Johan von Schreeb

• MD, PhD, Specialist in general surgery, global health and disaster medicine
• Professor at Karolinska Institutet

Background: The consequences of moral challenges among healthcare workers (HCWs) have been increasingly recognized. To date, however, there is limited knowledge about the predictors of and associations between moral distress, moral residue, and other psychological consequences among HCWs working in a pandemic context. Objective: We aimed to assess...

Background/Introduction A standardized system for assessing Emergency Medical Teams (EMT) performance is essential for enhancing EMT preparedness, response, and quality assurance. An after-action review (AAR) is a qualitative tool used to evaluate actions taken during emergencies, identifying best practices, gaps, and lessons learned. While AARs ha...

Background/Introduction Understanding surge capacity needs and EMT response following disasters is pivotal to improve the capacities to provide appropriate healthcare to populations affected. Although some research has analyzed individual EMT deployments in response to disasters, a comprehensive review of deployments since the 2010 Haiti earthquake...

Background/Introduction Understanding the disaster profile of WHO-regions is crucial for anticipating future needs for mobilizing emergency medical teams and enhancing healthcare surge during disasters. Objectives This study provides an overview of disaster profile and associated health needs globally and regionally. Method/Description Secondary...

Background Mobile Health Units (MHUs) provide critical healthcare to underserved populations, however, their effectiveness in conflict settings remains unexplored. This study aims to elucidate the use of MHUs in conflict settings as described in the literature. Methods We conducted a scoping review across twenty-three databases, including publicat...

Background Mobile Health Units have become important resources for healthcare delivery to dispersed populations following natural disasters. However, criticism regarding their operational flexibility, health coverage and cost-effectiveness remain unaddressed. There are few studies evaluating their usefulness in natural disasters and deployment repo...

Objective To quantitatively assess key performance indicator changes between selected pre-pandemic and pandemic periods at the Sant’Anna Hospital emergency department (ED) in Como, Italy through the retrospective use of Hospital Surge Preparedness and Response index (HSPRI). Methods This study collected the average length of stay (LOS), time-to-ph...

Trauma accounts for around 4.4 million deaths annually and is among the leading causes of death, disproportionately affecting low- and middle-income countries. Trauma quality improvement programmes may reduce adverse patient outcomes but lack robust evidence. This study assessed the effect of implementing a trauma quality improvement programme usin...

Objectives This study aimed to develop and evaluate a scenario-based e-simulation (SBES) to address the limited avilability of accessible and practical training for humanitarian public health responders. The objectives included SBES customisation, effectiveness evaluation, and identifying learning-enhancing design elements. Design A university-bas...

Recommendations for the management of malnutrition among infants aged less than 6 months (<6 m) are based on limited evidence. This study aimed to describe the characteristics, treatment outcomes and outcome‐associated factors among malnourished infants <6 m admitted at Médecins Sans Frontières (MSF) inpatient and ambulatory therapeutic feeding cen...

Background Health care workers (HCWs) are susceptible to moral stress and distress when they are faced with morally challenging situations where it is difficult to act in line with their moral standards. In times of crisis, such as disasters and pandemics, morally challenging situations are more frequent, due to the increased imbalance between pati...

Objectives This study aims to describe the injury patterns of the Beirut blast victims and assess hospitals’ disaster management and preparedness during the 2020 Beirut port blast. Methods A cross-sectional retrospective multicenter study was conducted in two stages. Data were collected on blast victims presented to participating hospitals from Au...

Background The Battle of Mosul (2016–2017) was an urban conflict resulting in over 9000 civilian deaths. Emergency Management Centre (EMC), located 90 km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating exploratory laparotomy (ex-lap) provide a unique window into the system...

The importance of measuring outcomes after injury beyond mortality and morbidity is increasingly recognized, though underreported in humanitarian settings. To address shortcomings of existing outcome measures in humanitarian settings, the Activity Independence Measure-Trauma (AIM-T) was developed, and is structured in three subscales (i.e., core, l...

Introduction: At the beginning of the COVID-19 pandemic, Italian emergency departments (EDs) had to hastily implement current surge response plans or create new ones. The objectives of this study are to quantitatively assess ED performance improvements between selected non-pandemic and pandemic periods at Sant’Anna hospital in Como, Italy, and to r...

Introduction: The Battle of Mosul (2016-2017) involved asymmetric warfare and excess civilian causalities. Emergency Management Centre (EMC) was a designated trauma center for the battle, located 80 km from Mosul. Exploratory laparotomy outcomes in local hospitals are poorly studied compared to military hospitals. Improving response to complex emer...

