Assessing the Preparedness of Healthcare Facilities for Disasters and Emergencies in Damghan, Iran

Abstract

Objectives
Iran is exposed to a wide range of natural and man-made hazards. Health-care facilities can play a significant role in providing life-saving measures in the minutes and hours immediately following the impact or exposure. The aim of this study was to determine the preparedness of health-care facilities in disasters and emergencies.

Methods
This cross-sectional study was conducted in Damghan, Semnan Province, in 2019. The samples consisted of all the 11 health-care facilities located in Damghan County. A developed checklist was used to collect the data, including 272 questions in 4 sections: understanding threatening hazards, functional, structural, and nonstructural vulnerability of health-care facilities. The data were analyzed using SPSS 21.

Results
The results revealed that the health-care facilities were exposed to 22 different natural and man-made hazards throughout the county. The total level of preparedness of the health-care centers under assessment was 45.8%. The average functional, structural, and nonstructural vulnerability was assessed at 49.3%, 31.6%, and 56.4%, respectively.

Conclusions
Conducting mitigation measures is necessary for promoting the functional and structural preparedness. Disaster educational programs and exercises are recommended among the health staff in health-care facilities.

Full text

Disaster Medicine and Public
Health Preparedness
www.cambridge.org/dmp
Original Research
Cite this article: Pourmohammadi B,
Heydari A, Fatemi F, Modarresi A. Assessing the
preparedness of healthcare facilities for
disasters and emergencies in Damghan, Iran.
Disaster Med Public Health Prep. doi: https://
doi.org/10.1017/dmp.2021.104.
Keywords:
preparedness; health-care facilities; disaster;
emergency
Corresponding author:
Farin Fatemi
Email: f_fatemi@semums.ac.ir.
© Society for Disaster Medicine and Public
Health, Inc. 2021.
Assessing the Preparedness of Healthcare
Facilities for Disasters and Emergencies in
Damghan, Iran
Behrad Pourmohammadi PhD1, Ahad Heydari PhD Candidate2, Farin Fatemi PhD1
and Ali Modarresi BSc3
1Research Center for Health Sciences and Technologies, Semnan University of Medical Sciences, Semnan, Iran;
2Department of Disaster and Emergency Health, School of Public Health, Tehran University of Medical Sciences,
Tehran, Iran and 3Damghan Health Network, Semnan University of Medical Sciences, Semnan, Iran
Abstract
Objectives: Iran is exposed to a wide range of natural and man-made hazards. Health-care
facilities can play a significant role in providing life-saving measures in the minutes and hours
immediately following the impact or exposure. The aim of this study was to determine the
preparedness of health-care facilities in disasters and emergencies.
Methods: This cross-sectional study was conducted in Damghan, Semnan Province, in 2019.
The samples consisted of all the 11 health-care facilities located in Damghan County. A devel-
oped checklist was used to collect the data, including 272 questions in 4 sections: understanding
threatening hazards, functional, structural, and nonstructural vulnerability of health-care facili-
ties. The data were analyzed using SPSS 21.
Results: The results revealed that the health-care facilities were exposed to 22 different natural
and man-made hazards throughout the county. The total level of preparedness of the health-
care centers under assessment was 45.8%. The average functional, structural, and nonstructural
vulnerability was assessed at 49.3%, 31.6%, and 56.4%, respectively.
Conclusions: Conducting mitigation measures is necessary for promoting the functional and
structural preparedness. Disaster educational programs and exercises are recommended among
the health staff in health-care facilities.
Iran has been rated as 1 of nations most at risk of extreme weather and geophysical events
according to a study ranking 229 countries on their vulnerability to disasters.1The total pop-
ulation of Iran was estimated at 82 million people in 2019. The statistics demonstrated that in the
last 40 years, more than 109,000 people died and 150,000 people got injured because of natural
disasters in Iran.2Human-related consequences of disasters and their impact on health service
delivery bring health to the top agenda of disaster management.3Natural and man-made disas-
ters have the potential to result in significant economic loss and human casualties.4The Sendai
Framework for Disaster Risk Reduction 2015-2030 outlines clear targets and priorities for action
to prevent new and reduce existing disaster risks. One of the priorities in the Sendai framework
is reducing casualties due to disasters by mitigating damage to basic health infrastructures and
service-delivery facilities.5
Iran is committed to the international community’s decision to adopt Primary Health Care
(PHC) to achieve community justice in terms of access to basic health services. According to the
structure of the PHC system, health-care facilities (HCFs) such as health house, rural, and urban
health centers as well as district health centers, have been established in Iranian governmental
health sector to achieve this aim since 1985.6,7Health houses are the first level of contact between
families and the health-care system in small village(s). They are staffed by a trained health-care
provider, named Behvarz, who is a multi-purpose health-care worker. Each health house covers
the health care of 1200 inhabitants. Rural health centers in the big villages are staffed by a quali-
fied physician together with a team of up to 10 health workers that cover almost 7000 inhab-
itants. Urban health centers provide similar health services as health houses and rural health
centers in the urban areas, and this network is managed by a district health center under the
supervision of at least 1 university in each province.8,9This integrated structure of the PHC
system is implemented across the country.
