Emergency Medical Services (EMS) is a critical part of Disaster Medicine (DM) and can limit morbidity and mortality with sufficient training and experience. Emergency systems in Armenia are in an early stage of development and there is no Emergency Medicine residency training available to EMS physicians. The Armenian EMS system was challenged by two concurrent disasters when the 2020 Nagorno-Karabakh War arose during the SARS-CoV-2 (COVID-19) pandemic.

This study assessed the state of disaster preparedness of the Armenian EMS system and effects of the simultaneous pandemic and war on EMS providers.

This was a cross-sectional study by anonymous survey of Yerevan EMS physicians who provided care to war casualties and COVID-19 patients.

Most participants had been a physician for ≤three years (52.1%). Many were in residency (64.6%).

Battlefield medicine experience was limited prior to the war. The majority reported no experience treating mass casualties (52.1%), explosives wounds (52.1%), or performing surgical procedures (52.1%). Greater battlefield medicine experience was found with ≥three years of experience as a physician (z-score -3.26; P value <.01) or EMS physician (z-score -2.76; P value <.01), and being ≥30 years old (z-score -2.11; P value = .03). Most participants felt in danger during the war at least sometimes (89.6%).

EMS physicians in Armenia had limited training and experience in DM prior to the 2020 Nagorno-Karabakh War, but practiced in a setting requiring extensive DM knowledge as evidenced by the simultaneous response to the COVID-19 pandemic and war. There is a strong need for DM training within the Armenian EMS system.

Health workforce development is essential for achieving the goals of an effective health system, as well as establishing national Health Emergency and Disaster Risk Management (Health EDRM).

The objective of this Delphi consensus study was to identify strategic recommendations for strengthening the workforce for Health EDRM in low- and middle-income countries (LMIC) and high-income countries (HIC).

A total of 31 international experts were asked to rate the level of importance (one being strongly unimportant to seven being strongly important) for 46 statements that contain recommendations for strengthening the workforce for Health EDRM. The experts were divided into a LMIC group and an HIC group. There were three rounds of rating, and statements that did not reach consensus (SD ≥ 1.0) proceeded to the next round for further ranking.

In total, 44 statements from the LMIC group and 34 statements from the HIC group attained consensus and achieved high mean scores for importance (higher than five out of seven). The components of the World Health Organization (WHO) Health EDRM Framework with the highest number of recommendations were “Human Resources” (n = 15), “Planning and Coordination” (n = 7), and “Community Capacities for Health EDRM” (n = 6) in the LMIC group. “Policies, Strategies, and Legislation” (n = 7) and “Human Resources” (n = 7) were the components with the most recommendations for the HIC group.

The expert panel provided a comprehensive list of important and actionable strategic recommendations on workforce development for Health EDRM.

There is evidence to suggest that patients delayed seeking urgent medical care during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. A delay in health-seeking behavior could increase the disease severity of patients in the prehospital setting. The combination of COVID-19-related missions and augmented disease severity in the prehospital environment could result in an increase in the number and severity of physician-staffed prehospital interventions, potentially putting a strain on this highly specialized service.

The aim was to investigate if the COVID-19 pandemic influences the frequency of physician-staffed prehospital interventions, prehospital mortality, illness severity during prehospital interventions, and the distribution in the prehospital diagnoses.

A retrospective, multicenter cohort study was conducted on prehospital charts from March 14, 2020 through April 30, 2020, compared to the same period in 2019, in an urban area. Recorded data included demographics, prehospital diagnosis, physiological parameters, mortality, and COVID-status. A modified National Health Service (NHS) National Early Warning Score (NEWS) was calculated for each intervention to assess for disease severity. Data were analyzed with univariate and descriptive statistics.

