Displaced populations face disproportionately high risk of communicable disease outbreaks given the strains of travel, health care circumstances in their country of origin, and limited access to health care in receiving countries.

Understanding the role of demographic characteristics in outbreaks is important for timely and efficient control measures. Accordingly, this study assesses chickenpox outbreaks in three large refugee camps on mainland Greece from 2016 – 2017, using clinical line-list data from Médecins du Monde (MdM) clinics.

Clinical line-list data from MdM clinics operating in Elliniko, Malakasa, and Raidestos camps in mainland Greece were used to characterize chickenpox outbreaks in these camps. Logistic regression was used to compare the odds of chickenpox by sex, camp, and yearly increase in age. Incidences were calculated for age categories and for sex for each camp outbreak.

Across camps, the median age was 19 years (IQR: 7.00 - 30.00 years) for all individuals and five years (IQR: 2.00 - 8.00 years) for cases. Males were 55.94% of the total population and 51.32% of all cases. There were four outbreaks of chickenpox across Elliniko (n = 1), Malakasa (n = 2), and Raidestos (n = 1) camps. The odds of chickenpox when controlling for age and sex was lower for Malakasa (OR = 0.46; 95% CI, 0.38 - 0.78) and Raidestos (OR = 0.36; 95% CI, 0.24 - 0.56) when compared Elliniko. Odds of chickenpox were comparable between Malakasa and Raidestos (OR = 1.49; 95% CI, 0.92 - 2.42). Across all camps, the highest incidence was among children zero-to-five years of age. The sex-specific incidence chickenpox was higher for males than females in Elliniko and Malakasa, while the incidence was higher among females in Raidestos.

As expected, individuals five years of age and under made up the majority of chickenpox cases. However, 12% of cases were teenagers or older, highlighting the need to consider atypical age groups in vaccination strategies and control measures. To support both host and displaced populations, it is important to consider risk-reduction needs for both groups. Including host communities in vaccination campaigns and activities can help reduce the population burden of disease for both communities.

Floods are the most frequent natural disasters with a significant share of their mortality. Preparedness is capable of decreasing the mortality of floods by at least 50%. This paper aims to present the psychometric properties of a scale developed to evaluate the behavior of preparedness to floods in Sudan and similar settings.

In this methodological scale development study, experts assessed the content validity of the items of the developed scale. Data were collected from key persons of 413 households living in neighborhoods affected by the 2018 floods in Kassala City in Sudan. A pre-tested questionnaire of sociodemographic data and the Flood Preparedness Behavior Scale (FPBS) were distributed to the participants’ houses and recollected. Construct validity of the scale was checked using exploratory factor analysis (EFA) and confirmatory factor analysis (CFA). Internal consistency of the scale was checked using Cronbach’s alpha. Test-retest reliability was assessed by Pearson’s correlation coefficient. Item analyses and tests of significance of the difference in the mean scores of the highest and lowest score groups were carried out to ensure discriminatory power of the scale items.

Experts agreed on the scale items. Construct validity of the scale was achieved using EFA by removing 34 items and retaining 25 items that were structured in three factors, named as: measures to be done before, during, and after a flood. Confirmatory factor analysis confirmed the construct obtained by EFA. The loadings of the items on their factors in both EFA and CFA were all > 0.3 with significant associations and acceptable fit indices obtained from CFA. The three factors were found to be reliable in terms of internal consistency (Cronbach’s alpha coefficients for all factors were > 0.7) and test-retest reliability coefficient. In item analysis, the corrected total item correlations for all the items were > 0.3, and significant differences in the means of the highest and lowest score groups indicated good item discrimination power.

The developed 25 items scale is an instrument which produces valid and reliable measures of preparedness behavior for floods in Sudan and similar settings.

Earthquakes rank among the most deadly natural disasters, and children are particularly affected due to their inherent vulnerability. Following an earthquake, there is a substantial increase in visits to emergency services. These visits stem not only from patients seeking care for physical traumas resulting from the earthquake and its subsequent complications, but also from individuals affected by the circumstances created by the disaster.

This study aims to determine the characteristics and outcomes of children who presented to the pediatric emergency department (PED) after the earthquake and to evaluate children who had crush injuries at a referral tertiary university hospital away from the earthquake area.

