Medical Preparedness Research Articles

Optimizing Special Operations Forces Operator Talents and Mission Capabilities: Human Performance Optimization and Total Force Fitness Capability-Based Blueprint and Targeting System.

The Special Operations Forces (SOF) community represents an impressive degree of diversity in talents, culture, mission essential tasks, and occupational risk exposures across Service branches, their career fields, and units. Sustaining the capabilities of the SOF Operator across a career lifespan requires collaboratively addressing the current gap between medical readiness and mission readiness with support services and their SOF end users. Given the diverse needs of SOF Operators and their units, realigning performance and health (P&H) service delivery to meet their specific needs will require the adoption of an alternative business framework, operationally focused metrics, and retargeting to ensure SOF Operators are not just medically ready, but mission ready. With restructuring of P&H service delivery occurring across the Department of Defense at all levels to support the 2018 National Defense Strategy, there is a greater need for collaborative synchronization, targeting, and validating operational return on investment with SOF Operators and SOF stakeholders. Here, we present the Human Performance Optimization (HPO) and Total Force Fitness (TFF) Capabilities-Based Blueprint (CBB) and Targeting System as an initial step to realigning service delivery. We examine the use of CBB as a translational tool to bridge the divide between P&H services and SOF Operator communities, and demonstrate how the CBB has significant applications to help construct appropriate programming and program evaluation, align resources and needs, and provide culturally appropriate services that should sustainably preserve SOF Operators' unique capabilities and their mission.

Optimizing Teamwork for Human Performance Teams: Strategies for Enhancing Team Effectiveness.

Human performance teams (HPTs) are highly capable and complex teams comprised of medical and performance professionals dedicated to supporting health and sustaining mission capabilities of the Special Operations Forces (SOF) warfighter community. As resources continue to be devoted to recruiting, hiring, and organizing HPTs, there is an increased need to support team-based capabilities, or their ability to work collaboratively and cooperatively across boundaries. In this article, we draw on existing evidence-based approaches to supporting team-based competencies to present a set of strategies designed to address barriers to cross-boundary teaming, catalyze innovation and precision of human performance optimization (HPO) service delivery, and maximize the impact of HPTs on warfighter medical and mission readiness. We begin by offering a conceptual paradigm shift that broadens the lens through which HPO intervention opportunities exist. We then explore how to promote a common understanding of the needs, performance demands, and occupational risks, which should clarify shared goals and targets for service delivery. We also discuss a refined strategy for hiring and recruiting members of HPTs, and finally, we propose opportunities for cultivating communication and collaboration across and within the HPO spectrum. By elevating HPT-based capabilities, the SOF community should be able to amplify the investment made in these invaluable resources.

STATE INSTITUTION «NATIONAL RESEARCH CENTER FOR RADIATION MEDICINE OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES OF UKRAINE» - RESEARCH ACTIVITIES AND SCIENTIFIC ADVANCE IN 2019.

Research activities and scientific advance achieved in 2019 at the State Institution «National Research Center forRadiation Medicine of the National Academy of Medical Sciences of Ukraine» (NRCRM) concerning medical problemsof the Chornobyl disaster, radiation medicine, radiobiology, radiation hygiene and epidemiology in collaborationwith the WHO network of medical preparedness and assistance in radiation accidents are outlined in the annualreport. The report presents the results of fundamental and applied research works of the study of radiation effectsand health effects of the Chornobyl accident.The report also shows the results of scientific-organizational and health care work, staff training.The Scientific Council meeting of NAMS approved the NRCRM Annual Report.

