The #effect of a #terrorist #attack on #emergency department inflow: an observation study using difference-in-differences methodology (Scand J Trauma Resusc & Emerg Med., abstract)

[Source: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, full page: (LINK). Abstract, edited.]

Original research / Open Access

The effect of a terrorist attack on emergency department inflow: an observation study using difference-in-differences methodology

Andreas Ekström, Fredrik Eng-Larsson, Olov Isaksson, Lisa Kurland and Martin Nordberg

Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 201927:57
/ DOI:

©  The Author(s). 2019

Received: 5 March 2019 – Accepted: 17 May 2019 – Published: 24 May 2019



Study objective

The objective of this study was to investigate how the terrorist attack in Stockholm, Sweden affected patient inflow to the general emergency departments (EDs) in close proximity of the attack. The study analyzed if, and to what extent, the attack impacted ED inflow during the following days and weeks.


In a retrospective observational study, anonymized aggregated data on ED arrivals (inflow of patients) to all seven of the EDs in the Stockholm County was analyzed using the Difference-in-Differences (DiD) estimator. The control groups were the affected hospitals in the years prior to the terrorist attack. The number of ED visits was retrieved from the Stockholm County Council administrative database.


The study shows a statistically significant reduction in overall ED inflow of 7–9% following the attack. The effect was strongest initially after the attack, and ED inflow regained normal levels within approximately three weeks’ time, without any significant rebound effect. The effect on ED inflow also decreased with distance from ground zero, and was not significant further away than 10 km.


The results showed that ED inflow was significantly decreased in the weeks immediately following the Stockholm terrorist attack. The reasons for this cannot be fully explained in this observational study. However, the results suggest that some patients actively choose when, where and if they should go to the ED.

Keywords: Emergency service – Hospital – Patient acceptance of health care – Terrorism – Health behavior

Keywords: Terrorism; Society; Sweden.


#Archaeological #evidence that a late 14th-century #tsunami devastated the coast of northern #Sumatra and redirected history (Proc Natl Acad Sci USA, abstract)

[Source: Proceedings of the National Academy of Sciences of the United States of America, full page: (LINK). Abstract, edited.]

Archaeological evidence that a late 14th-century tsunami devastated the coast of northern Sumatra and redirected history

Patrick Daly, Kerry Sieh, Tai Yew Seng, Edmund Edwards McKinnon, Andrew C. Parnell, Ardiansyah, R. Michael Feener, Nazli Ismail, Nizamuddin, and Jedrzej Majewski

PNAS first published May 28, 2019 / DOI:

Contributed by Kerry Sieh, April 11, 2019 (sent for review February 8, 2019; reviewed by Roland J. Fletcher, Anthony J. S. Reid, and Ezra B. W. Zubrow)



We demonstrate that a tsunami in the late 14th century CE destroyed coastal sites along a critical part of the maritime Silk Road and set in motion profound changes in the political economy of Southeast Asia. Our results provide a precise chronology of settlement and trade along a historically strategic section of the Sumatran coast and are robust physical evidence for the rise of the Aceh Sultanate. Tragically, coastal areas impacted by the late 14th century tsunami were devastated by the 2004 Indian Ocean tsunami. This makes our findings relevant to debates about hazard mitigation and risk reduction. This example shows that archaeological, historical, and geological data are relevant in discussions about the long-term sustainability of communities exposed to geological hazards.



Archaeological evidence shows that a predecessor of the 2004 Indian Ocean tsunami devastated nine distinct communities along a 40-km section of the northern coast of Sumatra in about 1394 CE. Our evidence is the spatial and temporal distribution of tens of thousands of medieval ceramic sherds and over 5,000 carved gravestones, collected and recorded during a systematic landscape archaeology survey near the modern city of Banda Aceh. Only the trading settlement of Lamri, perched on a headland above the reach of the tsunami, survived into and through the subsequent 15th century. It is of historical and political interest that by the 16th century, however, Lamri was abandoned, while low-lying coastal sites destroyed by the 1394 tsunami were resettled as the population center of the new economically and politically ascendant Aceh Sultanate. Our evidence implies that the 1394 tsunami was large enough to impact severely many of the areas inundated by the 2004 tsunami and to provoke a significant reconfiguration of the region’s political and economic landscape that shaped the history of the region in subsequent centuries.

tsunami – Sumatra – Aceh – postdisaster recovery – hazards

Keywords: Earthquakes; Tsunami; History; Society; Sumatra.


#Earthquake in Western #Iran: #Renovation Kills (PLoS Curr., abstract)

[Source: PLoS Currents Disasters, full page: (LINK). Abstract, edited.]

