@book {1399069, title = {Emergencies and Public Health Crisis Management-Current Perspectives on Risks and Multiagency Collaboration}, year = {2020}, publisher = {MDPI}, organization = {MDPI}, abstract = {

Disasters and public health emergencies are inevitable and can happen anywhere and anytime. However, they can be mitigated and their impacts can be minimized by utilizing appropriate measures in all four different phases of disaster management, i.e., mitigation and prevention, preparedness, response, and recovery. Several factors are crucial for achieving successful disaster management. Altogether, this Issue offers new insights into emergency and public health crisis management from a multiagency perspective and allows discussion about new potential risks; lessons learned; and the introduction of new concepts such as flexible surge capacity, and shows some new aspects of practicing multiagency collaboration before, during, and after disasters and public health emergencies.

}, author = {Amir Khorram-Manesh and Frederick M. Burkle Jr.} } @article {1399065, title = {Implications and limitations of Social Distancing Strategies (SDS) to mitigate the impact of COVID-19 pandemic}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, author = {Krzysztof Goniewicz and Frederick M. Burkle Jr. and Amir Khorram-Manesh} } @article {1389353, title = {Modeling pastoralist movement in response to environmental variables and conflict in Somaliland: Combining agent-based modeling and geospatial data}, journal = {PLOS ONE}, year = {2020}, abstract = {

This study explores how pastoralists respond to changing environments in Somaliland . An agent-based model is used to simulate the movement of nomadic pastoralists based on typologically diverse, historical data of environmental, interpersonal, and transactional variables in Somaliland and Puntland between 2008 and 2018. Through subsequent application of spatial analysis such as choropleth maps, kernel density mapping, and standard deviational ellipses, we characterize the resultant pastoralist population distribution in response to these variables.

}, author = {Erica Nelson and Saira Khan and Swapna Thorve and P. Gregg Greenough} } @article {1399078, title = {The Development of Swedish Military Healthcare System: Part II-Re-evaluating the Military and Civilian Healthcare Systems in Crises Through a Dialogue and Study Among Practitioners}, journal = {Military Medicine}, year = {2020}, abstract = {

Introduction: Historical changes have transformed Sweden from being an offensive to a defensive and collaborative nation with national and international engagement, allowing it to finally achieve the ground for the civilian{\textendash}military collaboration and the concept of a total defense healthcare. At the same time, with the decreasing number of international and interstate conflicts, and the military{\textquoteright}s involvement in national emergencies and humanitarian disaster relief, both the need and the role of the military healthcare system within the civilian society have been challenged. The recent impact of the COVID-19 in the USA and the necessity of military involvement have led health practitioners to anticipate and re-evaluate conditions that might exceed the civilian capacity of their own countries and the need to have collaboration with the military healthcare. This study investigated both these challenges and views from practitioners regarding the benefits of such collaboration and the manner in which it would be initiated.

Material and Method: A primary study was conducted among responsive countries using a questionnaire created using the Nominal Group Technique. Relevant search subjects and keywords were extracted for a systematic review of the literature, according to the PRISMA model.

Results: The 14 countries responding to the questionnaire had either a well-developed military healthcare system or units created in collaboration with the civilian healthcare. The results from the questionnaire and the literature review indicated a need for transfer of military medical knowledge and resources in emergencies to the civilian health components, which in return, facilitated training opportunities for the military staff to maintain their skills and competencies.

Conclusions: As the world witnesses a rapid change in the etiology of disasters and various crises, neither the military nor the civilian healthcare systems can address or manage the outcomes independently. There is an opportunity for both systems to develop future healthcare in collaboration. Rethinking education and training in war and conflict is indisputable. Collaborative educational initiatives in disaster medicine, public health and complex humanitarian emergencies, international humanitarian law, and the Geneva Convention, along with advanced training in competency-based skill sets, should be included in the undergraduate education of health professionals for the benefit of humanity.

}, author = {Amir Khorram-Manesh and Frederick M. Burkle Jr. and Phatthranit Phattharapornjaroen and Milad Ahmadi Marzaleh and Mohammed Al Sultan and Matti Mantysaari and Eric Carlstr{\"o}m and Krzysztof Goniewicz and Emelia Santamaria and John David Comandante and Robert Dobson and Boris Hreckovski and Glenn-Egil Torgersen and Luc J. Mortelmans and Mirjam de Jong and Yohan Robinson} } @article {1399070, title = {Humanitarian Aid Workers: The Forgotten First Responders}, journal = {Prehospital and Disaster Medicine}, year = {2020}, abstract = {

Humanitarian aid workers are an overlooked population within the structure of posttraumatic stress disorder (PTSD) research and assistance. This negligence is an industry-wide failure to address aid workers{\textquoteright} psychological health issues. The suspected numbers of death by suicide, diagnosed PTSD, depression, anxiety disorders, hazardous alcohol and drug consumption, emotional exhaustion, and other stress-related problems are impossible to quantify but are considered endemic. Tools for establishing organizational frameworks for mental health and psychosocial support are readily available. However, the capacity to implement this assistance requires the creation and practice of an open and non-judgmental culture, based on the realistic acceptance that aid work has become inherently dangerous. The possibility of developing a psychological problem because of aid work has increased along with the rise in levels of disease, injury, kidnapping, and assault. As a result, expressions of traumatic stress have become the norm rather than an exception. This commentary outlines the essential steps and components necessary to meet these requirements.

}, url = {https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/humanitarian-aid-workers-the-forgotten-first-responders/F7FA565F992B610CB51B96347205F09C}, author = {Robert I.S. Macpherson and Frederick M. Burkle Jr.} } @article {1395867, title = {Access to Care and Prevalence of Hypertension and Diabetes Among Syrian Refugees in Northern Jordan}, journal = {JAMA Network Open}, year = {2020}, abstract = {

Importance\ \ The management of noncommunicable diseases in humanitarian crises has been slow to progress from episodic care. Understanding disease burden and access to care among crisis-affected populations can inform more comprehensive management.

Objective\ \ To estimate the prevalence of hypertension and diabetes with biological measures and to evaluate access to care among Syrian refugees in northern Jordan.

Design, Setting, and Participants\ \ This cross-sectional study was undertaken from March 25 to April 26, 2019, in the districts of Ramtha and Mafraq, Jordan. Seventy clusters of 15 households were randomly sampled, and chain referral was used to sample Syrian households, representative of 59 617 Syrian refugees. Adults were screened and interviewed about their access to care. Data analysis was performed from May to September 2019.

Exposures\ \ Primary care delivered through a humanitarian organization since 2012.

Main Outcomes and Measures\ \ The main outcomes were self-reported prevalence of hypertension and diabetes among adults aged 18 years or older and biologically based prevalence among adults aged 30 years or older. The secondary outcome was access to care during the past month among adults aged 18 years or older with a diagnosis of hypertension or diabetes.