KORONAVİRÜS SALGINI SÜRECİNDE MASKENİN HAYATIMIZDAKİ YERİ

The effects of coronavirus causing the World Health Organization (WHO) to label the outbreak a pandemic on March 11, 2020 are ongoing. As there wasn't adequate medical readiness, individuals catching the disease and losing their lives are gradually increasing. Specialists state even if vaccine studies show success, restricted lifestyle will prolong. Governments are focusing on the importance of preventative precautions from the beginning. This study aims to present an overview of Turkey regarding the importance of masks in daily life as a prioritized precaution in fighting against the outbreak such as distancing and hygiene. Survey was used as a quantitative method. A 12-question survey, out of 4 were personal information questions, was conducted using Survey Monkey between July 1 and September 1, 2020. A suitable sampling method was used considering the logic behind online mediums and the circumstances shaped by the pandemic. 1697 individuals using social media such as WhatsApp, Instagram and Facebook participated in the study. 35 participants were left out as they did not comply with the requested format. The sample of the study was determined as 1662 individuals. Based on the collected data, behaviors and opinions of predominantly young, urban, college graduates/students regarding use of masks were analyzed, and the extent of the involvement of masks within the daily habits was presented. When the results were evaluated in general, it was seen that a significant portion of the participants said that the mask is indispensable;however, they did not seem to fully apply this in their life.

The Effect of Simulated Field Storage Conditions on Dental Restorative Materials for Military Field Use.

Dental readiness, one critical component of medical readiness, is adversely impacted by dental emergencies. Many dental emergencies require restorative materials such as glass ionomers, resins, and zinc oxide eugenols to remedy them. The Authorized Dental Allowance List (ADAL) and Authorized Medical Allowance List (AMAL) contain the equipment and materials used by Navy dentists to treat Sailors and Marines. These supplies are subjected to harsh storage conditions on deployments. Much is known about how materials behave when stored at room temperature, but less is known about how their properties are affected after exposure to high temperatures and humidity. We subjected five dental restorative materials to storage in aggravated conditions, and then tested them to determine which products are more robust. Unopened packages of Fuji Triage, Fuji IX GP (both GC America Inc., Alsip, Illinois), TPH Spectra ST Low Viscosity, Intermediate Restorative Material (both Dentsply Sirona, York, Pennsylvania), and Herculite XRV (Kerr Corporation, Orange, California) were exposed to 0, 5, or 10days' storage at 30-60°C with 95% relative humidity. After storage in these aggravated conditions, we tested the compressive strength, hardness, elastic modulus, flexural strength, flexural modulus, sorption, and solubility of each material. The physical properties of all materials were affected by storage in aggravated conditions, though the properties of some materials degraded more than others. Both glass ionomers, Fuji Triage (P=0.0012) and Fuji IX GP (P=0.0031), and the composite Herculite XRV (P=0.0253) lost compressive strength after 5 or 10days in aggravated conditions. The hardness values for all materials were affected (P<0.05) by the aggravated conditions, though the elastic modulus of TPH Spectra was not affected (P>0.05). None of the materials lost flexural strength (P>0.05) or had changes in their flexural modulus (P>0.05). The water sorption behavior of Fuji Triage (P=0.0426) and Fuji IX GP (P=0.0201) changed after 10days of aggravated storage, and the solubility of all materials was altered by the harsh conditions. Some materials degrade more than others in aggravated conditions. Both resin composite materials were more resistant to high temperatures and humidity levels than the glass ionomers tested. These changes in physical characteristics should be considered when reviewing or optimizing the ADAL/AMAL for different projected operational environments.

Accelerated Resolution Therapy-Based Intervention in the Treatment of Acute Stress Reactions During Deployed Military Operations.

The treatment and resolution of psychological traumas during military deployments directly supports medical readiness and the military mission and potentially prevents symptom progression to post-traumatic stress disorder (PTSD). However, current evidence-based trauma-focused psychotherapies can be difficult to employ during military contingency operations due to various barriers. Deployed military behavioral health providers need an effective, trauma-focused intervention that is suitable for the operational environment. In this retrospective case series, we describe how a therapeutic intervention based on accelerated resolution therapy (ART), an emerging trauma-focused psychotherapy, was pivotal in the treatment of acute stress reactions in eight deployed U.S. Army soldiers. ART can be conceptualized as a hybrid of several evidence-based psychotherapy techniques. In brief, ART is a manualized, procedural adaptation of eye movement desensitization and reprocessing (EMDR) that incorporates mindful awareness of emotions and sensations, bilateral eye movements, imaginal exposure, desensitization, visual and cognitive rescripting, and gestalt-style interventions for the processing of traumatic experiences. The eight deployed U.S. soldiers in this case series received a single 45 to 60minute session of an ART-based intervention within 96hours of a traumatic death. All of the treated soldiers had rapid improvement in both depressive and acute stress symptoms after treatment. Furthermore, the therapeutic benefits were sustained at 1year postincident despite continued exposure to the stress of deployed military operations for up to 6months after treatment. Based on these encouraging preliminary findings, the authors recommend that behavioral health providers who are preparing to deploy become familiar with ART or related interventions in order to develop the confidence and the skills that are needed to provide timely and effective trauma-focused care for deployed soldiers.

Enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial

Our objective was to determine whether an enhanced recovery after surgery pathway at the time of cesarean birth wouldpermit a reduction in postoperative length of stay and improvepostoperative patient satisfaction compared to standard perioperative care. Patients undergoing nonemergent cesarean delivery at ≥37 weeks of gestation were randomized to enhanced recovery after surgery or standard care. Enhanced recovery after surgery involved multiple evidence-based interventions bundled into 1 protocol. The primary outcome was discharge on postoperative day 2. Secondary outcome variables included pain medication requirements, breastfeeding rates, and various measures of patient satisfaction. From September 27, 2017, to May 2, 2018, a total of 58 women were randomized to enhanced recovery after surgery and 60 women to standard care. The groups were similar in medical comorbidities and in demographic and perioperative characteristics. Enhanced recovery after surgery was not associated with a significantly increased rate of postoperative day 2 discharges when compared with standard care (8.6% vs 3.3%, respectively; odds ratio, 2.74; 95% confidence interval, 0.51-14.70), but it was associated with a significantly reduced postoperative length of stay when compared with standard care, with a median length of stay of 73.5 hours (interquartile range, 71.08-76.62) vs 75.5 hours (interquartile range, 72.86-76.84) from surgery, difference in median length of stay (-1.92; 95% confidence interval, -3.80 to -0.29). Enhanced recovery after surgery was not associated with a reduction in postoperative narcotic use (117.16 ± 54.17 vs 119.38 ± 47.98 morphine milligram equivalents; mean difference, -2.22; 95% confidence interval, -20.86 to 16.42). More subjects randomized to the enhanced recovery after surgery protocol reported breastfeeding at discharge (67.2% vs 48.3%; P= .046). When patients were surveyed 6 weeks postpartum, those in the enhanced recovery after surgery group were more likely to feel that their expectations were met and that they had achieved their postoperative milestones earlier, and to report continued breastfeeding. Enhanced recovery after surgery at cesarean delivery was not associated with an increase in the number of women discharged on postoperative day 2, but that may have been related to factors other than patients' medical readiness for discharge. Evidence that enhanced recovery after surgery at cesarean delivery may have the potential to improve outcomes such as day of discharge is suggested by the observed reduction in overall postoperative length of stay, improved patient satisfaction, and an increase in breastfeeding rates. Even better results may accrue with more provider and patient experience with enhanced recovery after surgery.

77 Virtual Reality Trauma Simulation: An Immersive Method to Enhance Medical Personnel Training and Readiness

Immersive virtual reality (IVR) can be highly effective as a medical simulation training platform. Given recent advancements this technology has become increasingly portable and visually realistic. While IVR technology appears to hold promise, there is a great deal to learn about the best way to functionally develop, implement, and share these training resources. Several groups have created models that recreate current simulation lab environments with instructor input. While these systems increase training opportunities, decrease equipment needs, and offer broad potential, they still require a skilled trainer to ‘prompt the system.’ Removing this limitation seems like a potential way to increase scalability. We are currently in the process of creating, to our knowledge, the only simulator that would offer immediate autonomous feedback to users through both real-time patient physiologic responses and overall grading. We created a working group of 10 active duty or former military emergency physicians and 2 technical experts. We hosted 15 meetings to facilitate the development process. The program was developed with financial support from the Telemedicine and Advanced Technology Research Center (TATRC), through the primary vendor Exonicus, Inc, with support from Anatomy Next Inc, and Kitware, Inc. Development was completed using an agile project management style, which allowed our team to review progress and provide immediate feedback on previous milestones throughout its completion. The working group completed the resulting 4 simulation scenarios to evaluate perceived realism and training potential. Finally, while one member of the team was deployed, testing of the technology platform off the network in a deployed role 3/tent environment was conducted. Upon completion we created four IVR scenarios based on the highest mortality battlefield injuries: hemorrhage, tension pneumothorax, and airway obstruction. The working group unanimously indicated a high level of realism and potential training usefulness. Throughout this process there have been a number of lessons learned and we present those here to show what we have created as well as provide guidance to others creating IVR training solutions. Our team developed trauma scenarios that, to our knowledge, are the only IVR trauma scenarios to run autonomously without instructor input. Furthermore, we provide a potential template for the creation of future autonomous IVR training programs. This framework may offer a dynamic starting point as more teams seek to leverage the capabilities IVR offers.