There was a 31% decrease in physician-staffed prehospital interventions during the period under investigation in 2020 as compared to 2019 (2019: 644 missions and 2020: 446 missions), with an increase in prehospital mortality (OR = 0.646; 95% CI, 0.435 – 0.959). During the study period, there was a marked decrease in the low and medium NEWS groups, respectively, with an OR of 1.366 (95% CI, 1.036 – 1.802) and 1.376 (0.987 – 1.920). A small increase was seen in the high NEWS group, with an OR of 0.804 (95% CI, 0.566 – 1.140); 2019: 80 (13.67%) and 2020: 69 (16.46%). With an overall decrease in cases in all diagnostic categories, a significant increase was observed for respiratory illness (31%; P = .004) and cardiac arrest (54%; P < .001), combined with a significant decrease for intoxications (-58%; P = .007). Due to the national test strategy at that time, a COVID-19 polymerase chain reaction (PCR) result was available in only 125 (30%) patients, of which 20 (16%) were positive.

The frequency of physician-staffed prehospital interventions decreased significantly. There was a marked reduction in interventions for lower illness severity and an increase in higher illness severity and mortality. Further investigation is needed to fully understand the reasons for these changes.

The modern concept of terrorism has its roots in the “old continent” of Western Europe, more specifically in France, during the “Reign of Terror” period of the French Revolution. At the time, this form of state terror had a positive connotation: it was a legitimate means of defending the young state. While no single accepted definition of terrorism exists today, it is universally considered an attack on both state and society. The health care impacts of terrorist attacks often extend disproportionally beyond the casualty toll, but the potential for such events to induce mass casualties remains a concern to Disaster Medicine and Counter-Terrorism Medicine (CTM) specialists.

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 which occurred in Western Europe from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary weapon type, country where the incident occurred, and number of deaths and injured were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

A total of 15,306 events were recorded in Western Europe out of a total of 201,183 events world-wide between the years 1970 and 2019 inclusive. This resulted in a total of 5,548 deaths and 17,187 injuries. Explosives were used as a primary weapon/attack modality in 8,103 attacks, followed by incendiary attacks in 3,050 events and firearm use in 2,955 events. The use of chemical, biological, radiation, and nuclear (CBRN) weapons was rare and only accounted for 47 events.

From 1970 through 2019, 9.11% of all terrorist attacks occurred in Western Europe. Compared to global trends of attack methodologies in the same study period, the use of explosives as a primary attack modality in Western Europe was similar (52.94% in Western Europe versus 48.78% Global). Firearm use was comparatively low (19.31% versus 26.77%) and the use of CBRN as an attack modality was rare (0.30% versus 0.20%). The United Kingdom, Spain, and France accounted for over 65% of all terrorist attacks and over 75% of terrorism-related deaths in Western Europe.

The Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) developed Regional Collaboration Drills (RCDs) and is proposing an ASEAN Academic Network to strengthen capacity in disaster health management (DHM) in ASEAN Member States (AMS), as well as developing a standard training curriculum in DHM. This study aims to clarify the impacts and sustainability of the ARCH Project.

The four previous RCDs and the enhancement of academic activities were reviewed.

The ARCH Project developed the RCDs with simulation exercises based on possible disaster scenarios in each host country to test and validate the capacity of AMS International Emergency Medical Teams (I-EMTs), the Standard Operating Procedure (SOP) for I-EMT coordination, and regional tools, as well as the relevant domestic SOPs of the host countries for receiving international assistance. Following the RCD in Thailand, three AMS: Viet Nam, Philippines, and Indonesia, all of which are considered disaster-prone, successfully hosted RCDs with significant improvements. The project also established a sub-working group (SWG) to develop a standard curriculum in DHM. Two curricula developments, the Basic Course on DHM and In-Country Course for Coordination on EMTs, are on-going as part of the project activity. The establishment of the ASEAN Academic Network and the ASEAN Institute for DHM (AIDHM) are currently in the endorsement process of the ASEAN health sector.

