Populations displaced by conflict face numerous threats to their psychological well-being; consequently, the prevalence of mental health problems, including anxiety, depression, and post-traumatic stress disorder can be elevated as compared to populations who have not experienced forced displacement.

Little is known about the mental health needs of displaced Iraqis. The factors associated with a need for psychological services among patients at seven clinics served by two NGOs that are known sources of care for the displaced Iraqi population in Amman, Jordan were explored.

The survey was conducted in January and February 2008 and included a random sample of care seekers from seven clinics selected using interval sampling. Interviews on the health needs of displaced Iraqis and their access to services, including mental health services lasting approximately 20 minutes were conducted.

Of the 664 survey participants, 49% (95% CI = 45–53%) of respondents reported needing mental health services and 5% (95% CI = 3–8%) of those in need had access to services. The length of time spent in Jordan (adjusted OR = 1.08; 95% CI = 1.00–1.11) was associated with the need for mental health services and the adjusted odds of requiring psychological services was 39% less for individuals from outside of Baghdad as compared to Baghdad residents (OR = 0.61; 95% CI = 0.38–0.98). Responders citing violence as a factor were twice as likely to be from Baghdad (OR = 2.28; 95% CI = 1.03–6.91), while interviewees reporting displacement as a cause for needing mental health services were twice as likely to be female (OR = 2.14; 95% CI = 1.12–4.18). In individuals 35–44 years of age (OR = 0.36; 95% CI = 0.14–0.87) the need for mental health services due to displacement decreased by 64%, while being a part of a female-headed household decreased the need by 81% (OR = 0.19; 95% CI = 0.06–0.57%).

More attention should be given to expanding the local Jordanian health system capacity for the provision of mental service. Targeted social and psychiatric interventions that are culturally sensitive and aligned with Inter-Agency Standing Committee recommendations should be developed to compliment and expand the existing mental health service capacity in Jordan.

The military conflict that occurred between Lebanon and Israel in July and August of 2006 was characterized by the heavy bombardment of specific geographic regions in Israel, resulting in considerable civilian casualties and property damage.

Israeli civilians directly and indirectly exposed to bombardment were compared on exposure to the recent bombardment, trauma history, perceived life threat and peritraumatic dissociation during the recent bombardment, and current post-traumatic stress disorder (PTSD) symptom severity.

Following the conflict, data were collected by telephone from 317 Israeli residents randomly selected from two towns that were subject to differing levels of exposure to the bombardment.

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Exposure to trauma during the Second Lebanon War, prior trauma exposure, PTSD symptom severity, perceived life threat, and peri-traumatic dissociation.

The residents directly affected by the bombardment (Kiryat Shmona; KS) endorsed more trauma exposure, (p <0.01); more prior trauma, (p <0.01); more life threat, (p <0.01); and greater PTSD symptomatology (12 % of KY participants and 38% of KS participants had probable PTSD), compared to residents in the comparison town (Kfar Yona; KY). Both groups reported a similar degree of peri-event dissociation (KS: M = 7.2 ±3.7; KY: M = 7.3 ±3.0). Perceived life threat mediated the relationship between exposure to bombardment and PTSD symptomatology. Time spent in bomb shelters was not associated with PTSD symptom severity. Prior shelling-related trauma negatively predicted PTSD.

The terror of bombardment is a risk factor for PTSD among civil-ians. Although there is considerable resilience in chronically threatened commu-nities, it is prudent to develop and implement public health approaches to prevent those most distressed during and after attacks from developing PTSD. Because, to a small degree, prior trauma exposure buffers the response to bombardment, interventions should consider leveraging citizens' past successful coping.

The human impact of the tsunami that occurred on 26 December 2004 was enormous, with Indonesia bearing a huge proportion of the losses. The aftermath brought predictions of communicable disease outbreaks and widespread fear of epidemics. However, evidence from previous disasters due to natural hazards does not support all of these predictions. The objectives of this study were to: (1) describe the relative importance of infectious diseases and injuries as a consequence of a disaster due to natural hazards; and (2) identify key recommendations for the improvement of control and surveillance of these diseases during and after disasters.

A team from the Center for Research on the Epidemiology of Disasters visited Jakarta and Banda Aceh from 11–23 January 2005, and collected data from the Central and Provincial Ministries of Health (MOH), the World Health Organization (WHO), and a field hospital from the International Committee of the Red Cross in Banda Aceh. The epidemiological profiles of diseases before and after the tsunami were compared. Cholera, tetanus, wounds and wound infections, acute respiratory infections, malaria, and dengue were included in this analysis.