Results\ \ In 1022 randomly sampled households, 2798 adults aged 18 years or older, including 275 with self-reported diagnoses (mean [SD] age, 56.5 [13.2] years; 174 women [63.3\%]), and 915 adults aged 30 years or older (608 women [66.5\%]; mean [SD] age, 46.0 [12.8] years) were screened for diabetes and hypertension. Among adults aged 18 years or older, the self-reported prevalence was 17.2\% (95\% CI, 15.9\%-18.6\%) for hypertension, 9.8\% (95\% CI, 8.6\%-11.1\%) for diabetes, and 7.3\% (95\% CI, 6.3\%-8.5\%) for both conditions. Among adults aged 30 years or older, the biologically based prevalence was 39.5\% (95\% CI, 36.4\%-42.6\%) for hypertension, 19.3\% (95\% CI, 16.7\%-22.1\%) for diabetes, and 13.5\% (95\% CI, 11.4\%-15.9\%) for both conditions. Adjusted for age and sex, prevalence for all conditions increased with age, and women had a higher prevalence of diabetes than men (adjusted prevalence ratio, 1.3\%; 95\% CI, 1.0\%-1.7\%), although the difference was not significant. Complications (57.4\%; 95\% CI, 51.5\%-63.1\%) and obese or overweight status (82.8\%; 95\% CI, 79.7\%-85.5\%) were highly prevalent. Among adults aged 30 years or older with known diagnoses, 94.1\% (95\% CI, 90.9\%-96.2\%) currently took medication. Among adults aged 18 years or older with known diagnoses, 26.8\% (95\% CI, 21.3\%-33.1\%) missed a medication dose in the past week, and 49.1\% (95\% CI, 43.3\%-54.9\%) sought care in the last month.

Conclusions and Relevance\ \ During this protracted crisis, obtaining care for noncommunicable diseases was feasible, as demonstrated by biologically based prevalence that was only moderately higher than self-reported prevalence. The high prevalence of complications and obese or overweight status, however, suggest inadequate management. Programs should focus on reinforcing adherence and secondary prevention to minimize severe morbidity.

}, url = {https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2771453$\#$:~:text=Household\%20surveys\%20have\%20documented\%20that,more\%20adult\%20with\%20an\%20NCD.\&text=A\%202016\%20household\%20survey\%20among,\%25)\%20and\%20diabetes\%20(9.2\%25).}, author = {P. Gregg Greenough, MD, MPH and Ravi Goyal and Ratnayake, Ruwan and Fatma Rawashdeh and Raeda AbuAlRub and Nahla Al-Ali and Muhammad Fawad and Mohammad Bani Han} } @article {1399091, title = {The Impact of Experience, Length of Service, and Workplace Preparedness in Physicians{\textquoteright} Readiness in the Response to Disasters}, journal = {Journal of Clinical Medicine}, year = {2020}, abstract = {With an increasing number of natural and man-made disasters, the need for preparedness in all levels of management is obvious. Among healthcare professionals responding to these emergencies, physicians are of particular importance due to their significant roles as leaders and frontline workers in minimizing morbidity and mortality of the affected population. This study analyses the preparedness of 549 physicians from all medical centers in Lublin, Poland to formulate their observations, suggestions, and recommendations concerning the improvement of the chain of response in disaster management. The results of this study show that the perceived preparedness of physicians for disaster management and response is not as high as it should be, and the majority of the respondents perceived their disaster preparedness insufficient. Training of physicians in disaster management and principles of disaster medicine is needed, by focusing on the specificity of rescue response to emergencies following disasters, and medical and non-medical aspects of the response with particular emphasis on a management approach covering all hazards.}, author = {Krzysztof Goniewicz and Mariusz Goniewicz and Frederick M. Burkle Jr. and Amir Khorram-Manesh} } @article {1379995, title = {Network Analysis of Actors Working to Support Disaster Preparedness and Resilience in the Philippines}, year = {2020}, abstract = {The Harvard Humanitarian Initiative (HHI) partnered with Root Change to conduct a network analysis of actors working to support disaster preparedness and resilience in the Philippines. The study design is modeled after a summative phase external evaluation that HHI conducted in 2016-2017 on the START Network{\textquoteright}s Disasters and Emergency Preparedness Program (DEPP). Network analysis techniques applied in this evaluation have been adapted from the DEPP work to analyze the disaster resilience network in coastal Bangladesh under the Resilient Communities Program. In this report, we present the network analysis and methods used. We also detail findings and recommendations for HHI and other in-country partners about how these results can inform programs to strengthen disaster resilience and climate change in the Philippines.}, author = {Phuong Pham and Vincenzo Bollettino and Patrick Vinck and Ariana Marnicio and Lea Ivy Manzanero and Mark Toldo and Rachel Dickinson and Alexis Smart and Evan Bloom} } @article {1399079, title = {Sustainability Editorial Disasters and Public Health Emergencies-Current Perspectives in Preparedness and Response}, journal = {Sustainability}, year = {2020}, abstract = {

Disasters and public health emergencies are inevitable and can happen anywhere and anytime. However, they can be mitigated and their impacts can be minimized by utilizing appropriate measures in all four different phases of disaster management, i.e., mitigation and prevention, preparedness, response, and recovery. Several factors are crucial for achieving successful disaster management. In the mitigation and preparation phase, all risks should be reviewed and new ones should be added and analyzed carefully to propose proper solutions and plans. In the preparedness phase, the ability and knowledge of each organization and all individuals in the management system should be tested and evaluated to ensure good readiness in responding to an emergency. Furthermore, plans should be available at all levels of the emergency chain of action to cope with all issues in the response and recovery phases [1,2]. This Issue of Sustainability aimed to cover emergency and public health crisis management from a multiagency perspective, by discussing lessons learned, introducing new ideas about flexible surge capacity, and showing the way it can practice multiagency collaboration.

}, url = {https://www.mdpi.com/2071-1050/12/20/8561}, author = {Amir Khorram-Manesh and Frederick M. Burkle Jr.} } @article {1394069, title = {Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part II: The Database}, journal = {Prehospital and Disaster Medicine}, year = {2020}, abstract = {

This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.

}, url = {https://www.cambridge.org/core/journals/prehospital-and-disaster-medicine/article/global-public-health-database-support-to-populationbased-management-of-pandemics-and-global-public-health-crises-part-ii-the-database/2CF1F9CA713E055AE91080668F6ECC1F}, author = {Frederick M. Burkle Jr. and David A. Bradt and Joseph Green and Benjamin J. Ryan} } @article {1394068, title = {Global Public Health Database Support to Population-Based Management of Pandemics and Global Public Health Crises, Part I: The Concept}, journal = {Prehospital and Disaster Medicine}, year = {2020}, abstract = {This two-part article examines the global public health (GPH) information system deficits emerging in the coronavirus disease 2019 (COVID-19) pandemic. It surveys past, missed opportunities for public health (PH) information system and operational improvements, examines current megatrend changes to information management, and describes a new multi-disciplinary model for population-based management (PBM) supported by a GPH Database applicable to pandemics and GPH crises.}, url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7653233/}, author = {Frederick M. Burkle Jr. and David A. Bradt and Benjamin J. Ryan} } @article {1399092, title = {The gap of knowledge and skill {\textendash} One reason for unsuccessful management of mass casualty incidents and disasters}, journal = {American Journal of Emergency Medicine}, year = {2020}, author = {Krzysztof Goniewicz and Frederick M. Burkle Jr. and Amir Khorram-Manesh} } @article {1408825, title = {The Landscape of Disinformation on Health Crisis Communication During the COVID-19 Pandemic in Ukraine: Hybrid Warfare Tactics, Fake Media News and Review of Evidence}, journal = {Journal of Science Communication}, year = {2020}, abstract = {

The COVID-19 pandemic has impacted the world in ways not seen since the 1918{\textendash}1920 Spanish Flu. Disinformation campaigns targeting health crisis communication during this pandemic seek to cripple the medical response to the novel coronavirus and instrumentalize the pandemic for political purposes. Propaganda from Russia and other factions is increasingly infiltrating public and social media in Ukraine. Still, scientific literature has only a limited amount of evidence of hybrid attacks and disinformation campaigns focusing on COVID-19 in Ukraine. We conducted a review to retrospectively examine reports of disinformation surrounding health crisis communication in Ukraine during the COVID-19 response. Based on the themes that emerged in the literature, our recommendations are twofold: 1) increase transparency with verified health crisis messaging and, 2) address the leadership gap in reliable regional information about COVID-19 resources and support in Ukraine.