Assessing the pre-hospital care preparedness to face mass casualty incident in Saudi Arabia in 2017-2018.

Objectives:To assess the mass casualty incident (MCI) preparedness of pre-hospital care providers in Saudi Arabia and to identify and highlight their strengths and weaknesses when responding to MCIs.Methods:This cross-sectional descriptive quantitative analysis was conducted between January 2017 and 2018 and included all Saudi Red Crescent Authority (SRCA) general administration branches in 13 regions in Saudi Arabia. The modified version of the emergency medical specialists (EMS) incident response and readiness assessment (EIRRA) tool was used in this study.Results:The Makkah region has the largest number of ambulances and medics vehicles, followed by Riyadh.Makkah and Al Madinah Al Munawarah obtained a median score of 4 and showed substantial preparedness for MCIs. However, Al Madinah Al Munawarah showed higher level of MCI preparedness than Makkah, and a significant difference was found (p=0.019). By contrast, Riyadh and the Eastern region showed limited MCI preparedness. In addition, a moderate positive correlation was observed between the overall median scores and the number of physicians (r=0.656 and p=0.015).Conclusion:The SRCA showed substantial preparedness in Makkah and Al Madinah Al Munawarah. The SRCA were highly prepared to face MCIs.

Air Force Executive Nurse Leaders: Expanding Nursing Leadership During 1995-1999

Many great nurse leaders were pivotal in moving the nursing profession forward, but their efforts have not been recorded in history. Examining recorded history provides an opportunity to learn from our past, understand the impact of the past on current practice, and better plan to advance quality practice in the future. This article describes a study that explored the contributions to the nursing profession by the United States Air Force Executive Nurse Leadership initiative on the nursing profession between 1995 and 1999 in the context of the career of Brigadier General Linda J. Stierle. The article describes the research methods, including the oral history process. Discussion of the findings describe both her impact as an Air Force Executive Nurse Leader who significantly contributed to expanding opportunities for military nurses to lead interdisciplinary teams, command medical treatment facilities, advance medical readiness and nursing practice, and grow nursing as a science. Her influence continues today and the conclusion discusses implications for current nurses.

Simplified clinical algorithm for identifying patients eligible for same-day HIV treatment initiation (SLATE): Results from an individually randomized trial in South Africa and Kenya.