Certain diseases (e.g., cholera, malaria, dengue) are not always an immediate priority post-disaster. Rates of disaster-related health conditions requiring emergency response fell by half, and became negligible around four weeks after the precipitating events. Some conditions, such as aspiration pneumonia and tetanus, which normally are rare, require special preparedness for emergency personnel. In addition, resistant and rare pathogens are associated with disasters due to natural hazards in the tropics and require specialized knowledge for the rapid and successful treatment of related infections.

Within the first four weeks of a disaster, international humanitarian agencies in the health sector should start working with the MOH. The WHO surveillance system established immediately after the tsunami offers lessons for developing a prototype for future emergencies. Guidelines for tetanus and aspiration pneumonia should be included in disaster medicine handbooks, and humanitarian aid groups should be prepared to provide emergency obstetrics and post-natal services. Relief funding after naturally occurring disasters should consider funding sustainability. Donors should know when to stop providing emergency relief funds and transition to recovery/development strategies.

The global impact of severe acute respiratory syndrome (SARS) brought attention to the role of healthcare professionals as “first receivers” during infectious disease outbreaks, a collateral aspect to their role as responders. This article records and reports concerns expressed by Canadian emergency and critical care nurses in terms of organizational and social supports required during infectious disease outbreaks. The nature of work-family and family-work conflict perceived and experienced by nurses during infectious disease outbreaks, as well as the supports needed to enable them to balance their social roles during this type of heightened stress, are explored.

Five focus groups consisting of 100 nurses were conducted using a Structured Interview Matrix facilitation technique.

Four emergent themes included: (1) substantial personal/professional dilemmas; (2) assistance with child, elder, and/or pet care; (3) adequate resources and vaccinations to protect families; and (4) appropriate mechanisms to enable two-way communication between employees and their families under conditions of quarantine or long work hours.

Social and organizational supports are critical to help buffer the effects of stress for nurses and assist them in managing difficult role conflicts during infectious disease outbreaks. These supports are necessary to improve response capacity for bio-disasters.

While the number of humanitarian health workers has grown considerably along with the emphasis on evidence-based humanitarian practice over the last 15 years, no organization exists to ensure ongoing professionalization of this area of expertise.

To determine whether and to what degree the community of humanitarian health workers self-identify as a professional group; whether a need for a professional society exists to support such a group; and if so, what fundamental elements and activities should it encompass and provide.

A humanitarian, listserv-based survey was undertaken to evaluate humanitarian professional self-identification, needs for and interest in professional support functions, and priorities toward developing a professional organization to provide needed services.

The resulting respondent population represented a broad distribution of age and experience with education and experience being equally important factors in defining humanitarian health professionals. Respondents viewed themselves as humanitarian professionals nearly to the extent they viewed themselves as health-specific technical experts who happen to work in humanitarian assistance; they expressed a strong desire to establish a professional society reflecting that self-identification; and that body should focus on activities of education and training, networking and dialogue, and developing and refining core competencies to support best practices.

Humanitarian health workers self-identify as professionals in humanitarian assistance and as technical experts. A professional organization with specific support functions would be of interest to many humanitarian health professionals.

As members of the Japan Disaster Relief (JDR) team in Banda Aceh, three of the authors treated 1,891 patients following the tsunami of 2004. Of the 367 cases with traumatic injuries, 216 cases required antimicrobial therapy. The medical services were continued by the Japan Self-Defense (JSD) Medical Team until mid-March 2005. Of the 216 cases initially treated by JDR, 54 required prolonged antimicrobial therapy for persistent symptoms despite repeated debridement.The aim of this study is to recommend an appropriate antimicrobial therapy for water-associated wound infections in the absence of laboratory services in disaster settings following tsunami.

The JDR and JSD treatment records were analyzed retrospectively. In August 2006, 19 months after the tsunami, the authors investigated pathogens in natural aquatic habitats in the affected area in Banda Aceh. At the same time, interviews with tsunami survivors were performed to determine the influential factors that facilitated wound infections after the tsunami.

From the 49 water samples tested, Aeromonas sp., Vibrio sp., Klebsiella sp., and Proteus sp. were isolated from 24, 16, 15, and six samples, respectively. Regardless of the genus, almost all of the isolated gram-negative bacilli were sensitive to ciprofloxacin and gentamicin.

