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SPECIAL REPORT
Challenges in the Conduct of Health Disaster Response Studies:
Consensus Statement by the Task Force for Quality Control of
Disaster Management (TFQCDM)
Knut Ole Sundnes, MD Chair, Head of Anaesthesia, Norwegian Armed Forces Joint Medical Services;
Co-Chairs: Dag Hjelle, MD, Brigadier General and Director Norwegian Armed Forces Joint Medical
Services; Ernesto A. Pretto, JR. MD, MPH, Professor of Clinical Anesthesiology, University of Miami
Miller School of Medicine; Edmund M. Ricci, PhD Professor, Graduate School of Public Health,
University of Pittsburgh;
Jeffrey Arnold, MD, Chief Medical Officer Santa Clara Valley Health and Hospital System, Santa Clara
County, California, US; Yasufumi Asai, MD Emeritus Professor, Sapporo Medical University, Japan
Special advisor of Japan Disaster Relief (JICA) and Editor in Chief of Journal of Japan Association of
Disaster; Robert Balazs, MD Lt. Col Technical Officer (Medical) NATO Operational Logistics Planning
and Support Programme Office; Per Morten Boelstad Lt Col. Safety inspector (Infantry) Norwegian
Armed Forces joint medical services/risk, safety, preparedness and vulnerability; Felipe Cruz Vega, MD,
Mexican Institute of Social Security, Special Health Projects Division; Siddarth David Senior Research
Officer, School of Habitat Studies, Tata Institute of Social Sciences (TISS), Mumbai; Michel DeBacker
MD, Prof. Dr. Director, Disaster Medicine Unit Research Group on Emergency and Disaster Medicine,
Faculty of Medicine and Pharmacy Vrije Universiteit Brussel Laarbeeklaan, Belgium; Hon. Emmanuel
de Guzman, Philippine Climate Change Commissioner, Philippine climate Change Commission, San
Miguel, Manila, 1005 Philippines; S.William A. Gunn, MD Former Director Emergency Humanitarian
Operations, WHO, Geneva and member Academic Council of the United Nations System; Christian
Haggenmiller, MD; Omar Juma Khatib, MD; Leo Klein, MD Assoc. Prof. Brigadier General MD.,
PhD, Former Surgeon General of the Czech Armed Forces, Dept. of Military Surgery, Faculty of Military
Health Sciences, University of Defence, Charles University Teaching Hospital, Czech Republic; Istvan
Kopcso Brigadier General, Dr, PhD Medical Advisor Supreme Headquarters Allied Powers Europe
Belgium; Isidore K. Kouadio, MD, PhD, FETP, DMHA Regional Polio Certification Officer Global
Polio Eradication Initiative, WHO Regional Office for Africa, Brazzaville, Republic of Congo; Håkon
Lund, MD, Lt Col ,Seniorrådgiver and Senior Staff Officer, Norwegian Armed Forces Medical
Services; Ove Njå PhD Prof. University of Stavanger; Nobhojit Roy, MB, Prof & Head of Surgical
Services and Scientist 'G' BARC Hospital (Govt. of India), HBNI University, Mumbai; Sidika Tekeli,
MD Asst. Prof. Dr. Head of Department Hacettepe University Institute of Public Health Department of
Health Management in Disasters, Turkey; Andreas Ziegler, MD MSc EMDM MBA, Vienna Municipal
Ambulance Service.
Please address correspondence to:
Knut Ole Sundnes MD, (kosundnes@gmail.com) and
Ernesto A Pretto, Jr. MD, MPH (eapretto@med.miami.edu)