}, url = {https://jcom.sissa.it/archive/19/05/JCOM_1905_2020_A02}, author = {Sonny Patel and Omar Moncayo and Kristina Conroy and Doug Jordan and Erickson, Timothy} } @article {1399096, title = {Optimizing Scarce Resource Allocation During COVID-19: Rapid Creation of a Regional Health-Care Coalition and Triage Teams in San Diego County, California}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, abstract = {

Successful management of an event where healthcare needs exceed regional healthcare capacity requires coordinated strategies for scarce resource allocation. Publications for rapid development, training, and coordination of regional hospital triage teams manage the allocation of scarce resources during COVID-19 are lacking. Over a period of 3 weeks, over 100 clinicians, ethicists, leaders, and public health authorities convened virtually to achieve consensus on how best to save the most lives possible and share resources. This is referred to as population-based crisis management. The rapid regionalization of 22 acute care hospitals across 4500 square miles in the midst of a pandemic with a shifting regulatory landscape was challenging, but overcome by mutual trust, transparency, and confidence in the public health authority. Because many cities are facing COVID-19 surges, we share a process for successful rapid formation of healthcare care coalitions, Crisis Standard of Care, and training of Triage Teams. Incorporation of continuous process improvement and methods for communication is essential for successful implementation. Utilization of our regional healthcare coalition communications, incident command system, and the crisis care committee helped mitigate crisis care in the San Diego and Imperial County region as COVID-19 cases surged and scarce resource collaborative decisions were required.

}, url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7684024/}, author = {Asha Devereaux and Holly Yang and Gilbert Seda and Viji Sankar and Ryan C. Maves and Navaz Karanjia and John Scott Parrish and Christy Rosenberg and Paula Goodman-Crews and Lynette Cederquist and Frederick M. Burkle Jr. and Jennifer Tuteur and Chiara Leroy and Kristi L. Koenig} } @article {1399093, title = {Workflow Solutions for Primary Care Clinic Recovery During the COVID-19 Pandemic: A Primer}, journal = {Journal of Public Health Management and Practice}, year = {2020}, author = {Ann M. Nguyen and Attila J. Hertelendy and Melinda Ashton and Frederick M. Burkle Jr.} } @article {1399048, title = {COVID-19 a health reform catalyst? -Analyzing single-payer options in the U.S.: Considering economic values, recent proposals, and existing models from abroad}, journal = {Journal of Hospital Administration}, year = {2020}, abstract = {

The United States has continued to face severe health coverage and spending challenges that have been attributed to a fragmented multi-payer and fee-for-service delivery system which has become even more exposed by the COVID-19 pandemic. Legislators and healthcare professionals have tried to answer the challenges faced by the U.S. health system through the introduction of several state and federal proposals for a "Medicare-for-all" like system, which have failed to be adopted likely due to the lack of consideration for free-market economic values. Looking to existing models abroad can provide the U.S. with different ways to understand how to achieve the benefits of single-payer models with universal coverage while maintaining the integrity of free-market values. The health systems in wealthy, industrialized countries are closely referenced in this article because of the variation of methods in which each achieves a single-payer/universal coverage model as well as the contrast in their health outcomes compared to that of the U.S. The biggest considerations for any reform effort to achieve an efficient single-payer system with universal coverage is the maintenance of private health insurers and the degree to which expanded government influence would be accepted. The future state of health care remains uncertain and unstable as a result of the COVID-19 pandemic, therefore a window of opportunity exists now for leveraging this uncertainty to achieve reform.

}, author = {Alan Parnell and Krzysztof Goniewicz and Amir Khorram-Manesh and Frederick M. Burkle Jr. and Ahmed Al-Wathinani and Attila J. Hertelendy} } @article {1399051, title = {Crisis Standards of Care in a Pandemic: Navigating the Ethical, Clinical, Psychological, and Policy-making Maelstrom}, journal = {International Journal for Quality in Health Care}, year = {2020}, abstract = {

The COVID-19 pandemic has caused clinicians at the frontlines to confront difficult decisions regarding resource allocation, treatment options, and ultimately the life-saving measures that must be taken at the point of care. This article addresses the importance of enacting Crisis Standards of Care (CSC) as a policy mechanism to facilitate the shift to population-based medicine. In times of emergencies and crises such as this pandemic, the enactment of CSC enables concrete decisions to be made by governments relating to supply chains, resource allocation, and provision of care to maximize societal benefit. This shift from an individual to a population-based societal focus has profound consequences on how clinical decisions are made at the point of care. Failing to enact CSC may have psychological impacts for healthcare providers particularly related to moral distress, through an inability to fully enact individual beliefs (individually-focused clinical decisions) which form their moral compass.

}, author = {Attila J. Hertelendy and Gregory R. Ciottone and Cheryl L. Mitchell and Jennifer Gutberg and Frederick M. Burkle Jr.} } @article {1399050, title = {Does the Prosperity of a Country Play a Role in COVID-19 Outcomes?}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, abstract = {

Objective: This study aims to clarify the association between prosperity and novel coronavirus disease 2019 outcomes and its impact on the future management of pandemics.

Methods: This study is an observational study using information from two online registries. The numbers of infected individuals and deaths and the prosperity rank of each country were obtained from worldometer.info and the Legatum Institute{\textquoteright}s Prosperity Index, respectively.

Results: There is a combination of countries with high and low prosperity on the list of coronavirus disease 2019 infected countries. The risk of the virus pandemic seems to be more extensive in countries with high prosperity. A Spearman{\textquoteright}s rho test confirmed a significant correlation between prosperity, the number of coronavirus disease 2019 cases, and the number of deaths at the 99\% level.

Conclusion: New emerging pandemics affect all nations. In order to increase the likelihood of successfully managing future events, it is important to consider pre-existing health security, valid population-based management approaches, medical decision-making, communication, continuous assessment, triage, treatment, early and complete physical distancing strategies, and logistics. These elements cannot be taught on-site and on occasion. There is a need for innovative and regular educational activities for all stakeholders committed to safeguarding our future defense systems concerning diagnostic, protection, treatment, and rehabilitation in pandemics as well as other emergencies.

}, author = {Amir Khorram-Manesh and Eric Carlstr{\"o}m and Attila J. Hertelendy and Krzysztof Goniewicz and Carter B. Casady and Frederick M. Burkle Jr.} } @article {1379997, title = {Ukraine - Conflict in the Donbas: Civilians Hostage to Adversarial Geopolitics}, year = {2020}, abstract = {Since 2014, the war in the Donbas, fueled and sustained by local and regional political priorities, has inflicted a heavy burden of civilian death, injury, displacement, destruction, and lasting trauma. As the conflict continues, the people of Donbas are more isolated than ever from the rest of their country, subjected to discrimination and stigmatization by both the Ukrainian authorities and separatist leaders. Today, a confluence of factors continues to drive conflict in Eastern Ukraine. Triggered by the 2013 Euromaidan protests in Kyiv, the rupture between the post-Maidan Ukrainian government and local elites in the Donbas over aspirations of independence and self-determination highlighted the growing schism between those with Russian-oriented ambitions and those supporting the new Ukrainian regime. As clans, warlords, and oligarchs within Ukraine fight for political influence and financial gain, Russian influence continues to destabilize the Westward-leaning Ukrainian authorities in Kyiv, reinvigorating the enduring geopolitical rivalry between Russia and the West. Humanitarian operations in Eastern Ukraine are also under significant pressure by the separatist authorities. Agencies struggle to bridge the gap between critical needs and their response capacity, while being forced to rely almost exclusively on local organizations. In the process of humanitarian and access negotiations, agencies must guard against the instrumentalization of aid, the blurring of lines between political, military, and relief operations, and an ever-shrinking humanitarian space. What drives this protracted conflict? How have global politics and local agendas contributed to sustaining a {\textquotedblleft}frozen{\textquotedblright} conflict at the expense of communities and in the interest of asserting nationalist independence at all costs? How have the hopes of local communities in the Donbas withered over time, as they navigate the dissonance in geopolitical rhetoric and their lived reality? What avenues exist for reconciliation and unity amidst this violent divisiveness? This report explores these questions and offers reflections based on more than 250 interviews undertaken during two field visits to Ukraine, in both government and separatist-controlled areas, and one visit to Russia, between November 2019 and January 2020. It also draws on an extensive desk analysis of relevant literature to complement the findings of these interviews and consultations.}, url = {https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3657394}, author = {Emmanuel Tronc and Ana{\"\i}de Nahikian} } @article {1399046, title = {Ahmadreza Djalali, MD, PhD is Dying}, journal = {Prehospital and Disaster Medicine}, year = {2020}, author = {Frederick M. Burkle Jr.} } @article {1399045, title = {Bioterrorism Preparedness and Response in Poland: Prevention, Surveillance, and Mitigation Planning}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, abstract = {

