{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T06:18:57Z","timestamp":1783491537961,"version":"3.55.0"},"reference-count":44,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T00:00:00Z","timestamp":1783468800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002347","name":"Bundesministerium f\u00fcr Forschung, Technologie und Raumfahrt","doi-asserted-by":"publisher","award":["13N14923 \u2013 13N14925"],"award-info":[{"award-number":["13N14923 \u2013 13N14925"]}],"id":[{"id":"10.13039\/501100002347","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The ARMIHN project (\u201cAdaptives Resilienz Management im Hafen\u201d\/\u201cAdaptive Resilience Management in the Port\u201d) aims to develop an operational strategy for managing mass casualty incidents involving infectious diseases (MCI-ID) in port environments. The strategy considers structural, organizational, and technical measures, accounting for end-user needs and local infrastructural characteristics, with the aim of optimizing patient care and facilitating a rapid transition back to individual-level standards of care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A selective literature review identified existing national concepts, guidelines, and frameworks related to major incident management in Germany. Port infrastructural conditions were assessed through on-site inspections and stakeholder engagement. To evaluate the strategy, structured crisis management exercises were conducted, comprising three command-level tabletop exercises and one full-scale field exercise. Participant self-assessments were collected via a five-point Likert scale questionnaire before and after each exercise; pre-to-post differences were analyzed using Pearson's chi-square and Fisher's exact test where appropriate.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A MCI-ID operational strategy for the Port of Hamburg was developed in alignment with existing frameworks, integrating local infrastructural capacities and the expected temporal sequence of emergency resource deployment. The strategy comprises four phases: phase 1 (initial notification), Phase 2 (vessel arrival), Phase 3 (on-site rescue and medical response), and Phase 4 (transport and handover to preclinical emergency services). Exercise evaluations demonstrated statistically significant improvements across all domains, including basic MCI skills, incident management quality, confidence, and perceived team preparedness. Mean Likert scores increased from 3.33 to 4.03 in the command exercise (\n                      <jats:italic>p<\/jats:italic>\n                      &amp;lt; 0.001) and from 3.76 to 4.21 in the full-scale field exercise (\n                      <jats:italic>p<\/jats:italic>\n                      = 0.029), with approval rates improving by 18.2% to 63.0% across items.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The developed strategy addresses a structural gap in existing MCI frameworks by providing a port-and maritime-specific response concept for infectious mass casualty incidents. Grounded in disaster medicine principles and refined through stakeholder engagement and repeated exercises, the framework enhances operational preparedness among involved organizations. Its phase-based architecture offers a transferable foundation adaptable to diverse MCI scenarios and pathogen types, contributing to the long-term resilience of port-based emergency management systems.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1878189","type":"journal-article","created":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T05:57:44Z","timestamp":1783490264000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Managing infectious mass casualty incidents in port environments strategy development and evaluation within the ARMIHN project"],"prefix":"10.3389","volume":"14","author":[{"given":"Nadine","family":"Spr\u00f6ssel","sequence":"first","affiliation":[{"name":"Department of Orthopedics, Trauma Surgery and Rehabilitative Medicine, Department of Surgery, University Medicine Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julian","family":"Heuser","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Trauma Surgery and Rehabilitative Medicine, Department of Surgery, University Medicine Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Angelina","family":"Klein","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Trauma Surgery and Rehabilitative Medicine, Department of Surgery, University Medicine Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcus","family":"Oldenburg","sequence":"additional","affiliation":[{"name":"Central Department of Occupational