From the microbiological test results and analyses of the medical records and interviews, the researchers recommend the following regimen when clinical microbiological tests are not available: initial treatment with beta-lactam penicillins for three days, followed, if the first antimicrobial is not effective, by ciprofloxacin or any other relevant new quinolones, with the addition of gentamicin if necessary.

During 2005, Hurricanes Katrina and Rita struck the US Gulf Coast, displacing approximately two million people. With >250,000 evacuees in shelters, volunteers from the American Red Cross (ARC) and other nongovernmental and faith-based organizations provided services. The objective of this study was to evaluate the composition, pre-deployment training, and recognition of scenarios with outbreak potential by shelter health staff.

A rapid assessment using a 36-item questionnaire was conducted through in-person interviews with shelter health staff immediately following Hurricanes Katrina and Rita. Data were collected by sampling at shelters located throughout five ARC regions in Texas. The survey focused on: (1) public health capacity; (2) level of public health awareness among staff; (3) public health training prior to deployment; and (4) interest in technical support for public health concerns. In addition, health staff volunteers were asked to manage 11 clinical scenarios with possible public health implications.

Forty-three health staff at 24 shelters were interviewed. Nurses comprised the majority of shelter health volunteers and were present in 93% of shelters; however, there were no public health providers present as staff in any shelter. Less than one-third of shelter health staff had public health training, and only 55% had received public health information specific to managing the health needs of evacuees. Only 37% of the shelters had a systematic method for screening the healthcare needs of evacuees upon arrival. Although specific clinical scenarios involving case clusters were referred appropriately, 60% of the time, 75% of all clinical scenarios with epidemic potential did not elicit proper notification of public health authorities by shelter health staff. In contrast, clinical scenarios requiring medical attention were correctly referred >90% of the time. Greater access and support from health and public health experts was endorsed by 93% of respondents.

Public health training for sheltering operations must be enhanced and should be a required component of pre-deployment instruction. Development of a standardized shelter intake health screening instrument may facilitate assessment of needs and appropriate resource allocation. Shelter health staff did not recognize or report the majority of cases with epidemic potential to public health authorities. Direct technical support to shelter health staff for public health concerns could bridge existing gaps and assist surveillance efforts.

Few studies have examined post-disaster coping abilities of health facilities and hospitals. On 15 August 2007, a 7.9 (Richter) earthquake struck off the western coast of Peru near the Department of Ica that devastated the healthcare infrastructure. The impact of the earthquake on the health facilities in the four most affected provinces (Cañete, Chincha, Ica, and Pisco), the risk factors associated with the damages incurred, ability to provide services, and humanitarian assistance received were assessed.

A stratified, systematic sampling design was used to interview a sample of 40 health facilities. The most senior healthcare provider at each facility was interviewed about the facility's experience with service provision following the earthquake.

Sixty percent of the facilities reported some damage due to the earthquake; four (10%) were completely destroyed. A total of 78% of the facilities reported providing medical care within the first 48 hours after the earthquake and public facilities were more likely to remain open than were private facilities (p = 0.030). Facilities with an emergency response plan were more likely to provide services than were those without a plan (p = 0.043). Six months after the earthquake, similar numbers of HIV and tuberculosis (TB) patients were receiving treatment at the sampled facilities as prior to the earthquake, and no difficulties were reported in obtaining medications. Some form of assistance, most commonly medications, was received by 60% of the facilities; receipt of assistance was not associated with the facility type, location, damage incurred, or post-disaster service provision.

Response plans were an important factor in the ability to provide services immediately following an earthquake. While a facility's ability to provide services can be determined by structural impacts of the precipitating event, response plans help the staff to continue to provide services and care for affected populations, and appropriately arrange referrals when care cannot be provided at the facility. The findings suggest that health facilities in disasterprone areas should invest in developing and implementing disaster response plans in order to improve health service provision capacity during disasters.

The release of biohazardous agents could affect many people. Preparedness is crucial for adequate responses to accidental or deliberate release of biohazardous agents. It is believed that exercises based on simulated incident scenes are effective methods for the training of firefighters and biohazard response teams. Structured evaluations are important methods used to identify areas of ineffectiveness and to assure the quality of responses to releases of biohazards.

A local fire department conducted a full-scale biohazard exercise in an elementary school. The firefighters practiced prohibiting entry to the area, establishing security zones, evacuating victims, assessing hazards, preventing further dissemination, and sampling and keeping the suspicious material in safe custody.Trained observers systematically evaluated the exercise following a standardized evaluation protocol. A set of data collection templates were created based on standard operating procedures extracted from current guidelines.

