The Tijuana River Valley along the US-Mexico border faces a severe environmental and public health crisis from contamination of the Tijuana River with untreated sewage, urban runoff, and industrial waste, leading to water and air exposure concerns. The County of San Diego Health and Human Services Agency (CoSD HHSA) and the Centers for Disease Control and Prevention (CDC) conducted 189 household-level surveys to assess experiences with the crisis and address concerns. Survey results revealed that ~96% of households were concerned about the crisis. Top needs included requests for action (64.3%) and air (38.2%) and water (27.1%) quality improvement. Subsequently, CoSD HHSA developed data-driven outreach programs and resources (e.g., provision of air filters), enhanced messaging (e.g., providing educational materials, promoting behavioral health hotlines) related to the crisis to address household concerns, and shared the results with other agencies (e.g., the water board) to promote further action and safety messaging.
OBJECTIVE:Radiation and nuclear (R/N) incidents disproportionately threaten children due to biological sensitivity and psychosocial vulnerability. No standardized tool exists for systematic evaluation of pediatric response during post-incident Recovery. This paper introduces a specialized Pediatric After-Action Report (PAAR) template to address this gap. METHOD:The Pediatric After-Action Report (PAAR) template was developed by synthesizing disaster cycle principles, pediatric disaster medicine literature, and documented operational gaps from R/N incidents. Core functional domains were identified and structured into analytical and corrective action frameworks tailored to R/N-specific pediatric challenges. RESULTS:The PAAR provides a comprehensive instrument for evaluating pediatric response across radiation-specific triage, age-appropriate medical countermeasures, prolonged sheltering, mental health interventions, family reunification, and risk communication. Each domain includes targeted questions linked to a corrective action framework assigning responsibilities and timelines to translate findings into improved preparedness. This PAAR addresses a critical omission in CBRN disaster management. CONCLUSION:By enabling rigorous pediatric-focused after-action review, it ensures children's unique needs are systematically assessed and continuously improved. Its integration into exercise cycles and real-incident recovery is essential to closing the disaster cycle for the most vulnerable population.
OBJECTIVE:The increasing frequency and severity of climate-related disasters pose major threats to public health, particularly when they intersect with other crises like pandemics. Puerto Rico has faced multiple large-scale disasters in recent years, yet research on their cumulative health effects remains limited. This study examines associations between disaster exposure-Hurricane María and the COVID-19 pandemic-and self-reported physical, mental, and behavioral health among Puerto Rican adults using Behavioral Risk Factor Surveillance System data (2015-2021). METHODS:We used multivariable linear and log-binomial models, adjusting for key sociodemographic factors. RESULTS:Among 35,517 respondents, post-disaster periods were mostly linked to worse health outcomes, including more days of poor mental health, increased substance use, and more negative health perceptions. The early post-hurricane period showed the greatest harm, with participants reporting 2.47 more poor mental health days (P < 0.002), lower likelihood of exercise (PR = 0.65), and higher likelihood of smoking (PR = 1.20). Conversely, early and late pandemic periods showed apparent health improvements, though these findings require cautious interpretation. CONCLUSIONS:Our results underscore the need for disaster-responsive mental health care, resilient infrastructure, and policies addressing financial inequities that heighten vulnerability. Strengthening community networks and ensuring equitable preparedness and relief efforts are essential to reducing the health impacts of future disasters.
INTRODUCTION/OBJECTIVE:Early warning systems compress evacuation windows, creating secondary domestic hazards. This study analyzes the community epidemiology and behavioral dynamics of evacuation falls during Israel's 2026 missile crisis. METHODS:A retrospective study analyzed 2,941 emergency department visits. Daily alert volumes were integrated with municipal warning times (15-90 seconds) to calculate exposure-adjusted risk and map socioeconomic and architectural vulnerabilities. RESULTS:Evacuation falls comprised 36.9% of crisis presentations. Per-alert relative risk multiplied more than eightfold over time, revealing a "complacency-panic mismatch." Women comprised 66.7% of casualties aged 46+, indicating a caregiving ("kin-keeping") burden. This was supported by strict gender parity among injured infants (0-4), signaling passive trauma via burdened caregivers. Risk patterns depended on warning times: 0-30s zones shifted risk to younger adults (acute flight response), whereas 90s windows affected frail populations (43.7% aged 66+). Concurrently, 51.4% of injuries occurred in high-socioeconomic municipalities due to internal architectural hazards. CONCLUSIONS:Evacuation injuries represent a critical public health crisis. Mitigating this burden requires time-tailored protocols addressing caregiver biomechanics and household hazards, while prioritizing in-room protection for mobility-impaired individuals during acute scenarios.