Objectives: Biological weapons are one of the oldest weapons of mass destruction used by man. Their use has not only determined the outcome of battles, but also influenced the fate of entire civilizations. Although the use of biological weapons agents in a terrorist attack is currently unlikely, all services responsible for the surveillance and removal of epidemiological threats must have clear guidelines and emergency response plans.

Methods: In the face of the numerous threats appearing in the world, it has become necessary to put the main emphasis on modernizing, securing, and maintaining structures in the field of medicine which are prepared for unforeseen crises and situations related to the use of biological agents.

Results: This article presents Poland{\textquoteright}s current preparation to take action in the event of a bioterrorist threat. The study presents both the military aspect and procedures for dealing with contamination.

Conclusions: In Poland, as in other European Union countries fighting terrorism, preparations should be made to defend against biological attacks, improve the flow of information on the European security system, strengthen research centers, train staff, create observation units and vaccination centers, as well as prepare hospitals for the hospitalization of patients{\textemdash}potential victims of bioterrorist attacks.

}, author = {Krzysztof Goniewicz and Beata Osiak and Witold Paw{\l}owski and Robert Czerski and Frederick M. Burkle Jr. and Dorota Lasota and Mariusz Goniewicz} } @report {1399047, title = {Robert Fox Interview with Frederick M. Burkle on Population-based Triage Management}, year = {2020}, abstract = {Interview: At first sight, Population-based Triage, PBT for short, isn{\textquoteright}t the most enticing social formula-but it may be the key to how the UK manages the next stages of the current Corona quagmire-and prepare for the next one, when and not if it happens. It could, and probably should, become standard operating procedure in public health population-based management decisions in the outbreak of widespread pestilence and disease. We need that new Public Health Strategy now. Under the PBT plan the population as a whole is treated to the triage technique familiar in accident and emergency, and battlefield medicine. Medical and rescue teams concentrate on treating the salvageable in preference to those most likely to die. "Traditional health care systems care systems care for patients individually, while public health is caring for an entire population," says Professor Frederick Burkle, Senior Scholar and Scientist of Public Health at Harvard. He published his plan for a population-based approach to pandemic in 2006. It was used in the major desk-top exercise by Public Health England for tackling a major influenza pandemic, Operation Cygnus, in 2016. The report partly adopted the professor{\textquoteright}s clear-eyed approach to running a major pandemic operation, but left many questions open. If they had been addressed in the present Covid crisis, thousands of lives might have bene saved. Much the same goes for Exercise Isis carried out by National Health Scotland in 2018, focused on a major outbreak of MERS (Middle East Respiratory Syndrome). The lessons of both exercises have been taken aboard, according to Matt Hancock, but as they say in Scots law, it looks like a case of not proven. Both the Cygnus and Isis reports of 2017 and 2018 cannot conceal the serious shortcomings in preparation against a major public health emergency. The Cygnus exercise, for instance concentrates on the role of the Local Resilience Forums in coordinating emergency services-yet the representatives of the eight LRFs were explicit about their lack of resources. The LRFs have proved vital since March, but they have no statutory powers and no funding. More ominously the Isis report for the Scottish Health flags up the lack of availability of protective equipment-PPE-for a nationwide viral outbreak. The problem of managing a workable Public Health Emergency strategy for this coronavirus crisis is brilliantly illustrated BBC1{\textquoteright}s drama documentary, The Salisbury Poisonings. It tells the real events of the attack by the nerve agent Novichok on the Skripals in Salisbury two years ago. The heroine is the Wiltshire Public Health Officer Tracy.}, author = {Frederick M. Burkle Jr.} } @article {1380001, title = {English Version: "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"}, year = {2020}, abstract = {

This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq{\textquoteright}s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq{\textquoteright}s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

}, author = {Abdulrazzaq Al-Saiedi and Kevin Coughlin and Muslih Irwani and Waad Ibrahim Khalil and Phuong Pham and Patrick Vinck} } @article {1380000, title = {الترجمة العربية (Arabic Version): "Never Forget: Views on Peace and Justice Within Conflict-Affected Communities in Northern Iraq"}, year = {2020}, abstract = {

This survey offers a snapshot of the perceptions and attitudes about peace and justice within communities affected by the conflict with the Islamic State (IS). It is based on 5,213 interviews conducted in 2019 among a representative sample of internally displaced persons in northern Iraq and residents of the city of Mosul and surrounding areas.The research documents a severe lack of trust in official institutions, particularly in the Government of Iraq itself, stemming in large part from the belief that these institutions do not act in the best interest of the population. Few respondents had confidence in the Government of Iraq{\textquoteright}s ability to investigate the crimes committed by the Islamic State fairly and accurately and to provide justice to survivors of the conflict.Despite the mistrust, respondents favor local justice and truth-seeking mechanisms. They view these efforts as necessary to build a durable peace, alongside measures to address the root causes of the rise of IS and longstanding divisions between the people of Iraq. However, rather than the challenge being diversity itself, the challenge is the Government of Iraq{\textquoteright}s ability to promote and facilitate reconciliation and unity.Without an accountable government that is perceived to be legitimate and is trusted by all Iraqis, calls for justice and accountability may go unanswered, and the country risks slipping back into another conflict.

The research was conducted by the Harvard Humanitarian Initiative in partnership with Mosul University and the Iraq-based Public Policy Institute. It was supported by the Ministry of Foreign Affairs of the Netherlands, which played no role in the design, analysis or publication of the research.