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ABSTRACT
Background: A goal of disaster medicine is the conduct of studies to enable evidence-based learning
that will translate into prevention or reduction of the adverse effects of a disaster on human health and
the health system infrastructure. However, there is no consensus on priorities or best practice
methodology for disaster studies. In this report an international panel of public health experts and
disaster medicine practitioners identifies priorities and proposes solutions concerning the design and
conduct of such studies.
Methods: Interdisciplinary members of the Task Force for Quality Control of Disaster Management
conducted field studies after numerous large-scale disasters. We convened a series of workshops with
public health researchers and disaster medicine practitioners to analyze the literature and deconstruct the
health and medical aspects of disaster response to achieve consensus on priorities and methodology for
disaster response research.
Findings: We have identified research priorities and proposed guidelines for a consensus on the
adoption of a ‘mixed methods’ approach to broaden the scope and improve the quality of evidence-
based research in disaster medicine.
Interpretation: A universal consensus on study priorities and mixed-methods approach to disaster
medicine research will improve data collection and facilitate the uniform reporting of data for creation
of data banks and registries for comparison of all hazard disaster types. This will improve the scientific
rigor of disaster research to better enable the translation of evidence-based knowledge into cost-effective
programs for the prevention and mitigation of human suffering in all-hazard events.
INTRODUCTION
Disaster medicine is a newly emerging and interdisciplinary medical specialty. It is comprised of
two major domains within health care, emergency public health (EPH) and emergency medical services
(EMS). Each domain is characterized by a series of health and medical services delivered to a disaster-
impacted population. In many countries these activities are conducted according to a pre-conceived plan
and well-elaborated disaster response framework, which includes a concept of operations and detailed
descriptions of emergency support functions 1. A disaster response evaluation study is defined as a
scientific endeavor to gather evidence to elucidate the causes, circumstances, risk factors and extent of

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human and health system damage during the life cycle of a disaster (Fig 1). A major goal of such
studies is the conduct of assessments of the quality of life-saving and life-supporting actions
implemented during and after a disaster in order to improve response to future disasters. However, this
task has not been carried out in an optimal manner to date due to the complexities of performing
research during or after a disaster 2.
In this monograph an international panel of experts recognized as the ‘Task Force for Quality
Control of Disaster Management (TFQCDM)’ describe guidelines for the study of disaster. These
guidelines comprise consensus on priorities and on a combined retrospective methodological approach
we consider to best facilitate evidence-based data collection within the complex interdisciplinary
framework of emergency public health and disaster response. We have concluded that a combination of
evaluative and epidemiological methods blended into a ‘mixed methodology’ is the ideal study design
for disaster research. A mixed methods approach can be defined as:
“…focus on collecting, analyzing, and mixing both quantitative and qualitative data in a
single study or series of studies. Its central premise is that the use of quantitative and qualitative
approaches in combination provides a better understanding of research problems than either approach
alone.” 3,4
The challenge is to know which tools to apply, when, and for what priorities of study so as to
ensure ‘lessons learned’. The guidelines we have developed are based on experiences gained during
field survey studies of large-scale disasters during the period 1989-2005 5-19. After each study the scope
and the methodology were expanded to incorporate elements of both evaluation and epidemiological
research in order to increase the generalizability, applicability and scientific rigor of the methods. To
complement experiences gained in these early studies a series of workshops were convened with public
health researchers and practitioners to systematically deconstruct health and medical activities
commonly performed in the response to disasters and to identify research priorities and the most

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appropriate methodology to achieve study objectives. A critical analysis of previous disaster studies was
crucial to the process of establishing priorities and selecting a standard methodology. The result of these
efforts is a set of guidelines for evaluation and research of disaster response in the ‘Utstein Style’.
The Utstein Style guidelines format was selected because it provides a structured framework
consisting of templates (standardized forms) and registries (databases) for the uniform reporting of data
to compare disaster responses 20. A first volume of 3 planned volumes of these guidelines has been
published previously describing consensus on terminology and concepts: ‘Conceptual framework of
disasters’ 21. A second published volume describes consensus on the concept of operations: ‘Structural
Framework, Operational Framework and Preparedness,’ 22. The 3rd volume in this consensus project
will focus on ‘Methodology’. An abbreviated description of that methodology is presented herein for
review and feedback.
STUDY PRIORITIES
Pre-Event Phase:
A scientific assessment of the severity of impact of a disaster on a community cannot be fully realized
unless we can collect baseline data on community-wide all-hazard risk planning and preparedness prior
to the event under study, as follows:
 The level of awareness about known hazards by the population at risk.
 An assessment of the degree of socio-economic development of the community and especially of
the health system, its infrastructure and the types and extent of access to health care services
available to members of the community on an everyday basis. [The assessment of pre-event
status is facilitated by the use of selected World Health Organization (WHO) standard population
health indicators (Table 1)]

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 An assessment of the structure, organization, adequacy and investments in disaster planning and
preparedness programs, and the extent to which these were implemented or tested and achieved
stated objectives during actual and/or simulated events.