Earthquake in Western Iran: Renovation Kills


AUTHORS: Abbas Ostadtaghizadeh, Dr. Mona Khaleghy Rad, Hamidreza Aghababaeian, Mehdi Zare, Farnaz Kamranzad




Earthquake is the most important cause of death from natural disasters in Iran. This paper brings attention to the main causes of loss of life due to the Kermanshah province earthquake (Nov 12 2017), and provides a wakeup call about the unsafe nature of buildings there.


This study is based on official reports review and a field assessment in the areas affected by the earthquake in western Iran.


Although buildings in this area are mainly old structures, strangely, more than 70% of the destroyed buildings in this earthquake were under 5 years of age, newly built or renovated buildings according to mandated building codes.


Mandated building codes and construction rules and regulations are not respected even for the newly constructed or reconstructed structures buildings.

Keywords: Earthquake, Iran, construct, reconstruct, Building codes


The authors received no fund for this study.

Keywords: Earthquakes; Mass Casualty Events; Iran; Society.


#Quality of #Life of Persons Injured on 9-11: Qualitative Analysis from the #WTC #Health #Registry (PLoS Curr., abstract)

[Source: PLoS Currents Disasters, full page: (LINK). Abstract, edited.]

Quality of Life of Persons Injured on 9/11: Qualitative Analysis from the World Trade Center Health Registry


AUTHORS: Dr. Lisa M. Gargano, Robyn Gershon, Dr Robert Brackbill




A number of studies published by the World Trade Center Health Registry (Registry) document the prevalence of injuries sustained by victims of the World Trade Center Disaster (WTCD) on 9/11. Injury occurrence during or in the immediate aftermath of this event has been shown to be a risk factor for long-term adverse physical and mental health status. More recent reports of ongoing health and mental health problems and overall poor quality of life among survivors led us to undertake this qualitative study to explore the long-term impact of having both disaster-related injuries and peri-event traumatic exposure on quality of life in disaster survivors.


Semi-structured, in-depth individual telephone interviews were conducted with 33 Registry enrollees who reported being injured on 9/11/01. Topics included: extent and circumstance of the injury(ies), description of medical treatment for injury, current health and functional status, and lifestyle changes resulting from the WTCD. The interviews were recorded, transcribed, and inductively open-coded for thematic analysis.


Six themes emerged with respect to long term recovery and quality of life: concurrent experience of injury with exposure to peri-event traumatic exposure (e.g., witnessing death or destruction, perceived life threat, etc.); sub-optimal quality and timeliness of short- and long-term medical care for the injury reported and mental health care; poor ongoing health status, functional limitations, and disabilities; adverse impact on lifestyle; lack of social support; and adverse economic impact. Many study participants, especially those reporting more serious injuries, also reported self-imposed social isolation, an inability to participate in or take enjoyment from previously enjoyable leisure and social activities and greatly diminished overall quality of life.


This study provided unique insight into the long-term impact of disasters on survivors. Long after physical injuries have healed, some injured disaster survivors report having serious health and mental health problems, economic problems due to loss of livelihood, limited sources of social support, and profound social isolation. Strategies for addressing the long-term health problems of disaster survivors are needed in order to support recovery.


This publication was supported by Cooperative Agreement Numbers 2U50/OH009739 and 5U50/OH009739 from the National Institute for Occupational Safety and Health (NIOSH) of the Centers for Disease Control and Prevention (CDC); U50/ATU272750 from the Agency for Toxic Substances and Disease Registry (ATSDR), CDC, which included support from the National Center for Environmental Health, CDC; and by the New York City Department of Health and Mental Hygiene (NYC DOHMH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIOSH, CDC or the Department of Health and Human Services. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Keywords: Society; Terrorism; Mass Casualty Events; USA; New York.


Mass #Casualty #Decontamination in a #Chemical or #Radiological/ #Nuclear #Incident: Further Guiding Principles (PLoS Curr Dis., abstract)

[Source: PLoS Currents Disasters, full page: (LINK). Abstract, edited.]

Mass Casualty Decontamination in a Chemical or Radiological/ Nuclear Incident: Further Guiding Principles


AUTHORS: Holly Carter, Richard Amlôt, Richard Williams, G. James Rubin, John Drury



This short report presents a response to an article written by Cibulsky et al. (2016). The paper by Cibulsky et al. presents a useful and timely overview of the evidence surrounding the technical and operational aspects of mass casualty decontamination. It identifies three priority targets for future research, the third of which is how casualties needs can be met in ways that best support compliance with and effectiveness of casualty decontamination. While further investigation into behavioural, communication and privacy issues during mass decontamination is warranted, there is now a substantial body of research in this area which is not considered in detail in the succinct summary provided by Cibulsky et al. (2016). In this short report, we summarise the available evidence around likely public behaviour during mass decontamination, effective communication strategies, and potential issues resulting from a lack of privacy. Our intention is to help further focus the research needs in this area and highlight topics on which more research is needed.