}, author = {Abdulrazzaq Al-Saiedi and Kevin Coughlin and Muslih Irwani and Waad Ibrahim Khalil and Phuong Pham and Patrick Vinck} } @article {1399042, title = {50 States or 50 Countries: What Did We Miss and What Do We Do Now?}, journal = {Prehospital and Disaster Medicine}, year = {2020}, abstract = {

There have been multiple inconsistencies in the manner the COVID-19 pandemic has been investigated and managed by countries. Population-based management (PBM) has been inconsistent, yet serves as a necessary first step in managing public health crises. Unfortunately, these have dominated the landscape within the United States and continue as of this writing. Political and economic influences have greatly influenced major public health management and control decisions. Responsibility for global public health crises and modeling for management are the responsibility of the World Health Organization (WHO) and the International Health Regulations Treaty (IHR). This review calls upon both to reassess their roles and responsibilities that must be markedly improved and better replicated world-wide in order to optimize the global public health protections and its PBM.\ 

}, author = {Frederick M. Burkle Jr. and Asha V. Devereaux} } @article {1380002, title = {Bangladesh Network Analysis Report}, year = {2020}, abstract = {Coordination among actors during an emergency is crucial for effective, efficient action. The existence of pre-disaster relationships between actors can strengthen the speed with which coordination occurs in a disaster setting, making relationshipbuilding before a disaster an important element of preparedness. As such, understanding the relationships between stakeholders working to advance disaster resilience and response is a crucial first step to support institutional strengthening and capacity building. The Harvard Humanitarian Initiative (HHI), Concern Worldwide, and Jagrata Juba Shangha (JJS) are jointly implementing programs to enhance climate change adaptation and disaster resilience among coastal communities in Bagerhat District, Bangladesh. This district is located in Bangladesh{\textquoteright}s low-elevation coastal zones, which are especially vulnerable to natural disasters and have already begun to see the effects of climate change. Bagerhat has high levels of food and water insecurity and poverty, and is highly vulnerable to natural disasters and climate change impacts (5). The district has been heavily impacted by recent cyclones, and is experiencing sea level rise and saltwater intrusion. This network analysis was undertaken to support strengthening coordination and collaboration among actors working on climate change adaptation and disaster resilience in Bagerhat.}, author = {Sarah Ferguson and Vincenzo Bollettino and Phuong Pham and Patrick Vinck and Rachel Dickinson and Alexis Smart and Evan Bloom} } @article {1380003, title = {Case Study: Academic/NGO Collaboration to Understand Climate Change and Disaster Resilience Implementation in Bagerhat District, Bangladesh}, year = {2020}, abstract = {This case study describes a research collaboration between an academic institution and non-governmental organizations (NGOs) designed to inform programs to strengthen coordination in Bangladesh. The case describes the rationale for conducting the study, the research process, and outcomes of the research. The objective of the case study is to support local or municipal governments, NGOs, students, or other program managers to consider how collaboration with academic institutions could enhance their programs, as well as how research such as a network analysis could be useful to inform their work. For those interested in conducting a network analysis, the case also provides resources and tools to support researchers and organizations to replicate the study in their program context.}, author = {Vincenzo Bollettino and Sarah Ferguson} } @article {1399043, title = {Delayed Primary and Specialty Care: The Coronavirus Disease-2019 Pandemic Second Wave}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, abstract = {

Time is of the essence to continue the pandemic disaster cycle with a comprehensive post-COVID-19 health care delivery system RECOVERY analysis, plan and operation at the local, regional and state level. The second wave of COVID-19 pandemic response are not the ripples of acute COVID-19 patient clusters that will persist until a vaccine strategy is designed and implemented to effect herd immunity. The COVID-19 second wave are the patients that have had their primary and specialty care delayed. This exponential wave of patients requires prompt health care delivery system planning and response.

}, author = {Eric Weinstein and Luca Ragazzoni and Frederick M. Burkle Jr. and Mea Allen and David Hogan and Della Corte, Francesco} } @article {1395047, title = {Frequency and Factors Associated with Violence Against Female Sex Workers in Tehran, Iran}, journal = {Sexuality \& Culture}, year = {2020}, abstract = {

Female Sex Workers are among those women who are significantly more vulnerable to violence. Apart from the human rights perspective, assessing the frequency of violence among sex workers is especially important because of its relation to the spread of HIV and other sexually-transmitted infections. This cross-sectional, observational study was conducted among 263 female sex workers in southern parts of Tehran and their suburban regions in 2017 where the population is considered more socially and economically vulnerable. To evaluate univariate analysis between sexual violence and physical violence as dependent variables and the assumed exposures as well as confounders, the models were built distinctly. The models included exposures of the questionnaire as independent variables. The exposure factors with a p value of less than 0.2 were moved into the multiple logistic regression models. The rates of sexual violence and physical violence were reported as 72.2\% and 82.3\% respectively. According to our results, sexual violence is associated with higher education, working in streets, drug usage, having the experience of forced unprotected sex and feeling of discrimination. Physical violence is associated with low education, drug usage and feeling of discrimination in multiple analyses. Addressing the violence against female sex workers is a complex multifactorial issue in Iran. It requires structural changes in some social, legal, economic and health infrastructure programs.

}, author = {Nasim Sadat Hosseini Divkolaye and Javad Khalatbari and Marjan Faramarzi and Fariba Seighali and Shokoufeh Radfar and Ali ArabKhazaeli and Frederick M. Burkle Jr} } @article {1395107, title = {Geographic Information System Technology: Review of the Challenges for Its Establishment as a Major Asset for Disaster and Emergency Management in Poland}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, abstract = {

Technical and technological progress in the 21st century, especially emerging geographic information system (GIS) technology, offers new and unprecedented opportunities to counteract the impact of crisis situations and emergencies. Computerization and development of GIS enabled the digital visualization of space for interactive analysis of multiple data in the form of models or simulations. Additionally, computerization, which gives rise to a new quality of database management, requires continuous modernization of computer hardware and software. This study examines selected examples of the implications and impact of the GIS commonly used in Poland.

