This studyaimed to explore differences in the effects of online and in-persondecentralized learning programs on students' satisfaction, attitudes towardcommunity healthcare, and career intentions.Thiscross-sectional study used questionnaires administered before and after KobeUniversity's rural decentralized learning program (conducted in-person in 2018and 2019 and online in 2020). Of the 208 medical students who participated inany of these three, 198 were included in this study. Questionnaires had tenitems regarding program satisfaction, students' attitudes toward communityhealthcare, and career intention. Difference-in-differences analysis usinglinear regression was performed for the online and in-person programs' pre-postscore differences. = 18.58, p < 0.01, R2= 0.17) and recognition of whether local physicians looked happy  = 12.82, p < 0.01, R2 = 0.16). The online programshowed inferiority in the enjoyment of the program = -1.99, p = 0.05) and recognition of whether local physicians looked happy  = -2.32, p = 0.02).Both programsshowed improved scores for most outcomes. However, thedifference-in-differences analysis indicated significant differences in theenjoyment of the program (F The componentsof Kobe University's rural decentralized learning program could not beadequately replaced online. Further research should determine which componentscan be effectively replaced online and what results can be achieved when onlineprograms consciously constructed to include such elements are compared toin-person programs. Distance learning is not a new concept,,-,However, it is unclear how effective distance learning is in educational programs where medical students learn in community settings. Clinical training, which places medical students on a decentralized training platform  rather than tertiary educational institutions, is referred to as decentralized training and is widely adopted today.The COVID-19 pandemic has prevented medical students from completing their clinical rotations,Kobe University in Japan provides various medical education programs to undergraduate students in collaboration with rural communities. One program involves students learning in rural communities for three days over their summer vacation. Medical students interested in the program apply; during the program, they learn about the role of the medical institutions in the rural community, interact with local staff and other medical students, and experience local culture and customs. In 2020, the program was conducted in an online format due to the COVID-19 pandemic. This article presents details of the in-person and online decentralized learning programs followed by their evaluation.The purpose of this study is to explore whether there are differences in the effects of the in-person and online decentralized learning on students' satisfaction, their attitudes toward CHC, and their career intentions related to their eventual specialty and working location.This cross-sectional study used existing data from questionnaires administered before and after the decentralized learning program for evaluating the annual program.The study participants were medical students who participated in the rural decentralized learning summer program of Kobe University in 2018, 2019 (in-person), or 2020 (online). Although any medical student interested in the program could participate, most of the program participants were regional quota students who were required to work in underserved rural areas after graduation. The online program in 2020 was attended by 54 students, and the in-person program was attended by 154 students (72 in 2018 and 82 in 2019). The study participants were limited to the students who participated in the program. All the 2020 online program participants were included in this study, rather than a set based on statistical calculation. The sample size was set by adding two years' worth of participants  so that the ratio of exposure group to control was 1:2. We excluded those who had indicated that they did not want to participate in the study and those who did not respond to either the pre- or post-questionnaires from the study.This study was approved by the Institutional Review Board of Kobe University. Written consent was not sought from study participants individually, since this was an observational study using existing data. Instead, an opt-out format was applied to disclose study information to participants and provide them an opportunity to refuse participation in the study. We used an explanatory document for opt-out to reinforce that their participation in the study would not affect their academic standing; they could express their non-participation in the study at any time until the results were made public. The study information was posted to a mailing list that included the target students, and to a website, and the research was initiated after at least one month.,The questionnaire items used are listed in Appendix. We developed the 10 outcome items for this study based on existing studiesThe program staff, including the authors, distributed questionnaires to all program participants just before the orientation on the first program day and just before the end of the last day at the university, and asked them to answer them on the spot. The authors were responsible for the development of the program, and the co-author (OM) was in a position to evaluate the academic standing of some participating students. Thus, when the students responded to the questionnaire, they were assured that their responses would only be used to evaluate the program and that their academic standing would not be affected.Kobe University has provided the decentralized learning summer program in collaboration with rural communities—an extracurricular program—since 2015. Any medical student interested in CHC is welcome to attend. The purpose of the program is to foster students' motivation and interest in CHC through learning about the role of the medical institutions in the rural community, interacting with local staff and other medical students, and experiencing local culture and customs. The program was provided over three days in August, during Japan's summer vacation period. About 50 to 80 participants registered each year. During the in-person version of the program, orientation was held on the morning of the first day. Then, the program participants were divided into groups of about 10 people each, and each group traveled to a certain rural area of Hyogo Prefecture in Japan. The medical institutions and local governments in those rural areas collaborated to implement programs for each district. Each district offered unique content, but they ensured positive interactions with local residents, staff, and other students; experiences of CHC practices; and opportunities to learn about the local environment, culture, and customs. Specifically, the students interviewed local residents and staff about their lives and work, had a homestay for deep communication with local