The research was funded by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emergency Preparedness and Response at King’s College London in partnership with Public Health England (PHE). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, the Department of Health or Public Health England. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Keywords: Research; Abstracts; Nuclear Events; Toxic Chemicals; Radiations; Mass Casualty Events.


Qualitative Analysis of Surveyed #Emergency #Responders and the Identified #Factors That Affect First Stage of Primary #Triage #Decision-Making of Mass #Casualty #Incidents (PLoS Curr., abstract)

[Source: PLoS Currents Disasters, full page: (LINK). Abstract, edited.]

Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents


AUTHORS: Kelly R. Klein, Frederick M. Burkle Jr., Raymond Swienton, Richard V. King, Thomas Lehman, Carol S. North




After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage decisions.


A survey distributed electronically to medical providers with and without disaster experience. Questions asked included what disaster experiences they had, and to rank six attributes in order of importance regarding triage.


403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they used “gestalt”.(gut feeling) Twelve per cent were identified as having placed patients in an expectant category during triage. Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category.


Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving interventions, situational instincts, and logistics.


The authors received no specific funding for this work.

Keywords: Research; Abstracts; Mass Casualties Events.


#Clinical #Framework and #Medical #Countermeasure Use During an #Anthrax Mass-Casualty #Incident (@CDCgov / MMWR, summary)

[Source: US Centers for Disease Control and Prevention (CDC), MMWR Morbidity and Mortality Weekly Report, full page: (LINK). Summary, edited.]

Clinical Framework and Medical Countermeasure Use During an Anthrax Mass-Casualty Incident [      ]

Recommendations and Reports /  December 4, 2015 / 64(RR04);1-28 / CDC Recommendations

Prepared by William A. Bower, MD1, Katherine Hendricks, MD1, Satish Pillai, MD2, Julie Guarnizo2, Dana Meaney-Delman, MD3

1Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases; 2Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases; 3Office of the Director, National Center for Emerging and Zoonotic Infectious Diseases

Corresponding author: William A. Bower, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, CDC. Telephone: 404-639-0376; E-mail:



In 2014, CDC published updated guidelines for the prevention and treatment of anthrax (Hendricks KA, Wright ME, Shadomy SV, et al. Centers for Disease Control and Prevention expert panel meetings on prevention and treatment of anthrax in adults. Emerg Infect Dis 2014;20[2]. Available at These guidelines provided recommended best practices for the diagnosis and treatment of persons with naturally occurring or bioterrorism-related anthrax in conventional medical settings. An aerosolized release of Bacillus anthracis spores over densely populated areas could become a mass-casualty incident. To prepare for this possibility, the U.S. government has stockpiled equipment and therapeutics (known as medical countermeasures [MCMs]) for anthrax prevention and treatment. However, previously developed, publicly available clinical recommendations have not addressed the use of MCMs or clinical management during an anthrax mass-casualty incident, when the number of patients is likely to exceed the ability of the health care infrastructure to provide conventional standards of care and supplies of MCMs might be inadequate to meet the demand required. To address this gap, in 2013, CDC conducted a series of systematic reviews of the scientific literature on anthrax to identify evidence that could help clinicians and public health authorities set guidelines for intravenous antimicrobial and antitoxin use, diagnosis of anthrax meningitis, and management of common anthrax-specific complications in the setting of a mass-casualty incident. Evidence from these reviews was presented to professionals with expertise in anthrax, critical care, and disaster medicine during a series of workgroup meetings that were held from August 2013 through March 2014. In March 2014, a meeting was held at which 102 subject matter experts discussed the evidence and adapted the existing best practices guidance to a clinical use framework for the judicious, efficient, and rational use of stockpiled MCMs for the treatment of anthrax during a mass-casualty incident, which is described in this report. This report addresses elements of hospital-based acute care, specifically antitoxins and intravenous antimicrobial use, and the diagnosis and management of common anthrax-specific complications during a mass-casualty incident. The recommendations in this report should be implemented only after predefined triggers have been met for shifting from conventional to contingency or crisis standards of care, such as when the magnitude of cases might lead to impending shortages of intravenous antimicrobials, antitoxins, critical care resources (e.g., chest tubes and chest drainage systems), or diagnostic capability. This guidance does not address primary triage decisions, anthrax postexposure prophylaxis, hospital bed or workforce surge capacity, or the logistics of dispensing MCMs. Clinicians, hospital administrators, state and local health officials, and planners can use these recommendations to assist in the development of crisis protocols that will ensure national preparedness for an anthrax mass-casualty incident.


Keywords: US CDC; USA; Updates; Mass Casualty Events; Anthrax.