If the Ebola tragedy of West Africa has taught us anything, it should be that the 2005 International Health Regulations (IHR) Treaty, which gave unprecedented authority to the World Health Organization (WHO) to provide global public health security during public health emergencies of international concern, has fallen severely short of its original goal. After encouraging successes with the 2003 severe acute respiratory syndrome (SARS) pandemic, the intent of the legally binding Treaty to improve the capacity of all countries to detect, assess, notify, and respond to public health threats has shamefully lapsed. Despite the granting of 2-year extensions in 2012 to countries to meet core surveillance and response requirements, less than 20% of countries have complied. Today it is not realistic to expect that these gaps will be solved or narrowed in the foreseeable future by the IHR or the WHO alone under current provisions. The unfortunate failures that culminated in an inadequate response to the Ebola epidemic in West Africa are multifactorial, including funding, staffing, and poor leadership decisions, but all are reversible. A rush by the Global Health Security Agenda partners to fill critical gaps in administrative and operational areas has been crucial in the short term, but questions remain as to the real priorities of the G20 as time elapses and critical gaps in public health protections and infrastructure take precedence over the economic and security needs of the developed world. The response from the Global Outbreak Alert and Response Network and foreign medical teams to Ebola proved indispensable to global health security, but both deserve stronger strategic capacity support and institutional status under the WHO leadership granted by the IHR Treaty. Treaties are the most successful means the world has in preventing, preparing for, and controlling epidemics in an increasingly globalized world. Other options are not sustainable. Given the gravity of ongoing failed treaty management, the slow and incomplete process of reform, the magnitude and complexity of infectious disease outbreaks, and the rising severity of public health emergencies, a recommitment must be made to complete and restore the original mandates as a collaborative and coordinated global network responsibility, not one left to the actions of individual countries. The bottom line is that the global community can no longer tolerate an ineffectual and passive international response system. As such, this Treaty has the potential to become one of the most effective treaties for crisis response and risk reduction worldwide. Practitioners and health decision-makers worldwide must break their silence and advocate for a stronger Treaty and a return of WHO authority. (Disaster Med Public Health Preparedness. 2015;9:568–580)

On December 31, 2019 the China National Health Commission (NHC) reported that an unknown cause of pneumonia had been detected in Wuhan in Hubei province. On February 12, the disease caused by the novel coronavirus (2019-nCoV) was given a formal name, COVID-19. On January 20, 2020, the first case of COVID-19 was confirmed in Korea. The age-specific death rate was the highest among patients over 70 years of age, with underlying diseases in their circulatory system, such as myocardial infarction, cerebral infraction, arrythmia, and hypertension. Patients with underlying disease who are 70 years of age or older should recognize that there is a high possibility of developing a serious disease in case of viral infection and follow strict precautions.

This article provides practical ethical guidance for clinicians making decisions after a nuclear detonation, in advance of the full establishment of a coordinated response. We argue that the utilitarian maxim of the greatest good for the greatest number, interpreted only as “the most lives saved,” needs refinement. We take the philosophical position that utilitarian efficiency should be tempered by the principle of fairness in making decisions about providing lifesaving interventions and palliation. The most practical way to achieve these goals is to mirror the ethical precepts of routine clinical practice, in which 3 factors govern resource allocation: order of presentation, patient's medical need, and effectiveness of an intervention. Although these basic ethical standards do not change, priority is given in a crisis to those at highest need in whom interventions are expected to be effective. If available resources will not be effective in meeting the need, then it is unfair to expend them and they should be allocated to another patient with high need and greater expectation for survival if treated. As shortage becomes critical, thresholds for intervention become more stringent. Although the focus of providers will be on the victims of the event, the needs of patients already receiving care before the detonation also must be considered. Those not allocated intervention must still be provided as much appropriate comfort, assistance, relief of symptoms, and explanations as possible, given the available resources. Reassessment of patients' clinical status and priority for intervention also should be conducted with regularity.

(Disaster Med Public Health Preparedness. 2011;5:S46-S53)

Background: When the 2004 Indian Ocean tsunami suddenly hit unsuspecting coastal populations in Sri Lanka, it inflicted unprecedented devastation including 35,000 deaths and 500,000 people displaced. Evaluating the psychological impact of this natural disaster provides valuable insights into planning interventions and disaster preparedness.

Methods: A cross-sectional survey was conducted among 264 adult males and females ≥16 years old living in temporary shelters housing tsunami survivors at 6 months. Interviewer-administered structured interviews were conducted to measure posttraumatic stress disorder (PTSD) and its risk factors.