}, author = {Krzysztof Goniewicz and Maciej Magiera and Dorota Ruci{\'n}ska and Witold Paw{\l}owski and Frederick M. Burkle Jr. and Attila J. Hertelendy and Mariusz Goniewicz} } @article {1394074, title = {Declining Public Health Protections within Autocratic Regimes: Impact on Global Public Health Security, Infectious Disease Outbreaks, Epidemics, and Pandemics}, journal = {Prehospital and Disaster Medicine}, year = {2020}, abstract = {Public health emergencies of international concern, in the form of infectious disease outbreaks, epidemics, and pandemics, represent an increasing risk to the world's population. Management requires coordinated responses, across many disciplines and nations, and the capacity to muster proper national and global public health education, infrastructure, and prevention measures. Unfortunately, increasing numbers of nations are ruled by autocratic regimes which have characteristically failed to adopt investments in public health infrastructure, education, and prevention measures to keep pace with population growth and density. Autocratic leaders have a direct impact on health security, a direct negative impact on health, and create adverse political and economic conditions that only complicate the crisis further. This is most evident in autocratic regimes where health protections have been seriously and purposely curtailed. All autocratic regimes define public health along economic and political imperatives that are similar across borders and cultures. Autocratic regimes are seriously handicapped by sociopathic narcissistic leaders who are incapable of understanding the health consequences of infectious diseases or the impact on their population. A cross section of autocratic nations currently experiencing the impact of COVID-19 (coronavirus disease 2019) are reviewed to demonstrate the manner where self-serving regimes fail to manage health crises and place the rest of the world at increasing risk. It is time to re-address the pre-SARS (severe acute respiratory syndrome) global agendas calling for stronger strategic capacity, legal authority, support, and institutional status under World Health Organization (WHO) leadership granted by an International Health Regulations Treaty. Treaties remain the most successful means the world has in preventing, preparing for, and controlling epidemics in an increasingly globalized world.}, url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156578/}, author = {Frederick M. Burkle Jr.} } @report {1381390, title = {Harvard Humanitarian Initiative 2018-2019 Annual Report}, year = {2020}, abstract = {This Harvard Humanitarian Initiative Annual Report covers the 2018-2019 period of activities. Within it readers can find an overview of HHI{\textquoteright}s humanitarian research \& efforts, including HHI{\textquoteright}s role at Harvard University and finances for the time period.}, author = {Harvard Humanitarian Initiative} } @article {1394072, title = {Political Intrusions into the International Health Regulations Treaty and Its Impact on Management of Rapidly Emerging Zoonotic Pandemics: What History Tells Us}, journal = {Prehospital and Disaster Medicine}, year = {2020}, abstract = {For a large number of health care providers world-wide, the coronavirus disease 2019 (COVID-19) pandemic is their first experience in population-based care. In past decades, lower population densities, infectious disease outbreaks, epidemics, and pandemics were rare and driven almost exclusively by natural disasters, predatory animals, and war. In the early 1900s, Sir William Osler first advanced the knowledge of zoonotic diseases that are spread from reservoir animals to human animals. Once rare, they now make up 71\% or more of new diseases. Globally, zoonotic spread occurs for many reasons. Because the human population has grown in numbers and density, the spread of these diseases accelerated though rapid unsustainable urbanization, biodiversity loss, and climate change. Furthermore, they are exacerbated by an increasing number of vulnerable populations suffering from chronic deficiencies in food, water, and energy. The World Health Organization (WHO) and its International Health Regulation (IHR) Treaty, organized to manage population-based diseases such as Influenza, severe acute respiratory syndrome (SARS), H1N1, Middle East respiratory syndrome (MERS), HIV, and Ebola, have failed to meet population-based expectations. In part, this is due to influence from powerful political donors, which has become most evident in the current COVID-19 pandemic. The global community can no longer tolerate an ineffectual and passive international response system, nor tolerate the self-serving political interference that authoritarian regimes and others have exercised over the WHO. In a highly integrated globalized world, both the WHO with its IHR Treaty have the potential to become one of the most effective mechanisms for crisis response and risk reduction world-wide. Practitioners and health decision-makers must break their silence and advocate for a stronger treaty, a return of the WHO{\textquoteright}s singular global authority, and support highly coordinated population-based management. As Osler recognized, his concept of "one medicine, one health" defines what global public health is today.}, url = {https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7167298/}, author = {Frederick M. Burkle Jr.} } @report {1381388, title = {Displacement \& Destruction: Analysis of Idlib, Syria 2017-2020}, year = {2020}, abstract = {As the Syrian civil war enters its tenth year on\  March 15, the Signal Program on Human Security and Technology conducted satellite imagery analysis to capture the rapid expansion of displaced people{\textquoteright}s camps and the widespread impact of aerial bombardment in Idlib, Syria. This work was completed in collaboration with Save the Children and World Vision International. On 1 March 2020, the UN estimated that 961,286 individuals have been displaced since December 1, 2019; this is the largest mass displacement and acute humanitarian crisis since the\  Syrian conflict began in 2012. Analyzing two internally displaced person (IDP) camps, the Signal team found that the camp areas analyzed increased by approximately 100\% and 177\% respectively between September 2017 and February 2020. Camp growth between December 2019 and 2020 revealed new structures and further construction, consistent with a significant influx of displaced persons.\ \ The UN Human Rights Council reports that between May 2019 and January 2020, aerial bombardment and a surge of ground-level assaults contributed to a wave of IDPs throughout Idlib as civilian areas were repeatedly targeted. Signal{\textquoteright}s analysis of two areas in conflict-affected towns in southern Idlib found that approximately 30\% of structures were damaged; this figure likely underestimates the total damage.}, author = {Signal Program} } @article {1394769, title = {Opportunities Lost: Political Interference in the Systematic Collection of Population Health Data During and After the 2003 War in Iraq}, journal = {Disaster Medicine and Public Health Preparedness}, year = {2020}, abstract = {

The review of the article, {\textquotedblleft}Developing a Public Health Monitoring System in a War-torn Region: A Field Report from Iraqi Kurdistan,{\textquotedblright} prompted the writing of this commentary. Decisions to implement health data systems within Iraq require exploration of many otherwise undisclosed or unknown historical facts that led to the politicization of and ultimate demise of the pre-2003 Iraq war systematic health data monitoring system designed to mitigate both direct and indirect mortality and morbidity. Absent from the field report{\textquoteright}s otherwise accurate history leading up to and following the war is the politically led process by which the original surveillance system planned for the war and its aftermath was destroyed. The successful politicization of the otherwise extensively planned for public health monitoring in 2003 and its legacy harmed any future attempts to implement similar monitoring systems in succeeding wars and conflicts. Warring factions only collect military casualty data. The field report outlines current attempts to begin again in building a systematic health monitoring system emphasizing it is the {\textquotedblleft}only way to manage the complex post-war events that continue to lead to disproportionate preventable mortality and morbidity.{\textquotedblright}