According to estimations, these governmental health facilities deliver health-care services to
96% of the population across the country and the majority of people can only afford the costs of
HCFs.10 These HCFs play an essential role in providing life-saving services in Iran during disas-
ters and emergencies.11 In this study, some rural areas are as far as 120 kilometers from city or
some of these areas may be inaccessible due to road damage and landslides after disasters. Thus,
well-prepared prepared HCFs in these areas are vital for delivering primary health-care services
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to the affected people at least in the first few hours after the occur-
rence of a natural disaster until such time that the relief personnel
and equipment reach these areas.12,13
In previous studies examining the natural disasters in Iran, due
to numerous faults and high seismicity in the country, earthquake
is considered as the top hazard in the country.2,14 In August 2012,
Varzaghan-Ahar twin earthquakes in the northwest of Iran or in
November 2017, earthquake in Ezgele, Kermanshah, in the west
side of Iran, many HCFs even the newly built ones were not able
to continue their services to the affected people because of severe
damages occurring their structural components, such as columns,
beams, and walls during the earthquake.15,16 One of the important
lessons from these earthquakes was that particular attention had to
be paid to the rate of compliance with the national safety (building)
code during the construction of HCFs.17
Furthermore, since 2013, an office of the management of dis-
aster risk reduction has been established in both the urban HCFs
as well as the higher levels of health-care services. This is an
important step for disaster risk reductioninthehealth-caresys-
tem, but it needs to be strengthened and supported more from the
disaster-related programs and activities. The studies indicated
that it is important to have a comprehensive plan to measure
and promote the preparedness of HCFs against disasters and
emergencies.18,19 Also, several studies provided evidences about
usefulness and use of the safety assessment of health-care facili-
ties in improving the decision-making process during disasters
and emergencies in European countries.20–23 The total prepared-
ness of HCFs should be strengthened due to structural, nonstruc-
tural, and functional components in Iran. Each of the mentioned
preparedness components include financial and human resour-
ces, as well as facilities and standard operating procedures
(SOPs) that should be regularly evaluated and improved.24
Unfortunately, a majority of HCFs have poorly integrated disas-
ter plans to cope with the harmful consequences of natural and
human-induced disasters in Iran.25
Damghan County is located in the Semnan Province, the sixth
largest province in Iran situated on the Quaternary plain. Four
active faults are located in this region where the most dangerous
fault, called Astaneh in the north west of Damghan, has been
known as a likely source of sixth deadliest earthquake in the world.
Meanwhile, Damghan is faced with the heavy winds and extreme
weather in most days of a year as it is surrounded by the Alborz
mountain range from the north. Given the geographical location
of Damghan, exposure to risk of a variety of natural and man-made
disasters, social vulnerability, and lack of appropriate infrastruc-
tures, it is expected that a large population would refer to rural
and urban HCFs at the time of disasters and emergencies in this
county.26 So, the attempts have to focus on the vulnerability reduc-
tion of HCFs by enhancing the functional, structural, and non-
structural preparedness.27 The aim of this study is to evaluate
the preparedness of HCFs in Damghan County to disasters and
emergencies
Methods
Design and Setting
A cross-sectional study was conducted at HCFs in Damghan that
were affiliated with Semnan University of Medical Sciences. The
HCFs under assessment manage health service-delivery to popu-
lation throughout the county. The sampling method was census
and all existing HCFs were included in this study in 2019.
Collecting Data Instrument
The research team applied a checklist for collecting data in this
study. This checklist was developed based on the Hospital Safety
Index (HSI) checklist28 and the disaster risk assessment checklist
in Iranian primary health-care facilities29 Both of these tools have
been confirmed by specialists and applied in studies previously
for assessing the safety and preparedness of hospitals and
HCFs.25,30–32 The applied checklist consisted of three first items to
determine the characteristics of HCFs about location, building
age and material construction. The 272 other questions of checklist
divided into four sections to evaluate the preparedness of HCFs
against disasters and emergencies. The details of each section have
been described as follows:
Section A: Understanding Threatening Hazards
This section is composed of 45 hazards in five categories and refers
to the hazards in the surroundings or the events for which the
HCFs should be prepared to respond. The domains of assessing
hazards are divided into geological, hydro-meteorological, societal,
biological, and technological/man-made (Table 2).
