doi: 10.1111/j.1742-6723.2010.01342.

x Emergency Medicine Australasia (2010) 22, 483–487

EDITORIAL

Disaster medicine reporting: The need for new

guidelines and the CONFIDE statement emm_1342 483..487

David A Bradt1,2 and Peter Aitken3,4

1
Royal Melbourne Hospital, Melbourne, Victoria, Australia, 2Center for Refugee and Disaster Response,
Johns Hopkins Medical Institutions, Baltimore, Maryland, USA, 3Emergency Department, The Townsville
Hospital, and 4Anton Breinl Centre for Public Health and Tropical Medicine, James Cook University,
Townsville, Queensland, Australia

This issue of the journal introduces new guidelines for
authors of disaster case reports. This editorial examines
the drivers and implications of these guidelines.
Government agencies, professional societies, trade
associations and special interest groups produce vast
literature on various aspects of disasters. Much of this
literature worldwide is ‘grey’ – print published or web
published – but unobtainable through electronic index-
ing services. The electronic information alone is now so
extensive that the US National Library of Medicine has
created a Disaster Information Management Research
Center to help with national emergency preparedness
and response efforts.1 Within the published biomedical
literature, a recent 30 years review canvassing a range
of electronically indexed databases found the majority
of event-specific literature indexed in MEDLINE was
published across a broad spectrum of disciplines. The
top 10 journals cited are listed in Table 1.2 Over the
last decade, disaster literature accelerated markedly
prompted by the events of September 11, 2001, at the
World Trade Center, which yielded the greatest number
of event-specific, peer-reviewed publications to date
(686).2 New journals devoted to disasters continue to
emerge with recent ones receiving MEDLINE index-
ation before their first full year of publication.
The challenge for the reader keeping up with disaster
literature is therefore daunting. Finding good-quality
evidence within this corpus of literature creates another
set of hurdles for the reader.
First, the disciplines of medicine, public health and
disaster management differ in origins, definitions,
research paradigms and tools of evidence-based deci-
sion making.3,4 In evidence-based medicine, core con-
cepts are well known to most physicians. These core
concepts include population-intervention-comparison-
outcome questions, hierarchy of evidence strength
based upon methods of data acquisition and criteria
for determining adequacy of studies. However, impor-
tant questions in disaster medicine are not easily test-
able by evidence-based science. Disaster field
conditions are fluid, data are perishable and compete
with rumour, and security constraints prevail. As a
consequence, controlled studies in disasters are diffi-
cult to run. The level of scientific evidence behind
many of our actions in disaster medicine remains
weak. Disaster relief operations continue to rely
heavily on ‘eminence-based’ decisions by parties striv-
ing to broker goodwill and consensus.5 Underlying
issues include lack of agency expertise, dyscoordina-
tion between agencies in the field, inappropriate proxy
indicators, flawed scientific inference and erosion of
the concept of minimum standards.
Second, the cost-effectiveness of many disaster inter-
ventions remains unknown. For example, disaster
medical assistance teams, mobile field hospitals and
hospital ships operate in virtually uncharted cost-
effectiveness territory. The extensive work of the US
National Institutes of Health, the World Health Organi-
zation and the World Bank on cost-effectiveness analy-
sis, such as the Disease Control Priorities Project (DCP2),6
is remarkable in part for its lack of external validity in
disaster relief operations. Donor governments often

David A Bradt, MD, MPH, FACEM, FAFPHM, FAAEM, DTM&H, Honorary Physician; Peter Aitken, MB BS, FACEM, EMDM, M ClinED, Senior
Staff Specialist, Associate Professor.

