Chemical, biological, radiological, and nuclear (CBRN) incidents are those that involve chemical or biological warfare agents or toxic radiological or nuclear materials. These agents can cause disasters intentionally or accidentally. Hospitals play a crucial role in handling CBRN disasters. This study aimed to assess the CBRN preparedness of government hospitals in Riyadh.

A descriptive cross-sectional study was conducted across government hospitals in Riyadh. All government hospitals with more than 100 inpatient beds and an emergency department met the inclusion criteria. Hospital preparedness was assessed using an adaptation of the CBRNE (chemical, biological, radiological, nuclear, or explosive event) Plan Checklist. This adaptation was chosen due to the inclusion of explosive events in hospital disaster readiness, and its structural composition of key clinical guidelines necessary for a comprehensive disaster and readiness plan. Results were described in frequencies across several domains such as foundational considerations and planning which are used to assess plan preparedness using readiness tools, training, and awareness among staff members in accordance to a pre-established emergency plan, placed procedures and their implementation, and modules for preparing for a biological incident, a chemical incident, and a radiological or nuclear incident.

Of the 11 eligible hospitals, 10 participated in the study. Furthermore, CBRN considerations were included in the disaster plans of 7 hospitals. Drills had been conducted in collaboration with local agencies in only 2 hospitals. The staff had been trained to recognize the signs and symptoms of exposure to class (A) biological agents in less than half of the hospitals. Eight of the hospitals had antidotes and prophylactics to manage chemical incidents, but only half of them had radiation detection instruments. Personal protective equipment was available in all hospitals, but rapid access to stockpiles of medications was available in only half of them.

Government hospitals in Riyadh demonstrated insufficient CBRN preparedness as per the CBRNE Plan Checklist. Overall, there was a lack of preemptive planning, application of pre-established policies and procedures, and adequate staff training. Furthermore, several hospitals had insufficient stockpiles of medications and in concrete plans on accessing government stockpiles in the case of an emergency. Therefore, their staffs should be trained to manage CBRN emergencies, and local drills should be conducted to improve their preparedness.

The use of chemical, biological, radiation, and nuclear (CBRN) weapons is not new, and though rare, it is an issue of concern around the world due to their ability to cause large-scale mass-casualty events and their potential threat to global stability. The purpose of this study is to explore the use of CBRN weapons by non-state actors through analysis of the Violent Non-State Actor (VNSA) CBRN Event database, and aims to better inform health care systems of the potential risks and consequences of such events.

Data collection was performed using a retrospective database search through the VNSA CBRN Event database.

A total of 565 events were recorded. Five hundred and five (505) events (89.4%) involved single agents while 60 events (10.6%) involved multiple agents. Fatalities numbered 965 for chemical agents, 19 for biological agents, and none for radiological and nuclear events. Injuries numbered 7,540 for chemical agents, 59 for biological agents, 50 for radiological events, and none for nuclear attacks. Fatality and injury per attack was 2.22 and 17.37, respectively, for chemical event agents and 0.15 and 0.48, respectively, for biological event agents.

Violent Non-State Actors were responsible for 565 unique events around the world involving the use of CBRN weapons from 1990-2020. The United States (118), Russia (49), and Iraq (43) accounted for the top three countries where these events occurred. While CBRN events remain relatively rare, technological advances have the potential to facilitate the use of such weapons as part of a hybrid warfare strategy with significant repercussions for civilian health and health care systems.

The smallpox vaccination emergency preparedness program has been unsuccessful in enrolling sufficient numbers of healthcare workers.

The objective of this study was to use game theory to analyze a pre-event vaccination versus post-event vaccination program using the example of a terrorist considering an attack with smallpox or a hoax.

A three-person game (normal and extensive form), and an in-person game are played for pre-event and post-event vaccinations of healthcare workers facing the possibility of a smallpox attack or hoax.

