Pandemic influenza poses a great challenge to healthcare systems. Vaccinating medical teams and the population against pandemic influenza is the global recommended strategy to contain spread of the disease. As part of the efforts made to overcome the H1N1 pandemic, the Israeli Ministry of Health (MOH) initiated a general vaccination program for medical teams and the total country population. Due to low compliance rates of the medical staff, the MOH conducted regional conferences aimed at providing knowledge and encouraging staff to be vaccinated.

To evaluate the effect of the regional conferences on the compliance rates amongst medical providers to be vaccinated against H1N1.

Medical providers from the primary health care services were invited to conferences that were conducted in 3 regions. Attitudes of the teams regarding compliance to be vaccinated were assessed pre and post the conferences. Additionally, the actual rates of vaccinations were recorded over the period of vaccination program. Actual compliance rates before and after the conferences were compared to detect differences as well as the relationship between teams' attitudes and actual vaccinations.

Vaccination rates of medical providers remained low during the full vaccination period. Among the non-vaccinated, 24% to 29% reported before the conference that they agree to be vaccinated versus 57% to 62% following the conference. Analysis of the actual vaccination data among the medical providers did not demonstrate a change in compliance following the conferences and an overall decrease was noted after the first two weeks of the vaccinated project.

A statistically significant relationship was not found between reported attitudes of medical providers regarding readiness to be vaccinated and their actual vaccination. The MOH intervention did not achieve the expected result and did not raise compliance to be vaccinated.

Inappropriate distribution of casualties in mass casualty incidents (MCIs) may result in patient overload in primary medical facilities.

The aim of this study was to review the consequences of evacuating casualties from a bus accident to a single rural hospital and lessons learned regarding policy of casualty evacuation.

Hospital medical records of all casualties from primary and tertiary hospitals were independently reviewed by two senior trauma surgeons. In addition four senior trauma surgeons reviewed the impact of treatment provided in the primary hospital on patient outcomes.

31 survivors from the accident were transferred to the closest local hospital; 4 died en route to the hospital or within 30 minutes of arrival. 27 casualties were air evacuated from the local hospital within 2.5 to 6.15 hours to level I and II hospitals. Under-triage of 15% and over-triage of 7% were noted. 4 casualties did not receive treatment at the local hospital that might have improved their condition.

Over and under-triage might have been due to minimal trauma related experience of primary hospital personnel. Evacuation of casualties from an MCI to a limited capacity hospital may overwhelm the facility and affect its ability to provide appropriate medical care.

In MCIs occurring in rural areas, only immediate unstable casualties should be transferred to the closest primary hospital. On-site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.

Prehospital delay in trauma victims has been associated with worsened trauma outcomes, and forms the basis of emergency medical services (EMS). Survival rates of severely injured patients with life and limb threatening trauma were studied and corrlated with prehospital delays in Mumbai, India, where there is no central EMS system.

From October 2010 to March 2011, a researcher collected Injury Severity Score and prehospital time delay data in all severely injured patients arriving at the Trauma Centre. The time of injury, and time and mode of transport to the Trauma Centre were recorded, along with the details of the injury and the physiological parameters upon admission. Information regarding time and place of the crash, arrival to a trauma care facility, injuries, and survival were noted.

A taxicab was the most common mode of transport followed by a police van, private ambulances, and government ambulances. Patients reached the Trauma Centre more quickly when accompanied by relatives or police, and took longer if they were examined at peripheral centers, were unknown victims, or arrived by Government ambulances. Better outcomes were observed in patients with informal carers. The majority of the victims presented within three hours of trauma.

Prehospital delay did not correlate well with poorer outcomes. Further research is needed to determine how many injured die on the way to the hospital in countries without a formal EMS system. Implementation of a high-cost, state-funded EMS system in a congested, resource-poor, urban setting must be balanced with the insufficient evidence about whether prehospital field interventions actually improve survival outcomes.

Pakistan is a developing country with a basic prehospital system in some cities. The prehospital services are a mixture of government and private ambulances.There is no central regulatory body for them and no central command to control the influx and out flux of ambulances from the scene.

In this paper, five episodes of terrorist incidents in the country and will try to estimate the number of ambulances on the scene.

Retrospective data was collected and triangulation was done by three sources: (1) ambulance records; (2) visual estimation; and (3) print media. An estimate of total ambulances was reached along with dead and injured. Furthermore medical transport capacity was calculated where possible.

In majority of the incidents, it was found that there was a huge influx of ambulances beyond the need. This further adds to the chaos and confusion already present on the scene of disaster.

A Command and Control Center should be established to direct all ambulance control and movements.

Agriculture emergency responders always will require equipment and supplies. A rapid and effective logistical response depends upon having the right item in the right quantity at the right time at the right place for the right price in the right condition to the right responder. Established in 2004 by U.S. Homeland Security Presidential Directive 9, the National Veterinary Stockpile (NVS) within the U.S. Department of Agriculture (USDA), Animal and Plant Health Inspection Service, Veterinary Services is the nation's repository of critical veterinary supplies, equipment, vaccines, and services appropriate to respond to the most damaging animal diseases affecting human health and the economy. An overview of the NVS program, its capabilities, training and exercise strategy, and outreach to stakeholders will be presented.