Section B: Functional Components
This section includes 173 questions in 29 domains and considers
the levels of personnel preparedness in HCFs in response to disas-
ters and emergencies. Several domains under assessment include
the organization and structure, preparedness programs, risk
assessment, insurance, risk reduction measures, firefighting, as well
as practice and maneuver.
Section C: Structural Components
This section is designed based on five questions to addresses the
structural elements such as columns, beams, walls, and floors to
form part of the load-bearing system of the building.
Section D: Nonstructural Components
The last section of the checklist consists of 49 questions in seven7
domains and assesses the nonstructural elements of HCFs. The
domains under assessment are related to electrical/ communica-
tion/ air conditioning systems, water/fuel supplies, medical gases,
architectural elements, and office furniture. Table 3 presents the
preparedness domains of sections B, C, and D in the checklist.
The observations in the field were used for completing the
checklist in accordance with the ratings established for each
domain. The research team completed this process by investigating
the geographical maps and the backgrounds of incidents, as well as
visiting the physical location of HCFs. When the research team was
faced with missing data, they referred to the manager or the expe-
rienced staff of HCFs for assistance to complete data.
Data Analysis
Each hazard in section A of the checklist was completed by 2 ques-
tions: determine the existence of hazard, and if the hazard exists,
identify the hazard probability. The probability of risk occurrence
categorizes the risk level into 4 groups: 0 or below 1 (improbable
occurrence); number 1 (low probability of occurrence); number 2
(moderate probability of occurrence); number 3 (high probability
of occurrence). The functional, structural, and nonstructural pre-
paredness level was assessed by 3 scores including 1 (low), 2 (mod-
erate), and 3 (high) in the sections B, C, and D of the checklist,
respectively. The score range for preparedness domains was not
the same because the number of questions for each domain was
2 B Pourmohammadi et al.
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different with the other domains. An equal weight was given to all
assessed questions in the sections B, C, and D. Then, a normalized
scoring scheme on a 100-point scale was developed for analysis of
total preparedness. HCFs were classified into 3 preparedness cat-
egories according to their normalized total score: low (<34), aver-
age (34-66), and high (>66). The data were analyzed by SPSS
software, version 21.
Results
From March to May 2019, the preparedness of all HCFs to disasters
and emergencies in Damghan was assessed. Table 1 presents the
characteristics of the HCFs under assessment in this study.
The result of evidence based review including geographical
maps, backgrounds of incidents, field visiting, and interview about
the most important and threatening natural and man-made haz-
ards and their probability have been indicated in Table 2.
In general, urban and rural HCFs are at a high probability risk of
earthquake among the geologic hazards. The probability of landslides
following an earthquake is also estimated high to HCFs in this region.
Among the hydro-metrological hazards, urban and rural of HCFs are
at high risk of hurricane too. The probability of flash floods occur-
rence has been assessed at low and moderate level in urban and rural
HCFs, respectively. Additionally, the all assessed HCFs are at moder-
ate risk level of cyber-attack in comparison to other societal hazards.
Some evidence indicates that endemic diseases such as cuta-
neous leishmaniasis have a high potential to spread quickly and
convert to epidemics in the area understudy, particularly in the
rural HCFs. Also, water- and food-borne diseases are more
probable in the rural areas than in urban areas. The risk of ver-
min attacks can be classified at moderate level in both urban and
rural areas. Furthermore, man-made hazards such as fire,
chemical threats, power outage, and water outage have been
assessed at the moderate risk level in both urban and rural
HCFs understudy. Table 3 reports the descriptive analysis of
functional, structural, and nonstructural preparedness in the
HCFs under assessment.
According to Table 3, organizing and structure (5.5 ±1), needs
assessment (3.25 ±0.5), informing the stakeholders (9.5 ±0.57),
transportation (2.25 ±0.5), and exercise (17.5 ±2.64) scored below
the expected average among the elements of functional prepared-
ness in urban HFCs. These elements in rural HCFs included pre-
paredness plan (6.66 ±2.58), coordination (15.3 ±0.51),
evacuation (7.83 ±9.4). The mean score of disaster logistic factor
was less than the expected average in both urban and rural HCFs.
Additionally, the situation of water supply and fuel storage scored
5, which was less than 6 as the expected average among the assess-
ment of nonstructural elements. A similar result was obtained in
the assessment of structural elements (4 ±0), where the obtained
mean score was less than the expected average in both urban and
rural HCFs.
