The level of the emergency health workers professionals’ knowledge about chemical,biological,radiological,and nuclear (CBRN) hazards: The case of Turkey

1 Introduction

Chemical, Biological, Radiation and Nuclear (CBRN) events are defined as intentional or accidental events caused by dangerous chemical, biological, radiological, and nuclear agents that have the capacity to cause serious health problems on individuals and society [1].

Chemical hazards entail either poisoning or injury caused by chemical warfare agents and hazardous industrial or household chemicals. Biological hazards include the deliberate release of dangerous bacteria, viruses or toxins. Radiological hazards encompass diseases caused by exposure to harmful radioactive substances. Nuclear hazards refer to the exposure to nuclear radiation, alongside thermal, light, and pressure effects resulting from a nuclear explosion, and the life-threatening effects thereof on human health [2].

The “CBRN risk” refers to probability of damage to human health and the environment in terms of health and safety by the intentional or accidental release of CBRN agents into the environment and the severity degree of the damage [1]. CBRN threat risks have dramatically increased, especially in parallel with technological advancements and changes in warfare strategies throughout history. The geostrategic and geopolitical position of the country we live in (i.e., Türkiye), the risks posed by irregular urbanisation and industrial development, the unrest in our immediate geography in recent years, and natural disasters put us at risk and require us to get more prepared [3, 4].

It is crucial that emergency health workers respond to people exposed to chemical, biological, radiological and nuclear agents appropriately and in a timely manner. They moreover should be primarily qualified in introduction to CBRN, triage, response protocols, decontamination procedures, crime scene management, control of psychosocial effects, surveillance, communication, incident reporting, quarantine practices, and leadership during major public health emergencies [5].

Being prepared for CBRN disasters requires a multidisciplinary approach through which healthcare professionals have access to advice and support when they need it. Emergencies management should be holistic, incorporating first responders, emergency medical staff, public health specialists, toxicologists, lab technicians, local administrators, and experts – each lending their own expertise [6].

Identifying and protecting at-risk groups among the public are key to the success of CBRN disaster management. As such, emergency action plans need to consider the following: security, communication, psychological support, shelter, hygiene, clean water supply, transport, food, and health services. Healthcare professionals—one of the first responders in CBRN incidents should be knowledgeable about CBRN agents in disaster management and highly aware of them. Therefore, they have to protect both themselves and the victims of the incident. Healthcare professionals who are trained regarding CBRN agents and know the sources of communication, should raise the awareness level of other people each passing day.

This study aims to find out how much Turkish emergency health workers know about CBRN, as well as identify what possible factors contribute to their level of knowledge.

2 Materials and methods

3 Results

The mean age of the participants was 34.87±8.99 years (Min: 21, Max: 59, Median: 32.00). They were working in the profession for an average of 12.81±8.60 years (min: 1, Max: 37, Median: 11.00). The mean number of shifts per month was 8.40±1.43 (Min: 0, Max: 16, Median: 8.00). Table 1 shows the socio-demographic characteristics of the participants.

Fifty-two per cent (52.0%) of the participants reported that they had been trained on how to deal with CBRN. An average of 3.48±2.85 years (Min: 1, Max: 23, Median: 3.00) had elapsed since they had received that training (Table 2).

The results of the study revealed that the place of residence and status of choosing the profession willingly made no statistically significant difference in the distribution of being trained on CBRN (p > 0.05). Those who were aged between 26–35 years, female, had higher education levels, singles, physicians and were working for 10 years or less had had higher rates of receiving CBRN training (p < 0.05), which caused a statistically significant difference (Table 3).

The belief that they did “not have a sufficient grasp of CBRN” was high in those who were aged 25 years and younger, singles and had a tenure of less than 10 years. Moreover, female participants highly believed that they did “not have a solid grasp of CBRN.” Likewise, those who had received less than 8 years of medical training and reported to work in other fields (e.g. data analyses) believed that they “had no idea about CBRN” at all with a higher rate (p < 0.05) (Table 4).

The rate of perceiving CBRN training as “very necessary” was high in the group aged 25 years and younger and in those receiving a less than 8 years of medical education and being physicians. The rate of perceiving CBRN training as “necessary” was high in those were female, married, were working in the profession for 11–20 years and voluntarily chose their profession (p < 0.05) (Table 5).

CBRN hazards pose a great threat to human health and can cause a state of emergency. However, CBRN hazards pose not only a risk to the life of the patient or injured person who is directly exposed but also a major risk to the responders and even to the nearby community [10]. Therefore, staff who have to respond to a possible threat should be able to anticipate the possible damages caused by that threat, and then take the necessary precautions. One of the important institutions in the healthcare system for human health is pre-hospital emergency medical services. The difference between emergency health and other healthcare institutions is that it gives first aid and provides emergency medical assistance in the field by standing frontline in incidents that threaten human health [12]. While accomplishing this important task, they are exposed to many dangers and threats. This threat may occur in a standard case, or occur due to CBRN agents that occur unusually [12, 13]. This study aimed to determine the level of knowledge of emergency health workers, who may be exposed to threats due to their work environment, about CBRN as well as to identify the factors that may contribute to this level.