The medical records of children who presented to the PED from the earthquake area from February 6 through March 7, 2023 were retrospectively reviewed. Children rescued from under rubble were categorized as Group 1, those affected by earthquake conditions as Group 2, and patients seeking medical attention due to the follow-up of chronic illnesses were considered as Group 3. Patient data, including sociodemographic characteristics, time period under rubble (TPR), laboratory findings, and details of medical and surgical procedures, developing acute kidney injury (AKI), and the requirement for hemodialysis were recorded.

A total of 252 children were enrolled in the study, with 52 (20.6%) in Group 1, 180 (71.4%) in Group 2, and 16 (6.0%) in Group 3. The median age was six (IQR = 1.7-12.1) years. In the first group (n = 52), 46 (85.2%) children experienced crush injuries, 25 children (46.3%) developed crush syndrome, and 14 of them (14/25; 56.0%) required dialysis. In the second group, the most common diagnoses were upper respiratory tract infections (n = 69; 37.9%), acute gastroenteritis (n = 23; 12.6%), simple physical trauma (n = 16; 8.8%), and lower respiratory tract infections (n = 13; 7.1%). For children in the third group, pediatric neurology (n = 5; 33.3%), pediatric oncology (n = 4; 25.0%), and pediatric nephrology (n = 3; 18.8%) were the most frequently referred specialties.

Crush injuries, crush syndrome, and AKI were the most common problems in the early days following the earthquake. Along with these patients, children who were affected by the environmental conditions caused by the earthquake, as well as children with chronic illnesses, also accounted for a significant portion of visits to the PED, even if they were distant from the disaster area.

The consumption of alcohol within the Australian community continues to rise, impacting care delivery in already over-burdened emergency departments (EDs).

This study aimed to examine the impact of alcohol-related presentations (ARPs) to EDs on days with a public holiday or sporting event.

A retrospective cohort study was undertaken using routinely collected health data pertaining to patient presentations diagnosed with an alcohol-related disorder (ICD-10-AM code F10) to two EDs in Queensland, Australia from January 1, 2016 – December 31, 2020. Descriptive and inferential statistics were used to describe and compare ARPs on event days versus non-event days and uncomplicated versus other ARPs on event days only.

Of all 5,792 ARPs, nine percent (n = 529) occurred on public holidays or sporting event days. When compared by day type, type of presentation, mode of arrival, and day of week differed between event and non-event days. On event days, uncomplicated ARPs differed to other ARPs, with uncomplicated ARPs being younger, having shorter median length-of-stay (LOS), and less likely to be admitted to hospital.

In this multi-site study, public holidays and sporting events had a noteworthy impact on ARPs to EDs. Focused refinement on the clinical management of uncomplicated ARPs is warranted to inform future resource allocation, including on event days.

The threat of chemical, biological, radiologic, nuclear, and explosive (CBRNe) terrorist attacks has increased over time. The need for rapid and effective responses to such attacks is paramount. Effective medical counter-measures to CBRNe events are critical and training for such may effectively occur early in physician training. While some medical specialties are more involved than others, counter-terrorism medicine (CTM) spans all medical specialties.

All United States allopathic medical schools were examined via online curriculums and queries for academic content related to CBRNe and terrorist medical counter-measures.

Analysis of 153 United States allopathic medical schools demonstrated that 15 (9.8%) medical schools offered educational content related to CBRNe and terrorist counter-measures. This is in contrast to legislation following the September 11, 2001 attacks that called for high priority for such education.

Effective CBRNe medical counter-measures are currently in place; however, there is room for improvement in education that may begin during medical school. While certain medical specialties such as emergency medicine, primary care, and dermatology may have specific niches in such events, physicians of all medical specialties have something to offer, and even a basic education in medical school can help best prepare the nation for future attacks.

In Turkey, a total of 269 earthquakes took place from 1900 through 2023. The most devastating earthquakes in terms of casualties and extensive destruction occurred at 4:17am and 1:24pm local time on February 6, 2023 with the epicenters located in Pazarcik (Kahramanmaras) and Ekinozu (Kahramanmaras) and magnitudes of 7.7Mw and 7.6Mw, respectively. The aim of this study was to define the frequency of lung complications that occurred directly and/or developed during the intensive care follow-up of individuals affected by the Kahramanmaras earthquakes.