The RCDs are very effective to test and to validate the SOP and regional tools developed, providing opportunities for AMS I-EMT to familiarize the tools, as well as for host countries to assess their coordination capacity for receiving international assistance and identifying the country’s specific challenges, and verifying ASEAN regional coordination mechanism. The development of the standard curriculum can enhance regional capacity both in supporting disaster-affected countries and in receiving international assistance. A sustainable capacity development mechanism in DHM is envisaged through the establishment of the ASEAN Academic Network and AIDHM toward the goal of One ASEAN One Response.

Terrorist incidents occur with alarming frequency. Much is known about acute injuries and psychopathology arising from terrorism, as well as medical care and functional status assessed in early post-disaster periods. Survivors’ memories of these experiences may change over subsequent decades, and their perspectives may evolve. Little information is available on how survivors describe these experiences decades later.

This longitudinal qualitative study of directly-exposed survivors of the 1995 Oklahoma City bombing was conducted nearly a quarter century after the disaster. It collected systematic, open-ended descriptions of survivors’ injuries and medical care, assistance received and given, and disaster-associated losses. It sought to illuminate whether survivors recall long-term consequences of disaster exposure so long after the event, providing important details with great clarity and associated emotion, or alternatively lose memory and sharpness of recollection for these aspects of their bombing experience.

A sample of 182 bombing survivors was randomly recruited from a state registry of 1,092 bombing survivors and interviewed at approximately six months after the bombing (71% participation). The sample was re-interviewed an average of 23 years after the disaster (72% follow-up participation) using an open-ended interview with survivors describing in their own words their personal experience of the bombing and its effects on their lives. The interviews were audio recorded and professionally transcribed. Themes were identified in the text of the interviews, and passages were coded using qualitative software, achieving excellent inter-rater reliability for each theme. This article covers three of twelve total themes identified.

Nearly a quarter century after the bombing, this highly trauma-exposed Oklahoma City bombing survivor sample had memories that were still vivid, graphic, and evocative. They described injuries and medical care, assistance given and received, and losses with great detail and intensity. Despite the continuing strong emotions expressed by these survivors in relation to the bombing, the qualitative content suggested that lasting psychopathology was not a central concern.

This is one of the longest prospective longitudinal, qualitative studies ever conducted with highly trauma-exposed survivors of a terrorist bombing. These findings are critical to disaster emergency response and effective management of the disaster response and early care for the survivors, as the effects of the disaster may shape the rest of their lives.

The World Health Organization (WHO) declared climate change a defining issue in the 21st century with more intense heatwaves, higher risks of flooding and damaging storms, and a changing pattern of emerging infectious diseases. In this scenario, the response of Emergency Medical Teams (EMTs) to disasters represents a fundamental resource.

To expand EMT2-ITA-Regione Piemonte operational independence and to minimize its environmental footprint.

A multiphasic and prospective project is planned in order to:

(1) Reduce water consumption: use of a sterilizer designed with a set of high-efficiency heat exchangers enabling a substantial saving in water consumption by the vacuum pump and a significant reduction of total water usage through a recirculation system.

(2) Reduce demand for diesel: photovoltaic (PV) system to integrate the current energy production system based on diesel generators.

(3) Reduce paper consumption: use of sterilization management and traceability system and computerized medical record in order to be paperless.

(4) Improve staff awareness and education on greening practices: educational program for the staff focused on waste segregation/management and energy and water saving both in the hospital and in the Base of Operation (BoO).

EMT2-ITA-Regione Piemonte aims to reduce energy and water consumption by 30% and to become paperless.

Advances in greening initiatives offer to EMT2-ITA-Regione Piemonte the potential to improve its disaster medical response capabilities and to reduce its ecological footprint.

The objective of this study was to identify the perceived problems by medical and nursing professionals that have arisen in the Spanish Emergency Medical Services (EMS) as a consequence of the first wave of the severe acute respiratory syndrome-coronavirus-2/SARS-CoV-2 pandemic, as well as the measures or solutions adopted to manage those problems and improve response.

This was a cross-sectional study of quantitative and qualitative methodology (“mixed methods”) using a self-administered questionnaire in 23 key informants of EMS of Spain selected by purposeful sampling, followed by the statistical analysis of both types of variables and an integration of the results in the discussion.

