This research aimed to conduct an epidemiological analysis of the terrorist attacks, which took place in the Turkic states between 1970 and 2019, and their medical consequences in terms of weapons and attack types. The data collected from this research will be valuable for the development of preventive systems against attacks on Turkic states and offer insights on how to effectively prepare for potential future attacks.

The population of the research consisted of the weapons and types of attacks of the terrorist attacks in the Turkic states drawn from the Global Terrorism Database provided free of charge by START. The number of deaths, injuries, property damage, primary weapons, and types of attacks were analyzed by country.

Between 1970 and 2019, 4629 terrorist incidents occurred and 7496 people lost their lives and 10 928 people were injured. Among the types of weapons, the number of people who lost their lives was mostly in firearms, whereas the number of the injured was mostly in explosive weapons. Among the types of attacks, the number of people who lost their lives was mostly observed in the armed attack, whereas the injuries occurred mostly in the bombing attacks. Among the Turkic states, Turkey is the country most affected in terms of medical outcomes.

The terrorist attacks in the Turkic states reached their maximum number in the last 10 years. It is predicted that this number will increase further in the next years and affect more people medically.

Hospitals are vulnerable to terrorist attacks, as they must remain easily accessible to the general public. Hospitals are also occupied with both staff and patients 24 hours a day, 365 days a year, meaning that any attack is almost guaranteed to inflict a multitude of casualties. In addition to the immediate effects of attacking a hospital, there are also uniquely devastating second- and third-order effects when hospitals are attacked.

A focused search of the Global Terrorism Database (GTD) was performed to identify terrorist attacks against hospitals throughout the world. Data between the years 1970-2018 were selected, which included 191,465 entries in total. These entries were then searched for incidents containing the term “hospital” and the results were manually searched to identify trends in the number of incidents occurring per year, as well as the armament that was employed, and the regions of the world where the attacks occurred.

A total of 430 terrorist attacks on hospitals were identified in the GTD, resulting in 1,291 deaths and an additional 1,921 wounded. The frequency of terrorist attacks against hospitals has been steadily increasing over the last two decades and is disproportionate to the overall increase in terrorist attacks against all target types. Attacks have been carried out against hospitals in 61 different countries. The most common method used in these attacks was “bombing/explosion,” which accounted for 299 attacks. Of the known terrorist groups identified in the GTD, “Houthi extremists (Anshar Allah)” and “Islamic State of Iraq and the Levant (ISIL)” carried out the greatest number of attacks on hospitals.

There has been a disproportionate rise in the frequency of terrorist attacks on hospitals when compared to other target types, highlighting the vulnerability of these key structures. Unsurprisingly, these attacks have inflicted large casualty counts in addition to disrupting community health care and disaster response. Attacks against hospitals have been reported on every inhabited continent except Australia, making their protection a matter of international security. The rate of terrorist attacks on hospitals has increased dramatically over the last two decades, creating an urgent need to develop improved defense strategies that will better ensure their protection.

Using an ambulance as an attack modality offers many advantages to a terrorist organization. Ambulances can carry more explosives than most vehicles and can often bypass security. Yet, studies examining how terrorist organizations have incorporated ambulances into their attacks are lacking.

This article seeks to identify and analyze known instances in which an ambulance has been used in a terrorist attack.

The Global Terrorism Database (GTD) was searched for terrorist events that involved the use of an ambulance from the years 1970-2018. Variables of event time, location, and loss of life were analyzed.

Twenty instances where an ambulance had been used in a terrorist attack were identified from the GTD. Fifteen of the attacks occurred in the Middle East, while the remaining five occurred in Southeast Asia. All attacks except one had occurred after 2001, and 13 had occurred within the past decade. Most attacks (12/20) resulted in up to three people killed, while six attacks had 10-20 casualties. The deadliest attack occurred in Kabul, Afghanistan in 2018 and caused over 100 casualties. One event did not have casualty information in the GTD. In all cases, ambulances were used as vehicle-borne improvised explosive devices (VBIED) by terrorist organizations.

This study shows that terrorists are increasingly acquiring and utilizing ambulances in their attacks, often with deadly consequences. Security and public health experts must be aware of this hazard and work to deny terrorists access to these vehicles.

Pregnant females are uniquely vulnerable to morbidity and mortality associated with trauma and from secondary exposure to environmental agents during and following a terrorist attack. For clinicians and emergency management planners, there are several specific considerations for pregnant victims of terrorist events in the planning and response phases of a terrorist event.

A review of scientific, medical, and academic literature pertaining to women and terrorist activities was performed. In addition, government reports and media accounts of terrorist attacks where women were direcdy or centrally involved as perpetrators were collected and reviewed. Common elements, themes, and similarities were analyzed by the investigator to determine trends in injury patterns, distribution of exposed individuals, and the acute and long-term health effects associated with the gravid female and her unborn child.

Several causes of morbidity and mortality among pregnant females and their unborn children as the result of terrorist attacks were discussed in the literature. Physical trauma, toxic inhalation effects, bioterrorism considerations, and psychosocial impacts were among those discussed most often. The disaster epidemiology associated with these health events is described, as well as the strategies for prevention and clinical management of this unique group of victims.

A greater understanding of the types of hazards and exposures which may affect a pregnant woman or her unborn child during or following a terrorist attack can assist in developing plans for medical counterterrorism. This epidemiological information can benefit both clinicians and emergency planners in anticipating the potential health and medical needs as well as planning for potential protective actions that can be implemented before or immediately following a terrorist incident.

In the wake of domestic terrorists attacks on 11 September 2001 and subsequent bioterrorist events employing anthrax, there no longer can be any debate about the potential for attacks employing Nuclear, Biological, or Chemical (NBC)/Weapons of Mass Destruction (WMD). As one way of acknowledging this long-standing threat and, in a concerted effort to mitigate the effects of possible future domestic NBC/WMD terrorist attacks, the US Department of Defense (DOD) and other US governmental agencies already had mounted an effort to provide Domestic Preparedness Training for First Responders in urban centers throughout the USA.

A paper and pencil questionnaire specifically designed to evaluate the effectiveness of Domestic Preparedness Training for Emergency First Responders has been developed. An earlier version of this instrument was piloted with a convenience sample of firefighters and paramedics (n = 78) in a northwest state. Based on replies to the pilot questionnaire, a pool of 27 items based on the objectives and content of the NBC/WMD Domestic Preparedness Awareness and Operations courses (plus additional background and appraised competency items) were selected for inclusion in a Domestic Preparedness Questionnaire (DPQ).

This paper first describes the essential psychometric properties of the DPQ based on replies from baseline and follow-up samples (n = 206 and n = 246 respectively) of urban firefighters and paramedics employed by a metropolitan city in a northwest state. The DPQ was employed to evaluate the outcomes of Domestic Preparedness training provided to a sample of urban fire-service personnel. The DPQ documented significant improvements in a group of “DP trained”-urban firefighters (n = 80) both in their awareness and operations content knowledge as well as in their perceived competencies to respond to acts of biological, chemical, or nuclear terrorism “in their own community” at four months post-training. A comparison group of “Not DP-trained” firefighters (n = 78) showed no statistically significant changes on these DPQ indices, suggesting that the documented improvements in the “DP-trained” firefighters on the DPQ were not due to “test reactivity” or to “historical” factors.

The findings suggest that the DPQ has adequate inter-item and test-retest reliability, possesses concurrent validity, and appears to be a sensitive measure of the Domestic Preparedness Training provided for urban firefighter and paramedic First Responders.