A retrospective evaluation was conducted on the files of 69 patients who were rescued from the debris of collapsed buildings after the Kahramanmaras earthquakes and followed up in the intensive care unit in terms of the time under the debris, demographic data, vital signs, and lung complications that were present at the time of admission and developed during follow-up. SPSS for Windows v. 20.0 was used for data analysis.

The study included a total of 69 patients, of whom 29 (42%) were female and 40 (58%) were male. The mean age was 39.9 (SD = 16.9) years. The mean time under the debris was 53.9 (SD = 52) hours, and the mean time from rescue to the intensive care unit admission was 18.7 (SD = 12.8) hours. One or more pulmonary complications were detected in 52.2% (n = 36) of the patients at the time of admission. During the follow-up, 30.4% (n = 21) of the patients developed pulmonary congestion, 13.0% (n = 9) pneumonia, 1.5% (n = 1) alveolar hemorrhage, and 1.5% (n = 1) atelectasis, while no additional lung complications developed in the remaining 37 patients (53.6%).

Severe cases of individuals recovered from the debris can have a high prevalence of earthquake-related lung disorders and chest trauma, which may be associated with high mortality. The timely identification and effective intervention of pulmonary complications that may develop during follow-up can reduce mortality.

Investigating the developments in the ever-growing field of disaster medicine and revealing the scientific trends will make an important contribution to researchers in related fields. This study aims to identify the contributions of emergency medicine physicians (EMPs) and trends in disaster medicine publications.

The expressions “disaster medicine” or “disaster*” and “medicine*” were searched in the Web of Science (WoS) database. Research and review papers produced by EMPs from 2001 through 2021 were included in the study. Basic descriptive information was assessed such as the number of publications, authors, citations, most active authors, institutions, countries, and journals. In addition, conceptual, intellectual, and social structures were analyzed.

The study included a total of 346 papers written by 1,500 authors. The mean citation rate per publication was 13.2. Prehospital and Disaster Medicine, Disaster Medicine and Public Health Preparedness, and Academic Emergency Medicine were the journals with the highest number of publications and the highest number of citations. The most common keywords used by the authors were “disaster medicine,” “emergency medicine,” and “disaster/disasters.” According to the distribution of the corresponding authors by country, the United States (n = 175), Japan (n = 23), Italy (n = 20), Australia (n = 17), and Canada (n = 17) had the highest number of publications. The institutions that produced the most publications were John Hopkins University (n = 37), Brigham and Women’s Hospital (n = 27), George Washington University (n = 25), University Piemonte Orientale (n = 24), and Brown University (n = 22).

Increasingly, EMPs have contributed to disaster medicine publications over the years. This study can be used as a guide for EMPs and other researchers who want to contribute to the disaster medicine literature.

Hemodynamic collapse in multi-trauma patients with severe traumatic brain injury (TBI) poses both a diagnostic and therapeutic challenge for prehospital clinicians. Brain injury associated shock (BIAS), likely resulting from catecholamine storm, can cause both ventricular dysfunction and vasoplegia but may present clinically in a manner similar to hemorrhagic shock. Despite different treatment strategies, few studies exist describing this phenomenon in the early post-injury phase. This retrospective observational study aimed to describe the frequency of shock in isolated TBI in prehospital trauma patients and to compare their clinical characteristics to those patients with hemorrhagic shock and TBI without shock.

All prehospital trauma patients intubated by prehospital medical teams from New South Wales Ambulance Aeromedical Operations (NSWA-AO) with an initial Glasgow Coma Scale (GCS) of 12 or less were investigated. Shock was defined as a pre-intubation systolic blood pressure under 90mmHg and the administration of blood products or vasopressors. Injuries were classified from in-hospital computed tomography (CT) reports. From this, three study groups were derived: BIAS, hemorrhagic shock, and isolated TBI without shock. Descriptive statistics were then produced for clinical and treatment variables.

Of 1,292 intubated patients, 423 had an initial GCS of 12 or less, 24 patients (5.7% of the original cohort) had shock with an isolated TBI, and 39 patients had hemorrhagic shock. The hemodynamic parameters were similar amongst these groups, including values of tachycardia, hypotension, and elevated shock index. Prehospital clinical interventions including blood transfusion and total fluids administered were also similar, suggesting they were indistinguishable to prehospital clinicians.