Common problems had been identified in many EMS, as well as similar solutions in some of them. Among the former, the following had been found: lack of leadership and support from managers, initial shortage of personal protective equipment (PPE), lack of participation in decision making, initial lack of clinical protocols, and slowness and/or lack of adaptability of the system, among others. Among the solutions adopted: reinforcement of emergency call centers, development of specific coronavirus disease 2019 (COVID-19) telephone lines and new resources, personal effort of professionals, new functions of EMS, support to other structures, and reinforcement of the role of nursing.

The general perception among the respondents was that there was a lack of support and communication with health care managers and that the staff expertise was not used by policy makers to make decisions adapted to reality, also expressing the need to improve the capacity for analysis of the EMS response. Few respondents reported good overall satisfaction with their EMS response. The EMS adopted different types of measures to adapt to the COVID-19 pandemic.

Natural disasters (NDs) are calamitous phenomena that can increase the risk of infections in disaster-affected regions. This study aimed to evaluate the frequency of malaria and cutaneous leishmaniasis (CL) before and after earthquakes, floods, and droughts during the past four decades in Iran.

Malaria and CL data were obtained from the reports of the Ministry of Health and Medical Education in Iran for the years 1983 through 2017. The data of NDs were extracted from the Centre for Research on the Epidemiology of Disasters (CRED). Interrupted time series analysis with linear regression modeling was used to estimate time trends of mentioned diseases in pre- and post-disaster conditions.

For the periods preceding the disasters drought and flood, a decreasing time trend for malaria and CL was found over time. The time trend of malaria rate preceding the 1990 earthquake was stable, a downward trend was found after 1990 disaster until 1997 (β coefficient: −10.7; P = .001), and this declining trend was continued after 1997 disaster (β coefficient: −2.7; P = .001). The time trend of CL rate preceding the 1990 earthquake had a declining trend, an upward trend was found after 1990 earthquake until 1999 (β coefficient: +8.7; P = .293), and a slight upward trend had also appeared after 1999 earthquake (β coefficient: +0.75; P = .839).

The results of the current study indicated the occurrence of earthquakes, floods, and droughts has no significant effect on the frequency of malaria and CL in Iran.

Emergency Medical Services (EMS) is a critical part of Disaster Medicine and has the ability to limit morbidity and mortality in a disaster event with sufficient training and experience. Emergency systems in Armenia are in an early stage of development and there is no Emergency Medicine residency training in the country. As a result, EMS physicians are trained in a variety of specialties.

Armenia is also a country prone to disasters, and recently, the Armenian EMS system was challenged by two concurrent disasters when the 2020 Nagorno-Karabakh War broke out in the midst of the SARS-CoV-2/coronavirus disease 2019 (COVID-19) pandemic.

This study aims to assess the current state of disaster preparedness of the Armenian EMS system and the effects of the simultaneous pandemic and war on EMS providers.

This was a cross-sectional study conducted by anonymous survey distributed to physicians still working in the Yerevan EMS system who provided care to war casualties and COVID-19 patients.

Survey response rate was 70.6%. Most participants had been a physician (52.1%) or EMS physician (66.7%) for three or less years. The majority were still in residency (64.6%). Experience in battlefield medicine was limited prior to the war, with the majority reporting no experience in treating mass casualties (52.1%), wounds from explosives (52.1%), or performing surgical procedures (52.1%), and many reporting minimal to no experience in treating gunshot wounds (62.5%), severe burns (64.6%), and severe orthopedic injuries (64.6%). Participants had moderate experience in humanitarian medicine prior to war. Greater experience in battlefield medicine was found in participants with more than three years of experience as a physician (z-score −3.26; P value <.01) or as an EMS physician (z-score −2.76; P value <.01) as well as being at least 30 years old (z-score −2.11; P value = .03). Most participants felt they were personally in danger during the war at least sometimes (89.6%).