BackgroundThe World Health Organization recommends "same-day" initiation of antiretroviral therapy (ART) for HIV patients who are eligible and ready. Identifying efficient, safe, and feasible procedures for determining same-day eligibility and readiness is now a priority. The Simplified Algorithm for Treatment Eligibility (SLATE) study evaluated a clinical algorithm that allows healthcare workers to determine eligibility for same-day treatment and to initiate ART at the patient’s first clinic visit.Methods and findingsSLATE was an individually randomized trial at three outpatient clinics in urban settlements in Johannesburg, South Africa and three hospital clinics in western Kenya. Adult, nonpregnant, HIV-positive, ambulatory patients presenting for any HIV care, including HIV testing, but not yet on ART were enrolled and randomized to the SLATE algorithm arm or standard care. The SLATE algorithm used four screening tools—a symptom self-report, medical history questionnaire, physical examination, and readiness assessment—to ascertain eligibility for same-day initiation or refer for further care. Follow-up was by record review, and analysis was conducted by country. We report primary outcomes of 1) ART initiation ≤28 days and 2) initiation ≤28 days and retention in care ≤8 months of enrollment. From March 7, 2017 to April 17, 2018, we enrolled 600 patients (median [IQR] age 34 [29–40] and CD4 count 286 [128–490]; 63% female) in South Africa and 477 patients in Kenya (median [IQR] age 35 [29–43] and CD4 count 283 [117–541]; 58% female). In the intervention arm, 78% of patients initiated ≤28 days in South Africa, compared to 68% in the standard arm (risk difference [RD] [95% confidence interval (CI)] 10% [3%–17%]); in Kenya, 94% of intervention-arm patients initiated ≤28 days compared to 89% in the standard arm (6% [0.5%–11%]). By 8 months in South Africa, 161/298 (54%) intervention-arm patients had initiated and were retained, compared to 146/302 (48%) in the standard arm (6% [(2% to 14%]). By 8 months in Kenya, the corresponding retention outcomes were identical in both arms (137/240 [57%] of intervention-arm patients and 136/237 [57%] of standard-arm patients). Limitations of the trial included limited geographic representativeness, exclusion of patients too ill to participate, missing viral load data, greater study fidelity to the algorithm than might be achieved in standard care, and secular changes in standard care over the course of the study.ConclusionsIn South Africa, the SLATE algorithm increased uptake of ART within 28 days by 10% and showed a numerical increase (6%) in retention at 8 months. In Kenya, the algorithm increased uptake of ART within 28 days by 6% but found no difference in retention at 8 months. Eight-month retention was poor in both arms and both countries. These results suggest that a simple structured algorithm for same-day treatment initiation procedures is feasible and can increase and accelerate ART uptake but that early retention on treatment remains problematic.Trial registrationClinicaltrials.gov NCT02891135, registered September 1, 2016. First participant enrolled March 6, 2017 in South Africa and July 13, 2017 in Kenya.

Dynamic Measurement in Health Professions Education: Rationale, Application, and Possibilities.

Dynamic measurement modeling (DMM) is a psychometric paradigm that uses longitudinal data to estimate individual students' growth in measured skills over the course of an educational program (i.e., growth scores). DMM represents a more formal way of assessing learning progress across the health professions education continuum. In this article, the authors provide justification for this approach in health professions education and demonstrate its proof-of-concept use with three time points of United States Medical Licensing Examination Step exams to generate growth scores for 454 current and recent medical learners. The authors demonstrate that learners vary substantially on their growth scores, and those growth scores exhibit psychometric reliability. In addition, growth scores significantly and positively correlated with indicators of medical learner readiness (e.g., undergraduate grade point average and Medical College Admission Test scores). These growth scores were also capable of significantly and positively correlating with future ratings of clinical competencies during internship as assessed through a survey sent to their program directors at the end of the first postgraduate year (e.g., patient care, interpersonal skills). These preliminary findings of reliability and validity for DMM growth scores provide initial evidence for further investigation into the suitability of a dynamic measurement paradigm in health professions education.

Combat and Noncombat Musculoskeletal Injuries in the US Military.

Musculoskeletal Injuries (MSKI) are exceedingly common in the US Military, resulting in compromised military medical readiness and a substantial burden on both health care and financial resources. Severe combat-related MSKI sustained during nearly 2 decades of conflict in Iraq and Afghanistan have resulted in frequently devastating injuries that challenge acute care capabilities, require extensive rehabilitation, and often result in long-term disability. Non-combat-related MSKI, while often less severe, are far more common than combat-related MSKI and overall cause a substantially greater number of lost duty days and nondeployable Service Members. Given the strain placed on health care and financial resources by MSKI, further efforts must be directed towards prevention, treatment, and rehabilitative strategies in order to mitigate the burden of MSKI in the US Military.