Table 1. Characteristic of HCFs under study, Damghan, 2019
HCFs Type Age Material construction HCFs Type Age Material construction
HCF 1 Rural 40 Brick HCF 7 Urban 16 Concrete
HCF 2 Rural 40 Brick HCF 8 Rural 40 Brick
HCF 3 Urban 29 Brick HCF 9 Urban 40 Brick
HCF 4 Urban 40 Concrete HCF 10 Rural 40 Concrete
HCF 5 Rural 3 Iron HCF 11 Rural 39 Brick
HCF 6 Rural 40 Concrete
Table 2. Recognition and occurrence probability of threatening hazards in HCFs, Damghan, 2019
Hazard type Hazards
HCFs
Hazard type Hazards
HCFs
Urban Rural Urban Rural
Geologic Earthquake 3a3 Societal Cyber-threats 2 1
Landslides (following earthquake) 1 2 Burglary 1 1
Subsidence 1 2 Biologic Epidemics 1 2
Hydro-metrologic Tornado 1 1 Vermin attacks 2 2
Hurricane 3 3 Wild animal attacks 1 2
Heavy rain 1 2 Technologic/man-made Gas explosion 1 1
Flash flood 1 2 Fires 2 2
Landslides (following heavy rain/flood) 1 2 Harmful agents release 2 1
Extreme temperature 2 2 Power outage 2 2
Dust storm 2 2 Water outage 2 2
Blizzard 1 1 Immediate HFC evacuation 1 1
Heavy winds 3 3 Mass casualty incidents 1 1
Societal Displaced population 0b1
Security threat to HCFs/ staff 0 0
Kidnapping 1 1
aNumbers ≥1 indicate the risk occurrence probability values in the assessed location of the HCF (Refer to the method, data analysis section).
bNumbers =0 indicate the lack of risk occurrence probability because the hazard type does not exist in the assessed location of HCF.
Disaster Medicine and Public Health Preparedness 3
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Table 3. The mean and SD of functional, structural, and non-structural preparedness in HCFs, Damghan, 2019
Component Preparedness domain
HCFs
Preparedness domain
HCFs
Urban Rural Urban Rural
Mean
(SD)
Mean
(SD)
Mean
(SD)
Mean
(SD)
Functional preparedness Organizing and structure 5.5 (1) 6.33 (1) Assistance and volunteers management 8 (0) 8 (0)
Preparedness plan 10.25 (0.5) 6.66 (2.58) Finance affairs 2 (0) 2 (0)
Risk assessment 15.5 (0.57) 14.83 (1.47) Safety and security 18 (0) 18 (0)
Risk mitigation measures 6 (0) 5.33 (0.51) Informing to stakeholders 2.25 (0.5) 3 (0)
Insurance coverage 3 (0) 3 (0) Rapid response team 3.75 (0.5) 3.83 (0.4)
Coordination 16 (0) 15.3 (0.51) Fire extinguishing 7.25 (0.5) 8 (0)
Incident command system 7.75 (1.25) 8 (0.63) Exercise 17.5 (2.64) 18.5 (0.83)
Communication and early warning 9 (0) 9 (0) Recovery 5 (0) 5 (0)
Evacuation 8 (0.81) 7.83 (9.40) Environmental health services delivery 11 (0) 11 (0)
Need assessment 3.25 (0.5) 3.5 (0.45) Communicable disease services delivery 12 (0) 12 (0)
Logistic 9.5 (0.57) 10.16 (0.98) Non-communicable disease services delivery 9 (0) 9 (0)
Mental health of staff and their families 2 (0) 2 (0) Reproductively health services delivery 13 (0) 13 (0)
Service continuation 7 (0) 7 (0) Nutrition services delivery 10 (0) 10 (0)
Transportation 2.25 (0.5) 3 (0) Societal-mental services delivery 11 (0) 11 (0)
Non-structural preparedness Electrical System 12 (0) 12 (0) Medical gases 8 (0) 7.14 (0.38)
Communication system 8 (0) 8 (0) Heating, ventilation, and air conditioning systems 5 (0) 5 (0)
Water supply 5 (0) 5 (0) Furnishing and office equipment 45 (0.81) 45 (0)
Fuel storage (gas, petrol, gasoline) 4 (0) 4 (0)
Structural preparedness Structural elements 4 (0) 4 (0)
Abberviation: SD, standard deviation.
4 B Pourmohammadi et al.
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Scoring normalization of total preparedness indicated that 6
HCFs (58%) were classified as low preparedness, 2 HCFs (18%)
were categorized as moderate preparedness, and the other 3
HCFs (24%) had high preparedness to emergencies and disasters.