Prior to the COVID-19 pandemic and simultaneous 2020 Nagorno-Karabakh War, EMS physicians in Armenia had limited training and experience in Disaster Medicine. This system, and the frontline physicians on whom it relies, was strained by the dual disaster, highlighting the need for Disaster Medicine training in all prehospital medical providers.

The Glasgow Coma Scale (GCS) was devised in 1974 as a way of tracking the progress of neurosurgical coma patients. It is comprised of three components: eye movement, response to verbal commands, and motor function. Since then, it has become the primary tool in Emergency Medical Services (EMS) and emergency departments for assessing cognitive function and triaging patients in the setting of acute trauma. However, the GCS was never intended to be used in such a way. It has been demonstrated that there is a high degree of inter-rater variability when assigning GCS scores for trauma patients. Potential differences in GCS score assignments between different countries were examined. It was hypothesized there would be differences in mean total and component scores.

Using de-identified data from the Pan-Asian Trauma Outcomes Study (PATOS), the distributions of GCS scores from six countries were assessed: Japan, Korea, Malaysia, Taiwan, Thailand, and Vietnam. Using SPSS data analysis, a one-way ANOVA and Bonferroni post-hoc tests were performed to compare the means of the three GCS components and the total GCS scores reported by EMS personnel caring for trauma patients.

Data from 15,173 cases showed significant differences in mean total GCS score between countries (P <.001) as well as in mean component GCS scores (P <.001 for each of eye, verbal, and motor). Post-hoc tests showed that EMS personnel in Korea assigned significantly lower scores compared to all other countries in both component and total GCS scores. Field personnel in Japan, Malaysia, and Vietnam assigned the highest scores and significantly differed from the other three countries on component and total scores; Thailand and Taiwan had similar scores but significantly differed from the other four countries on component and total scores. Visual inspection of mean component and total GCS score histograms revealed differences in score assignment patterns among countries.

There are a number of significant differences in the mean total and component GCS scores assigned by EMS personnel in the six Asian countries studied. More investigation is necessary to determine if there is clinical significance to these differences in GCS score assignments, as well as the reasons for the differences.

This report tries to capture the impact of the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) in each ASEAN Member State (AMS) and Japan as a result of the ARCH Project implementation since July 2016.

Impact on AMS: The analysis of the impact on AMS was based on a comparison of the impact of the project on management and coordination of Emergency Medical Teams (EMTs), and application of the project outcome in actual emergency operations compared to the previous status in each AMS.

Impact on Japan: The history of the development of disaster medicine in Japan was reviewed, with an aim to analyze the impact of supporting AMS through the ARCH Project on Japan, and the possibility of bi-directional cooperation in the future.

Impact on AMS: Since the initiation of the ARCH Project, AMS has made significant progress in WHO EMT accreditation, strengthening EMTCC capacity for receiving international assistance, as well as the development of legislation or strategic plans related to DHM, and application of the Project products such as standard operating procedures or regional tools in actual disasters/emergencies.

Impact on Japan: Disaster medicine in Japan originated from the Cambodian refugees’ relief mission in 1979. Since then, the management system has been strengthened including the foundation of the Japan Disaster Relief (JDR) Team, a structure with a legal foundation. The experience gained through international operations has contributed to the development of Japan’s domestic disaster response system. Japan learned the operational effectiveness of the post-disaster health surveillance system through the disaster response operation in 2013 Typhoon Yolanda Disaster in Philippines and introduced a modified system in Japan for domestic disaster response, which was later refined and proposed for an international standard.

ARCH Project is highly appreciated by AMS as the opportunity to share knowledge and experience among countries and thereby contributing to achieving the “One ASEAN, One Response” concept, as well as the driving force for each AMS to develop its capacity in DHM. While the ARCH Project started to support AMS to strengthen its regional capacity in disaster health management, it is important to build a bi-directional relationship between ASEAN and Japan in terms of mutual learning and support to tackle future disasters.