Results: The participation rate was 97%. Of the subjects, 56% met criteria for symptoms of PTSD, with females at 64% and males at 42%. Females had at least twice the risk of experiencing PTSD (odds ratio [OR] 2.27, 95% confidence interval [CI] 1.37–3.76). This sex difference persisted after adjusting for age, marital status, being a parent, loss of family members, amount of social support, education level, and level of depression (OR 2.14, 95% CI 1.21–3.80). Depression was significantly associated with PTSD (OR 7.19, 95% CI 3.83–13.52).

Conclusions: In this directly affected population, a majority met criteria for PTSD, indicating a significant long-term public health burden. The findings also confirm that females are at much higher risk for PTSD than males, suggesting that special mental health efforts should be targeted at women exposed to trauma. (Disaster Med Public Health Preparedness. 2007;1:34–43)

Objectives: To identify health care workers most at risk for H1N1 infection before vaccination and compare health outcomes after vaccination.

Methods: The indices used to gauge employee health were laboratory-confirmed H1N1 data, laboratory-confirmed influenza A data, and employee sick hours records. In phase 1 of this 2-phase study, absenteeism records for 6,093 hospital employees before vaccine administration were analyzed according to department and employee position during the spring 2009 H1N1 pandemic.

Results: Records of 123 confirmed reports of laboratory-confirmed influenza A or novel H1N1 infections in hospital employees were also analyzed. Two thirds of the H1N1 cases occurred during June (infection rates in parentheses): 34 in physicians and medical personnel (6.7%), 36 in nurses and clinical technicians (2.2%), 39 in Administrative & Support Personnel (infection rate = 1.2%), 3 in Social Workers & Counselors (infection rate = 1.0%), 8 in Housekeeping & Food Services (infection rate = 2.7%), and 3 in Security & Transportation (infection rate=3.9%). When analyzed according to department, the adult emergency department (infection rate = 28.8%) and the pediatric emergency department (infection rate = 25.0%) had the highest infection rates per department.

Conclusions: Of the reported cases of H1N1 in health care workers, 49% occurred in a population that constitutes less than 20% of the total population studied. Physicians and medical personnel had a higher infection rate than other employee positions, whereas ED personnel had the highest infection rate.

(Disaster Med Public Health Preparedness. 2010;4:47-54)

Background: On September 13, 2008, Hurricane Ike, a category 2 storm with maximum sustained winds of 110 mph, made landfall near Galveston, Texas. Ike produced a damaging, destructive, and deadly storm surge across the upper Texas and southwestern Louisiana coasts. Thirty-four Texas counties were declared disaster areas by the Federal Emergency Management Agency; 15 counties were under mandatory evacuation orders. To describe causes of death associated with this hurricane and identify prevention strategies during the response and recovery phases, the Texas Department of State Health Services (DSHS) monitored mortality data in 44 counties throughout the state. This report summarizes Ike-related deaths reported by Texas medical examiners, justices of the peace (coroners), forensic centers, public health officials, and hospitals.

Methods: Based on the Centers for Disease Control and Prevention (CDC) disaster-related mortality surveillance form, DSHS developed a state-specific 1-page form and collected (optimally daily) data on demographic, date and place of death, and cause and circumstance of deaths. A case was defined as any death that was directly or indirectly related to Ike among evacuees, residents, nonresidents, or rescue personnel in the declared disaster counties, counties along the Texas Gulf coast or counties known to have evacuation shelters occurring September 8, 2008, through October 13, 2008. Analyzed data were shared with the state emergency operation center and the CDC on a daily basis.

Results: The surveillance identified 74 deaths in Texas as directly (10 [14%]), indirectly (49 [66%]), or possibly (15 [20%]) related to Ike. The majority of deaths (n = 57) were reported by medical examiners. Deaths occurred in 16 counties of the 44 counties covered by the surveillance. The majority of deaths occurred in Harris and Galveston (28 [38%] and 17 [23%]), respectively. The deceased ranged in age from younger than 1 year to 85 years, with an average age of 46 years (median 50 years); 70% were male. Of the 74 deaths, 47 (64%) resulted from injuries, 23 (31%) from illnesses, and 4 (5%) were undetermined. Among the injuries, carbon monoxide poisoning (13 [18%]) and drowning (8 [11%]) were the leading causes of injury-related deaths. Cardiovascular failure (12 [16%]) was the leading cause of illness-related deaths.

Conclusions: Defining the relation of death to hurricane using an active mortality surveillance system is possible. The active mortality surveillance form used in Ike provided valuable daily information to DSHS, state emergency management officials, and the CDC regarding the characteristics of deaths in the state. Most of the Ike-related deaths were caused by injury (direct and indirectly related) such as carbon monoxide poisonings and drowning and may have been preventable by educating the public.