The average preparedness level of HCFs understudy was equal to
45.8%. The highest level of preparedness was related to nonstruc-
tural section with 56.4%, while the lowest preparedness belonged to
the structural section with 31.6%. Furthermore, functional prepar-
edness was equal to 49.3% in this study.
Discussion
The present study indicated that, among the geological hazards,
earthquake is the most likely to occur in Damghan County, and
health-care centers are most highly affected by this natural disaster.
Reviewing the documents showed that there are 4 active faults
passing underneath Damghan. One of these faults, called
Astaneh, on the northwest of Damghan, accounted for the sixth
largest earthquake in the world, measuring 7.6 M and killing
200,000.26 This result corresponds with the study conducted by
Dargahi et al., in the preparedness evaluation of health units of
Kermanshah, 2017.33 Additionally, in the present study, the prob-
ability of landslides following an earthquake is also higher in the
mountainous regions of 3 rural HCFs.
Among the weather hazards, storms and floods were the most
likely to occur, which could be due to the geography of the region,
the town’s confinement by the Alborz mountains to the north, dif-
ference in the elevation of the various districts, and the land slope.34
Also, the occurrence probability of blizzard and heavy winds are
predicted higher in the mountainous areas of the county in com-
parison to the plain regions that include more than 60% (7 of 11) of
assessed HCFs.
Among man-made disasters, fires are very likely due to noncom-
pliance with safety requirements, lack of fire prevention systems
such as automatic fire detecting or extinguishing systems. Cyber-
attacks are also highly likely due to the lack of well-established com-
puter infrastructures in the health-care centers. In addition,
Damghan is a biologically vulnerable area in terms of cutaneous
leishmaniasis as it is home to the major sources of the disease such
as rodents.35 Also, the evidence indicates occurrence of cutaneous
leishmaniasis epidemic in rural areas of Damghan in 2009, where
more than 100 new cases occur annually.36 One study demonstrated
that the incidence of the disease is higher in the plain rural areas than
in urban areas,37 where 43% of health centers studied was located in
such areas in the present study. In addition, in some cases the inad-
equate environmental health and potential problems in water chlo-
rination in these areas have been associated with outbreaks of water-
and food-borne diseases.38
The results of this study revealed that the level of total prepar-
edness in the HCFs is approximately 46%. A similar study in
Kermanshah also showed that this figure is approximately 35%
in existing HCFs,33 while similar surveys on preparedness in
Tabriz and Qazvin hospitals indicated that these hospitals are only
moderately prepared for the disasters.39,40 The difference in read-
iness between HCFs and hospitals in Iran can be attributed to their
success in attracting more funds. The rural population accounts for
more than 26% of the total population of the country and the rural
residents could access to HCFs only for the necessary health-care
services. In general, the unequal delivery and access to medical ser-
vices are implicated in disasters. In recent years, disasters have
posed greater threats to communities lacking the enough resources
and timely access to health-care services by the disaster-affected
people.41 Currently, Iran has developed its capacities to reduce dis-
aster risk and increase preparedness at international, national, and
local levels, but due to limited resources and some inappropriate
practices in the past, it is still insufficient.42,43
An important finding of this study is that all factors evaluated in
the structural section of urban and rural health centers have a lower
score than the expected average. In case such conditions persist and
without retrofitting of existing buildings, seismic vulnerability of
these HCFs increases.44 In the case of earthquake occurrence, they
are highly likely to collapse, leading to disruption of health-care
services, exacerbation of the injuries, and a higher mortality rate
of vulnerable groups such as pregnant women, children, and the
elderly. This situation is similar to what happened in the Bam
earthquake, 2003, Iran, where 90% of HCFs were damaged or in
Sumatra earthquake in western Indonesia in 2009, where 8 of
the 9 primary health-care centers collapsed by the earthquake.27,45
Thus, intactness of HCFs during disasters is crucial to responding
to health needs and preventing further mortality.