Following a terrorist attack, responses to a psychosocial disaster range from low-intensity initiatives to high-intensity treatment. Some studies described post-disaster psychosocial services and planning across Europe. However, little is known about the psychosocial support (PS) actually delivered after terrorist attacks.

This study assesses prevalence and the factors associated with not receiving short-term PS among terror-exposed people with probable mental health disorders following the January 2015 terrorist attacks in France.

This study used data from the first wave of a longitudinal survey conducted six months after the attacks. Prevalence and factors associated with not receiving PS were described in the immediate period (48 hours), the early post-immediate period (48 hours-one week), and the medium-term (over one week) using a robust Poisson regression for each of the three periods.

Nearly one-half of the participants (N = 189) did not receive PS in any period (46.6% in the immediate period, 45.5% in the early post-immediate period, and 54.5% in the medium-term). In each period, not receiving PS was associated with not being very close to the attack sites. Not receiving PS in the immediate period was also associated with being a direct witness (DW) rather than being directly threatened (DT) and not having support in daily life; in the early post-immediate period, not receiving PS was associated with not having a peri-traumatic dissociation experience and being followed for a psychological problem before the attacks; and in the medium-term period, it was associated with perceived social isolation.

The characteristics of the terror exposure and social support seemed to influence presence or absence of PS after the terrorist attack and highlight the need for strategies to reach out to people regardless of the type of exposure.

Research in cardiac care has identified significant gender-based differences across many outcomes. Women with heart disease are less likely both to be diagnosed and to receive standard care. Gender-based disparities in the prehospital setting are under-researched, but they were found to exist within rates of 12-lead electrocardiogram (ECG) acquisition within one urban Emergency Medical Services (EMS) agency.

This study evaluates the quality improvement (QI) initiative that was implemented in that agency to raise overall rates of 12-lead ECG acquisition and reduce the gap in acquisition rates between men and women.

This QI project included two interventions: revised indications for 12-lead acquisition, and training that highlighted sex- and gender-based differences relevant to patient care. To evaluate this project, a retrospective database review identified all patient contacts that potentially involved cardiac assessment over 18 months. The primary outcome was the rate of 12-lead acquisition among patients with qualifying complaints. This was assessed by mean rates of acquisition in before and after periods, as well as segmented regression in an interrupted time series. Secondary outcomes included differences in rates of 12-lead acquisition, both overall and in individual complaint categories, each compared between men/women and before/after the interventions.

Among patients with qualifying complaints, the mean rate of 12-lead acquisition in the lead-in period was 22.5% (95% CI, 21.8% - 23.2%) with no discernible trend. The protocol change and training were each associated with a significant absolute level increase in the acquisition rate: 2.09% (95% CI, 0.21% - 4.0%; P = .03) and 3.2% (95% CI, 1.18% - 5.22%; P = .003), respectively. When compared by gender and time period, women received fewer 12-leads than men overall, and more 12-leads were acquired after the interventions than before. There were also significant interactions between gender and period, both overall (2.8%; 95% CI, 1.9% - 3.6%; P < .0001) and in all complaint categories except falls and heart problems.

This QI project resulted in an increase in 12-leads acquired. Pre-existing gaps in rates of acquisition between men and women were reduced but did not disappear. On-going research is examining the reasons behind these differences from the perspective of prehospital providers.

Health staff in South Sudan and Nigeria face extreme risks while providing services: in 2021, at least 18 health care workers were killed in South Sudan and Nigeria, while 32 were kidnapped. Reporting of such incidents takes place via the WHO coordinated SS. However, such event reporting is not designed to capture “lower scale” security incidents, nor does it capture possible solutions. As such, the IRC in coordination with the Health Cluster and national organizations are conducting a survey to complement the existing analysis with insights of frontline health care workers, to support program design, funding requests, and advocacy activities. Research questions include:

• What are the most common incidents of violence against health care workers?

• What has been the impact of these incidents on staff well-being, on the health system/sector, and on access to health care for the wider community?