The complexity, mystery, and sometimes physical invisibility of CBRN threats may strike fear in the public and healthcare workers alike. Numerous international studies have mentioned the fear factor in how healthcare professionals approach CBRN incidents. Obscurity feeds fear; however, the need for practical training and drills for awareness of CBRN threats is obvious. While 52.0% of the participants reported that they received CBRN training, but an average of 3.48±2.85 years (Min: 1, Max: 23, Median: 3.00) had elapsed since the training was completed. The study by Malich et al. [14], emphasised the necessity of on-site medical care and training for first aid workers during CBRN incidents. This includes knowledge about CBRN agents, their health effects and corresponding toxidromes, and how to use proper tools and equipment (including self-protection). It also entails knowing about the additional complexities of the triage, transfer and decontamination requirements, and interactions [14]. It was found in the study that those who were aged between 26–35 years, female, had higher education levels, were singles, were physicians and were working for 10 years or less had higher rates of CBRN training (p < 0.05), causing a statistically significant difference (p < 0.05). Şen and Ersoy [15] conducted a study looking at how prepared a hospital emergency team was for disasters. They discovered that participants who attended the training and drills had a high level of knowledge about Chemical, Biological, Radiological or Nuclear incidents [15]. The training to be delivered to voluntary staff members would lead to success in the preparedness of hospitals for disasters. In their study on CBRN training, Kako et al., emphasised that the scenario-based training models can make a significant contribution to improving the knowledge of emergency health workers [16]. There are similar studies in the literature [17, 18].

In the present study, the belief that they did “not have a sufficient grasp of CBRN” was higher in those who were aged 25 years and younger and were working for less than 10 years. In their study, Dinçer and Kumru found that the participants working in the hospital for 6–10 years were mostly prepared for disasters and emergencies [19]. In the study by Valkanova and Kostadinov, all the participants were grouped based on their work experience: having a work experience of less than 5 years (14 participants), having a work experience of 6–15 years (18 participants), and having a work experience of 16–30 years (20 participants). The participants were asked the following question: “Do you know what medical information you should gather, analyse and disseminate in the event of the use of weapons of mass destruction?”. The results of the participants having a working experience of 6–15 years were better than the others [20].

In the present study, most of the female participants believed that they did “not have a solid grasp of CBRN.” By contrast, some other studies investigating the same topic found no significant correlation between CBRN preparedness and gender among healthcare workers [19, 21]. This may be due to the fact that the gender ratios in the region in our study population are not close to each other and the number of male participants is more than the number of female participants.

The present study revealed that participants who held a PhD knew significantly more about how to deal with CBRN hazards compared to those with any other level of education (primary/secondary/high school, Bachelor’s, Master’s), as they tend to be more advanced in terms of knowledge and age. Eyison et al., came to a similar conclusion as well [22]. Schumacher et al. [23], asked questions about disasters to people of different educational and occupational groups (e.g. anaesthesiology, emergency and intensive care staff). They observed that how much participants knew varied widely according to their level of education and occupation [23]. Similarly, a study by Aydın (2019) that looked at how willing healthcare professionals were to deal with CBRN incidents indicated just how important to identify their willingness about CBRN [24].

According to findings of the present study, the participants who were under 25 years old, had less than 8 years of medical education, and were physicians highly perceived CBRN training as “very necessary.” Public health services must be prepared to handle various kinds of CBRN emergencies, including natural disasters, technological accidents, and terrorist attacks. This is only possible when healthcare staff members who work in at-risk zones are given regular and compulsory CBRN training. Moreover, regulations and drafts should be prepared to cover and standardise the content of these trainings. In their study, Aminizadeh et al. drafted a standard assessment tool aimed at determining hospital preparedness for biological CBRN incidents, and enabling healthcare institutions and administrators or government officials to map out a route for themselves in case such an incident were to suddenly strike [25].

5 Conclusion and recommendations

Numerous CBRN threats have impaired people’s health and quality of life over the past years. It is essential for the responders who would prevent the spread of the incident over a wide area when people encounter or come into contact with any CBRN threat, to protect their own health in order to maintain continuity in the fight against such a threat. Therefore, the related staff should be informed about how to use personal protective equipment.

CBRN emergencies can be caused by any number of reasons, and threaten public health. Public healthcare services assume important medical responsibilities such as surveillance of diseases, stocking drugs, and identifying and treating CBRN victims. Besides, public health professionals also have important duties in developing CBRN training and improving response capacity.

Therefore, CBRN training should be made compulsory for all healthcare professionals who work in at-risk zones in order to raise their awareness. Furthermore, hands-on seminars and drills should be organised to better prepare them for CBRN incidents. More educational content (e.g. posters, brochures, public announcements) is also needed to raise awareness of the public against CRBN risks.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the Ethics Committee of the Gaziantep Islam Science and Technology University (Number: 2022/90, Date: March 23, 2022) for the study.

Informed consent

Informed consent was obtained from all the subjects participating in the study.

Conflicts of interest

The authors declare no conflict of interest.