Full pre-event vaccinations of all targeted healthcare workers are not necessary to deter a terrorist attack. In addition, coordinating vaccinations among healthcare workers, individual healthcare worker risk aversion, and the degree to which terrorists make the last move based on specific information on the status of pre-event vaccination all greatly impact strategy selection for both sides. A Nash Equilibrium of pre- and post-event vaccination strategies among a large number of healthcare professionals will tend to eliminate the advantage (of the terrorists) of a smallpox attack over a hoax, but may not eliminate some probability of a smallpox attack.

Emergency preparedness would benefit from game theory analysis of the costs and payoffs of specific terrorism/counter-terrorism strategies.

Emergency medical services (EMS) providers are ill-prepared in the areas of training and equipment for weapons of mass destruction (WMD) events and other public health emergencies.

A nationally representative sample of the basic and paramedic emergency medical service providers in the United States was surveyed to assess whether they had received training in WMD and/or public health emergencies, as part of their initial provider training and as continuing medical education (CME) within the past 24 months. Providers also were surveyed as to whether their primary EMS agency had the necessary specialty equipment to respond to these specific events.

More than half of EMS providers had some training in WMD response. Hands-on training was associated with EMS provider comfort in responding to chemical, biological and radiological events and public health emergencies (OR = 3.2; 95% CI = 3.1–3.3). Only a small portion (18.1%) of providers surveyed indicated that their agencies had the necessary equipment to respond to a WMD event. The comfort level and having equipment to respond these incidents was not as highly associated as the comfort level and having had training to respond to these incidents.

Lack of training and education as well as the lack of necessary equipment to respond to WMD events is associated with decreased comfort among emergency medical services providers in responding to chemical, biological, and radiological incidents. Better training and access to appropriate equipment may increase provider comfort in responding to these types of incidents.

The public health system has a specialized body of knowledge and expertise in bioterrorism and public health emergency management that can assist in the development and delivery of continuing medical education (CME) programs to meet the needs of emergency medical services (EMS) providers.

A nationally representative sample of the basic and paramedic EMS providers in the United States was surveyed to assess whether they had received training in weapons of mass destruction, bioterrorism, chemical terrorism, radiological terrorism, and/or public health emergencies, and how the training was provided.

Local health departments provided little in the way of training in biologic, chemical, or radiological terrorism to responders (7.4%–14.9%). State health departments provided even less training (6.3%–17.3%) on all topics to EMS providers. Training provided by the health department in bioterrorism and public health emergency response was associated with responder comfort in responding to a bioterrorism event (OR = 2.74,95% CI 2.68,2.81).

Local and state public health agencies should work with the emergency medical services systems to develop and deliver training with an all-hazards approach to disasters and other public health emergencies.

Numerous studies have suggested that emergency medical services (EMS) providers areill-prepared in the areas of training and equipment for response to events due to weapons of mass destruction(WMD) and other public health emergencies (epidemics, etc.).

A nationally representative sample of basic and paramedic EMS providers in the United States wassurveyed to assess whether they had received training in WMD and/or public health emergencies as part of their initial provider training and as continuing medical education within the past 24 months. Providers also were surveyed as to whether their primary EMS agency had the necessary specialty equipment to respond to these specific events.

More than half of EMS providers had some training in WMD response. Hands-on training was associated with EMS provider comfort in responding to chemical, biological, and/or radiological events and public health emergencies (odds ratio (OR) = 3.2, 95% confidence interval (CI) 3.1, 3.3). Only 18.1% of providers surveyed indicated that their agencies had the necessary equipment to respond to a WMD event. Emergency medical service providers who only received WMD training reported higher comfort levels than those who had equipment, but no training.

Lack of training and education as well as the lack of necessary equipment to respond to WMD events is associated with decreased comfort among emergency medical services providers in responding to chemical, biological, and/or radiological incidents. Better training and access to appropriate equipment may increase provider comfort in responding to these types of incidents.