residents, and a world café where they discussed healthcare needs for the community among students. They learned about several topics, including health education for local residents, home care, outpatient and inpatient care at local medical institutions, agricultural experience, and traditional cultural experience. The program's structure had been previously reported as effective in providing experiences that fostered students' motivation toward CHC.Although the entire process was conducted in-person until 2019, the COVID-19 pandemic forced the university to implement the 2020 program online. We used the video conferencing system to conduct the program, and the students participated from their homes. To ease the students' burden of viewing their computer screens for a long time, the program was restructured into three half days rather than full days. Each district provided a half-day program, and the students participated in two districts' programs in two days, compared to one district in the previous version. Each district also provided opportunities to interact with staff, showed videos of CHC practices, and offered presentations on cultural and environmental attributes, such as showing images of local culture, environment, and industry and introducing the good aspects and attractions of the district. However, the districts did not provide any opportunities to interact with local residents or other students in their group. It was assumed that identifying local residents who were familiar with online communication would be difficult. Furthermore, it seemed difficult for students to interact with each other in a relaxed and informal manner in the online environment provided by the organizers.On the last day, students reflected in groups using the breakout-room function of the video conferencing system and conducted a presentation of their experiences in the program. Although there were some difficulties, such as cancellations by scheduled participants, poor video connectivity, and audio problems on the day of the program, the entire process was completed with no major problems.First, we addressed the issue of mixed VAS and NRS scores by dividing each VAS score by 10 and then rounding to the nearest NRS . Next, to assess the construct validity of the questionnaire, we used the pre-program questionnaire results to perform the maximum likelihood estimation of the confirmatory factor analysis on the conceived five-factor model: satisfaction, role modeling, conviction/confidence, generalist/rural, and specialist/urban. Then, we calculated the Cronbach's alpha for each category to assess internal consistency. Finally, we evaluated the effectiveness of the online and in-person programs, and the differences in the effects between the two programs. For each outcome, the difference in NRS (including deemed NRS) score from baseline was calculated using a paired t-test. Then, the difference-in-differences between the online and in-person groups were calculated using a linear regression analysis adjusted for grade and gender. Adjusted linear regression analyses treating the post-NRS score as outcome were conducted as sensitivity analyses, and program style as exposure; grade, gender, and pre-NRS score were used as confounders for each item. Complete case analysis was performed to address the missing data. All statistical analyses were conducted using Stata.A total of 208 students  participated in the rural CHC program over the three years; 10 did not respond to the questionnaire , and no one requested non-participation. Therefore, 198 participants  were included in the study. There were no missing values in the analyzed data, and the participants did not show different characteristics between the online and in-person program styles . The con(148) = 8.69, p < 0.01) and recognition that physicians working in a community were honorable (t (148) = 3.84, p < 0.01). In addition, in the online program, only the confidence in practicing CHC showed a medium effect size (d = 0.54), while in the in-person program, the enjoyment of the program (d = 0.94), the worthiness of the program (d = 0.70), perceiving the local physician as happy (d = 0.76), and the worthiness of practicing CHC (d = 0.52) showed medium or large effect size. Both programs resulted in career intentions toward general practice and rural practice (p ≦ 0.01), but the effect sizes were small (d = 0.18-0.28). The difference-in-differences analysis using a multiple linear regression also showed that the online program did not result in the same enjoyment of the program  = -1.99, p = 0.05) and showed lowered recognition that physicians working in a community look happy  = -2.32, p = 0.02). These models resulted in significant F  = 18.58, p < 0.01, R2 = 0.17; F  = 12.82, p < 0.01, R2 = 0.16, for the enjoyment of the program and perceiving the local physician as happy, respectively  = 27.46, p < 0.01, R2= 0.36) and worthiness  = 26.07, p < 0.01, R2= 0.35) of the program. The online program predicted lower adjusted post-score of enjoyment  = -5.10, p < 0.01) and worthiness  = -4.57, p < 0.01) of the program, as shown in ectively . SensitiAlthough distance learning has been actively used during the COVID-19 pandemic, evidence for the effect of distance learning on a decentralized learning program is lacking. By using questionnaires gathered before and after the pandemic, we explored whether there were differences in the effects of the online and in-person formats of Kobe University's rural CHC programs  on students' satisfaction, attitudes toward CHC, and career intentions. Both programs showed score improvements in the aforementioned outcomes; however, students' program satisfaction was significantly lower in the online program, and the influence on their attitudes toward CHC also tended to be lower.Our results suggest that distance learning is effective for medical students in decentralized learning settings, although the effects are small. The components of Kobe University's rural decentralized learning program—learning about the role of the medical institutions in the rural community, interacting with local staff and other medical students, and experiencing local culture and customs—may be implemented online. Distance learning, if properly adapted, would be an effective tool during a pandemic such as COVID-19, or when there is limited access to educational resources. Moreover, it would be financially taxing for the university to support the travel of all medical students to rural areas; additionally, the farther the rural area, the more the travel time required. Distance learning provides an opportunity for universities with fewer resources to create decentralized learning programs. Although building flexible resources regarding potential infectious disease outbreaks is beneficial, the overall educational impact and the lessons learnt now can be more relevant over time.,However, although previously mentioned studies have stated that distance learning was not inferior to in-person