In the case of functional preparedness, the most effective factors
in the reduction of the preparedness level against disasters and
emergencies in HCFs include organization and structure,
coordination, exercise, informing stakeholders, and risk reduction
plans, including risk assessment and emergency evacuation and
logistics. Similar results were obtained in the study of disaster pre-
paredness of HCFs in Kermanshah. Insufficient water and electric-
ity resources were other factors in the reduction of nonstructural
preparedness in urban and rural HCFs in this study. According to
the preparedness principles of hospitals and HCFs for disasters, it
is recommended that these critical centers are provided with
adequate water and electricity resources up to 72 h after the disas-
ter, so that over time, the organization is able to be self-sufficient
and continue operating and delivering health-care services to dis-
aster-affected people in an independent manner.46,47
Regarding the moderate percentage of HCFs preparedness
(47%), it is necessary to enhance the overall disaster preparedness
level according to functional, structural, and nonstructural assess-
ments. The measures for promoting preparedness in HCFs should
focus on structural, functional, and nonstructural preparedness,
respectively. Furthermore, the individual framework is necessary
for health-care accessibility post disaster in rural and urban set-
tings.48 Planning and implementing the disaster management pro-
grams are essential in increasing the overall hospital disaster
preparedness level.49 As the World Health Organization (WHO)
worked seriously on disaster preparedness programs in 2008-
2009 as part of a global campaign,25,50 there may be a need to attract
the support of international organizations, such as WHO and
United Nations International Strategy for Disaster Reduction
(UNISDR), to enhance the preparedness level of HCFs to deal with
these disasters.
Conclusions
Regarding the high proneness of Damghan County to natural
disasters, the prepared HCFs have a main role in reducing the vul-
nerability to the harmful impacts of disasters. This study indicated
that the average level of preparedness of HCFs was less than 50%,
and it is not very reliable to assure the continuity of delivery of
health services to the affected people at times of emergencies
and disasters.
Thus, required resources should be allocated to the health sys-
tem for promoting the preparedness level of HCFs. Due to the low
preparedness in the structural component, it is essential to invest in
Disaster Medicine and Public Health Preparedness 5
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this area for improving the structural preparedness. Constructing
new buildings for HCFs in accordance with seismic safety codes or
retrofitting the existing buildings would be recommended to
enhance the level of structural preparedness. Also, continuous
training courses and conducting periodic exercises are necessary
for increasing the level of functional preparedness. Despite an
appropriate level of nonstructural preparedness in assessment of
HCFs, providing enough power and water backup for 72 h after
disasters is suggested for maintaining the delivery of health services
to the affected population in the acute phase of disasters and
emergencies.
Author Contributions. F.F. and B.P. conceptualized and designed the study
and A.M. collected data. A.H. and F.F. analyzed data, and F.F. and B.P. wrote
and edited the manuscript. All authors read and approved the final manuscript.
Declaration of Conflicting Interests. The authors declare that they have no
competing interest.
Ethical Standards. The Ethics Committee of Semnan University of Medical
Sciences approved this study (IR.SEMUMS.REC.1397.108).
References
1. McGeown J. Bangladesh, Indonesia and Iran top natural disaster ranking -
France, Italy, USA at “high risk”. 2010. https://reliefweb.int/report/
bangladesh/bangladesh-indonesia-and-iran-top-natural-disaster-ranking-
france-italy-usa-high. Accessed April 19, 2021.
2. UNISDR. UNISfDR. National report of the Islamic Republic of Iran on dis-
aster reduction. Geneva. 2005. https://www.unisdr.org/2005/mdgs-drr/
national-reports/Iran-report.pdf. Accessed April 19, 2021.
3. Ardalan A, Masoomi G, Goya M, et al. Disaster health management: Iran’s
progress and challenges. Iran J Public Health. 2009;38(1):93–97.
4. Yi P, George SK, Paul JA, et al. Hospital capacity planning for disaster
emergency management. Socio-Econ Plan Sci. 2010;44(3):151–160.
5. UNDRR. Sendai framework for disaster risk reduction 2015-2030. Geneva,
Switzerland: United Nations Office for Disaster Risk Reduction. 2015. https://
www.undrr.org/publication/sendai-framework-disaster-risk- reducti on-2015-
2030. Accessed April 19, 2021.
6. Park J, Park A. Park’s Textbook of Preventive and Social Medicine. Tehran:
Samat; 2004.
7. Asadi-Lari M, Sayyari A, Akbari M, et al. Public health improvement in
Iran–lessons from the last 20 years. Public Health. 2004;118:395–402.
8. Naeli J, Mogimi D. Primary Care Health Promotion Policy Document.
Tehran, Iran: Ministry of Health; 2007.
9. Tabrizi JS, Pourasghar F, Gholamzadeh Nikjoo R. Status of Iran’s pri-
mary health care system in terms of health systems control knobs: a review
article. Iran J Public Health. 2017;46(9):1156–1166.
10. Damari B, Riazi-Isfahani S. Evaluating the women health volunteers pro-
gram in Iran- a quarter century experience (1992-2016). Arch Iran Med.
2018;21(12):566–571.