Hemodynamic compromise in the setting of isolated severe TBI is a rare clinical entity. Current prehospital physiological data available to clinicians do not allow for easy delineation between these patients from those with hemorrhagic shock.

After the 2023 Turkey earthquake, thousands of people evacuated to different fields. Earthquake victims still need health care in the evacuation location. This study aims to determine the emergency department (ED) and outpatient clinic utilization characteristics of the evacuated earthquake victims outside the earthquake zone and to provide suggestions for planning the health care facilities in the regions where the evacuated earthquake victims will be placed.

This retrospective, observational study was conducted in a tertiary university hospital from February 7, 2023 through February 20, 2023. All evacuated earthquake victims who presented to the study hospital were included in the study. Non-victim patients were included as the control group. Missing medical records were excluded. Demographic characteristics of the patients, outpatient clinics, International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10) codes, and outcomes were recorded.

A total of 15,128 patients were included in the final analysis. Six-hundred-nine (4.0%) of the patients were evacuated victims. Three-hundred forty-six (56.8%) evacuated victims used the ED. One-hundred fifty-six (25.6%) earthquake victims were in the pediatric age group. Earthquake victims used the ED more than the control group in adult and pediatric age groups (22.5% versus 51.7% and 30.2% versus 71.8%; P <.001, respectively). Earthquake victims frequently presented to the hospital during night shifts in both age groups (P <.05). Pediatric victims were more hospitalized than the control group (4.8% versus 10.9%; P = .001). Diseases of the respiratory system were the most common emergency diagnosis of the victims in both age groups (26.5% and 57.1%, respectively). The most frequently used outpatient clinic was ophthalmology in both age groups (14.6% and 20.5%, respectively).

Evacuated victims, especially pediatric victims, used the ED more than other outpatient clinics. Diseases of the respiratory system were the most common emergency diagnosis of the victims, and the most frequently preferred outpatient clinic was ophthalmology. The most common diseases and frequently preferred clinics should be considered in planning health care for the evacuated earthquake victims.

Airway management is a cornerstone in the prehospital care of critically ill or injured patients. Surgical cricothyrotomy offers a rapid and effective solution when oxygenation and ventilation fail using less-invasive techniques. However, the exact indications, incidence, and success of prehospital surgical cricothyrotomy are unknown, with variable rates reported in the literature. This study aimed to examine prehospital indications and success rates for surgical cricothyrotomy within a large, suburban, ground-based Emergency Medical Services (EMS) system.

This is a retrospective analysis of 31 patients who underwent paramedic performed surgical cricothyrotomy from 2012 through 2022. Key demographic parameters were analyzed, including the incidence of cardiac arrest, call type (trauma versus medical), initial airway management attempts, number of endotracheal intubation (ETI) attempts before surgical airway, and average time to the establishment of a surgical airway in relation to the number of ETI attempts. Surgical cricothyrotomy success was defined as the acquisition of four-phase end-tidal capnography reading. The primary data sources were the EMS electronic medical records, and descriptive statistics were calculated.

A total of 31 patients were included in the final analysis. Of those who received a surgical cricothyrotomy, 42% (13/31) occurred in the trauma setting, while 58% (18/31) were medical calls. In all patients who underwent surgical cricothyrotomy, the median (IQR) time to the procedure was 17 minutes (IQR = 11-24). In trauma patients, the median time to surgical cricothyrotomy was 12 minutes (IQR = 9-19) versus 19 minutes (IQR = 14-33) in medical patients. End-tidal carbon dioxide (ETCO2) detection and placement success was confirmed in 94% (29/31) of patients. Endotracheal intubation was attempted in 55% (17/31) before subsequent surgical cricothyrotomy, with 29% (9/31) receiving more than one ETI attempt. The median time to surgical cricothyrotomy when multiple prior intubation attempts occurred was 33 minutes (IQR = 23-36) compared to 14.5 minutes (IQR = 6-19) in patients without a preceding intubation attempt.

Prehospital surgical airway can be performed by paramedics with a high degree of success. Identification of the need for surgical cricothyrotomy should be determined as soon as possible to allow for rapid securement of the airway and to ensure adequate oxygenation and ventilation.

Patients with ventricular assist devices (VADs) represent a growing population presenting to Emergency Medical Services (EMS), but little is known about their prehospital care. This study aimed to characterize current EMS protocols in the United States for patients with VADs.