education,These experiences and positive emotions are helpful in fostering students' motivation toward CHC.There are several limitations to this study. The first is that most of the medical students who participated were regional quota students. They receive prior benefits, such as special entrance qualifications and scholarships. They are required to work in specified medical institutions, mainly in underserved rural areas, for a certain period after graduation. Therefore, they are likely to be naturally highly motivated for community and rural healthcare. It is unclear whether this would have a similar effect on medical students who are not quota students; therefore, care should be taken when generalizing these results.The second is that only short-term effects were evaluated. The goal of the rural decentralized learning program is to increase the number of physicians working in community and rural healthcare. However, it is not easy to assess the long-term effects of a single exposure on a physician's career choice because it is affected by diverse exposures over time. Nevertheless, the evaluation of short-term changes in medical students' attitudes and career intentions as surrogate markers should not be disregarded. Third, paper questionnaires were changed to online ones, and the VAS was replaced by the NRS. Regarding the questionnaire used in this study, there is no certainty that this replacement does not affect the results. However, the questionnaire style would not have had much effect because there was no significant difference in the response rates for the paper and online questionnaires (96.8% vs 90.7%). Furthermore, considering that there are reports that VAS and NRS in pain assessment are strongly correlated,Both online and in-person rural CHC decentralized learning programs improved students' satisfaction, attitudes toward CHC, and career intentions; however, some components of rural programs could not be adequately replaced online. Since this study evaluated only one educational program, it does not deny the possibility of distance learning for decentralized learning. Further research is needed to determine which components can be effectively substituted online and what results can be achieved when online programs consciously constructed to include such elements are compared to in-person programs. The accumulation of diverse educational evidence is an important resource for promoting an appropriate blend of online and in-person education. Distance learning has an advantage over traditional education in terms of travel time and cost. Once a proper integration method for distance learning on decentralized learning is identified, comprehensive competencies and skills of medical students and their interest in rural healthcare can be increased more efficiently. Although the COVID-19 pandemic posed many challenges, it also allowed for the rapid development of distance learning. This also provides an opportunity to develop a more efficient decentralized learning system.We would like to thank the medical institutions and local governments in the rural areas who collaborated to implement the programs. This study was supported by Grant-in-Aid for Challenging Research (Exploratory) from the Japan Society for the Promotion of Science (JSPS KAKENHI Grant Number 19K22759).The authors declare that they have no potential conflict of interest.


Injury prevention programs for children and adolescents need to be immersive and interactive. This study assessed a bicycle injury prevention program using technology-based education based on the Activated Health Education model and evaluated its effect on environmental factor awareness and attitude toward helmet-wearing. Using virtual reality technology, elementary and middle school students could experience simulated bicycle accidents. It was followed by an awareness phase that included a 30-min lecture where students self-learned and discussed risk-preventive factors. Students then developed user-created content and customized helmets they were given. We assessed students before the program, immediately afterward, and one month after the program. The number of respondents who said they were aware of surrounding bicycle lanes increased from 75.3% (pre-program) to 92.5% (one month after). Those who said they wore helmets often or always rose from 14.3% (pre-program) to 32.5% (one month later). The number needed to treat helmet-wearing behavior was approximately four, meaning that four people were required to participate in the program to have an impact on one person’s helmet-wearing. We found that virtual reality and computer-based activities can help children and adolescents experience bicycle accidents, be aware of risk factors, and change their behaviors responsibly. Cycling is currently being spotlighted as an economical, eco-friendly, short-distance sport for both transportation and leisure that also promotes health. However, cyclists are vulnerable when using roads, especially children and young people . AccordiIn addition, bicycle crashes are a common cause of traumatic brain injury (TBI) in children ,5,6. HelIt is essential to not only regulate the wearing of helmets by law but also instill the habit of wearing them from early childhood or adolescence ,18. TherHealth education must be rooted in health behavior theories to develop, manage, and evaluate successful health education interventions. Of the many planning theories and models currently being used by health educators , the ActIn the experiential phase, individuals usually become aware of their actual health behavior through field studies, laboratory testing/screening, and surveys of targeted conduct. Previously, bicycle rodeos or skills training was used to gain experience, but they present problems with place, logistics, and safety. Virtual reality (VR) can be a potential alternative that provides a realistic bicycle accident experience without those problems . VR offeTechnology-based interventions, such as internet programs or software for injury prevention that incorporate VR, are not new. Most programs were designed for pediatric injury prevention, including pedestrian safety, fire safety, and dog-bite prevention ; howeverFor this study, we aimed to evaluate the effect of a bicycle safety education program for children and adolescents based on the AHE model, using VR and computer-based activity, with measurements conducted immediately afterward and one month later. In addition, we hypothesized that children and adolescents who underwent this education program would show a significant improvement in their perception of bicycle helmet use behavior and environmental factors after undergoing this education program compared to before receiving it.In this study, we used the before and after study design to evaluate the effects of bicycle safety education programs.For this study, we assessed an educational program that was developed in advance and conducted at a community center in a suburban part of South