Introduction: In response to the global upward trend of humanitarian emergencies, the humanitarian health workforce has grown substantially in the last decades. Still, humanitarian education and training programs are limited in availability, geographical locations, and teaching methods, and are too expensive for local respondents. To address these...

Introduction: On August 4, 2020 a massive explosion struck the Beirut Harbor in Lebanon. Approximately 220 people were killed and over 7000 were injured, of which 12% were hospitalized. Despite being weakened by an economic crisis and increasing numbers of COVID-19 cases, the national healthcare system responded promptly. Within a day, Internationa...

Background Breastfeeding (BF) should be protected, promoted, and supported for all infants in humanitarian settings. The re-establishment of exclusive BF is also a central part of the management of acutely malnourished infants under 6 months (<6 m). Médecins Sans Frontières (MSF) runs a nutrition project in Maiduguri, a protracted emergency setting...

Background: The Battle of Mosul (2016–2017) was an urban conflict resulting in over 9000s civilian deaths. Emergency Management Centre (EMC), located 90km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating ex-lap provide a unique window into the system of care delivery in con...

Background The purpose of this study was to identify the possible needs for undergraduate disaster medicine education in Sweden and to make informed recommendations for the implementation of disaster medicine content in medical and nursing schools in Sweden. Methods An online survey was distributed to undergraduate medical and nursing students thr...

Aims: This study quantifies to what extent Health care workers (HCWs) experienced moral stress and to what extent their experiences of moral stress were related to gender and age as well as to working directly with COVID-19 patients and other work-related factors. Methods: This study consists of a cross-sectional survey that was conducted among 16,...

A standardized set of measures to assess functioning after trauma in humanitarian settings has been called for. The Activity Independence Measure for Trauma (AIM-T) is a clinician-rated measure of independence in 20 daily activities among patients after trauma. Designed in Afghanistan, it has since been used in other contexts. Before recommending t...

In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study...

Goal: Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key...

Introduction: On August 4, 2020, a massive explosion struck the Beirut Harbor in Lebanon. Approximately 220 people were killed and around 7,000 were injured, of which 12% were hospitalized. Despite being weakened by economic crisis and increasing numbers of coronavirus disease 2019 (COVID-19) cases, the national health care system responded prompt...

Background Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their well...

Introduction Globally, haemorrhage is the leading cause of both maternal mortality and preventable trauma death. For patients suffering from haemorrhage, prompt blood transfusion can be life-saving; however, safe and sufficient blood is often lacking in low-resource settings (LRS). Autotransfusion (AT), in which the patient’s own blood is collected...

Due to rising temperatures and CO2 emissions, climate change has become one of the most important global issues. We described the relationship between extreme weather-related events and death, globally, from 1999 through 2018. We used data from the emergency events database of the Université Catholique de Louvain. We also categorized the countries’...

Background Clinical outcomes after negative-pressure wound therapy (NPWT) and standard treatment of conflict-related extremity wounds are similar. In resource-limited settings, cost affects the choice of treatment. We aimed to estimate treatment-related costs of NPWT in comparison with standard treatment for conflict-related extremity wounds. Meth...

Objective Health system resilience can increase a system’s ability to deal with shocks like floods. Studying health systems that currently exhibit the capacity for resilience when shocked could enhance our understanding about what generates and influences resilience. This study aimed to generate empirical knowledge on health system resilience by ex...

Healthcare-associated infections, commonly caused by poor hand hygiene, represent a significant source of disease and economic burden for healthcare systems, especially those in resource-limited settings. The few existing studies on hand hygiene compliance in resource-limited hospital settings suggest that compliance is insufficient. The difference...

A massive explosion have ripped Beirut on August 4, 2020, leaving behind more than 6000 casualties, 800 regular floor admissions, 130 intensive care unit admissions, and over 200 deaths. Buildings were destroyed, hospitals in Beirut were also destroyed, others became nonfunctional. A disaster code was initiated in all the hospitals. Victims were tr...

Background Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address...

International guidelines stipulate that autoclavation is necessary to sterilize surgical equipment. World Health Organization (WHO) guidelines for decontamination of medical devices require four levels of decontamination: cleaning, low- and high-level disinfection, as well as sterilization. Following disasters, there is a substantial need for wound...

Background: Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts. Objective: This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongo...

Background In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma s...

Background: In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma s...

Background: In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma...

Introduction Floods are the most common type of natural disaster worldwide and are projected to become more frequent and more extreme. Cambodia is prone to annual, seasonal flooding. Floods impact health in many ways and can disrupt the health system through destruction of infrastructure and loss or diversion of human, economic and physical resourc...