OBJECTIVES:This systematic review and meta-analysis aimed to identify and synthesize evidence on risk factors for COVID-19 in incarcerated populations. METHODS:A systematic search of PubMed, Scopus, and Google Scholar was conducted for English articles until October 2025. Study quality was assessed using the PRISMA checklist and NOS tool. Meta-analysis was performed in Stata 17 using a random-effects model, with odds ratios as the primary effect measure and statistical significance set at P < 0.05. Heterogeneity was evaluated via I2 statistics. RESULTS:Twelve articles were ultimately included in the study. For the meta-analysis, only 5 articles were considered, which evaluated sex, age, and vaccination status as the risk factors of COVID-19. The total sample size was 176169, consisting of 169117 males and 7,726 females. In most studies, the average age was reported to be around 40 years. Fully vaccinated prisoners were less likely to contract COVID-19 than unvaccinated ones (OR: 0.38; 95% CI: 0.22, 0.67; P = 0.001), while no significant relationships were found regarding sex and age. CONCLUSIONS:Our findings confirm that full vaccination significantly protects against COVID-19 in prisons. Prioritizing vaccination campaigns, along with measures like mask use and hand hygiene, is essential to protect incarcerated individuals and the wider community.
OBJECTIVE:This study aimed to examine the barriers and facilitators influencing voluntary participation in health care crises. METHODS:This qualitative and exploratory study was conducted in 2025 at governmental health care centers in eastern Iran. Data were collected through a series of unstructured interviews. Stratified, purposeful, and snowball sampling were employed. Data analysis was performed using the qualitative thematic analysis approach as outlined by Braun and Clarke. RESULTS:Data saturation was achieved after conducting interviews with 14 participants. Barriers to voluntary participation among health care personnel were organized into four primary themes: Physical, Psychological, and Emotional Challenges; Organizational Issues; Financial and Material Constraints; and Family, Social, and Cultural Concerns. Conversely, facilitators promoting voluntary participation were classified into 5 main themes: Intrinsic Motivation, Values, and Personal Characteristics; Cultural, Social, and Family Support; Organizational Support and Leadership; Experience and Skills; and Material and Financial Incentives. CONCLUSIONS:Barriers and facilitators varied across clinical and paramedical professions, with differences also noted between physicians and nurses. The negative impact of closed, autocratic, and non-transparent organizations highlighted the importance of an open, accountable, and equitable environment in promoting voluntary engagement.
Chemical, biological, radiological, and nuclear (CBRN) incidents present escalating risks across the Middle East and North Africa (MENA) amid geopolitical instability, cross-border threats, and evolving non-state actor capabilities. This policy analysis examines why prevailing case-level and ministry-siloed governance is insufficient for population-level CBRN readiness, weighs alternative coordination models, and outlines an artificial intelligence (AI)-enabled, centrally coordinated public-health strategy adapted to the region's heterogeneity and resource constraints. We propose a National Emergency Management Advisory Council to provide statutory inter-ministerial authority and stewardship for a National CBRN Dashboard that delivers decision support, inventory tracking, simulation, and rapid triage. We situate this within existing backgrounds and analyze legal authority, financing, data governance, and feasibility in low-resource settings. While prototype AI models report high accuracy for antidote optimization, agent classification, and triage, we argue these metrics reflect controlled research, not operational readiness, and require external validation, robustness testing, and cybersecurity safeguards. A phased, evidence-graded roadmap is proposed to move MENA CBRN management from reactive to predictive and adaptive models.