© 2010 The Authors

EMA © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 DA Bradt and P Aitken

choose options for disaster health interventions based on
political criteria for engagement rather than scientific
criteria for lives saved.
Third, disaster case reports remain a prominent part
of biomedical journal reporting on disasters with a reli-
ance on descriptive accounts. Several different types of
report have emerged in the literature.
Table 1. Top 10 journals for peer-reviewed, event-specific
literature by number of publications (1977–2009) (adapted from2)
Prehospital and Disaster Medicine
Journal of Traumatic Stress
Military Medicine
Psychiatric Services
Journal of the American Medical Association
Lancet
Morbidity and Mortality Weekly Reports
Journal of Nervous and Mental Disease
American Journal of Public Health
Environmental Health Perspectives
• Brief case report
• Rapid epidemiological assessment
• Comprehensive case report
• Comprehensive country profile
In our experience, the most common and least useful is
the brief case report. These are typically written from a
donor’s or intervenor’s perspective, and are often
plagued by anecdotal, descriptive, breathless reporting
of process rather than outcome. This type of reporting, as
well as the field engagement described, has been charac-
terized as ‘disaster tourism’.7 Dissemination occurs in
proportion to the public interest in the event, and esteem
of the parent journal, rather than the strength of the
science. This practice creates disaster mythology. Peer-
reviewed literature may take years to correct the miscon-
ceptions devolving from particular disasters.8–10
Nonetheless, there is still a role for duly diligent case
reports – especially when the science is young. To do
this, there needs to be an appropriate reporting struc-
ture that encompasses context, perspective and out-

Table 2. CONsensus Guidelines on Reports of Field Interventions in Disasters and Emergencies (CONFIDE)
Key components
Introduction
1. State specific objectives of the report.
Context
2. Describe the disaster in terms of type, location, area affected, population affected, damage assessment and epidemiological impact.
3. Describe the donor agency/organization/individuals (intervenors) undertaking the field intervention to include specific goals of
intervention, team membership (disciplines and numbers) and mechanism of accountability to host country health authorities.
Access to the Field
4. Who gave permission to enter the disaster, treat patients, and when were those permissions given?
5. What was the timeline of field intervention? When did the intervenors deploy to the field, when did the deploying team examine
its first patient, and how long did the intervenors stay in the field? Specifically, when did the report authors enter and exit the
field. Use GMT references.
Self Sufficiency and Unmet Needs in the Field
6. How did the deploying medical team secure its food, water, power and medical waste disposal in the field?
7. What translation requirements existed, and how were those requirements addressed?
8. What other providers served the same catchment population as the deploying team?
Data Environment
9. Did the deploying team contribute to the initial rapid assessment undertaken by the humanitarian community? If not, why not?
10. Did the deploying team serve as a sentinel reporting site and contribute to the local disease surveillance system? If not, why not?
11. Did the deploying team participate in the local health coordination process? If not, why not?
Patient Care and Epidemiology
12. Using descriptive statistics, characterize all patients treated by the team during the deployment.
13. What standardized case management protocols governed patient care?
14. What referral process occurred for patients needing care beyond that available in the treatment facility?
15. At the departure of the deploying team, to whom were patients at the treatment facility handed over or referred for continuing
care.
Funding
16. Give the source of funding for the intervention, and estimate direct and indirect support costs.

484 © 2010 The Authors

EMA © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 Editorial

Table 3. Case reports: proposed utilities and formats

Type 1: Brief Case Report
• report of present practice for epidemiologically unusual disaster or unusual response to it
• perspective – relief agency or disaster victims on the ground
• submission time – within 4 weeks of acute onset disaster
• length – 1500 words
• recommended structure – simple narrative
• caveat – may be newsworthy in general professional practice but unlikely to be accepted as a case report in specialty journal
Type 2: Rapid Epidemiological Assessment
• report of choice for epidemiologically unusual disaster or unusual response
• perspective – relief sector lead agency or international coordinating agency in the field
• submission time – within 3 months of acute onset disaster
• length – 4000 words
• recommended structure
䊊 background

䊊 sources and methods

䊊 pre-existing indicators

䊊 disaster impact

䊊 current health indicators

䊊 health sector overview

䊊 domestic and international response

䊊 summary of health situation

䊊 programmatic rationale

䊊 recommendations

Type 3: Comprehensive Case Report

• report of choice for overview of disaster impact, relief and rehabilitation (if applicable); amalgamates data from primary and
secondary sources, and has strong evaluation component that demonstrates scholarship of integration and application
• perspective – relief sector lead agency or international coordinating agency in the field
• submission time – within 1 year of disaster
• length – 4000 words
• recommended structure
䊊 mechanism and impact