(Disaster Med Public Health Preparedness. 2011;5:23-28)

Background: In April 2009, King County, Washington, experienced a sustained outbreak of 2009 H1N1 influenza A. This report describes the epidemiology of that outbreak in King County, home to a diverse population of 1.9 million people.

Methods: The 2 primary sources of data are case investigations of reported laboratory-confirmed 2009 H1N1 influenza A and a population-based syndromic surveillance system that captures data from emergency departments (EDs). A syndromic category for influenza-like illness was defined based on chief complaint and diagnosis.

Results: ED visits for influenza-like illness peaked quickly in the first week of the outbreak and remained high for approximately 6 weeks, with school-age children accounting for the greater number of ED visits, followed by young adults. Children ages 0 to 4 years had the highest rate of hospitalization. Among reported cases, blacks, Asians, and Hispanics were more likely to be hospitalized. Predisposing factors associated with admission were immune compromise, chronic lung disease, chronic heart disease, pregnancy, diabetes, and asthma. Of people receiving antiviral treatment, 34% started their medication more than 2 calendar days after the onset of illness. Mean days between illness onset and antiviral treatment were greater for blacks, Hispanics, and foreign language speakers.

Conclusions: The spring 2009 influenza A H1N1 outbreak disproportionately affected children, young adults, and racial and ethnic minorities. Opportunities exist to improve the timeliness of antiviral treatment. Potential barriers to care for racial and ethnic minorities should be proactively addressed to ensure prompt evaluation and treatment. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S109–S116)

Objectives: One of the most striking features of the ongoing conflict in the Democratic Republic of Congo (DRC) is the use of sexual violence. In spite of the brutality of these crimes, the experiences of women affected by sexual violence in Eastern DRC remain poorly characterized. This analysis aimed to (1) provide detailed demographics of sexual violence survivors presenting to Panzi Hospital; (2) examine how demographic factors might impact patterns of sexual violence; and (3) describe care-seeking behavior among sexual violence survivors.

Methods: The demographics and care-seeking behavior of sexual violence survivors in South Kivu Province were described from a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital (2004-2008).

Results: A total of 4311 records were reviewed. The mean age of survivors was 35 years. Most women (53%) were married, self-identified with the Bashi tribe (65%), and reported agriculture as their livelihood (74%). The mean time delay between sexual assault and seeking care was 10.4 months. Five reasons were identified to help explain the lengthy delays to seeking care: waiting for physical symptoms to develop or worsen before seeking medical attention, lack of means to access medical care, concerns that family would find out about the sexual assault, stigma surrounding sexual violence, and being abducted into sexual slavery for prolonged periods of time.

Conclusions: Many sexual assault survivors have very delayed presentations to medical attention. Promoting timely access of medical care may best be facilitated by reducing stigma and by educating women about the benefits of early medical care, even in the absence of injuries or symptoms.

(Disaster Med Public Health Preparedness. 2012;6:393-401)

A widely produced chemical, chlorine is used in various industries including automotive, electronics, disinfectants, metal production, and many others. Chlorine is usually produced and transported as a pressurized liquid; however, as a gas it is a significant pulmonary irritant. Thousands of people are exposed to chlorine gas every year, and while large-scale exposures are uncommon, they are not rare. Symptoms are usually related to the concentration and length of exposure, and although treatment is largely supportive, certain specific therapies have yet to be validated with randomized controlled trials. The majority of those exposed completely recover with supportive care; however, studies have shown the potential for persistent inflammation and chronic hyperreactivity. This case report describes an incident that occurred in Graniteville, South Carolina, when a train derailment exposed hundreds of people to chlorine gas. This report reviews the events of January 6, 2005, and the current treatment options for chlorine gas exposure.(Disaster Med Public Health Preparedness. 2014;0:1-6)

Diagnostic testing to identify patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) plays a key role to control the coronavirus disease (COVID-19) pandemic. While several countries have implemented the use of diagnostic testing in a massive scale as a cornerstone for infection control and surveillance, other countries affected by the pandemic are hampered by its limited testing capacity. Pooled testing was first introduced in the 1940s and is now used for screening in blood banks. Testing is done by pooling multiple individual samples together. Only in the case of a positive pool test would individual samples of the pool be tested, thus substantially reducing the number of tests needed. Several studies regarding their use for SARS CoV-2 have been done in the United States, Israel, and Germany. Studies have shown that an individual positive sample can still be detected in pools of up to 32 samples, and possibly even 64 samples, provided that additional polymerase chain reaction (PCR) amplification cycles are conducted with a sensitivity of 96%. Simulation studies to determine optimal pool size and pooling techniques have also been conducted. Based on these studies, pooled testing is shown to be able to detect positive samples with sufficient accuracy and can easily be used with existing equipment and personnel for population-wide screening.