OBJECTIVE:Hospital mass casualty incident (MCI) plans must be able to remain operational during wartime. This study examined the impact of the October 7, 2023, attacks on the activation and execution of an MCI protocol in a hospital in southern Israel. METHODS:This qualitative study employed thematic analysis of semi-structured interviews conducted with 19 Emergency Department (ED) staff members who worked on October 7, 2023. Interview questions were developed by the authors, based on their professional experiences as physicians, with input from personnel involved in the October 7, 2023, response. Thematic saturation was considered achieved when consecutive interviews yielded no new themes. RESULTS:Three themes were identified. Threats to staff safety affected staff mobilization and prevented evacuation of patients from the ED. The prolonged and evolving nature of the attacks created unpredictability. Limited official information was partially compensated for through alternative information sources. Finally, a culture of frequent MCI drills contributed to maintaining patient flow and standards of care. CONCLUSIONS:During wartime, MCI plans can remain effective by prioritizing staff safety and mitigating burnout. Information should be collected from multiple sources to compensate for uncertainty and limited situational awareness. Frequent, realistic drills help to maintain operational performance under the extreme stress of war.
BACKGROUND:Floods are increasing with climate change, and evacuating medically vulnerable people receiving home healthcare remains challenging. Patients dependent on medical devices and long-term care face complex challenges throughout the evacuation process. However, key factors influencing successful evacuation and effective support strategies remain underexamined. This study aimed to identify such factors and essential support measures across evacuation phases. METHODS:Semi-structured interviews were conducted with 13 participants-family caregivers, healthcare providers, and municipal officials-from July 2022 to March 2023 in 3 Japanese regions. Snowball sampling was used via medical administrative institutions. Thematic analysis followed COREQ guidelines, focusing on three phases: preparation, evacuation, and post-evacuation. Ethics approval was obtained (MG2022-01). RESULTS:Preparation showed heterogeneous readiness: some services had hazard maps and manuals/BCPs, whereas household engagement was limited and operationalization was constrained by resources. During evacuation, participants described transport and staffing limitations, difficulty in moving medical equipment, and uncertainty about feasible options, with occasional consideration of vertical evacuation. Post-evacuation challenges centered on shelter sanitation and supplies, continuity of medical support, and coordination of support systems. CONCLUSIONS:A three-phase, multi-stakeholder perspective clarifies how constraints accumulate and informs coordinated planning among municipalities, home-care teams, and families. Limitations include a small, region-specific sample and no direct patient interviews.
OBJECTIVE:Terrorist attacks targeting the mining sector represent an under-explored threat. This study aims to characterize the epidemiology, distribution, and features of mining-related terrorism events. METHODS:A retrospective search of the Global Terrorism Database was performed, querying attacks between 1970 and 2020 with "business" as primary target type and "mining" as subtype. Attacks were analyzed by region, perpetrating group, modality, and weapon type. RESULTS:There were 541 mining-related attacks from 1970 to 2020, leading to 617 deaths and 574 injuries. Frequency of mining-related attacks has increased in recent years, particularly after 2010. Geographically, South Asia (23.7%), South America (22.9%), and Southeast Asia (22.7%) had the most attacks. Attacks in sub-Saharan Africa comprised a smaller percentage of attacks (16.6%), but the largest fraction of deaths (60.0%) and injuries (61.5%). Anarchist/revolutionary groups were the most common perpetrators (46.0%). Religious extremist groups were responsible for fewer attacks (6.1%) but had outsized impact in terms of deaths (16.4%) and injuries (17.6%). Armed assault was the most common modality (28.1%) and comprised most deaths (56.9%) and injuries (51.0%). Hostage-taking comprised 19.0% of incidents, with 775 hostages taken. Coal (20.0%) and gold (10.4%) were the most targeted minerals. CONCLUSIONS:Mining-related terrorist attacks have increased in recent years and are characterized by high operational success, politically motivated perpetrating groups, disproportionate lethality in sub-Saharan Africa, and frequent hostage-taking.