The importance of undergraduate coursework in student success at South Carolina medical institutions

The importance of undergraduate coursework in determining medical school student readiness reaches far beyond preparation to take the standardized Medical College Admissions Test (MCAT®). Since medical schools employ a rigorous and fast-paced learning system to instruct prospective medical students on (A) didactic information in the basic sciences and (B) the critical methodology of clinical practice, it is essential for applicants to be well-equipped for the challenge that this type of scholarship requires. A research study investigated current medical students enrolled at the four medical schools in the State of South Carolina: The Medical University of South Carolina (MUSC), University of South Carolina College of Medicine Columbia (USCSOM-Columbia), University of South Carolina College of Medicine Greenville (USCSOM-Greenville) and Edward Via College of Medicine Spartanburg (VCOM-Spartanburg). Questionnaires were distributed in the form of Google surveys to all medical institutions in order to distribute them to all students enrolled (M1-M4). The results were received, compiled, and analyzed. The data demonstrated striking similarities in the responses received from medical students representing all four professional schools regarding their evaluation how well they were prepared as undergraduates. The significance of these results is discussed. Key words: Medical education, medical school, South Carolina, MCAT, South Carolina.

Improving medical student preparedness for practice in line with the General Medical Council's outcomes for graduates: a pilot study.

The 2018 Outcomes for Graduates1 highlight non-technical skills as an important part of what should be expected of an F1 (foundation year 1) doctor. However, studies show that medical school graduates have a relative weakness in these areas.2–4 There is a growing body of evidence for simulation as a learning tool in recent years;5 however, greater benefits are observed when simulation environment aligns with clinical practice.6 Studies have experimented with applying simulation to non-technical skills7–9 with great success; however, application of prolonged and repeated simulation to non-technical skills in medical students has not been studied in detail. Each …

Length of Stay Beyond Medical Readiness in Neurosurgical Patients: A Prospective Analysis.

In an era of growing healthcare costs, there is increased pressure on medical care providers to discharge patients once they are medically fit. However, it is not uncommon for patients to stay beyond medical readiness (BMR). To analyze the frequency with which patients remain in the hospital BMR. A prospective cohort analysis utilizing a database maintained between 2014 and 2015 included 718 adults admitted to the neurosurgical service. The attending for admitted patients was asked on a daily basis as to whether the patient was medically cleared for discharge. Standard statistical analyses were performed. Of the 718 patients, 105 (14.6%) remained in the hospital BMR. Of the patients who presented with a spinal pathology, 17.8% had a length of stay (LOS)-BMR compared to 13.9% who presented with cerebrovascular pathologies and 14.8% who presented with a brain tumor. The average LOS-BMR was 1.8 d. Only 7.7% of patients who were discharged home had an LOS-BMR compared to 30.7% of patients who were discharged to a skilled nursing facility or rehabilitation center (P<.001). In logistic regression, a physical therapy consultation and discharge to a specialized nursing facility were both associated with a longer LOS (average 2.4 d longer, P<.001, and 6.2 d longer, P=.028, respectively). However, neither was associated with an LOS-BMR. LOS-BMR is an important process engineering concept within neurosurgery that represents a potential area for improvement to maximize limited healthcare resources. A sizeable portion of neurosurgical patients remained in the hospital BMR.

SAFE: A Comprehensive Data Visualization System

Short abstract: The authors discuss SAFE, a comprehensive data visualization system that enhances logistics, medical preparedness, and responses for mass-participation endurance events such as marathons.

Heterogeneity in Military Trauma Casualty Care.

Military combat casualty care is at the forefront of military medical readiness, but there is little data on current proficiency of deployed personnel. A previous study identified a potential performance gap in military trauma teams. This study aims to evaluate a subsequent team to determine if heterogeneity of teams exists and to determine if this level of efficiency persists or can be improved. Military trauma teams at the Role 3 hospital in Bagram, Afghanistan, were evaluated over the course of a single deployment between April and October 2018. Trauma teams were directly observed and performance of the ATLS primary trauma survey timed. These results were compared to previously published times from Kandahar and Bagram Role 3 sites from Oct 2016 to Apr 2017. Time to completion of the primary survey in 2018 was statistically faster than the times reported from the Role 3 sites from Oct 2016 to Apr 2017 (344.75 s vs. 482.8 s, p < 0.05). The greatest improvements of efficiency were in the time periods between assessing the airway and breathing, evaluating the patient's circulation, and completing of the primary survey. Trauma teams can vary significantly in their efficiency in evaluating trauma patients. Whether this is clinically significant is currently debatable, but it highlights a possible readiness gap for deploying military personnel and the heterogeneity of military combat casualty care.

