Disaster medicine reporting: The need for new guidelines and the CONFIDE statement

Authors

  • David A Bradt,

    1. Royal Melbourne Hospital, Melbourne, Victoria, Australia
    2. Center for Refugee and Disaster Response, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA,
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  • Peter Aitken

    1. Emergency Department, The Townsville Hospital
    2. Anton Breinl Centre for Public Health and Tropical Medicine, James Cook University, Townsville, Queensland, Australia
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  • David A Bradt, MD, MPH, FACEM, FAFPHM, FAAEM, DTM&H, Honorary Physician; Peter Aitken, MB BS, FACEM, EMDM, M ClinED, Senior Staff Specialist, Associate Professor.

This issue of the journal introduces new guidelines for authors of disaster case reports. This editorial examines the drivers and implications of these guidelines.

Government agencies, professional societies, trade associations and special interest groups produce vast literature on various aspects of disasters. Much of this literature worldwide is ‘grey’– print published or web published – but unobtainable through electronic indexing services. The electronic information alone is now so extensive that the US National Library of Medicine has created a Disaster Information Management Research Center to help with national emergency preparedness and response efforts.1 Within the published biomedical literature, a recent 30 years review canvassing a range of electronically indexed databases found the majority of event-specific literature indexed in MEDLINE was published across a broad spectrum of disciplines. The top 10 journals cited are listed in Table 1.2 Over the last decade, disaster literature accelerated markedly prompted by the events of September 11, 2001, at the World Trade Center, which yielded the greatest number of event-specific, peer-reviewed publications to date (686).2 New journals devoted to disasters continue to emerge with recent ones receiving MEDLINE indexation before their first full year of publication.

Table 1.  Top 10 journals for peer-reviewed, event-specific literature by number of publications (1977–2009) (adapted from2)
Prehospital and Disaster Medicine
Journal of Traumatic Stress
Military Medicine
Psychiatric Services
Journal of the American Medical Association
Lancet
Morbidity and Mortality Weekly Reports
Journal of Nervous and Mental Disease
American Journal of Public Health
Environmental Health Perspectives

The challenge for the reader keeping up with disaster literature is therefore daunting. Finding good-quality evidence within this corpus of literature creates another set of hurdles for the reader.

First, the disciplines of medicine, public health and disaster management differ in origins, definitions, research paradigms and tools of evidence-based decision making.3,4 In evidence-based medicine, core concepts are well known to most physicians. These core concepts include population-intervention-comparison-outcome questions, hierarchy of evidence strength based upon methods of data acquisition and criteria for determining adequacy of studies. However, important questions in disaster medicine are not easily testable by evidence-based science. Disaster field conditions are fluid, data are perishable and compete with rumour, and security constraints prevail. As a consequence, controlled studies in disasters are difficult to run. The level of scientific evidence behind many of our actions in disaster medicine remains weak. Disaster relief operations continue to rely heavily on ‘eminence-based’ decisions by parties striving to broker goodwill and consensus.5 Underlying issues include lack of agency expertise, dyscoordination between agencies in the field, inappropriate proxy indicators, flawed scientific inference and erosion of the concept of minimum standards.

Second, the cost-effectiveness of many disaster interventions remains unknown. For example, disaster medical assistance teams, mobile field hospitals and hospital ships operate in virtually uncharted cost-effectiveness territory. The extensive work of the US National Institutes of Health, the World Health Organization and the World Bank on cost-effectiveness analysis, such as the Disease Control Priorities Project (DCP2),6 is remarkable in part for its lack of external validity in disaster relief operations. Donor governments often choose options for disaster health interventions based on political criteria for engagement rather than scientific criteria for lives saved.

Third, disaster case reports remain a prominent part of biomedical journal reporting on disasters with a reliance on descriptive accounts. Several different types of report have emerged in the literature.

  • • Brief case report
  • • Rapid epidemiological assessment
  • • Comprehensive case report
  • • Comprehensive country profile

In our experience, the most common and least useful is the brief case report. These are typically written from a donor's or intervenor's perspective, and are often plagued by anecdotal, descriptive, breathless reporting of process rather than outcome. This type of reporting, as well as the field engagement described, has been characterized as ‘disaster tourism’.7 Dissemination occurs in proportion to the public interest in the event, and esteem of the parent journal, rather than the strength of the science. This practice creates disaster mythology. Peer-reviewed literature may take years to correct the misconceptions devolving from particular disasters.8–10

Nonetheless, there is still a role for duly diligent case reports – especially when the science is young. To do this, there needs to be an appropriate reporting structure that encompasses context, perspective and outcomes. There are reasons for optimism. Disaster relief operations are becoming increasingly standardized in management of information as well as interventions. Initial rapid assessments (IRAs), Health Resources Availability Mapping System (HeRAMS) and syndromic disease surveillance have long histories of development led by the World Health Organization. The cluster system, itself, now has over 30 iterations worldwide. Although field execution is sometimes poor – Haiti is a recent example – use of standardized data-gathering tools and inter-agency processes is increasingly seen as core responsibilities of responders in the health sector.

We also take heart from the systematization of scientific reporting requirements undertaken by biomedical scientists and journal editors. These requirements inform investigators and authors what information is required to ensure readers and reviewers can properly evaluate a study. For randomized controlled trials, the Consolidated Standards of Reporting Trials (CONSORT) statement emerged in 199611 followed by the Quality of Reports of Meta-analyses (QUORUM) statement in 1999.12 For observational studies, the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement emerged in 200713 followed by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statement in 2010.14 There have also been efforts, such as the Utstein Template,15 to standardize the language of disasters and promote consistent use of definitions.