11. Top M, Gider Ö, Tas Y. An investigation of hospital disaster preparedness
in Turkey. J Homel Secur Emerg Manag. 2010. doi: 10.2202/1547-7355.1781
12. Achour N, Price A. Resilience strategies of healthcare facilities: present and
future. Int J Disaster Resilience Built Environ. 2010;1(3):264–276.
13. DeFraites RF, Hickey P, Sharp TW, et al. The health care response to
disasters, complex emergencies, and population displacement. In: Ryan
ET, Hill DR, Solomon T, Aronson NE, Endy TP, eds. Hunter’s Tropical
Medicine and Emerging Infectious Diseases. 10th ed. London: Elsevier;
2020:219–227.
14. Peyravi M, Marzaleh M, Khorram-Manesh A. An overview of the strengths
and challenges related to health on the first 10 days after the large earthquake in
the west of Iran, 2017. Iran J Public Health. 2019;48(5):963–970.
15. Pouraghaei M, Jannati A, Moharamzadeh P, et al. Challenges of Hospital
Response to the Twin Earthquakes of August 21, 2012, in East Azerbaijan,
Iran. Disaster Med Public Health Prep. 2017;11(4):422–430.
16. Khankeh H, Kolivand PH, Beyrami Jam M, et al. Kermanshah health care
services: a lesson learned from Iran’s recent earthquake. Health Emerg
Disaster Q. 2018;3(4):221–233.
17. Ochi S, Kato S, Kobayashi K, et al. Disaster vulnerability of hospitals: a
nationwide surveillance in Japan. Disaster Med Public Health Prep.
2015;9(6):614–618.
18. Drenkard K, Rigotti G, Hanfling D, et al. Healthcare system disaster pre-
paredness, part 1: readiness planning. J Nurs Admin. 2002;32(9):461–469.
19. Heidaranlu E, Ebadi A, Khankeh HR, et al. Hospital disaster prepar-
edness tools: a systematic review. PLoS Curr. 2015;7ecurrents.dis.
7a1ab3c89e4b433292851e349533fd77.
20. Ingrassia PL, Mangini M, Azzaretto M, et al. Hospital disaster prepared-
ness in Italy: a preliminary study utilizing the World Health Organization
Hospital Emergency Response Evaluation Toolkit. Minerva Anestesiol.
2016;82(12):1259–1266.
21. Rockenschaub G, Harbou KV. Disaster resilient hospitals: an essential for
all-hazards emergency preparedness. World Hosp Health Serv.
2013;49(4):28–30.
22. Radovi´c V, Vitale K, Tchounwou P. Health facilities safety in natural
disasters: experiences and challenges from South East Europe. Int J
Environ Research Public Health. 2012;9(5):1677–1686.
23. Goniewicz K, Misztal-Okońska P, Pawłowski W, et al. Evacuation from
healthcare facilities in Poland: legal preparedness and preparation. Int J
Environ Res Public Health. 2020;17(5):1779.
24. Chartoff SE, Kropp AM, Roman P. Disaster Planning. Treasure Island, FL:
StatPearls Publishing; 2018.
25. Ardalan A, Kandi Keleh M, Saberinia A, et al. 2015 estimation of hospi-
tals safety from disasters in I.R.Iran: the results from the assessment of 421
hospitals. PLoS One. 2016;11(9):e0161542.
26. Ramzi HR, Jalili M. Seismotectonic and seismicity analysis of the
Damghan Region, Iran. J Geol Soc India. 2015;85:619–626.
27. Fuady A, Pakasi T, Mansyur M. Primary health centre disaster prepared-
ness after the earthquake in Padang Pariaman, West Sumatra, Indonesia.
BMC Res Notes. 2011;4:81.
28. World Health Organization & Pan-American Health Organization.
Hospital safety index: guide for evaluators. 2nd ed. 2015. https://apps.
who.int/iris/handle/10665/258966. Accessed April 19, 2021.
29. Ardalan A, Shariati M, Kandi M, et al. Disaster Risk Assessment in
Primary Health Care Facilities. Tehran: Ministry of Health and Medical
Education; 2011.
30. Ardalan A, Kandi M, Talebian MT, et al. Hospitals safety from disasters in
IR Iran: the results from assessment of 224 hospitals. PLoS Curr. 2014;6:
ecurrents.dis.8297b528bd45975bc6291804747ee5db.
31. Ardalan A, Mowafi H, Malekafzali Ardakani H, et al. Effectiveness of a
primary health care program on urban and rural community disaster pre-
paredness, Islamic Republic of Iran: a community intervention trial.
Disaster Med Public Health Prep. 2013;7(5):481–490.
32. Djalali A, Ardalan A, Ohlen G, et al. Nonstructural safety of hospitals for
disasters: a comparison between two capital cities. Disaster Med Public
Health Prep. 2014;8(2):179–184.