Background Four and a half million people die globally every year due to traumatic injuries. One major cause of preventable death is bleeding. Blood for transfusion is often unavailable in resource-limited settings, where a majority of trauma deaths occur. Intraoperative autotransfusion (IAT) has been proposed as a safe and feasible lifesaving alte...

Introduction Resilient health systems have the capacity to continue providing health services to meet the community’s diverse health needs following floods. This capacity is related to how the community manages its own health needs and the community and health system’s joined capacities for resilience. Yet little is known about how community partic...

Introduction An earthquake is a hazard that may cause urgent needs requiring international assistance. To ensure rapid funding for such needs-based humanitarian assistance, swift decisions are needed. However, data to guide needs-based funding decisions are often missing in the acute phase, causing delays. Instead, it may be feasible to use data bu...

background In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. Methods In this pragmati...

Introduction Current research of moral distress is mainly derived from challenges within high-resource health care settings, and there is lack of clarity among the different definitions. Disaster responders are prone to a range of moral challenges during the work, which may give rise to moral distress. Further, organizations have considered increas...

Background: Health systems are based on 6 functions that need to work together at all times to effectively deliver safe and quality health services. These functions are vulnerable to shocks and changes; if a health system is unable to withstand the pressure from a shock, it may cease to function or collapse. The concept of resilience has been intr...

Background In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. Methods Retrospective cohort study using routinely collected patient data from the International Co...

Introduction Routine health service provision decreased during the 2014–2016 Ebola virus disease (EVD) outbreak in Sierra Leone, while caesarean section (CS) rates at public hospitals did not. It is unknown what made staff provide CS despite the risks of contracting EVD. This study explores Sierra Leonean health worker perspectives of why they cont...

Determinants of functional outcomes after trauma

Introduction There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. Materials and Methods Th...

Introduction International Emergency Medical Teams’ (I-EMTs) response to disasters has been characterized by a late arrival, an over-focus on trauma care, and a lack of coordination and accountability mechanisms. Analysis of I-EMT performance in past and upcoming disasters is deemed necessary to improve future response. Objective This study aimed...

It has become clear that disaster relief needs to transition from good intentions or a charity-based approach to a professional, outcome-oriented response. The practice of medicine in disaster and conflict is a profession practiced in environments where lack of resources, chaos, and unpredictability are the norm rather than the exception. With this...

Background: Floods affect over 85 million people every year and are one of the deadliest types of natural disasters. The health effects of floods are partly due to a loss of access to health care. This loss can be limited with proper flood preparedness. Flood preparedness is especially needed at the primary health care (PHC) level. Flood preparedne...

Human stampedes are a major cause of mortality in mass gatherings, but they have received limited scientific attention. While the number of publications has increased, there is no recent review of new study results. This study compiles and reviews available literature on stampedes, their prevention, preparedness, and response. A search for peer-rev...

In the original article, Johan von Schreeb’s last name was spelled incorrectly. It is correct as reflected here.

Background In an attempt to assess the effects of the Ebola viral disease (EVD) on hospital functions in Sierra Leone, the aim of this study was to evaluate changes in provisions of surgery and non-Ebola admissions during the first year of the EVD outbreak. Methods All hospitals in Sierra Leone known to perform inpatient surgery were assessed for...

Introduction Most epidemiological studies from conflicts are restricted to either combatants or civilians. It is largely unknown how the epidemiology differs between the two groups. In 2016, an Iraqi-led coalition began retaking Mosul from the terrorist group Islamic State of Iraq and Syria. One key institution that received trauma patients from Mo...

Unlike other disasters, injury rates after earthquakes are still on the rise at a global scale. With an estimated one million people injured by earthquakes in the last decade, the burden of injury is considerable. Importantly, the surgical procedures carried out by healthcare facilities are capable to avert part of this burden. Yet both burdens rem...

BACKGROUND In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increase the risk of infection. The use of negative pressure wound therapy (NPWT) has been described in the treatment of acute conflict-related wounds but reports are retrospective and with limited follow-up. OBJECTIVE To investigat...

Background: In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up. Objective: The objective...

Although global spending in response to humanitarian crises is growing, humanitarian assistance is under threat from political, economic and security sources. To protect the principles of humanitarian assistance, we must ensure that it remains neutral, impartial and independent, argues Johan von Schreeb.

Purpose of review Natural disasters have injured more than 2 million people in the last 10 years and led to significant international medical relief deployment. Knowledge of expected injury patterns following these disasters is an important part of planning for type and size of outside surgical assistance. This review aims to summarize what is know...