Korea. The community center organized all matters of the recruitment and operation of the participants following legal regulations, including the provision of informed consent for community education and the protection of personal information. The target audience was limited to children and adolescents from the fourth grade of elementary school to the third grade of middle school (aged 11 to 16 years old). Data were provided to the research team to assess the program’s effect after removing identifiable information and anonymizing it.The program was structured according to the AHE theory . For thehttps://kahoot.com/, accessed on 13 July 2019).The awareness phase began with a 30-min lecture. The purpose of the lecture was not to impart information such as traffic signs or cycling skills but to encourage students to assess related information to facilitate their engagement. Students then searched the internet to identify risk factors and discussed how to distinguish between environmental and host factors. Furthermore, they searched for and talked about ways to prevent bicycle accidents and presented their results and conclusions. In the end, the students took a quiz using Kahoot! . The students also designed and printed logos expressing their personalities using LogoMakr , then customized the helmets they were given.In this program, the responsibility phase was implemented one week after the experiential and awareness phases, which were held in one day. The students developed user-created content (UCC) lasting from 1 to 3 min. The UCC was made and edited using Powtoon (We conducted the pre-program assessment on the first day of the program. The post-program assessment was conducted at the end of the program (one week later). Another assessment, one month later, was sent to the respondents via mobile phone .Eighty students were recruited initially. Unexpectedly, it rained heavily on the first day of the program, so three students could not attend. Some students attended only the first day of the program, so they could not finish the post-program assessment, and we treated them as censored cases. After one month, the community center sent another assessment survey to the students who participated, with three reminder texts over one week. They were treated as censored cases if they did not respond within that period. For paired analysis, all censored cases were excluded because individual participants should have been observed longitudinally.All responses were expressed as the number and proportion of respondents. Knowledge tests were carried out before, immediately after, and one month after the program ended . QuestioOf the group, 77, 68, and 40 students responded to the assessments before the program, immediately afterward, and one month later, respectively. Of these, there were 37 (48.1%), 35 (51.5%), and 27 (67.5%) elementary school students, respectively. In the pre-program assessment, 63 students (81.8%) said they owned a bicycle, and 41 (53.3%) said they had a helmet. In other words, only 65% of student bicycle owners had a helmet. When comparing across grades, 67.6% of elementary and 40.0% of middle school students said they had helmets; the higher the grade, the lower the rate of helmet ownership. When asked about experiences of bicycle-related injuries in the past month, 14.3% of the students had experienced injuries in the pre-program assessment, while only 5% experienced injuries in the assessment one month later.To determine how aware students were of environmental factors for bicycling, we asked them whether they knew of bicycle lanes in the neighborhood. The number of respondents aware of bicycle lanes increased from 75.3% pre-program to 92.5% one month later. When asked about the frequency of wearing helmets, the proportion of respondents who said they wore them often or always rose from 14.3% pre-program to 32.5% one month later .The percentage of correct answers to the questions about types of bicycle lanes was maintained at 88.3% (pre-program), 89.7% (post-program), and 90.0% (one month later). The percentage of correct answers to the question on how to use the crosswalk with a bicycle remained high at 97.4% (pre-program), 95.6% (post-program), and 100% (one month later). The percentage of correct answers to the questions about the bicycle pre-inspection rose from 68.8% (pre-program) to 86.8% (post-program), and 95.0% (one month later). The percentage of correct answers to the question about traffic signs related to bicycles rose from 11.7% (pre-program) to 39.7% (post-program), and 30.0% (one month later), which was lower than the percentage of correct answers to other questions.The students appeared to be satisfied with the program. By grade, overall satisfaction among middle school students was lower than that of elementary school students. When asked about the degree to which they learned new things about bicycle safety, the average score of the respondents was 7.7 out of 10 .p-value = 0.0225) about 5.5 times , and the risk difference was 0.26 (95% CI: 0.046–0.469). The NNT for helmet-wearing was about 4, indicating that four students needed to be educated to cause one more student to wear a helmet  that were commented on included not wearing protective equipment (helmets), riding in the wrong direction on the road, jaywalking on a bicycle, riding in places other than bicycle lanes, and lack of knowledge of traffic signs or violations of traffic rules. Students also mentioned appropriate clothing, proper helmet-wearing, and pre-inspection methods . Weather (rain or snow), road surface conditions, and illegal bike lanes were mentioned as environmental factors. Some students referred to legal regulations related to bicycle lane use, proper bicycle parking, and dealing with an accident.We aimed to investigate whether a program rooted in VR and computer-based education based on the AHE model could improve bicycle safety for elementary and middle school students. According to the assessment outcomes, the participants’ knowledge of bicycle safety and their awareness of the surrounding bicycle environment were improved or maintained. In addition, the rate of wearing a bicycle helmet increased. Students evenly recognized and presented host and environmental factors related to bicycle accidents in the context of UCC. Students reinforced their sense of responsibility through this program to investigate and self-learn safety behaviors for accident prevention.Our results support that technology-based injury prevention programs influence behavior change. Recently, programs using digital technology have been introduced in health education ,35. ExpeIn this program, students can experience VR using a smartphone and Google Cardboard. This experience suggests that logistics problems can be solved more easily than other bicycle riding experiences. Indeed, there was heavy rain on the first day of the program, but the participants experienced riding a bicycle on a sunny day through VR. The Google Cardboard format we used