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Table 1. Template for Assessment of Pre-Event Status Basedon SelectedIndicators of Pre Event
Socio-Economic Development and the Post DisasterSeverity Score (DSS).
____________________________________________________________________________________
Checklist:
Indicator of Socio-economic Development *Range
GDP/per capita income (current U.S.$) Low Middle High
Real GDP Growth (%) Low Middle High
Proportion of population rural/urban Low Middle High
Under 5 Infant mortality rate Low Middle High
Maternal mortality rate Low Middle High
Life expectancy Low Middle High
Literacy rate Low Middle High
Proportion of population cell phones/1000 Low Middle High
Proportion of homeless population Low Middle High
Number of residential structures Low Middle High
Number of office buildings Low Middle High
Number of hospitals Low Middle High
Number of vehicles in use/1000 Low Middle High
Annual energy consumption (eq. Kg of oil/capita) Low Middle High
____________________________________________________________________________________
Pre-Event Development Score:
* The range of the score prior to the event is based on the total sum for each category: Middle (average among nations):
Low = 5 points(poorly developed);Middle = 10 points (Average development);High = 15 points (highly developed) .The
change in score before vs after the disasterprovides an estimate of the severity of the disaster on the socio-economic
development of the affected community..
Event Phase:
Once the event has impacted a population we can attempt a study to determine the degree of damage to
the health and health system within the affected community (Table 2). The disaster study should aim to
assess human damage and the extent of disruption or destruction of the health system infrastructure. The
ideal timing for such studies is immediately after the end of relief and response activities. Evaluative
study tools are essential to collect administrative, medical record and interview data from survivors and
responders on the quality of overall life-saving activities implemented during the event. For each
activity the following categories of information must be collected:

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 The structure, process, adequacy, timeliness, outcomes and costs of the damage and of the needs
assessments performed on the disaster-impacted community or society; and the process, and
cost-efficiency of supplying those needs from within the affected community (local response) or
from without (external response).
 The identification, prioritization and process of implementation of the emergency relief function
 The structure, process, adequacy, timeliness, outcomes and costs (and possible opportunity costs)
of the delivery and management of the health and medical response
 The outcomes of specific public health and medical interventions to prevent or reduce morbidity,
mortality and disability among disaster impacted victims as determined by pre-established
standard-of-care end points, as well as the ability or inability of the impacted health system to
provide health services to survivors during the event (triage, application of first aid, emergency
transport, definitive care, potable water, epidemiological surveillance, etc.)
Table 2. Template for Assessment of Pre- and Post-Event Health Status/Health Disaster
Severity Score (HDSS)
____________________________________________________________________________________
Checklist:
Indicator of Health System Development *Range (Before/After)
_____________________________________________________________________________________
 Human Impact:
 Affected Population: # # #
 Crude Mortality Rate/10,000 # # #
 Crude Injury Rate/10,000 # # #
 Health System infrastructure:
 Number and type of hospitals/capita* Low Middle High
 Number of beds/capita Low Middle High
 Number of health care workers/capita* Low Middle High
 Number of Critical Care beds Low Middle High
 Average ICU bed occupancy rates (Past 6 months) Low Middle High
 Number of Ambulances/EMS systems Low Middle High
 Percent population with access to potable water Low Middle High
 _____________________________________________________________________________________