Background: Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption...

Background: Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them....

There is limited knowledge on the effect of seasonal flooding on health over time. We quantified the short-and long-term effects of floods on selected health indicators at public healthcare facilities in 11 districts in Cambodia, a flood-prone setting. Counts of inpatient discharge diagnoses and outpatient consultations for diarrhea, acute respirat...

Appendix S1 Template memorandum of understanding between CapaCare and partner hospital (Word document) Appendix S2 Post‐Graduate Surgical Training Curriculum – extracts from the student guide (Word document) Appendix S3 Logbooks and evaluation schemes (Word document) Table S1 Operative data for observed and indirectly supervised surgical procedu...

Background: Civilians constitute 33-51% of victims in armed conflicts. Several reports on civilian injuries exist, but few have focused on injuries afflicting females. We analyzed routinely collected data on weapon-related injuries from the International Committee of the Red Cross (ICRC) hospital in northwestern Pakistan in order to define injury...

Methods: A literature search of the databases Medline (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA); Cinahl (EBSCO Information Services; Ipswich, Massachusetts USA); Global Health (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science Core Collection (Thomson Reuters; New York, New York...

Background Surgical task‐sharing may be central to expanding the provision of surgical care in low‐resource settings. The aims of this paper were to describe the set‐up of a new surgical task‐sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety, and estimate its future role in co...

Healthcare professionals worldwide must condemn attacks on hospital and healthcare workers in Syria and other nations in conflict. Must recognize the neutrality of healthcare workers and their rights to care for any sick and injured patient, regardless of nationality, race, religion, or political point of view

Study/Objective The aim was to, 1) study the relation between disaster outcomes after earthquakes, expressed as number of dead and injured, and the performance of five pre-identified severity, and risk-scoring indexes, 2) to inform a model that in an initial phase of a disaster can be used to predict severity and levels of need, and thereby guide t...

Study/Objective This research maps and explores existing legal systems that, within a disaster context, may be applied to hold International Emergency Medical Teams accountable for medical errors. Background International Emergency Medical Teams (IEMT) provide clinical care to populations affected by disasters. However, while well intended, their...

Study/Objective To assess whether ‘wound infection’ is an independent risk factor for amputation or death. Background Data on the epidemiology of wound infection in patients with war-associated injuries is limited and mainly describes military combatants. It is unknown to what extent wound infection itself is a factor contributing to serious compl...

Study/Objective To establish a “core curriculum” for the Emergency Medical Teams (EMTs) internationally, by conducting a systematic mapping study of all training programs currently targeting EMTs internationally. Background Standardized education and training are essential components to improve global emergency response, by providing mechanisms to...

Study/Objective To assess whether war wound severity corresponds to consumption of resources in a limited resource setting. Background The International Committee of the Red Cross (ICRC) has developed a Wound Classification system (RCWC) for assessing war wound severity. The RCWC score is based on wound size, tissue involved, existence of fracture...

Study/Objective This study summarizes available literature on stampedes, their prevention, preparedness, and response. Background Human stampedes are among the major causes of mortality in mass gatherings, but have received scarce scientific attention. The literature has increased over the last years but, to our knowledge, there is no updated revi...

Study/Objective To assess whether there is a difference in hospital workload for treating weapon-wounded females compared to males. Background Civilians constitute 33-51% of victims in armed conflict. Several reports on civilian injuries exist but few are focusing on injuries afflicting females. We analyzed routinely collected data on weapon-relat...

Study/Objective The objective of this review was to elucidate the health problems over time, following flood and storm disasters Background The health care response to a flood or storm disaster should be guided by the expected health needs of the affected population, for both existing conditions and those caused by the disaster. It is essential to...

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BackgroundA systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery. Methods All trauma deaths that occurred w...

The wars in the Middle East have led to unprecedented threats and attacks on patients, healthcare workers, and purposeful targeting of hospitals and medical facilities. It is crucial that every healthcare provider, both civilian and military, on either side of the conflict become aware of the unique and inherent protections afforded to them under I...

In 2013, the WHO EMT Initiative published the Classification and Minimum Standards for Foreign Medical Teams in Sudden Onset Disasters in response to concerns from the humanitarian community that the world had largely failed in its efforts to provide life- and limb-saving care following the Haiti earthquake and Pakistan floods. Many of the teams ar...

An increasing number of international emergency medical teams are deployed to assist disaster-affected populations worldwide. Since Haiti earthquake those teams have been criticised for ill adapted care, lack of preparedness in addition to not coordinating with the affected country healthcare system. The Emergency Medical Teams (EMTs) initiative, a...