}, author = {Frederick M. Burkle Jr.} } @webarticle {1394079, title = {Collective trauma is real, and could hamper Australian communities{\textquoteright} bushfire recovery}, year = {2020}, url = {https://theconversation.com/collective-trauma-is-real-and-could-hamper-australian-communities-bushfire-recovery-131555}, author = {Erin Smith and Frederick M. Burkle Jr.} } @webarticle {1394077, title = {How Worried Should We Be About the Novel Coronavirus?}, year = {2020}, url = {https://www.civilbeat.org/2020/02/how-worried-should-we-be-about-the-coronavirus/}, author = {Seiji Yamada and Frederick M. Burkle Jr.} } @report {1381394, title = {Household Disaster Resilience Assessment, Bagerhat District, Bangladesh}, year = {2020}, author = {Patrick Vinck and Sarah Ferguson and Vincenzo Bollettino} } @article {1395229, title = {Chloroquine, hydroxychloroquine and COVID-19}, journal = {Toxicol Commun}, volume = {4}, year = {2020}, month = {2020}, pages = {40-42}, abstract = {The media have featured the antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) to treat coronavirus (COVID-19). Political leaders have touted their use and recommended availability to the public. These anti-inflammatory agents have substantial human toxicity with a narrow therapeutic window. CQ and HCQ poisoning cause myocardial depression and profound hypotension due to vasodilation. Bradycardia and ventricular escape rhythms arise from impaired myocardial automaticity and conductivity due to sodium and potassium channel blockade. With cardiotoxicity, ECGs may show widened QRS, atrioventricular heart block and QT interval prolongation. CQ may also cause seizures, often refractory to standard treatment. Of concern is pediatric poisoning, where 1-2 pills of CQ or HCQ can cause serious and potentially fatal toxicity in a toddler. The treatment of CQ/HCQ poisoning includes high-dose intravenous diazepam postulated to have positive ionotropic and antidysrhythmic properties that may antagonize the cardiotoxic effects of CQ. Infusions of epinephrine titrated to treat unstable hypotension, as well as potassium for severe hypokalemia may be required. Current scientific evidence does not support treatment or prophylactic use of these agents for COVID-19 disease. Regulatory and public health authorities recognize that CQ/HCQ may offer little clinical benefit and only add risk requiring further investigation before wider public distribution.}, issn = {2473-4306}, doi = {10.1080/24734306.2020.1757967}, author = {Erickson, T B and Chai, P R and Boyer, E W} } @article {1395222, title = {Five Decades of Global Chemical Terror Attacks: Data Analysis to Inform Training and Preparedness}, journal = {Disaster Med Public Health Prep}, year = {2020}, month = {2020 Jul 24}, pages = {1-12}, abstract = {BACKGROUND: Chemical weapons attacks during the recent conflict in Syria and Iraq highlight the need to better understand the changing epidemiology of chemical weapons use, especially among non-state actors. Public health professionals and policy-makers require this data to prioritize funding, training, chemical weapons preparedness, disaster response, and recovery. The purpose of this investigation is to provide descriptive data that can be used by policy-makers and public safety officials to better prepare for these potential attacks. METHODS: A five-decade descriptive retrospective review of The Global Terrorism Database, maintained by the National Consortium for the Study of Terrorism and Responses to Terrorism, was conducted to understand trends in chemical agents, targets, and routes of exposure. We reviewed and analyzed data specific to these documented chemical attacks between 1970 and 2017. RESULTS: 383 terror attacks involved chemical weapons over the study period. A specific agent was named in 154 incidents, while 124 incidents could be classified into traditional chemical weapons categories (eg, vesicant, choking agents). A route of exposure was identified in 242 attacks, with the most common routes of exposure being dermal-mucosal and inhalational. Caustic agents were used in the highest portion of attacks (25\%) where the route of exposure was known. Explosive devices were used in 21\% of attacks to deliver these chemical agents. Of particular note, private citizens and educational facilities were targeted in 25\% and 12\% of attacks, respectively. The average number of attacks increased from 6 per year between 1970 and 2011 to 24.9 per year between 2011 and 2017 (coinciding with the start of the Syria conflict). The most commonly utilized chemicals were chlorine (26.0\%), tear gas (20.8\%), and cyanide (15.6\%). Blood agent incidents declined from 32.6\% before the September 11, 2001 attacks to 13.6\% after 2001, while nerve agent attacks fell from 9.3\% to 1.2\%. In contrast, choking (namely chlorine) and vesicant (mustard) agent use increased from 7\% to 48.1\% and from 2.3\% to 6.2\% of attacks, respectively. CONCLUSIONS: Chemical weapon use in global terrorism remains an increasingly common occurrence that requires better characterization. The average number of chemical terrorist attacks per year is increasing, with a large proportion resulting from the conflicts in Iraq and Syria. Choking (chlorine) and vesicant (mustard) agents have become the predominant chemical terror agent since 2001, with a decreased incidence of blood (cyanogenic) and nerve (sarin) agents. Future preparedness initiatives should focus on vulnerable targets such as private citizens and educational institutions. Improving blast injury response is essential, along with prioritizing disaster training focused on choking agents, vesicants, and caustics.}, issn = {1938-744X}, doi = {10.1017/dmp.2020.176}, author = {DeLuca, Michael A and Chai, Peter R and Goralnick, Eric and Erickson, Timothy B} } @article {1395226, title = {Intentional Hydroxychloroquine Overdose Treated with High-Dose Diazepam: an Increasing Concern in the COVID-19 Pandemic}, journal = {J Med Toxicol}, volume = {16}, year = {2020}, month = {2020 07}, pages = {314-320}, abstract = {INTRODUCTION: Recent attention on the possible use of hydroxychloroquine and chloroquine to treat COVID-19 disease has potentially triggered a number of overdoses from hydroxychloroquine. Toxicity from hydroxychloroquine manifests with cardiac conduction abnormalities, seizure activity, and muscle weakness. Recognizing this toxidrome and unique management of this toxicity is important in the COVID-19 pandemic. CASE REPORT: A 27-year-old man with a history of rheumatoid arthritis presented to the emergency department 7~hours after an intentional overdose of hydroxychloroquine. Initial presentation demonstrated proximal muscle weakness. The patient was found to have a QRS complex of 134~ms and QTc of 710~ms. He was treated with early orotracheal intubation and intravenous diazepam boluses. Due to difficulties formulating continuous diazepam infusions, we opted to utilize an intermitted intravenous bolus strategy that achieved similar effects that a continuous infusion would. The patient recovered without residual side effects. DISCUSSION: Hydroxychloroquine toxicity is rare but projected to increase in frequency given its selection as a potential modality to treat COVID-19 disease. It is important for clinicians to recognize the unique effects of hydroxychloroquine poisoning and initiate appropriate emergency maneuvers to improve the outcomes in these patients.}, keywords = {Adult, Coronavirus Infections, COVID-19, Diazepam, Drug Overdose, Drug-Related Side Effects and Adverse Reactions, Humans, Hydroxychloroquine, Male, Pandemics, Pneumonia, Viral, Suicide, Attempted, Treatment Outcome, United States}, issn = {1937-6995}, doi = {10.1007/s13181-020-00790-8}, author = {Chai, Peter R and Ferro, E G and Kirshenbaum, J M and Hayes, B D and Culbreth, S E and Boyer, E W and Erickson, T B} } @article {1395227, title = {Pesticide Exposure and Heat Exhaustion in a Migrant Agricultural Worker: A Case of Labor Trafficking}, journal = {Ann Emerg Med}, volume = {76}, year = {2020}, month = {2020 08}, pages = {215-218}, abstract = {To our knowledge, there are no published reports of heat exhaustion and pesticide exposure in a labor trafficked patient in the literature. Here we represent the case of J.C.J.L., who was labor trafficked. He presented to a local emergency department with heat exhaustion and pesticide exposure related to working conditions in a Mississippi corn field. Unfortunately, while he received medical treatment, his labor trafficking condition was missed. Emergency departments should be equipped to assess for human trafficking and connect trafficked persons with the resources they need. Emergency physicians should maintain a high index of suspicion for human trafficking among migrant workers presenting with occupation-related complaints.