OBJECTIVE:While the World Health Organization established minimum standards for emergency medical teams (EMTs) in 2013, globally recognized competency standards for individual disaster medical responders remain lacking. This study identifies and synthesizes existing competencies, qualifications, and training requirements for physicians, nurses, and paramedics who serve as deployable disaster response specialists on EMTs. METHODS:A scoping review was conducted following PRISMA-ScR guidelines. Comprehensive searches of five databases were performed in September, 2024. Gray literature from 22 governmental and non-governmental organizations was also reviewed. Studies addressing competencies or requirements for disaster specialists (physicians, nurses, paramedics) participating in disaster response were included. RESULTS:Fifty-four studies were included, most being nursing-focused (n = 28, 51.9%). Studies predominantly originated from the United States (n = 15, 27.8%) and China (n = 9, 16.7%). Training program duration ranged from single-day workshops to multi-week courses, with varied delivery formats. Core competencies identified across professions included Incident Command System knowledge, triage skills, communication abilities, personal protective equipment use, psychological first aid, ethical-legal preparedness, clinical-technical skills, and leadership capabilities. CONCLUSIONS:Substantial convergence exists around core disaster medicine competencies, yet significant variability persists in training approaches and duration. The establishment of globally recognized, evidence-based competency standards for individual disaster medical specialists represents a critical next step.
Abstract Objective Immigrant households and those that speak languages other than English are underrepresented in disaster preparedness research. Study authors conducted a needs assessment of Spanish-speaking families to identify strengths and opportunities for education and resources in this population. Methods In this mixed-methods study, authors partnered with Promotoras de Salud , or Spanish-speaking community health liaisons, to conduct focus groups and surveys with Spanish-speaking family representatives. Recordings were transcribed, translated from Spanish to English, and analyzed using modified grounded theory to identify key themes. Results The results demonstrated that while many Spanish-speaking households have experience with disasters, there are significant gaps in information and supplies. Participants reported perceived barriers to preparation including lack of knowledge, language barriers, and lack of sense of belonging. Participants consistently indicated interest in improving disaster preparedness for themselves and their families. Conclusions This study demonstrates a clear opportunity to create and share climate disaster preparedness information with Spanish-speaking immigrant populations, who already have valuable experience and resources within their communities. Next steps include expanding outreach to a broader geographic scope of communities and focused assessments of special populations. This study underscores the importance of inclusive, culturally responsive disaster preparedness educational materials.
OBJECTIVE:The increasing frequency of international disasters necessitates robust military-civilian collaboration, often requiring the U.S. Department of Defense (DoD) to augment civilian humanitarian assistance and disaster relief (HADR) capacity and support U.S. geopolitical objectives. METHODS:A retrospective quantitative analysis was performed on 149 international HADR events involving DoD support between 1997 and 2024. Data were collated from U.S. Department of State records and narrative reports from the DoD. Events were categorized by geographic area, disaster type, and alignment with the United Nations Humanitarian Cluster System. RESULTS:The DoD supported HADR efforts in 68 countries, with the Philippines, Iraq, and Indonesia being the most frequent recipients. More than 50% of events occurred in South America and the Indo-Pacific. The most common triggers for support were earthquakes, complex emergencies, and tropical cyclones. Mapping activities to the UN Cluster System revealed that the DoD primarily provided support for Logistics, Early Recovery, and Health. CONCLUSIONS:Following major disasters, rapid deployment of DoD capabilities was indispensable in austere environments where civilian federal organizations and local governments were overwhelmed, incapacitated, or nonexistent. Addressing data deficiencies and coordinating military-civilian readiness are critical for enhancing the effectiveness of future responses.
Objective: This study investigates the relationship between anxiety-stress levels, quality of life, and occupational balance among rescue workers, exploring how daily activity satisfaction correlates with psychological well-being. Methods: A cross-sectional survey was conducted with 74 rescue workers (87.8% male) between May and September 2023. Participants completed the Integrated Anxiety Stress Scale, WHOQOL-BREF, and the Occupational Balance Questionnaire (OBQ-T). Data analysis utilized non-parametric tests, including Spearman's correlation and Kruskal-Wallis tests, to examine variables during the post-acute recovery phase of the February 2023 earthquakes. Results: Anxiety levels were low (81.1%), while quality of life and occupational balance were moderate to high. Significant negative correlations were identified between anxiety-stress and all quality of life domains (r= -0.45 to -0.62, p003C0.01), and occupational balance (r= -0.45, p<0.01). Occupational balance showed positive correlations with all quality of life domains (r= 0.43 to 0.55, p<0.01). Conclusions: Despite a professional culture of resilience, rescue workers face significant time poverty and life toll that disrupt daily rhythms. Enhancing occupational balance through organizational support and practical time management is essential for long-term well-being and job performance.
