Preparedness and Preventive Behaviors for a Pandemic Disaster Caused by COVID-19 in Serbia.

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2. The disease was first detected in Wuhan, the capital of China's Hubei province, in December 2019 and has since spread globally, especially to Europe and North America, resulting in the ongoing global coronavirus pandemic disaster of 2019-2020. Although most cases have mild symptoms, there is some progression to viral pneumonia and multi-organ failure and death. More than 4.6 million cases have been registered across 216 countries and territories as of 19 April 2020, resulting in more than 311,000 deaths. Risk to communities with continued widespread disease transmission depends on characteristics of the virus, including how well it spreads between people; the severity of resulting illness; and the medical or other measures available to control the impact of the virus (for example, vaccines or medications that can treat the illness) and the relative success of these. In the absence of vaccines or medications, non-pharmaceutical interventions were the most important response strategy based on community interventions such as person-to-person distancing, mask-wearing, isolation and good personal hygiene (hand-washing)-all of which have been demonstrated can reduce the impact of this seemingly unstoppable globally spreading natural disaster. This paper presents the results of quantitative research regarding the level of citizen preparedness for disasters caused by coronavirus disease (COVID-19) in Serbia. The survey was conducted using a questionnaire that was requested and then collected online among 975 respondents during disaster in April 2020. The questionnaire examined citizens' basic socio-economic and demographic characteristics, their knowledge, preparedness, risk perception and preventive measures taken individually and as a community to prevent the death and widespread transmission of novel coronavirus disease 2019 in the Republic of Serbia. Based on the findings that there are major differences in the public's perception of risks posed by communicable disease threats such as presented by COVID-19, emergency management agencies should use these differences to develop targeted strategies to enhance community and national preparedness by promoting behavioral change and improving risk management decision-making.

Hajj stampede disaster, 2015: Reflections from the frontlines.

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

Emergent use of social media: a new age of opportunity for disaster resilience.

Social media are forms of information and communication technology disseminated through social interaction. Social media rely on peer-to-peer (P2P) networks that are collaborative, decentralized, and community driven. They transform people from content consumers into content producers. Popular networking sites such as MySpace, Facebook, Twitter, and Google are versions of social media that are most commonly used for connecting with friends, relatives, and employees. The role of social media in disaster management became galvanized during the world response to the 2010 Haiti earthquake. During the immediate aftermath, much of what people around the world were learning about the earthquake originated from social media sources. Social media became the new forum for collective intelligence, social convergence, and community activism. During the first 2 days following the earthquake, "texting" mobile phone users donated more than $5 million to the American Red Cross. Both public and private response agencies used Google Maps. Millions joined MySpace and Facebook discussion groups to share information, donate money, and offer comfort and support. Social media has also been described as "remarkably well organized, self correcting, accurate, and concentrated," calling into question the ingrained view of unidirectional, official-to-public information broadcasts. Social media may also offer potential psychological benefit for vulnerable populations gained through participation as stakeholders in the response. Disaster victims report a psychological need to contribute, and by doing so, they are better able to cope with their situation. Affected populations may gain resilience by replacing their helplessness with dignity, control, as well as personal and collective responsibility. However, widespread use of social media also involves several important challenges for disaster management. Although social media is growing rapidly, it remains less widespread and accessible than traditional media. Also, public officials often view P2P communications as "backchannels" with potential to spread misinformation and rumor. In addition, in absence of the normal checks and balances that regulate traditional media, privacy rights violations can occur as people use social media to describe personal events and circumstances.

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

OBJECTIVE: Open-source information consists of a range of publicly available material, including various periodicals, news reports, journal publications, photographs, and maps. Although intelligence agencies regularly use open-source information in developing strategically important intelligence, the disaster community has yet to evaluate its use for planning or research purposes. This study examines how open-source information, in the form of Internet news reports and public access disaster databases, can be used to develop a rapid, 72-hour case report. METHODS: Open-source information was extrapolated from several news reports on a terrorist bombing that occurred in Russia on 05 December 2003, using a self-devised "data" collection sheet, and background information collected on the nature of similar disasters using three public access databases. RESULTS: The bulk of health-related information was collected in the first 13 hours after the event, including casualty demographics, immediate dead, total dead, admitted, and treated-and-released. The complex and prolonged rescue of casualties was identified, as well as the presence of unexploded ordnance. This incident also was identified as the first publicly reported suicide terrorist bombing of a commuter train. CONCLUSIONS: Open-source information has the potential to be a helpful tool in reconstructing a chain of events and response. However, its use must be validated further and used appropriately. Standards for collection and analysis also must be developed.

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

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

Medical treatment of radiological casualties: current concepts.

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

Demystifying bioterrorism: misinformation and misperceptions.

The true threat of bioterrorism remains mysterious and elusive to the common citizen. It principally has become the dominion of a few "experts", many of whom have limited apparent expertise, who have failed to effectively communicate the risks and realities to society, and have instead created an air of uncertainty surrounding the topic. Unlike the great classic deceptions of modern life (e.g., "the check is in the mail"), the misinformation and misperceptions associated with bioterrorism can be dangerous and are not merely humorous. Indeed, it is possible to grasp the facts as well as fallacies associated with bioterrorism, and, as a result, demystify this nightmare scenario and prepare for the "unthinkable".

Public health issues in disasters.

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

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

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

The role of the applied epidemiologist in armed conflict.

BACKGROUND: Applied epidemiologists are increasingly working in areas of insecurity and active conflict to define the health risks, suggest feasible means to reduce these risks and, monitor the capacity and reconstruction of the public health system. In 2001, The Carter Center and the United States Institute for Peace sponsored a conference within which "Violence and Health" was discussed and a working group on applied epidemiology formed. The group was tasked to describe the skills that are essential to effective functioning in these settings and thereby provide guidance to the applied epidemiology training programs. METHODS: We conducted a literature review and consultation of a convenience sample of practitioners of applied epidemiology with experience in conflict areas. RESULTS AND CONCLUSIONS: The health programs designed to prevent and mitigate conflict are in their early stages of implementation and the evaluation measures for success are still being defined. The practice of epidemiology in conflict must occur within a larger humanitarian and political context to be effective. The skills required extend beyond the normal epidemiological training that focuses on the valid collection and interpretation of data and fall into two general categories: (1) Conducting a thorough assessment of the conflict setting in order to design more effective public health action in conflict settings, and (2) Communicating effectively to guide health program implementation, to advocate for needed policy changes and to facilitate interagency coordination. These are described and illustrated using examples from different countries.

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

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

Introduction: consequences of terrorism.

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