States with state-wide EMS protocols were included. Protocols were obtained from the state EMS website. If not available, the office of the state medical director was contacted. For each state, protocols were analyzed for patient and VAD assessment and treatment variables.

Of 32 states with state-wide EMS protocols, 21 had VAD-specific protocols. With 17 (81%) states noting a pulse may not be palpable, protocols recommended assessing alternate measures of perfusion and mean arterial pressure (MAP; 15 [71%]). Assessment of VAD was advised through listening for pump hum (20 [95%]) and alarms (20 [95%]) and checking the power supply (15 [71%]). For treatment, EMS prehospital consultation was required to begin chest compression in three (14%) states, and mechanical (device) chest compressions were not permitted in two (10%) states. Contact information for VAD coordinator was listed in a minority of five (24%) states. Transport of VAD equipment/backup bag was advised in 18 (86%) states.

This national analysis of EMS protocols found VAD-specific EMS protocols are not universally adopted in the United States and are variable when implemented, highlighting a need for VAD teams to partner with EMS agencies to inform standardized protocols that optimize these patients’ care.

Medical professionals can use mass-casualty triage systems to assist them in prioritizing patients from mass-casualty incidents (MCIs). Correct triaging of victims will increase their chances of survival. Determining the triage system that has the best performance has proven to be a difficult question to answer. The Advanced Prehospital Triage Model (Modelo Extrahospitalario de Triaje Avanzado; META) and Sort, Assess, Lifesaving Interventions, Treatment/Transport (SALT) algorithms are the most recent triage techniques to be published. The present study aimed to evaluate the META and SALT algorithms’ performance and statistical agreement with various standards. The secondary objective was to determine whether these two MCI triage systems predicted patient outcomes, such as mortality, length-of-stay, and intensive care unit (ICU) admission.

This retrospective study used patient data from the trauma registry of an American College of Surgeons Level 1 trauma center, from January 1, 2018 through December 31, 2020. The sensitivity, specificity, and statistical agreement of the META and SALT triage systems to various standards (Revised Trauma Score [RTS]/Sort Triage, Injury Severity Score [ISS], and Lerner criteria) when applied using trauma patients. Statistical analysis was used to assess the relationship between each triage category and the secondary outcomes.

A total of 3,097 cases were included in the study. Using Sort triage as the standard, SALT and META showed much higher sensitivity and specificity in the Immediate category than for Delayed (Immediate sensitivity META 91.5%, SALT 94.9%; specificity 60.8%, 72.7% versus Delayed sensitivity 28.9%, 1.3%; specificity 42.4%, 28.9%). With the Lerner criteria, in the Immediate category, META had higher sensitivity (77.1%, SALT 68.6%) but lower specificity (61.1%) than SALT (71.8%). For the Delayed category, SALT showed higher sensitivity (META 61.4%, SALT 72.2%), but lower specificity (META 75.1%, SALT 67.2%). Both systems showed a positive, though modest, correlation with ISS. For SALT and META, triaged Immediate patients tended to have higher mortality and longer ICU and hospital lengths-of-stay.

Both META and SALT triage appear to be more accurate with Immediate category patients, as opposed to Delayed category patients. With both systems, patients triaged as Immediate have higher mortality and longer lengths-of-stay when compared to Delayed patients. Further research can help refine MCI triage systems and improve accuracy.

Medical resuscitations in rugged prehospital settings require emergency personnel to perform high-risk procedures in low-resource conditions. Just-in-Time Guidance (JITG) utilizing augmented reality (AR) guidance may be a solution. There is little literature on the utility of AR-mediated JITG tools for facilitating the performance of emergent field care.

The objective of this study was to investigate the feasibility and efficacy of a novel AR-mediated JITG tool for emergency field procedures.

Emergency medical technician-basic (EMT-B) and paramedic cohorts were randomized to either video training (control) or JITG-AR guidance (intervention) groups for performing bag-valve-mask (BVM) ventilation, intraosseous (IO) line placement, and needle-decompression (Needle-d) in a medium-fidelity simulation environment. For the interventional condition, subjects used an AR technology platform to perform the tasks. The primary outcome was participant task performance; the secondary outcomes were participant-reported acceptability. Participant task score, task time, and acceptability ratings were reported descriptively and compared between the control and intervention groups using chi-square analysis for binary variables and unpaired t-testing for continuous variables.