There were 60 firefighters, eight members of the incident command, 16 simulated victims, and 18 trained observers that participated in the exercise. Out of 31 standard operating procedures, 20 were in accordance with the guidelines, 10 were performed incorrectly, and one was not applicable. Major problems related to the assessment and handling of the suspicious material, the use of protective equipment, and decontamination of victims. Reasons for incomplete and/or conflicting documentation included insufficient knowledge and training of observers, imprecise instructions about documentation, and the size of observation zones.

Intensive education and training of response activities is necessary. Each fire department should perpetually reassess their technical equipment and specific skills and their communication and command structures. The applied documentation system performed well in disclosing discrepancies between observed response activities and current recommendations. Using external observers provided transparent and independent data. However, intensive observer training is necessary. Observer training should include detailed, written instructions and short guidelines that could be available during the exercise.

The Working Group on Mental Health and Psychosocial Support was convened as part of the 2009 Harvard Humanitarian Action Summit. The Working Group chose to focus on ethical issues in mental health and psychosocial research and programming in humanitarian settings. The Working Group built on previous work and recommendations, such as the Inter-Agency Standing Committee's Guidelines on Mental Health and Psychosocial Support in Emergency Settings.

The objective of this working group was to address one of the factors contributing to the deficiency of research and the need to develop the evidence base on mental health and psychosocial support interventions during complex emergencies by proposing ethical research guidelines. Outcomes research is vital for effective program development in emergency settings, but to date, no comprehensive ethical guidelines exist for guiding such research efforts.

Working Group members conducted literature reviews which included peer-reviewed publications, agency reports, and relevant guidelines on the following topics: general ethical principles in research, cross-cultural issues, research in resource-poor countries, and specific populations such as trauma and torture survivors, refugees, minorities, children and youth, and the mentally ill. Working Group members also shared key points regarding ethical issues encountered in their own research and fieldwork.

The group adapted a broad definition of the term “research”, which encompasses needs assessments and data gathering, as well as monitoring and evaluation. The guidelines are conceptualized as applying to formal and informal processes of assessment and evaluation in which researchers as well as most service providers engage. The group reached consensus that it would be unethical not to conduct research and evaluate outcomes of mental health and psychosocial interventions in emergency settings, given that there currently is very little good evidence base for such interventions. Overarching themes and issues generated by the group for further study and articulation included: purpose and benefits of research, issues of validity, neutrality, risk, subject selection and participation, confidentiality, consent, and dissemination of results.

The group outlined several key topics and recommendations that address ethical issues in conducting mental health and psychosocial research in humanitarian settings. The group views this set of recommendations as a living document to be further developed and refined based on input from colleagues representing different regions of the globe with an emphasis on input from colleagues from low-resource countries.

Out-of-hospital cardiac arrest is one of the leading causes of death in Mexico, but many survival and prognostic factors are unknown. The aim of this study was to assess out-of-hospital cardiac arrest in a Mexican city.

This was a prospective, cohort study that evaluated the records of the major ambulance services in the city of Queretaro, Mexico. Means, standard deviation, and percentages for the categorical variables were obtained. Logistic regression was performed to determine the effects between interventions, times, and return of spontaneous circulation (ROSC).

For an 11-month period, 148 out-of-hospital cardiac arrest cases were recorded. The mean age of the victims was 54 ±22.6 years and 90 (65.3%) were males. Forty-nine cases were related to cardiac disease, 46 to other disease, 27 to trauma, 18 to terminal illnesses, and three to drowning. Twelve (8.6%) patients had a pulse upon hospital arrival, but none survived to discharge. No victims were defibrillated prior to ambulance arrival. The collapse-assessment interval was 22.5 ±19:1 minutes, the mean value for the ambulance response times was 13:6 ±10:4 minutes. Basic emergency medical technicians applied chest compressions to 40 victims (27.2%), controlled the airway in 32 (21.8%), and defibrillated seven (4.8%). Chest compressions and airway control showed an OR of 8 and 12 respectively for ROSC.

The poor survival rate in this study emphasizes the need to improve efforts in provider training and public education. Authorities must promote actions to enhance prehospital emergency services capabilities, shorten response times, and provide community education to increase the chances of survival for out-of-hospital cardiac arrest victims in Mexico.