Improving medical student preparedness for practice in line with the General Medical Council’s outcomes for graduates: a pilot study

Improving medical student preparedness for practice in line with the General Medical Council’s outcomes for graduates: a pilot study

Risk Assessment tool for Religious Mass Gathering Events of India

ObjectiveTo develop a risk assessment tool to assess the public health and environmental risks associated with religious mass gathering events of Tamil Nadu, a state in the southern part of IndiaIntroductionIn spite of the fact that mass gatherings are an undeniably regular element of our society attended by huge crowds yet such occasions are not very well understood. Even though such gatherings are accumulations of "well people", vast number of people associated with mass gatherings can put a serious strain on the entire health care system1.The public health implications of mass gathering events include a potential increased risk for disease transmission because of the variability and mobility of those attending the event and increased media attention. Risk assessment for mass gathering events is crucial to identify the potential health hazards which aids in planning and response activities specific to the event2. Preparing for mass gatherings offer an opportunity to improve health service delivery, enhance health promotion and strengthen public health systems3.In India, many of the religious festivals are observed with mass gatherings and prayers. Large crowd participate in such festivals as participants to observe the unique rituals and also as spectators. Literature indicates that in India, we might be well equipped for response activities but the scientific concept of risk assessment i.e., to understand the existing risks, identify the risks, characterize the risks and plan for risk reduction strategies accordingly are at an infant stage .The little that has been done in the field of mass gatherings has generally focused on description of preparedness activities of single event, crowd control, prevention of stampedes with little attention to public health preparedness. The present project is an attempt to systemize the process of risk assessment by developing a risk assessment tool consisting of characteristics peculiar to planned religious mass gatherings of Indian context.MethodsQualitative approach was followed to identify the risks associated with mass gathering events and to identify the domains and items to be included in the risk assessment tool. Firstly, an extensive review of literature about the risks associated with the mass gathering events was done. Secondly, Key Informants (n=20) involved in planning and management of religious mass gathering events in the State of Tamil Nadu, India were purposively identified and interviewed using a semi structured interview guide. Principle of redundancy was followed. Content/Thematic analysis was done using Atlas.ti software. Currently, the project is in the phase of obtaining content validity of the developed tool. Followed by this, a mobile application based upon the validated tool will be developed which will be further field tested for feasibility in a selected mass gathering event in Tamil Nadu. Using a self administered content validity questionnaire, the experts will be asked to assess the relevance of the items of the tool. Agreement proportions between the experts will be calculated. S-CVI (Scale Content Validity Index), index for inter-rater agreement (agreement proportion) and Kappa agreement coefficient will be calculated.ResultsA sum total of 48 unique health risks have been identified. Stampedes, fire accidents, structural collapse, drowning, outbreak of communicable diseases, exacerbation of existing medical illnesses (like cardiac diseases, asthma etc) etc are the some of the health risks identified. Six domains (characteristics related to event, participant, environment, disaster preparedness, medical service preparedness and pre event planning activities) and 21 items have been generated from the content analysis of key informant interviews and literature review.ConclusionsSome special events and unforeseen events occur in places of mass gatherings besides fixed places of worshipping .Such events cause more damage to human beings and property. Special events like idol procession, chariot pulling, fire walking, animal sacrificing happen pulling larger crowds within the mass gatherings. In order to inform all planning and delivery activities it is essential to understand the mass gathering context and risk assessments. This tool can be used by public health managers to identify key public health and environmental risks at the planning stage before the event takes off. At the planning stage, use of this tool will help in putting the required measures in place in order to address the potential risks identified. The tool can be used as a guiding instrument during and after the event as well. The investigators further plan to develop a mobile based app from this risk assessment tool and test it out in a selected mass gathering event of the state of Tamil Nadu located in southern part of India. Feedback from public health managers about the mobile based risk assessment tool can be instrumental in further modifying the tool. By contributing to public health preparedness activities during mass gathering events in a country with poor resources like India, this research activity is an initiative that is expected to lead to health systems strengthening.