Sixty participants were enrolled (mean age 34.8 years; 72% male). In the EMT-B cohort, there was no difference in average task performance score between the control and JITG groups for the BVM and IO tasks; however, the control group had higher performance scores for the Needle-d task (mean score difference 22%; P = .01). In the paramedic cohort, there was no difference in performance scores between the control and JITG group for the BVM and Needle-d tasks, but the control group had higher task scores for the IO task (mean score difference 23%; P = .01). For all task and participant types, the control group performed tasks more quickly than in the JITG group. There was no difference in participant usability or usefulness ratings between the JITG or control conditions for any of the tasks, although paramedics reported they were less likely to use the JITG equipment again (mean difference 1.96 rating points; P = .02).

This study demonstrated preliminary evidence that AR-mediated guidance for emergency medical procedures is feasible and acceptable. These observations, coupled with AR’s promise for real-time interaction and on-going technological advancements, suggest the potential for this modality in training and practice that justifies future investigation.

This study assesses the operational challenges and clinical outcomes encountered by a university-based Emergency Medical Team (EMT) during the medical search and rescue (mSAR) response to the February 2023 earthquakes in Kahramanmaraş, Turkey.

In this observational study, data were retrospectively collected from 42 individuals who received mSAR services post-earthquake. The challenges were categorized as environmental, logistical, or medical, with detailed documentation of rescue times, patient demographics, injury types, and medical interventions.

In this mSAR study, 42 patients from 30 operations were analyzed and divided into environmental (26.2%), logistical (52.4%), and medical (21.4%) challenge groups. Median rescue times were 29 (IQR 28–30), 36.5 (IQR 33.75–77.75), and 30.5 (IQR 29.5–35.5) hours for each group, respectively (P = .002). Age distribution did not significantly differ across groups (P = .067). Hypothermia affected 18.2%, 45.5%, and 66.7% in the respective groups. Extremity injuries were most common in the medical group (88.9%). Intravenous access was highest in the medical group (88.9%), while splinting was more frequent in the medical (55.6%) and logistical (18.2%) groups. Hypothermia was most prevalent in the medical group (66.7%), followed by the logistical group (45.5%). Ambulance transport post-rescue was utilized for a minority in all groups.

The study concludes that logistical challenges, more than environmental or medical challenges, significantly prolong the duration of mSAR operations and exacerbate clinical outcomes like hypothermia, informing future enhancements in disaster response planning and execution.

The aim of this study is to determine the demographic, clinical characteristics, and outcomes of the patients who applied to the emergency department (ED) of Akdeniz University Faculty of Medicine Hospital (Antalya, Türkiye) after the Kahramanmaraş-Pazarcık earthquake dated February 6, 2023, as earthquake victims were included in the study. The results of the study could be a guide in terms of emergency health services and the healthy management of disasters.

The study included patients over the age of 18 who presented as earthquake victims to the ED of Akdeniz University Medical Faculty Hospital from February 6, 2023 through March 8, 2023. The demographic data of the patients, including age, gender, earthquake zone, time and manner of arrival to the ED, time under debris, length-of-stay (LOS) in the service and intensive care unit (ICU), infection rates, culture results, and mortality, were retrospectively analyzed using the hospital automation system.

A total of 1,833 earthquake victims presented to the ED. Of these patients, 1,294 were adults and 539 were children. Services and the ICU admitted a total of 137 adult patients. In the first week, 414 (31.99%) of the patients presented to the ED, while 82 (59.85%) of the hospitalized patients were admitted.

Hatay ranked first with 573 (44.28%) patients in the distribution of patients presented to the ED according to earthquake regions. In the distribution of hospitalized patients by earthquake regions, the patients requiring the most hospitalization were from the province of Hatay, with 68 (49.63%) patients.

During hospital observations, the medical staff took 132 culture samples based on the positive clinic of the patient. The microorganisms detected in the culture studies were different from the flora of the hospital. The mortality at seven days was two (1.45%), and at the end of 30 days, the mortality was six (4.37%).

The ED evaluated all affected cases, with most patients being brought by their relatives using their own means, and had low mortality rates despite presenting with fewer injuries. New environmental conditions that developed after the earthquake caused unexpected results, especially in terms of community-acquired agents.