33. Dargahi A, Farrokhi M, Poursadeghiyan M, et al. Evaluation of func-
tional preparedness and non structural safety of different health units of
Kermanshah University of Medical Sciences in coping with natural disas-
ters. Health Emerg Disasters Q. 2017;2(4):201–206.
34. Mohammadi S, Nokandeh Z, Khorsandi A, et al. Epidemiology of cuta-
neous leishmaniasis in Damghan district. J Mil Med. 2010;12(3):131–135.
35. Pourmohammadi B, Mohammadi-Azni S. Molecular detection of
Leishmania major in Hemiechinus auritus: a potential reservoir of zoonotic
cutaneous Leishmaniasis in Damghan, Iran. J Arthropod Borne Dis.
2019;13(3):334–343.
36. Pourmohammadi B, Mohammadi-Azni S, Kalantari M. Natural
infection of Nesokia indica with Leishmania major and Leishmania
infantum parasites in Damghan city, Northern Iran. Acta Trop.
2017;170:134–139.
37. Almasi-Hashiani A, Shirdare MR, Emadi J, et al. Epidemiological study of
Cutaneous Leishmaniasis in Marvdasht, Fars Province, Iran. Q J North
Khorasan Univ Med Sci. 2012;3(4):15–23.
6 B Pourmohammadi et al.
https://www.cambridge.org/core/terms. https://doi.org/10.1017/dmp.2021.104
Downloaded from https://www.cambridge.org/core. New York University Libraries, on 11 Jul 2021 at 12:17:39, subject to the Cambridge Core terms of use, available at

38. Angoua ELE, Dongo K, Templeton MR, et al. Barriers to access improved
water and sanitation in poor peri-urban settlements of Abidjan, Cote
d’Ivoire. PLoS One. 2018;13(8):e0202928.
39. Vali L, Masoud A, JabariBeyrami H, et al. Readiness of hospitals affiliated
with Tabriz University of Medical Sciences to face disasters. J Health Dev.
2014;3:62–70.
40. Khazaei MY, Jamaly Z, Safi KM, et al. How is training hospitals of Qazvin
preparedness against disaster in 2015? Ann Trop Med Public Health.
2017;10:1205–1209.
41. Davis J, Wilson S, Brock-Martin A, et al. The impact of disasters on pop-
ulations with health and health care disparities. Disaster Med Public Health
Prep. 2010;4(1):30–38.
42. Owens M, Buffington C, Frost M, et al. The South Dakota Model: health
care professions student disaster preparedness and deployment training.
Disaster Med Public Health Prep. 2017;11(6):735–740.
43. UNISDR. Global assessment report on disaster reduction. 2009. Geneva; 2009.
http://www.irdrinternational.org/2013/01/25/unisdr-global-assessment-
report-on-disaster-risk-reduction-2009/. Accessed April 19, 2021.
44. Mu˜noz A, Quiun D, Tinman M, eds. Repair and seismic retrofitting of
hospital and school buildings in Peru. Proceedings of the Thirteenth
World Conference on Earthquake Engineering; 2004; Vancouver, Canada.
45. Kalantar MH, Sagafinia M, Ebrahimi A, et al. Major earthquakes of the
past decade (2000-2010): a comparative review of various aspects of man-
agement. Trauma Mon. 2012;17(1):219–229.
46. Pan American Health Organization.Hospital Safety Index; Guide for
Evaluators. Washington, DC: Pan American Health Organization; 2008.
47. Ciottone G, Biddinger P, Darling R, et al. Ciottone’s Disaster Medicine.
2nd ed. Amsterdam: Elsevier; 2015.
48. Nepal Earthquake 2015, Post Disaster Recovery Framework - 2016-2020.
Government of Nepal, National Reconstruction Authority. Kathmandu,
May 2016.
49. Pengfei Y, Santhosh KG, Jomon AP, et al. Hospital capacity planning for
disaster emergency management. Socio Econ Plan Sci. 2010;44(3):151–160.
50. Rajaei-Ghafouri R, Mirzahosseini S, Pouraghaei M. Are our hospitals
safe against disasters? An evaluation of hospital safety index in Tabriz,
Iran. J Anal Res Clin Med. 2018;6(3):139–144.
Disaster Medicine and Public Health Preparedness 7
https://www.cambridge.org/core/terms. https://doi.org/10.1017/dmp.2021.104
Downloaded from https://www.cambridge.org/core. New York University Libraries, on 11 Jul 2021 at 12:17:39, subject to the Cambridge Core terms of use, available at