murky when considered globally. This review delves into the intricacies of prehospital intensive care units' deployment for trauma care, scrutinizing their configurations, operational practices, and the inherent challenges and research priorities. METHODS: A scoping review was performed for eligible studies. The result was uploaded to the RAYYAN research platform, facilitating simultaneous evaluation of the studies by all researchers. RESULTS: A total of 42 studies were initially selected. Four studies were duplicates, and 25 studies were unanimously removed as irrelevant. The remaining studies (n = 13) were included in the review, and the outcomes were categorized into diverse subgroups. CONCLUSIONS: A country's emergency medical services must achieve specific milestones in education, competency, resource availability, and performance to effectively harness the potential of a prehospital intensive care unit. While certain nations are equipped, others lag, highlighting a global disparity in readiness for such advanced care modalities.

Influence of experience, tenure, and organisational preparedness on nurses' readiness in responding to disasters: An exploration during the COVID-19 pandemic.

Background: The coronavirus 2019 (COVID-19) pandemic has placed unprecedented challenges on the nursing practice, particularly in Poland. Nurses, as crucial healthcare service providers, have faced organisational disruptions, altered working conditions, and heightened professional anxieties. Methods: We undertook a comprehensive survey across all medical centres in Lublin, Poland in 2020 to understand nurses' attitudes towards their roles and working conditions during the pandemic. This involved 470 nurses completing a questionnaire which focused on four pivotal areas: readiness to be on call in a disaster situation (even when not formally asked); willingness to work overtime in a disaster without additional compensation, preparedness to undertake health risks by caring for individuals with infectious diseases or exposure to hazardous substances, and willingness to be transferred to other departments during a disaster. Results: We found that excessive workload, fear of infection, and feelings of helplessness significantly influenced nurses' readiness to work overtime, particularly when unpaid. We also presented the ethical dilemmas that nurses encountered during the pandemic and how these dilemmas affected their decision-making processes. We further explored the impact of variables such as nurses' professional experience, tenure, and level of organisational preparedness on their readiness to respond to crisis situations. Conclusions: Gaining an understanding of nurses' perspectives is key for formulating strategies to bolster their professional engagements and resilience during crises. Addressing these issues can help build a more robust and well-prepared healthcare system that can effectively navigate future crises.

The impact of the three-level collaboration exercise on collaboration and leadership during scenario-based hospital evacuation exercises using flexible surge capacity concept: a mixed method cross-sectional study.

BACKGROUND: Hospitals play a crucial role in responding to disasters and public health emergencies. However, they are also vulnerable to threats such as fire or flooding and can fail to respond or evacuate adequately due to unpreparedness and lack of evacuation measures. The United Nations Office for Disaster Risk Reduction has emphasised the importance of partnerships and capacity building in disaster response. One effective way to improve and develop disaster response is through exercises that focus on collaboration and leadership. This study aimed to examine the effectiveness of using the 3-level collaboration (3LC) exercise in developing collaboration and leadership in districts in Thailand, using the concept of flexible surge capacity (FSC) and its collaborative tool during a hospital evacuation simulation. METHODS: A mixed-method cross-sectional study was conducted with 40 participants recruited from disaster-response organisations and communities. The data from several scenario-based simulations were collected according to the collaborative elements (Command and control, Safety, Communication, Assessment, Triage, Treatment, Transport), in the disaster response education, "Major Incident Medical Management and Support" using self-evaluation survey pre- and post-exercises, and direct observation. RESULTS: The 3LC exercise effectively facilitated participants to gain a mutual understanding of collaboration, leadership, and individual and organisational flexibility. The exercise also identified gaps in communication and the utilisation of available resources. Additionally, the importance of early community engagement was highlighted to build up a flexible surge capacity during hospital evacuation preparedness. CONCLUSIONS: the 3LC exercise is valuable for improving leadership skills and multiagency collaboration by incorporating the collaborative factors of Flexible Surge Capacity concept in hospital evacuation preparedness.

Social and Healthcare Impacts of the Russian-Led Hybrid War in Ukraine - A Conflict With Unique Global Consequences.

Russia's fear of Ukraine becoming a member of the European Union and the North Atlantic Treaty Organization catalyzed the current conflict in Ukraine. The invasion also alarmed other countries, such as Finland and Sweden, who have themselves considered a formal partnership with NATO. Russia's actions to date have created massive instability and political tensions that uniquely influence the health and socio-political life of civilians in Ukraine and the entire region. The direct and indirect threats of war "gone regional," "global", or "nuclear" have energized these countries and their historical alliances to reassess their own socio-political, environmental, and health-care consequences. All countries of the region have clear histories of forced occupation and decades of threats resulting from World War II and its aftermath. The purpose of this rapid communication is 2-fold. First, it discusses the socio-political and health-care consequences of the ongoing Ukrainian conflict in Finland, Russia, Sweden, Poland, and Ukraine. Second, it clarifies the most essential elements of the Hybrid War which cause uniquely distinctive violations of humanitarian laws, treaties, and conventions.