In this issue of Emergency Medicine Australasia, we take the first step in systematizing disaster case reports by drawing up specific Instructions for Authors coupled with our CONsensus Guidelines on Reports of Field Interventions in Disasters and Emergencies (CONFIDE). We seek to help authors report on complex issues of disasters. We seek to help the reader make informed judgments about these issues by bringing the reader as close as possible to field data. We seek to foster the work of future scholars undertaking critical event analysis, disaster comparisons and translational research. Finally, we seek to engage with other biomedical journal editors in pursuit of best practice standards for disaster reporting. To these ends, key components of the CONFIDE guidelines are listed in Table 2. A summary of our case report typology is presented in Table 3. Additional information for authors is posted on the web.16 For reasons cited above, in the absence of extremely unusual hazards or compelling epidemiology, the journal is unlikely to publish brief case reports in the future. Other types of disaster case reports will be welcomed.

Table 2.  CONsensus Guidelines on Reports of Field Interventions in Disasters and Emergencies (CONFIDE)
Key components
Introduction
1. State specific objectives of the report.
Context
2. Describe the disaster in terms of type, location, area affected, population affected, damage assessment and epidemiological impact.
3. Describe the donor agency/organization/individuals (intervenors) undertaking the field intervention to include specific goals of intervention, team membership (disciplines and numbers) and mechanism of accountability to host country health authorities.
Access to the Field
4. Who gave permission to enter the disaster, treat patients, and when were those permissions given?
5. What was the timeline of field intervention? When did the intervenors deploy to the field, when did the deploying team examine its first patient, and how long did the intervenors stay in the field? Specifically, when did the report authors enter and exit the field. Use GMT references.
Self Sufficiency and Unmet Needs in the Field
6. How did the deploying medical team secure its food, water, power and medical waste disposal in the field?
7. What translation requirements existed, and how were those requirements addressed?
8. What other providers served the same catchment population as the deploying team?
Data Environment
9. Did the deploying team contribute to the initial rapid assessment undertaken by the humanitarian community? If not, why not?
10. Did the deploying team serve as a sentinel reporting site and contribute to the local disease surveillance system? If not, why not?
11. Did the deploying team participate in the local health coordination process? If not, why not?
Patient Care and Epidemiology
12. Using descriptive statistics, characterize all patients treated by the team during the deployment.
13. What standardized case management protocols governed patient care?
14. What referral process occurred for patients needing care beyond that available in the treatment facility?
15. At the departure of the deploying team, to whom were patients at the treatment facility handed over or referred for continuing care.
Funding
16. Give the source of funding for the intervention, and estimate direct and indirect support costs.
Table 3.  Case reports: proposed utilities and formats
Type 1: Brief Case Report
• report of present practice for epidemiologically unusual disaster or unusual response to it
• perspective – relief agency or disaster victims on the ground
• submission time – within 4 weeks of acute onset disaster
• length – 1500 words
• recommended structure – simple narrative
• caveat – may be newsworthy in general professional practice but unlikely to be accepted as a case report in specialty journal
Type 2: Rapid Epidemiological Assessment
• report of choice for epidemiologically unusual disaster or unusual response
• perspective – relief sector lead agency or international coordinating agency in the field
• submission time – within 3 months of acute onset disaster
• length – 4000 words
• recommended structure
 ○ background
 ○ sources and methods
 ○ pre-existing indicators
 ○ disaster impact
 ○ current health indicators
 ○ health sector overview
 ○ domestic and international response
 ○ summary of health situation
 ○ programmatic rationale
 ○ recommendations
Type 3: Comprehensive Case Report
• report of choice for overview of disaster impact, relief and rehabilitation (if applicable); amalgamates data from primary and secondary sources, and has strong evaluation component that demonstrates scholarship of integration and application
• perspective – relief sector lead agency or international coordinating agency in the field
• submission time – within 1 year of disaster
• length – 4000 words
• recommended structure
 ○ mechanism and impact
 ○ disaster management
  ▪ initial field response
  ▪ relief operations command and control
  ▪ hazards inventory
 ○ morbidity, mortality and disease surveillance
 ○ recovery process
 ○ discussion
  ▪ epidemiological perspective
  ▪ operational perspective
 ○ implications for provider groups on future best practices
Type 4: Comprehensive Country Profile
• report of choice for overview of emergency/disaster experience in country or catchment area
• perspective – practitioner, donor or host country health authority representative
• submission time – not applicable
• length – 4000 words
• recommended structure
 ○ baseline demographic and health status
 ○ underlying socio-political issues especially affecting current professional practice
 ○ profiles of selected practices/problems/disasters
 ○ discussion
  ▪ local health burden
  ▪ technical issues

We acknowledge there are many ways to report science. Disasters remain a multidisciplinary endeavour, and no one owns the truth. Indeed, in disasters of conflict, the first casualty may be truth itself. However, we believe these guidelines will increase the utility of case reports for the reader and other scholars. Improving disaster reporting is merely a first early step. The real goal is improving disaster science. We reaffirm to our readers and authors our commitment to that process, our respect for their work and our own willingness to learn from their experience.

Competing interests

David A. Bradt: Editorial Board, Emergency Medicine Australasia. Peter Aitken: Section Editor Disaster Medicine, Emergency Medicine Australasia.

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