• What are the priorities in preventing such incidents and reducing their impact?

To identify incidents of violence against health care as experienced by health care staff in 2022.

To identify health workers perspective on causes, impact, and what works in terms of prevention and response.

A self-administered, online survey targeting all health staff working for the humanitarian community in South Sudan and Northeastern Nigeria.

This study is on-going with results expected by early September.

This study is on-going with results expected by early September.

In fostering community and culture through entertainment in shared spaces, performing arts venues have also become targets of terrorism. A greater understanding of these attacks is needed to assess the risk posed to different types of venues, to inform medical disaster preparedness, to anticipate injury patterns, and to reduce preventable deaths.

A search of the Global Terrorism Database (GTD) was conducted from the year 1970 through 2019. Using pre-coded variables for target/victim type and target subtype, attacks involving “business” and “entertainment/cultural/stadium/casino” were identified. Attacks targeting performing arts venues were selected using the search terms “theater,” “theatre,” “auditorium,” “center,” “hall,” “house,” “concert,” “music,” “opera,” “cinema,” and “movie.” Manual review by two authors was performed to confirm appropriateness for inclusion of entries involving venues where the primary focus of the audience was to view a performance. Descriptive statistics were performed using R (version 3.6.1).

A total of 312 terrorist attacks targeting performing arts venues were identified from January 1, 1970 through December 31, 2019. Two-hundred nine (67.0%) attacks involved cinemas or movie theaters, 80 (25.6%) involved unspecified theaters, and 23 (7.4%) specifically targeted live music performance venues. Two-hundred thirty-four (75.0%) attacks involved a bombing or explosion, 50 (16.0%) damaged a facility or infrastructure, and 17 (5.4%) included armed assault. Perpetrators used explosives in 234 (75.0%) attacks, incendiary weapons in 50 (16.0%) attacks, and firearms in 19 (6.1%) attacks. In total, attacks claimed the lives of 1,307 and wounded 4,201 persons. Though fewer in number, attacks against music venues were responsible for 29.4% of fatalities and 35.0% of those wounded, and more frequently involved the use of firearms. Among 95 attacks falling within the highest quartile for victims killed or wounded (>two killed and/or >ten wounded), 83 (87.4%) involved explosives, seven (7.4%) involved firearms, and three (3.2%) involved incendiary methods.

While uncommon, terrorist attacks against performing arts venues carry the risk for mass casualties, particularly when explosives and firearms are used.

Mass-casualty incident (MCI) triage systems aim to provide the best possible health care to the greatest number of affected people with the available resources in the context of a mass-casualty event. The Spanish Prehospital Advanced Triage Method (Modelo Extrahospitalario de Triaje Avanzado; META) was designed to improved patient sorting in MCIs.

The aim of this study was to estimate and compare sensitivity and specificity of META and the Manchester Triage System (MTS) in MCIs by retrospectively applying both triage algorithms to real MCI patients from the Emergency and Disaster Research Unit (Unidad de Investigación en Emergencia y Desastres; UIED) MCI database.

This was a comparative study of two triage methods using sensitivity and specificity with the Revised Trauma Score (RTS) as the gold standard. A total of 134 MCI patients from the UIED database were included. An MCI in Asturias is defined as an incident that involves four or more victims that require ambulance mobilization.

Patients mean age was 39.85 years (95% CI, 35.9-43.8) with an age range from one to 88 years old. In total, 54.4% of the patients were female. The most common types of MCI involved were fires (51.0%), followed by road traffic accident (43.3%) and street fight (3.7%). For MTS, the overall sensitivity was 30.6% (95% CI, 22.9-39.1) and specificity was 66.0% (95% CI, 60.0-71.7). For META triage algorithm, the overall sensitivity was 79.9% (95% CI, 72.1-86.3) and specificity was 89.9% (95% CI, 85.7-93.3).

The META triage algorithm is a reliable triage system; thus, it can be recommended to be used in an MCI.

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.

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.

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.

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.

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.

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.

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).

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.