Medicine and Maritime Medicine, Medical University Hamburg-Eppendorf","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lukas","family":"Belz","sequence":"additional","affiliation":[{"name":"Central Department of Occupational Medicine and Maritime Medicine, Medical University Hamburg-Eppendorf","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Volker","family":"Harth","sequence":"additional","affiliation":[{"name":"Central Department of Occupational Medicine and Maritime Medicine, Medical University Hamburg-Eppendorf","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lena","family":"Ehlers","sequence":"additional","affiliation":[{"name":"Hamburg Port Health Center","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin","family":"Dirksen-Fischer","sequence":"additional","affiliation":[{"name":"Hamburg Port Health Center","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Boris","family":"Tolg","sequence":"additional","affiliation":[{"name":"University of Applied Sciences Hamburg","place":["Hamburg, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Axel","family":"Ekkernkamp","sequence":"additional","affiliation":[{"name":"Department of Orthopedics, Trauma Surgery and Rehabilitative Medicine, Department of Surgery, University Medicine Greifswald","place":["Greifswald, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"M. Sinan","family":"Bakir","sequence":"additional","affiliation":[{"name":"MSB Medical School Berlin, University of Health and Medicine","place":["Berlin, Germany"]},{"name":"Department of Orthopedics, Trauma Surgery and Rehabilitative Medicine, Department of Surgery, University Medicine Greifswald","place":["Greifswald, Germany"]},{"name":"Helios Clinic Berlin-Buch, Center for Orthopedics and Trauma Surgery","place":["Berlin, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,7,8]]},"reference":[{"key":"B1","unstructured":"Council directive 2008\/114\/EC of 8 December 2008 on the identification and designation of European critical infrastructures and the assessment of the need to improve their protection\n          \n          2008"},{"key":"B2","volume-title":"ISPS Code: International Ship and Port Facility Security Code and SOLAS Amendments; Adopted on 12 December 2002","year":"2003"},{"key":"B3","unstructured":"Geneva\n          World Health Organization\n          Handbook for inspection of ships and issuance of ship sanitation certificates\n          \n          2011"},{"key":"B4","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1017\/dmp.2020.187","article-title":"Medical transport for 769 COVID-19 patients on a cruise ship by Japan disaster medical assistance team","volume":"1","author":"Anan","year":"2020","journal-title":"Disaster Med Public Health Prep"},{"key":"B5","doi-asserted-by":"publisher","first-page":"773","DOI":"10.1128\/microbiolspec.IOL5-0007-2015","article-title":"Infections on cruise ships","volume":"3","author":"Kak","year":"2015","journal-title":"Infect Dis Clin"},{"key":"B6","unstructured":"Belluz\n              J\n            \n          \n          The coronavirus cruise ship quarantine is a scary public health experiment: The largest outbreak outside China is floating at sea - 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Experiences from the disaster control exercise of the Free State of Saxony \u201cAkut 2016\u201d]\n          \n          2017"},{"key":"B30","first-page":"349","article-title":"\u201cGestufte Einsatzplanung MANV auf Grundlage einer Gefahrenanalyse [Graduated deployment planning MCI based on a hazard analysis]\u201d","author":"Neitzer","year":"2018","journal-title":"Sanit\u00e4ts-, Betreuungs- und Verpflegungsdienst: Handbuch f\u00fcr Helfer und F\u00fchrungskr\u00e4fte"},{"key":"B31","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1007\/s100490050158","article-title":"Verletztensammelstelle","volume":"2","author":"Langhorst","year":"1999","journal-title":"Notfall Rettungsmed."},{"key":"B32","doi-asserted-by":"publisher","first-page":"238","DOI":"10.1055\/a-0629-6807","article-title":"Sichtung bei Massenanfall von Verletzten\/Erkrankten \u2013 wie und wer?","volume":"34","author":"Sefrin","year":"2018"},{"key":"B33","unstructured":"Central command for maritime emergencies (Haveriekommando Cuxhaven)\n          \n          2018"},{"key":"B34","unstructured":"Maritime declaration of health"},{"key":"B35","unstructured":"Central command for maritime emergencies\n          \n          2020"},{"key":"B36","unstructured":"Bundesamt\n              f\u00fcr Bev\u00f6lkerungsschutz und Katastrophenhilfe\n            \n          \n          Protokoll 7. 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