The goals of the NVS program are to deploy countermeasures against the 17 most damaging animal disease threats within 24 hours, and to help states/tribes/territories plan, train, and exercise the receipt, processing, and distribution of NVS countermeasures. To meet these goals, the NVS program heavily relies upon science-based logistics to identify animal vaccines and other countermeasures to respond, and sound business processes to purchase, hold, maintain, and deploy the countermeasures. Significant resources also are dedicated to the NVS outreach activities, which interface directly with federal/state/tribe/territory animal health stakeholders. NVS team members work hand-in-hand with these leaders to help develop written NVS-specific plans for their jurisdictions, provide logistics training, and sponsor discussion-based and operations-based exercises in accordance with the Homeland Security Exercise and Evaluation Program.

The USDA NVS exists to provide states/tribes/territories the countermeasures they need to respond to catastrophic animal disease outbreaks created by either terrorists or nature. As logistical experts, the NVS team develops plans for logistical emergency response, manages their supply chain of countermeasures, and helps stakeholders improve logistical response capabilities.

Measles still remains an important cause of morbidity and mortality among children in many developing countries, especially in refugee settings where fatality rates as high as 33% have been documented. From January to April 2004, concurrent measles and rubella outbreaks had occurred in four transit camps hosting 2,767 Liberian refugees in Cote d'Ivoire.

This study describes the epidemiology of concurrent measles and rubella outbreaks, and the investigation of a Disease Surveillance Team.

Patients meeting the case-definition (rash and fever > 38°C) were detected actively. Blood sample were collected for measles and rubella IgM antibody confirmation.

Sixty rash and fever cases were identified. During weeks 8 to 13, measles IgM testing had resulted in 61.1% positive tests. The highest incidence (18.5%) was observed in children below 9 months. Ninety-three percent of children aged between 6 months and 12 years received a measles vaccination but the rash and fever cases continued to occur. This prompted a systematic test for both measles and rubella IgM antibodies. Rubella IgM testing had resulted in 74.0% positive tests. The highest incidence (3.88%) was found in children between 5–15 years. Supplemental immunization with a measles-mumps-rubella (MMR) vaccine was conducted, following which, no fever and rash cases were documented.

This study indicates the importance of an early serological testing for measles and rubella together or the use of the MMR vaccine rather than only measles vaccine in disasters settings. Good management of surveillance data will be an asset for effective immunization strategies in refugee settings.

Research into how war-displaced communities value or prioritize aid response is limited. A clearer conceptualization of what affected populations seek from the international humanitarian response to their needs would be valuable in planning for emergencies.

Exploring internally displaced person's (IDP) experiences and perceptions of the humanitarian response, with a focus on health risks, resources, and health services received during their displacement.

A mixed-method approach using both quantitative and qualitative methods was used. This study assessed the perceptions of IDPs on provision of health and other services using an interviewer-administered-questionnaire (survey) using a sample frame that included the entire displaced population of 150,000 IDPs living in 97 camps. Findings from the survey were synthesized with the key themes that emerged through the qualitative methodology. In-depth interviews were conducted with health cluster actors. An innovative child-to-child (CTC) based research methodology was used to ascertain the insights and perceptions of displaced children and adolescents.

The survey revealed community satisfaction with health care services immediately after displacement (within IDP camps) improved considerably from 63% to 80% (6 months after the acute phase). Significant gains also were registered for shelter (54.2% to 81.4%), and sanitation (47.4% to 62%). Satisfaction of services rendered by primary healthcare workers also were high; 81.7% for public health midwife (who provided maternal and child health care), and 76.8% for public health inspectors (who provided environmental health and disease control). However, CTC workshops revealed inequalities in access to food based on ‘caste’ and occupation. Protection issues relating to violence from community and militant groups were reported.

Despite IDP satisfaction with healthcare services, there were gaps in food security and violence/protection activities. Recognizing of the role/impact community health volunteers play in health care is an important factor in enhancing primary health care services in IDP camps.

Recently, the local governments in Japan implemented the measures for people requiring assistance during a disaster (PRAD). These measures aim to provide public assistance during a disaster for the citizens who registered themselves to the PRAD list in advance, by sharing their personal information among relevant local authorities. However, the needs for such assistance were not clear among chronic disease patients, and there are some concerns about privacy protection in relation to the PRAD list.

The objective of this study is to describe the attitudes toward the registration to the PRAD list among rheumatoid arthritis (RA) patients.

Study subjects were the members of a nationwide RA patient group in Japan. Of about 20,000 members, 1,477 who lived in the municipalities affected by disasters from 2004 to 2006 were enrolled. Self-administered questionnaires were sent by mail. The subjects were asked their attitudes toward the registration to the PRAD list and categorized into three groups: (1) no need for assistance; (2) need assistance but will not register; and (3) need assistance and wish to register or already registered. Their concerns about privacy protection as well as socio-demographic and health status were also asked.