No standardized cognitive aid (CA) exists to support the first medical responder during the initial organizational phase of a mass casualty incident (MCI). We aimed to develop such a tool through expert consensus using the Delphi method.A 2-round Delphi process was conducted with 20 expert prehospital physicians. Following a structured literature review, 46 items were submitted for evaluation using a 9-point Likert scale. Consensus criteria were defined a priori in accordance with HAS methodological guidelines. Retained items were ergonomically optimized using the Cognitive Aids in Medicine Assessment Tool (CMAT).All 20 experts participated in round 1 (100%); 18 completed round 2 (90%). After 2 rounds, 31 items were retained (acceptance rate 67%): 20 with strong agreement and 11 with relative agreement. The final CA is organized along the operational timeline of the first medical responder.This Delphi-based CA provides a structured, consensus-derived support tool for first medical responders during MCIs. Prospective studies in real or high-fidelity simulation settings are needed to evaluate its operational impact.
OBJECTIVE:This study examined hospital preparedness and radiation risk perception among nurses in Iran, uniquely applying the Transtheoretical Model to identify behavioral predictors of emergency readiness. METHODS:This cross-sectional study was conducted among 152 health care workers in three teaching hospitals. Four validated tools assessed hospital preparedness, knowledge, risk perception, and stages of change. Linear regression identified predictors of behavioral progression. RESULTS:While the hospital equipment domain scored highest (mean 18.3/21), the education domain scored lowest (mean 2.3/4). Notably, 85.5% of nurses remained in the passive stages of change, with only moderate levels of risk perception. Cognitive (β = 0.937) and behavioral processes (β = 0.763) strongly predicted stage advancement, extending previous findings on behavioral determinants of disaster preparedness. CONCLUSION:This study suggests that psychological readiness may play an important role in radiation emergency preparedness. Stimulus control and reinforcement management represent critical behavioral targets that are often overlooked in traditional training. Policymakers should consider shifting from awareness-only approaches to stage-matched, behaviorally driven interventions that address nurses' emotional barriers and support sustained readiness.
Introduction In the aftermath of the 2023 Turkey earthquakes, severely damaged hospitals necessitated efficient patient transportation. This research aims to assess the applicability of trauma assessment tools (TRISS, ISS, RTS) in determining transportation methods for earthquake-affected patients when local hospitals are incapacitated, particularly for patients transported by air ambulance and those who self-arrive from a location 1,100 km away.Methodology This retrospective analysis involved 397 patients from a hospital 1,100 km away from the 2023 Turkey Earthquake. We assessed patients who arrived by air ambulance or self-transport following the earthquake, calculating TRISS, ISS, and RTS scores. We sought intergroup differences to establish transportation strategies.Results TRISS and ISS exhibited good predictive value (AUC 0.723 and 0.880, respectively), while RTS was less useful. The median RTS score was 8 for both the Air transfer and Walk-in patients' groups. The median RTS score was similar for air transfer and walk-in patients. For air transfer patients, most admissions occurred on the first day, while walk-in patients peaked on the eighth day.Conclusion ISS and TRISS effectively identify patients requiring air transport post-earthquake. Distant hospitals should prepare to receive air transferred patients within the first five days, and self-admitted patients from the fourth day onward.
Patient transfers provide a critical mechanism for enhancing care capacity and distributing patient load across hospitals and communities. Yet, during disasters and surge events, decisions about where to send patients are often made by Medical Operations Coordination Centers and similar centralized regional coordination bodies, with limited visibility into how transfers are unfolding across the broader hospital system. This study proposes a spatial-network framework, informed by a typology of patient transfers, that represents interhospital transfers as patient flows across a geographic network of hospitals. The framework provides tools to identify and interpret transfer patterns that coordination bodies need to enhance situational awareness and make timely, informed decisions at the local, regional, and state levels. Using inpatient discharge data from a Florida health agency, this study further demonstrates the framework's applicability during a disaster and shows how administrative health data can be transformed into spatial networks that support interhospital transfer coordination decision-making.