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.

Does climate change transform military medicine and defense medical support?

Background: Climate change has effects on multiple aspects of human life, such as access to food and water, expansion of endemic diseases as well as an increase of natural disasters and related diseases. The objective of this review is to summarize the current knowledge on climate change effects on military occupational health, military healthcare in a deployed setting, and defense medical logistics. Methods: Online databases and registers were searched on August 22nd, 2022 and 348 papers retrieved, published between 2000 and 2022, from which we selected 8 publications that described climate effects on military health. Papers were clustered according to a modified theoretical framework for climate change effects on health, and relevant items from each paper were summarized. Results: During the last decades a growing body of climate change related publications was identified, which report that climate change has a significant impact on human physiology, mental health, water- and vector borne infectious diseases, as well as air pollution. However, regarding the specific climate effects on military health the level of evidence is low. The effects on defense medical logistics include vulnerabilities in the cold supply chain, in medical devices functioning, in need for air conditioning, and in fresh water supply. Conclusions: Climate change may transform both the theoretical framework and practical implementations in military medicine and military healthcare systems. There are significant knowledge gaps on climate change effects on the health of military personnel in operations of both combat and non-combat nature, alerting the need for prevention and mitigation of climate-related health issues. Further research within the fields of disaster and military medicine is needed to explore this novel field. As climate effects on humans and the medical supply chain may degrade military capability, significant investments in military medical research and development are needed.

The Impacts of Armed Conflicts and Civilian Uprisings on Children's Health.

Besides the most common causes of death, children under 14 may suffer from the consequences of disasters and emergencies caused by natural and manmade risks and hazards. These incidents may be prevented by proper risk assessment and the prevention of unnecessary deaths by increasing the safety and well-being of children. An increasing number of manmade incidents are seen in international, non-international, and domestic conflicts when government forces use heavy and light weapons within countries with autocratic leadership. These deaths should be mitigated by holding perpetrators responsible for their deeds and respecting international humanitarian law, human rights, and children's rights.

Narcissistic Sociopathy in Global Autocratic Leaders: Arrested Development, Obsessive Demand for Power, and the Emergence of Unlawful Hybrid Wars.

There are several reasons why war occurs. The most lethal wars are those caused by 1 man's decisions solely driven by an obsessive need for power. With disregard for International Humanitarian Law and the Geneva Convention, these wars, referred to as hybrid warfare, purposefully target civilians directly resulting in millions of deaths, injuries, mass migration, and other severe global and public health consequences. The purpose of this commentary is to investigate the developmental nature of those decision-makers and the consequences of their acts of aggression both locally and globally. There is a clear relationship between the psychological developments of individuals with narcissistic and psychopathological disorders and the implications of an abnormal progression of these individuals and their obsessive desire for singular leadership, which seriously impacts health-care security and its essential elements provided by international humanitarian law and Geneva Convention. Current double standards of the West allow narcissistic sociopaths and autocratic leaders to neglect international law, especially the so-called international humanitarian law. This double standard must be ceased and replaced by an international investigative system with universal standards, a special tribunal covering hybrid war crimes as well as the crime of aggression, and to prevent future leaders from choosing the same strategies.

Employees Perception of Organizational Crises and Their Reactions to Them - A Norwegian Organizational Case Study.

Organizational sensemaking is crucial for resource planning and crisis management since facing complex strategic problems that exceed their capacity and ability, such as crises, forces organizations to engage in inter-organizational collaboration, which leads to obtaining individual and diverse perspectives to comprehend the issues and find solutions. This online qualitative survey study examines how Norwegian Sea Rescue Society employees perceived the concept of an organizational crisis and how they sensed their co-workers react to it. The scope was the ongoing COVID-19 pandemic, a global event affecting all countries and organizations and responding similarly globally. Data were collected during the Fall of 2020. The instrument of choice was the Internal Crisis Management and Crisis Communication survey (ICMCC). The results showed that the overall sample strongly believed in their organization's overall resilience level. However, a somewhat vague understanding of roles and responsibilities in a crisis where detected, together with some signs of informal communication, rumor spreading, misunderstanding, frustration, and insecurity. This study contributes to the academic field of organizational research, hence crisis management and sensemaking, and could be valuable to managers and decision-makers across sectors. Increased knowledge about how employees react to a crisis may help optimize internal crisis management planning and utilize robust mitigation and response strategies.