Of 1,477, 664 (45%) responded validly, and 596 (40%) answered on their attitudes toward the PRAD list. Of these, 365 (61%) reported they need assistance, though 30% of them (108) did not wish to register. A majority of the subjects concerned about privacy protection among those did not wish to register (65%) as well as among those wished to register (55%). Patients who lived alone, and those with low income were more likely to wish to register.

There are substantial needs for public assistance during a disaster among RA patients although the privacy protection issue would be a barrier to be overcome for successful utilization of the list.

Populations that participated in this project represented > 46% of the total H1N1 patients hospitalized and 34% of deaths in the state of Oregon.

A committee was convened by the Oregon Health Authority to increase access to vulnerable populations. The committee determined the project must be supported by: (1) a local advocacy group; (2) a local Health Department; and (3) an emergency medical services (EMS) provider agency to provide immunization. This project involved outreach to a vulnerable population that may not be able to utilize mass vaccination clinics and may have limited access to medical services. Outreach was accomplished using three models: (1) volunteers delivering meals; (2) mailings to those receiving in-home meals; and (3) a community organization that conducted a flu clinic frequented by people with disabilities. Three models were developed for receiving calls and scheduling appointments. All projects followed the same procedure for vaccine administration.

Seventy home-bound individuals met the criteria for vaccination. Post-survey results indicated: 55.2% lived alone and were homebound. Over 70% had previously received their vaccinations from their healthcare provider and 38.9% were not previously vaccinated due to vaccine availability. Fifty-eight individuals were vaccinated. Partner organizations were surveyed after their efforts were completed. Findings indicated that relationships between the EMS agencies and providers were greatly enhanced.

Outreach using nontraditional partners was an effective method to reach a vulnerable population. The project demonstrated that qualified vaccinators can be mobilized quickly. However, because this resource-intensive effort is more costly than providing mass vaccination, similar projects should only be utilized when less costly means are not effective, or when the risk level of the vulnerable population being served warrants it.

One of the most prevalent issues identified by Emergency Response Program Organizations (ERPOs), is the inability to care for an overwhelming number of contaminated patients within a civilian community. Even when emergency responders successfully decontaminate and triage large numbers of patients at the scene, it is unlikely that neighboring hospitals are prepared and equipped to receive such a large amount of patients and treat them within the boundaries of the existing healthcare system. Thus, planners must avoid any collapse of the healthcare system and may need to redistribute existing resources to enhance and facilitate patient outcome. As a response to this issue, ERPOs should develop an alternative healthcare facility: the Off-Site Triage, Treatment and Transportation Center (Off-Site Center). This Center is a temporary patient clearinghouse to be disassembled once the flow of new patients has diminished to the point that they can be handled by the existing healthcare systems.

The Off-Site Center is intended to care for patients who have been triaged as “Minimal” at the scene, those patients who are worried that they might have been exposed to contamination, and those who self-refer to the Center.

Planners, administrators, first responders, medical professionals, and public health and emergency management personnel must evaluate the Concept of Operation for the Off-Site Center in order to increase their level of preparedness and provide effective mass-casualty care.

In this report, some general guidelines will be provided for the efficient planning and management of an Off-Site Center. A practical example will be also illustrated: a case study in Bergamo during a May 2010 National Meeting of the Italian Association of Alps Infantry Troops.

Singapore is considered a prime target for transnational terrorism. Perpetrators may select an explosive radiation dispersal device or “dirty bomb” as their weapon of choice. Additional risks of a local radiological emergency may arise from mishaps involving visiting marine nuclear-powered vessels. Strategies and methods used to enhance preparedness to respond to radiological mass-casualty incidents (MCIs) will be described.

A core group comprising hospital emergency managers and radiology and emergency department staff spearheaded preparedness efforts. The Ministry of Health Guiding Document on managing radiological MCIs provides the principles and operational concepts to anchor the development of local protocols. Discussion sessions, site visits, drills, and exercises are conducted to improve organization performance. Expert opinion and feedback from various stakeholders and partners help shaped the overall plan.

Preparedness activities focused on improving surge response capability through broad categories include: 1. Staff—Radiation response teams were developed and assigned roles and responsibilities. Training and education programs were created for different staff positions, e.g., on correct usage of electronic personal dosimeters and acute radiation syndrome. 2. Stuff—Material resources such as antidotes, and expendables like floor covering were procured and stored. 3. System—These areas include: (a) activation procedures; (b) communication plans; (c) safety measures; (d) casualty transfer protocols; and (e) handling radiologically contaminated waste and materials. 4. Space—Potential care areas, such as radiation isolation rooms were designated. An algorithm was devised to guide casualty management.

Facility preparedness for radiological MCIs requires multidisciplinary involvement and the creation of trusting partnerships. More research is needed to identify the metrics to measure success objectively and aid protocol revisions.