has the potential for large-scale distribution asmost smartphones have the technology to be incorporated into a simple, cheap headset to display content in the VR format. Content is distributed easily via YouTube or mobile applications. The availability of consumer-level 360° cameras is also making it easier for amateur filmmakers to create and distribute 360° footage for viewing within a VR headset [The indirect experience of using VR has the advantage of fewer time or place limitations compared to direct bicycle riding. VR education can expose the user to risk factors without being vulnerable to injury, thereby boosting the learners’ cognition and presenting various environments through digital manipulation . VR offeThe program’s goal was to raise students’ awareness of behavioral changes. When comparing the pre-program and one-month later assessments, it was found that helmet-wearing had significantly improved. There was a positive relationship with helmet ownership, and previous research recommended helmet promotion development, including social marketing strategies to maximize consumer acceptance for middle school students .A meta-analysis published in 2011  revealedThere was a significantly greater knowledge of helmet and safety rules and the ability of hazard discrimination for the intervention group to the control group in the school-based experiment using the eHealth product, which utilizes video, animation, and images to train children . In anotIn the present study, when the children made and printed their helmet logos, they reinforced their sense of responsibility for their safety. Moreover, students had to confirm the safe behavior or skill of bicycling and attain a level of cognition that could explain the host factors of bicycle injury (both to themselves and others) to provide accurate information in their UCC. These activities could encourage helmet use for reasons other than safety and link helmet ownership to behaviors. Another goal was to raise awareness of environmental factors. In the UCC developed by the students, we found an increase in students’ awareness of the risk factors in the cycling environment. According to the assessment, one month after the program ended, the students’ awareness of the location of the surrounding bicycle lanes increased. However, it was difficult to determine the accuracy of the responses because it was not possible to conduct a field survey.Since the goal of this program was not to deliver knowledge or information, the understanding of traffic laws and road signs did not increase. The students were encouraged to search for data and obtain information independently, but they found it difficult to acquire knowledge about road signs and traffic rules. Regarding the questions about bicycle signs and hand signals, the percentage of correct answers increased according to the outcomes of all assessments; however, the percentage was very low overall. This is because students have little experience learning about bicycle-related laws or signs. Moreover, information on traffic signs and rules is not commonly found in the online content that teenagers encounter. In a previous study on the effect of pedestrian safety education for children using VR, children trained within a virtual environment showed improvement in pedestrian behavior but not in knowledge about pedestrian safety . In anotWhile the overall results of the program evaluation are highly promising, there are several limitations. First, this program was designed not for research but for implementation at a community center. For this reason, there was no control group used to evaluate the program’s effectiveness. However, the pre-and post-assessment revealed the efficacy of the new approach to injury prevention education for children and adolescents. Second, the students participated in the program voluntarily, which could have led to a biased population already interested in computer-based education or safety issues. The small number of participants is also a limitation that makes it difficult to generalize the findings. In previous studies using VR, the number of participants varied widely, from a study of 44  to as maThere is significant potential for technology-based education programs, through computer or mobile technology, to be used for injury prevention. Based on robust health behavior or education theory, technology can be powerful in affecting behavior change and awareness of environmental factors. The evaluation of technology-based education  based on the AHE model for bicycle injury prevention in children and adolescents indicated that participants’ attitudes toward wearing bicycle helmets and their perception of a safe environment were significantly improved. As technology improves and evidence grows, such interventions should be implemented and disseminated widely.


Earthquakes are among the most impressive natural phenomena with very high potential to set off a chain of effects that significantly affects public health through casualties and injuries. Related disasters are attributed not only to the strong ground motion and coseismic phenomena but also to secondary effects, comprising mainly landslides and tsunamis, among others. All these can create harsh conditions favorable for the emergence of infectious diseases that are capable of causing additional human and economic losses and disruption of the emergency and recovery process. The present study comprises an extensive narrative review of the existing literature on the earthquake-triggered infectious diseases recorded worldwide, along with their symptoms, causative pathogens, associated risk factors, most vulnerable population groups, and prevention strategies. Respiratory, gastrointestinal, and vector-borne diseases, as well as wound and skin infections, are mainly recorded among the earthquake-affected population. Measures for effectively preventing earthquake-triggered infectious diseases are also proposed. One of the widely proposed measures is the establishment of a proper disease surveillance system in order to immediately and effectively identify the pre- and post-disaster occurrence of infectious diseases. This approach significantly contributes to disease trends monitoring, validation of early warning, and support of the emergency response and recovery actions. Earthquakes are among the most impressive geological processes and remain one of the most unpredictable natural disasters, with the potential to cause destructive effects on humans and structures. Based on an overview of the last 20 years disasters, 552 earthquakes occurred, accounting for 8% of all disasters worldwide and ranking third after floods  and storms  .Despite the low percentage of earthquakes in the total number of disasters worldwide from 2000 to 2019, and despite the quantitative predominance of mainly hydro-meteorological phenomena, earthquakes are among the deadliest events that can also cause mega-disasters with tens to thousands of human casualties, injured, and