}, keywords = {Adult, Dehydration, Emergency Service, Hospital, Farmers, Heat Exhaustion, Human Trafficking, Humans, Male, Mississippi, Occupational Exposure, Pesticides, Renal Insufficiency, Transients and Migrants}, issn = {1097-6760}, doi = {10.1016/j.annemergmed.2020.03.007}, author = {Stoklosa, Hanni and Kunzler, Nathan and Ma, Zheng Ben and Luna, Juan Carlos Jimenez and de Vedia, Gonzalo Martinez and Erickson, Timothy B} } @article {1395221, title = {Rapid Assessment of Opioid Exposure and Treatment in Cities Through Robotic Collection and Chemical Analysis of Wastewater}, journal = {J Med Toxicol}, volume = {16}, year = {2020}, month = {2020 04}, pages = {195-203}, abstract = {INTRODUCTION: Accurate data regarding opioid use, overdose, and treatment is important in guiding community efforts at combating the opioid epidemic. Wastewater-based epidemiology (WBE) is a potential method to quantify community-level trends of opioid exposure beyond overdose data, which is the basis of most existing response efforts. However, most WBE efforts collect parent opioid compounds (e.g., morphine) at wastewater treatment facilities, measuring opioid concentrations across large catchment zones which typically represent an entire municipality. We sought to deploy a robotic sampling device at targeted manholes within a city to semi-quantitatively detect opioid metabolites (e.g., morphine glucuronide) at a sub-city community resolution. METHODS: We deployed a robotic wastewater sampling platform at ten residential manholes in an urban municipality in North Carolina, accounting for 44.5\% of the total municipal population. Sampling devices comprised a robotic sampling arm with in situ solid phase extraction, and collected hourly samples over 24-hour periods. We used targeted mass spectrometry to detect the presence of a custom panel of opioids, naloxone, and buprenorphine. RESULTS: Ten sampling sites were selected to be a representative survey of the entire municipality by integrating sewer network and demographic GIS data. All eleven metabolites targeted were detected during the program. The average morphine milligram equivalent (MME) across the nine illicit and prescription opioids, as excreted and detected in wastewater, was 49.1 (standard deviation of 31.9) MME/day/1000-people. Codeine was detected most frequently (detection rate of 100\%), and buprenorphine was detected least frequently (12\%). The presence of naloxone correlated with city data of known overdoses reversed by emergency medical services in the prehospital setting. CONCLUSION: Wastewater-based epidemiology with smart sewer selection and robotic wastewater collection is feasible to detect the presence of specific opioids, naloxone, methadone, and buprenorphine within a city. These results suggest that wastewater epidemiology could be used to detect patterns of opioid exposure and may ultimately provide information for opioid use disorder (OUD) treatment and harm reduction programs.}, issn = {1937-6995}, doi = {10.1007/s13181-019-00756-5}, author = {Endo, Norkio and Ghaeli, Newsha and Duvallet, Claire and Foppe, Katelyn and Erickson, Timothy B and Matus, Mariana and Chai, Peter R} } @article {1395223, title = {SARS-CoV-2 Titers in Wastewater Are Higher than Expected from Clinically Confirmed Cases}, journal = {mSystems}, volume = {5}, year = {2020}, month = {2020 Jul 21}, abstract = {Wastewater surveillance represents a complementary approach to clinical surveillance to measure the presence and prevalence of emerging infectious diseases like the novel coronavirus SARS-CoV-2. This innovative data source can improve the precision of epidemiological modeling to understand the penetrance of SARS-CoV-2 in specific vulnerable communities. Here, we tested wastewater collected at a major urban treatment facility in Massachusetts and detected SARS-CoV-2 RNA from the gene at significant titers (57 to 303 copies per ml of sewage) in the period from 18 to 25 March 2020 using RT-qPCR. We validated detection of SARS-CoV-2 by Sanger sequencing the PCR product from the gene. Viral titers observed were significantly higher than expected based on clinically confirmed cases in Massachusetts as of 25 March. Our approach is scalable and may be useful in modeling the SARS-CoV-2 pandemic and future outbreaks. Wastewater-based surveillance is a promising approach for proactive outbreak monitoring. SARS-CoV-2 is shed in stool early in the clinical course and infects a large asymptomatic population, making it an ideal target for wastewater-based monitoring. In this study, we develop a laboratory protocol to quantify viral titers in raw sewage via qPCR analysis and validate results with sequencing analysis. Our results suggest that the number of positive cases estimated from wastewater viral titers is orders of magnitude greater than the number of confirmed clinical cases and therefore may significantly impact efforts to understand the case fatality rate and progression of disease. These data may help inform decisions surrounding the advancement or scale-back of social distancing and quarantine efforts based on dynamic wastewater catchment-level estimations of prevalence.}, issn = {2379-5077}, doi = {10.1128/mSystems.00614-20}, author = {Wu, Fuqing and Zhang, Jianbo and Xiao, Amy and Gu, Xiaoqiong and Lee, Wei Lin and Armas, Federica and Kauffman, Kathryn and William Hanage and Matus, Mariana and Ghaeli, Newsha and Endo, Noriko and Duvallet, Claire and Poyet, Mathilde and Moniz, Katya and Washburne, Alex D and Erickson, Timothy B and Chai, Peter R and Thompson, Janelle and Alm, Eric J} } @article {1395224, title = {SARS-CoV-2 titers in wastewater foreshadow dynamics and clinical presentation of new COVID-19 cases}, journal = {medRxiv}, year = {2020}, month = {2020 Jun 23}, abstract = {Current estimates of COVID-19 prevalence are largely based on symptomatic, clinically diagnosed cases. The existence of a large number of undiagnosed infections hampers population-wide investigation of viral circulation. Here, we use longitudinal wastewater analysis to track SARS-CoV-2 dynamics in wastewater at a major urban wastewater treatment facility in Massachusetts, between early January and May 2020. SARS-CoV-2 was first detected in wastewater on March 3. Viral titers in wastewater increased exponentially from mid-March to mid-April, after which they began to decline. Viral titers in wastewater correlated with clinically diagnosed new COVID-19 cases, with the trends appearing 4-10 days earlier in wastewater than in clinical data. We inferred viral shedding dynamics by modeling wastewater viral titers as a convolution of back-dated new clinical cases with the viral shedding function of an individual. The inferred viral shedding function showed an early peak, likely before symptom onset and clinical diagnosis, consistent with emerging clinical and experimental evidence. Finally, we found that wastewater viral titers at the neighborhood level correlate better with demographic variables than with population size. This work suggests that longitudinal wastewater analysis can be used to identify trends in disease transmission in advance of clinical case reporting, and may shed light on infection characteristics that are difficult to capture in clinical investigations, such as early viral shedding dynamics.}, doi = {10.1101/2020.06.15.20117747}, author = {Wu, Fuqing and Xiao, Amy and Zhang, Jianbo and Moniz, Katya and Endo, Noriko and Armas, Federica and Bonneau, Richard and Brown, Megan A and Bushman, Mary and Chai, Peter R and Duvallet, Claire and Erickson, Timothy B and Foppe, Katelyn and Ghaeli, Newsha and Gu, Xiaoqiong and Hanage, William P and Huang, Katherine H and Lee, Wei Lin and Matus, Mariana and McElroy, Kyle A and Nagler, Jonathan and Rhode, Steven F and Santillana, Mauricio and Tucker, Joshua A and Wuertz, Stefan and Zhao, Shijie and Thompson, Janelle and Alm, Eric J} } @article {1395225, title = {Traumatic pedestrian and bicyclist injuries associated with intoxication}, journal = {Am J Emerg Med}, year = {2020}, month = {2020 Aug 16}, abstract = {BACKGROUND: Drug and alcohol use are risk factors for trauma among operators of motor vehicles and contribute to trauma in pedestrians and bicyclists. We describe the prevalence of drug and alcohol use and clinical consequences in a cohort of pedestrians and bicyclists with trauma. METHODS: We analyzed a 25-month data set of 916 trauma team activations from January 2017-January 2019 at an urban, level I trauma center. Blood ethanol levels and urine toxicology screens were obtained in 94 pedestrian and bicyclist trauma activations. We compared pedestrians or bicyclists with a positive urine or blood screen (n~=~69) to those with negative screens (n~=~25). We conducted a retrospective chart review to determine mechanism of injury, injury pattern, and disposition from the emergency department (ED). RESULTS: Overall, 38 (55\%) of injured patients with positive screen were pedestrians and 31 (45\%) were bicyclists. Fentanyl was the most commonly detected drug (n~=~38; 40\%), followed by opiates (n~=~27; 29\%), and tetrahydrocannabiol (THC) (n~=~23; 25\%). Twenty-one patients were positive for ethanol. Pedestrians and bicyclists with positive toxicology screens were significantly more likely to sustain fractures (p~<~.01), require an operative procedure (p~<~.05), or intensive care unit admission (p~<~.05). CONCLUSION: Our study builds on previous literature which suggests that intoxicated bicyclists and pedestrians suffer frequent and more severe injury than their sober counterparts. Public health campaigns should educate bicyclists and pedestrians about the risks of cycling or walking in areas of road traffic while under the influence of alcohol or illicit drugs.}, issn = {1532-8171}, doi = {10.1016/j.ajem.2020.08.024}, author = {Tonellato, D J and Ransohoff, J R and Nash, C and Melanson, S E F and Petrides, A K and Tolan, N V and Goldberg, S A and Boyer, E W and Chai, P R and Erickson, T B} } @article {1395228, title = {"Emerging Technologies and Medical Countermeasures to Chemical, Biological, Radiological, and Nuclear (CBRN) Agents in East Ukraine"}, journal = {Conflict and Health}, volume = {14}, year = {2020}, month = {2020}, pages = {24}, abstract = {Since 2014, Ukraine has been beset by an armed conflict with international and internal dimensions. The nature of this conflict is multidimensional, and disaster preparedness and response in this context must be as well. Health experts from Ukraine, the United States of America, United Kingdom, Czech Republic, and Norway convened for an educational event in Dnipro, East Ukraine on November 11-15, 2019. At the event, "Emerging Technologies and Countermeasures to CBRN Agents: Advanced Training Response to Conflict and Security Challenges in East Ukraine," over 1,000 participants participated in panel discussions, didactic lectures, and an advanced training on various dimensions of disaster response. This report provides an overview of the key discussions and outcomes of the event.}, issn = {1752-1505}, doi = {10.1186/s13031-020-00279-9}, author = {Patel, Sonny S and Grace, Robert M and Chellew, Patrick and Prodanchuk, Mykola and Romaniuk, Olha and Skrebets, Yuriy and Ryzhenko, Sergii A and Erickson, Timothy B} }