䊊 disaster management

䊏 initial field response

䊏 relief operations command and control

䊏 hazards inventory

䊊 morbidity, mortality and disease surveillance

䊊 recovery process

䊊 discussion

䊏 epidemiological perspective

䊏 operational perspective

䊊 implications for provider groups on future best practices

Type 4: Comprehensive Country Profile

• report of choice for overview of emergency/disaster experience in country or catchment area
• perspective – practitioner, donor or host country health authority representative
• submission time – not applicable
• length – 4000 words
• recommended structure
䊊 baseline demographic and health status

䊊 underlying socio-political issues especially affecting current professional practice

䊊 profiles of selected practices/problems/disasters

䊊 discussion

䊏 local health burden

䊏 technical issues

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EMA © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
 DA Bradt and P Aitken
comes. There are reasons for optimism. Disaster relief
operations are becoming increasingly standardized in
management of information as well as interventions.
Initial rapid assessments (IRAs), Health Resources
Availability Mapping System (HeRAMS) and syndro-
mic disease surveillance have long histories of develop-
ment led by the World Health Organization. The cluster
system, itself, now has over 30 iterations worldwide.
Although field execution is sometimes poor – Haiti is a
recent example – use of standardized data-gathering
tools and inter-agency processes is increasingly seen as
core responsibilities of responders in the health sector.
We also take heart from the systematization of scien-
tific reporting requirements undertaken by biomedical
scientists and journal editors. These requirements
inform investigators and authors what information is
required to ensure readers and reviewers can properly
evaluate a study. For randomized controlled trials,
the Consolidated Standards of Reporting Trials
(CONSORT) statement emerged in 199611 followed by
the Quality of Reports of Meta-analyses (QUORUM)
statement in 1999.12 For observational studies, the
Strengthening the Reporting of Observational Studies
in Epidemiology (STROBE) statement emerged in
200713 followed by the Meta-analysis of Observational
Studies in Epidemiology (MOOSE) statement in 2010.14
There have also been efforts, such as the Utstein Tem-
plate,15 to standardize the language of disasters and
promote consistent use of definitions.
In this issue of Emergency Medicine Australasia, we
take the first step in systematizing disaster case reports
by drawing up specific Instructions for Authors coupled
with our CONsensus Guidelines on Reports of
Field Interventions in Disasters and Emergencies
(CONFIDE). We seek to help authors report on complex
issues of disasters. We seek to help the reader make
informed judgments about these issues by bringing the
reader as close as possible to field data. We seek to
foster the work of future scholars undertaking critical
event analysis, disaster comparisons and translational
research. Finally, we seek to engage with other biomedi-
cal journal editors in pursuit of best practice standards
for disaster reporting. To these ends, key components of
the CONFIDE guidelines are listed in Table 2. A
summary of our case report typology is presented in
Table 3. Additional information for authors is posted on
the web.16 For reasons cited above, in the absence of
extremely unusual hazards or compelling epidemiology,
the journal is unlikely to publish brief case reports in
the future. Other types of disaster case reports will be
welcomed.
486
EMA © 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
We acknowledge there are many ways to report
science. Disasters remain a multidisciplinary endeav-
our, and no one owns the truth. Indeed, in disasters of
conflict, the first casualty may be truth itself. However,
we believe these guidelines will increase the utility of
case reports for the reader and other scholars. Improv-
ing disaster reporting is merely a first early step. The
real goal is improving disaster science. We reaffirm to
our readers and authors our commitment to that
process, our respect for their work and our own willing-
ness to learn from their experience.
Competing interests
David A. Bradt: Editorial Board, Emergency Medicine
Australasia. Peter Aitken: Section Editor Disaster Medi-
cine, Emergency Medicine Australasia.
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submit.asp?ref=1742-6731&site=1
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