homeless people in earthquake-affected areas. In terms of the economic impact, earthquakes have caused economic losses of 636 million over the above period , an amount that assigns earthquakes third place on the list after storms  and floods  [Several factors are responsible for the high mortality and morbidity of earthquakes. They can be classified into factors related to the seismotectonic setting and the geotechnical regime of the affected area, the time of earthquake occurrence, the weather conditions during the post-disaster period, the demographic characteristics of the affected area, the social, cultural, and community characteristics, and the structural characteristics of the built environment ,10,11,12Earthquakes cause a multitude of accompanying and subsequent phenomena ,14 with Earthquake casualties can be classified as instantaneous, rapid, or delayed ,16,17,18Τhe main causes of earthquake casualties worldwide comprise (i) the collapse of buildings due to ground shaking ,39,40,41Major injuries are mainly attributed to the partial or total collapse of buildings, movement of landslide material, generation of post-earthquake fires, physical impact with debris in fast-flowing tsunami water, and spill of hazardous chemicals ,53,54,55As regards the earthquake effects on survivors’ mental health, the most common psychiatric conditions seen among earthquake survivors are post-traumatic stress disorder (PTSD) and major depression (MD) . The preFrom the abovementioned, it is clear that earthquakes have the potential to set off a chain of events that significantly affect public health and can also create adverse conditions in the affected communities, favorable for the occurrence of sporadic cases, outbreaks, and epidemics of infectious diseases.Although it is impossible to accurately predict which diseases would be transmitted after a certain type of natural hazard, infectious diseases can be categorized as either water-borne, air-borne, or vector-borne diseases, or contamination from wounded injuries . InfectiThe aim of this study is to conduct an extensive narrative review of the existing scientific literature to present the infectious diseases associated with earthquakes and their accompanying effects that occurred worldwide. Furthermore, their symptoms and their causative pathogens are also reviewed, along with the risk factors associated with the occurrence of infectious diseases. This review also highlights the magnitude of earthquakes followed by infectious diseases, as well as their distribution in active and seismic fault systems worldwide.Based on the data of this review, as well as lessons learned and good practices from emergency responses to parallel occurrence and evolution of geophysical and biological hazards in recent years, the most effective prevention strategies to mitigate the adverse effects of earthquakes on public health will be highlighted and presented in a multi-hazard frame. The proposed measures aim at protecting all involved in an emergency situation, starting from the affected local population and the most vulnerable population groups up to the first responders, including Civil Protection staff, health workers, members of voluntary groups, and staff of emergency shelters.For this narrative review, all major medical, scientific, and technical research databases and resources contained in the National Center for Biotechnology Information (NCBI), part of the National Library of Medicine (NLM), were thoroughly investigated to identify documented sporadic cases, outbreaks, and epidemics of infectious diseases in humans around the world, which were considered to be associated with earthquakes and earthquake-triggered phenomena, including landslides and tsunami. More specifically, keyword searches were conducted on PubMed, Scopus and ScienceDirect.The search terms were based on the World Health Organization (WHO) document “Communicable diseases following natural disasters: risk assessment and priority interventions” . A list No standard definition of what constitutes an infectious disease outbreak was used to avoid omitting potentially relevant studies of public health significance. Additionally, no filters were used to identify specific study designs.Sporadic cases, outbreaks, and epidemics of infectious diseases in humans induced by earthquakes and their accompanying phenomena, including landslides and tsunamis, were documented worldwide at various points in time, since the review was not focused on a specific time period. Based on the available related information, it was found that the earthquakes associated with the occurrence of infectious diseases fell within a time period from 1980 to 2016.The main parameters of the studied earthquakes such as the moment magnitude, the intensity and the number of human losses, injured people, and total affected people are summarized in As shown in In terms of their distribution, the earthquakes that have the potential to induce infectious diseases in the post-disaster period occur within major active fault systems worldwide, such as the Tethyan Alpine system , the Circum Pacific Belt, better known as the Ring of Fire , and the Caribbean-Central America fault system (an earthquake in Haiti).Reporting of the infectious disease occurrence after destructive earthquakes generated around the world between 1980 and 2016 showed that the incidence of infectious diseases increased after each of these earthquake events. Respiratory, gastrointestinal, and skin infections are the most common infections detected in the post-earthquake period. The presence and recording of wound infections is also pronounced. The timing and magnitude of an earthquake, its area of occurrence , the earthquake-triggered environmental effects, including landslides, hydrological anomalies, and tsunamis, and the synergy with different types of natural hazards can play an essential role in the increased incidence of infectious diseases.n = 13), the 2015 Gorkha  Mw = 7.8 earthquake (n = 11), the 1999 Izmit (Turkey) Mw = 7.6 earthquake (n = 9), the 1999 Chi-Chi (Taiwan) Mw = 7.7 earthquake (n = 9), the 2003 Bam (Iran) earthquake Mw = 6.6 (n = 8), the 2010 Haiti (n = 8) Mw = 7.0 earthquake, and the 2004 Indonesia Mw = 9.2 earthquake (n = 7) (Taking into account the information presented in  (n = 7) .Upper respiratory tract infections were observed quite frequently in the short-term period after disasters induced by earthquakes generated in several continents, including North America  earthquake was higher than that of neighboring unaffected counties ,82. MostSurveillance of infections in the rural town of San Sebastian after the 2001 El Salvador earthquake showed that upper respiratory infections (30%) were the second most prevalent after skin infections .Survivors of the 2003 Bam earthquake in Iran were temporarily housed in tents and received daily visits as part of an infectious disease surveillance system. Upper respiratory tract infections were recognized as the most common