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Health Disaster Severity Score: each indicator is given an arbitrary point score – Low (5) - Middle (10) – High
(15).The change in the score (before vs. after) is an estimate of the severity of damage sustained by the health
system infrastructure (Health Disaster Severity Score).
Post-Event Phase:
A major priority of the study is the assessment of how the affected community recovered from the event.
The priorities during the rehabilitation/recovery phase include the following:
 Identification, prioritization, timing of initiation and implementation of relief and recovery
projects, and whose aim is the resumption of the normal activities of daily living [lifelines
(electricity, water, gas, shelter, food distribution, transportation, communication)], as well as the
resumption of normal health services, school, work and leisure activities
 Assessment of the health and medical care costs to restore health care services and for the long
term rehabilitative care of the mentally and physically disabled caused by the disaster itself
 Assessment of the organization, coordination, sources of funding, costs and adequacy of plans to
reconstruct societal infrastructure (hospitals, roads, bridges, housing, schools, entertainment
facilities, parks, etc.)
Study Designand Methods
We propose consensus on the adoption of a mixed method design for evidence-based research on health
and medical response efforts in a disaster. The study tools employed whether evaluative or
epidemiological are based on the questions asked and the character of the information to be obtained
(qualitative vs. quantitative) and the objectives and specific aims of the study according to the following
considerations: 1) Evaluative methods gather information to be used to assess the quality of the medical
and public health services and interventions deployed using pre-established measures of effectiveness

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and/or quality indicators and outcome parameters 23-28. 2) Epidemiological research methods are used to
collect concurrent or retrospective quantitative data primarily about the fate of casualties. Whenever
possible data collection instruments must be designed a priori to facilitate uniform reporting of data for
input into data banks and registries that can be used for hypothesis testing (Table 3). Also, the study
design must provide a mechanism for concurrent data collection, which will serve a dual role: a) to
monitor the quality of delivery of services during the event and; b) for risk factor analysis in
retrospective case control studies after the event.
With regard to the implementation of the study, the first phase should involve the following
thought process: 1) identification of the problem(s) to be studied; 2) formulation of the questions or
hypotheses based on the problems identified, and; 3) validation of the research questions through
substantial literature and background research. A primary objective of the study must be to uncover risk
factors for adverse health effects of hazards, in addition to the utility and effectiveness of interventions
employed to prevent or reduce injury or death.
As in any investigative process the findings are only as good as the research questions asked and the
methods used to collect reliable data to answer them. Evaluative tools (eg. survey methodology) are
applicable for the collection of information from key target audiences who participated in the
organization or delivery of the relief and response and to define the parameters of the quality of those
activities according to standard evaluation categories 23,24. The following are sample questions to be
asked of eyewitnesses in health disaster studies:
 What was the hazard type?
 What was its intensity (Richter scale, Saffir-Simpson wind scale, etc.)?
 What was the population at risk?

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 What were the demographic features of the affected population (age, gender) or other important
characteristics?
 Were there secondary disasters (fires, dam burst, landslides, etc.)
 Was there early warning of the hazard or early warning systems employed?
 How well did early warning systems function?
 When and how did victims become identified for care?
 What types of medical care/surgical procedures were provided to each victim?
 Who provided the care (lay bystanders, search and rescue, paramedics, physicians, etc.)?
 What was the outcome or the result of the care provided?
 What factors worsened the outcome with regard to injury, death or disability?
 Was the care provided in a timely manner and appropriate for the various injury conditions?
 Were the interventions appropriate for the identified needs?
 How many people required temporary shelters?
In addition disaster research is employed to investigate morbidity and mortality statistics (descriptive),
incidence and prevalence of injuries, and exposure response for the determination of risk factors for
illness, injury and death 28. The following are a sample of health data for quantitative analysis and
hypothesis testing that are usually collected within the context of a mixed methods health disaster study:
 What were the injury types according to cause and mechanism (crush, drowning, burn, traumatic
brain injury, malnutrition, etc.)
 Injury type according to anatomic region (head, neck, thorax, extremities)
 Circumstances of injury or death (building collapse, entrapment, flooding, fire, explosion,
drought, etc.)

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 Mechanism and pattern of dying (asphyxiation, exsanguination, hemorrhagic shock, ventricular
fibrillation cardiac arrest, hypothermia, starvation, etc.)
 What was the severity of injuries (Injury severity scores)?
 Timing of death (instant, delayed, protracted)
 Location of injury or death (inside or outside of a building, out-of-hospital, during transport, in-
hospital, etc.)
 Types and quantity of medical/surgical interventions employed (extrication, fluid resuscitation,
basic or advanced trauma life support, resuscitative surgery, amputations, etc.), if possible by
ICDM-10 codes.
 Types of disabilities?
Epidemiological methods can be combined with evaluation methods to assess the influence of first
aid training on relief efforts using inferential statistical analyses 9. Case-control methodology has been
used since the 1970s to identify risk factors based on differences in circumstances between populations
of injured and uninjured at the time of disaster impact 29-38. Prospective randomized clinical trials have
not been reported in disaster situations due to the unpredictable nature of disasters.
Table 4. Template for Concurrent Data Collection on DisasterCasualties
____________________________________________________________________________________
 Name
 Age (if known)
 Date of birth (if known)
 Gender
 Numeric identifier/bar code
 Date of injury
 Date and time the victim was identified
 Location of the victim when injured
 Distance to treatment facility
 Mode of transportation to the treatment facility
 Distance to food sources

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 Distance to potable water/water source
 Preliminary diagnosis or cause of injury/illness
 Type of treatment(s) provided at the scene of injury, during transport, and in-hospital
 Triage status of the victim on arrival to the treatment facility (EG. walking wounded, urgent, critical, dead on
arrival)
________________________________________________________________________________________
Discussion
We propose a consensus for the study of disaster response based on previous experiences in disaster
studies and on a systematic analysis by public health experts and practitioners on the priorities for study
and best methodology for disaster response research 3,4. There are many benefits that should accrue with
the prioritization of the objectives and the systematic application of standardized research methods for
the study of disaster 39. These guidelines provide purpose and structure and a detailed road map for the
formulation of questions and hypotheses, identification of sources of data, and data collection templates
in disaster situations. It also provides guidance on when and how to apply a mixed methodological
approach. In addition, the structure and processes of the methods are generic enough to have
applications in other domains within the broader disaster field. Its proper application by trained teams
should result in increasing validity of the findings and enhanced reproducibility and generalizability
applicable to all-hazards disaster research.
The practical application of these consensus guidelines should result in evidence-based findings, and
conclusions and recommendations to enhance the cost-effectiveness of the medical responses to
disasters and their outcomes. Ongoing use of the processes outlined and the uniform reporting of data
using standardized checklists and templates should facilitate the creation of data banks and registries to
inform disaster planners as they review and revise existing disaster preparedness programs and
interventions in anticipation of future disasters.

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Further development of the guidelines will include a consensus on a set of key indicators or best
practices for each activity. Once the indicators have evolved, a set of measurements and potentially
critical pathways should develop for each of the indicators. Ultimately, appropriate benchmarks will
evolve and be tested using select indicators and methods for measurement. Once this is achieved, real
quality monitoring capabilities will be in place. Numerous examples of tools for use in rapid needs
assessment serve as models.
There are several limitations to the methodology presented. A primary limitation of
retrospective data collection is that much of the needed information is not documented or may be
inconsistent. Also, information collected from individuals is subject to recall bias and is perishable.
Perishable data change with the passage of time and consequently their value also decreases with the
passage of time. In fact, much of the interview data obtained in or following disaster situations is subject
to change by many confounding factors such as the influence of media reports, and the sharing of
information between victims, between responders, and between others involved in the care delivered to
the victims. Thus, for certain data, the time selected for data collection is crucial. Despite these
limitations an attempt is made to reconstruct the events from data collected from individuals within the
affected population namely, uninjured survivors, injured survivors and data on non-survivors. Another
source of information is the group of individuals who were involved in the relief effort. These subgroups
are primary sources of data collection.
In conclusion, this consensus paper is meant to raise awareness among the general medical and
humanitarian relief communities about an approach that will lead to an increased scope and
systematic evidence-based study of disaster. We hope that the publication of this paper will lead
to a debate within academic circles that will lead to a better understanding of the challenges of
this particular area of research.

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Fig. 1. LIFE CYCLE OF A DISASTER FROM A HEALTH PERSPECTIVE
Pre-event Health Status
Event
Damage
4. Disturbances in Health Status
5. Identification of Needs
6. Responses
7. Changes in Health Status
NO 8. RestoredHealth Status?
YES
End

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