problem. Overall, 792 cases occurred 3 weeks after the earthquake due to the low temperatures, especially at night . The stuA search of the medical records of all outpatients examined between August 2006 and December 2008, following the 2005 Kashmir earthquake in Pakistan, showed that the most common condition was viral upper respiratory tract infection (23%) .After the 2009 Sumatra earthquake, 1015 patients were examined at two primary health care clinics. Respiratory diseases accounted for the most frequent diagnoses .After the 2010 Haiti earthquake, approximately 42,361 cases were recorded during the period from 25 January to 24 April 2010. Nationally, the most commonly reported cases were acute respiratory infections (16.3%) .Ten days after the 2013 Lushan earthquake in Sichuan Province (China), common infectious diseases recorded in children included respiratory infections, among others .In the Philippines in 2013, disasters were attributed to different types of natural hazards: a flood, an earthquake, and a typhoon. Communicable infectious diseases were the predominant group of diseases recorded in all three types of disasters and included acute respiratory infections .Cephalonia Island (Ionian Sea) is located in one of the most seismic active areas of Europe. It was affected by the early 2014 earthquakes, on January 26 and February 3 with Mw = 6.1 and Mw = 5.9, respectively. The earthquakes were generated during the winter period characterized by low temperatures and rainfall for several days between the two events, leading to an increase of respiratory infection cases .Contagious airborne diseases were among the most common findings observed after the 2015 Gorkha earthquake . Among tThe two earthquakes that struck Kumamoto (Japan) in April 2016 caused evacuation in the earthquake-affected area. Evacuees were forced to spend an extended period of time in temporary camps and experienced upper respiratory tract infections, among other gastrointestinal and skin infections .As regards the impact of earthquake-induced tsunami on public health, it is demonstrated that the harsh conditions following the Indian Ocean tsunami caused by the Mw = 9.2, Sumatra–Andaman earthquake on 26 December 2004, the Samoa tsunami caused by the Mw = 8.1, Samoa earthquake on September 29, 2009, and the Great East Japan tsunami caused by the Mw = 9.0, Tohoku (Japan) earthquake on 11 March 2011, have favored the emergence and incidence increase of respiratory infectious diseases . Among tCoccidiodes immitis, which grows in the upper layers of soil in limited semi-arid areas of the western hemisphere . Approximately 60% of infected individuals are asymptomatic. The disease most commonly presents as an influenza-like respiratory illness, although a wide range of clinical symptoms may occur. Overall, only 1 in 200 people infected with C. immitis develop diffuse diseases [After the Northridge earthquake, between 24 January and 15 March 1994, Ventura County  experienced a major epidemic of coccidioidomycosis, a respiratory disease caused by inhalation of airborne spores of the dimorphic fungus diseases .Landslides that occurred after the earthquake and its strong aftershocks in the Santa Susana Mountains located north of Simi Valley resulted in dust clouds that were dispersed into nearby valleys by northeasterly winds . FollowiIndividuals who reported physical presence in dust clouds were 3 times more likely to be diagnosed with acute coccidioidomycosis than those who did not. The risk of being diagnosed with acute coccidioidomycosis increased with increasing duration of exposure and staying in dust clouds .C. immitis spread with dust clouds due to landslides caused by the 1994 Northridge earthquake [Both the location and timing of the outbreaks strongly suggest that the outbreak of coccidioidomycosis in Ventura County was caused when arthrospores of rthquake .Mycobacterium tuberculosis infection in children from earthquake-affected areas showed that of the 5476 children tested, 355 were positive for the tuberculin skin test, used to diagnose latent tuberculosis, and 16 had active tuberculosis. Although the prevalence of tuberculosis did not differ significantly between areas that were severely or less severely affected by the earthquake, living in a shelter with >25 people was found to have a significant effect on the tuberculosis incidence. Tuberculin skin test positivity appeared to be associated with older age, previous tuberculosis treatment, known contact with a person with tuberculosis, and living on a geographically isolated island. These data should be taken seriously in the design of national tuberculosis control programs, particularly with regard to the role that children’s vulnerability and geographically isolated communities play in the transmission and maintenance of tuberculosis [Following the 2013 Bohol (Philippines) earthquake, an assessment of the risk of rculosis .In 2010, Haiti suffered a devastating earthquake that destroyed the healthcare infrastructure in the capital Port-au-Prince and left 1.5 million people homeless. Subsequently, there was an increase in reported tuberculosis in the affected population . Even beCompared to previous national estimates , undiagnosed tuberculosis was three times higher in a shelter with internal displaced people  and five times higher in an urban slum  . Early dSix months after the 2008 Sichuan earthquake, tuberculosis cases recorded in hospitals in the affected Wenchuan region have increased compared to the same period of the previous year. Overall, 88.27% of patients lived in simply constructed temporary shelters in the affected area, among which only 58.06% met adequate sanitary conditions. Poor living conditions, overcrowding, excessive fatigue and stress, treatment interruption, and temporary inability to manage patients resulting from the disaster likely contributed to the worsening of tuberculosis epidemiology .A 14-year-old girl, who was living with her family in a temporary emergency shelter, presented with fever, abdominal pain, and vomiting at a temporary health center in the earthquake-affected city of Bhakatpur in Gorkha . Clinical abdominal examination indicated acute peritonitis. On laparotomy, three ileal perforations were identified, and histopathological examination showed cystic granulomas. Combined with the fact that her father had pulmonary tuberculosis with positive sputum, the child was diagnosed with tuberculous peritonitis and responded well to the administered anti-tuberculosis chemotherapy .Waterborne and foodborne diseases are mainly caused by the ingestion of water or food contaminated with pathogenic microorganisms  derived from human or animal feces. Gastrointestinal infections associated with earthquakes have been reported following the 1980 Irpinia  , 1999 IzOver a period of seven weeks after the 1980 Irpinia earthquake  32 suspected outbreaks were reported, of which only two were confirmed: (a) an outbreak of gastroenteritis in a group of firefighters (39 cases) and (b) an outbreak of viral hepatitis (Hb negative) (6 cases) in a community in the province of Potenza adjacent to the earthquake zone .After the 1999 Izmit earthquake, several factors, such as very hot weather conditions, close contact with the local population left homeless after the event, and the absence of proper water and sanitation systems in the area, could have increased the risk of infectious diseases among members of the Israeli Defense Force (IDF) search and rescue (SAR) team. A mild gastroenteritis outbreak was recorded among SAR personnel at the secondary rescue site in Chinargik town, where 30 out of 62 IDF soldiers complained of two to three loose or watery stools accompanied by abdominal pain. The incident was attributed to poor food handling practices because the cooked meats had been stored without refrigeration for several hours . The lowExcept from the respiratory infections, the 2014 Cephalonia Island (Greece) earthquakes also resulted in a gastrointestinal outbreak comprising 22 gastroenteritis cases among soldiers that developed diarrhea and abdominal pain 6–7 h after consuming a meal prepared by the same catering company. However, no clinical sample was collected for laboratory testing .Members of search and rescue (SAR) teams and first responders visiting and operating in affected areas are characterized as vulnerable groups of travelers. Following the earthquakes in Nepal in April and May 2015, there was an influx of such teams in the affected areas. Common problems recorded among volunteers included traveler’s diarrhea and skin problems. It was found that the volunteers were not adequately prepared for the situations they were likely to face, suggesting that proper information and advice on health issues before acting to the affected area can help reduce the incidence of health problems among this particular group . An asseThe distribution of shigellosis is worldwide and is estimated to cause around 600,000 deaths per year. Two thirds of cases and the majority of deaths are in children under 10 years of age. Outbreaks are observed in overcrowding conditions and where personal hygiene rules are not followed such as in prisons , day carShigella species, Salmonella species, and Giardia intestinalis, could be the possible causes of diarrheal disease outbreaks due to the hot summer, damaged infrastructure, and difficulties in obtaining safe drinking water [Shigella species were the most common isolates [Immediately after the devastating 1999 Izmit (Turkey) earthquake, an infectious disease surveillance system was set up in Kocaeli province, which was the most affected by the earthquake. Waterborne microorganisms that were observed before the earthquake, such as ng water . Diarrheisolates .Following the 1999 Chi-Chi (Taiwan) earthquake, 15 cases of shigellosis were recorded in Nantou County from 21 September to 31 October 1999. Four and eleven cases were reported in Nantou County during the corresponding periods in 1997 and 1998, respectively . The incSalmonella enterica infection occurred in children in the town of L’Aquila  between June 2013 and October 2014, four years after the 6 April 2009 devastating earthquake [S. enterica strain probably following contamination of natural springs’ water due to geological processes that occurred during the devastating earthquake [An epidemic of rthquake . Salmonerthquake .Francisella tularensis transmission [Wild and domestic animals, such as rabbits or rodents, as well as ticks, can transmit tularemia to humans. There are four modes of transmission, including ingestion of contaminated food or water, handling infected animals, insect bites, and inhalation of contaminated dust . In Eurosmission .The first case of tularemia in the town of Golcuk, Kocaeli province was recorded after 5 patients were admitted to a central hospital in the province in January 2005 . They alVibrio cholerae. Transmission of the disease occurs through the consumption of contaminated food or water [Cholera is an acute diarrheal disease caused by the intestine being attacked by the enterotoxin produced by the bacterium or water . Water iV. cholerae, Ogawa biotype, serogroup O1, as the causative pathogenic agent. Several of the patients reported drinking untreated water from the Artibonite River and not using toilets [After the 2010 Haiti earthquake, cholera was thought to have been reintroduced to Haiti after the country had been cholera-free for almost a century . On 19 O toilets . Therefo toilets .V. cholerae serogroup O1 serotype Ogawa due to drinking contaminated water in densely populated areas of Kuleshwor and Kalimati districts in Kathmandu [V. cholerae were reported in 2015, of which 150 were identified in Kathmandu Valley.In addition to Haiti, cholera outbreaks occurred after the 2015 Gorkha earthquake in Kathmandu, the capital and largest city of Nepal. Twenty-nine people developed cholera from athmandu . Accordiathmandu , 169 casH. pylori infection [H. pylori was found in disaster survivors compared to patients screened during the same period before the earthquake. These results suggest that a seismic event could contribute to the development of H. pylori infection in individuals living in the disaster-affected areas [One month after the 2011 Van earthquake in Turkey, 209 dyspeptic patients undergoing gastroscopy were screened for the presence of nfection . A signied areas .Giardia lamblia that colonizes the small intestine of mammals. Humans become infected accidentally by ingesting protozoan cysts either through ingestion of feces-contaminated food and water or through direct contact with infected individuals [Giardiasis is an infection of the digestive tract by the protozoan ividuals .Giardia infection included the use of communal toilets  and water supply from municipal sewers  [Giardia lamblia was found in children living in camps after the Armenian earthquake. Giardiasis is an emerging disease after destructive events and appropriate prevention measures should be implemented during these conditions [On 25 January 1999, a strong earthquake destroyed 70% of the houses in the city of Armenia (Colombia). Emergency shelters were organized and operated for up to 2 years after the disaster. Parasitological studies carried out on the affected population showed that giardiasis was the most common parasitic infection . Factorsl tanks) . A high nditions .Giardia cysts from drinking water at a rate of about 99%, but the use of more than one disinfectant is required [The application of hygiene measures and adequate washing of fruits and vegetables before consumption help to avoid ingestion of contaminated cysts. Protozoan cysts are known to survive in chlorinated water but can be destroyed by boiling, drying, and freeze/thaw cycles. Filtration processes have been shown to be effective in removing required .p < 0.05) [Two earthquakes in the north-western region of Turkey destroyed 80% of the houses and schools in the city of Düzce in 1999. Oztürk et al.  compared < 0.05) .The 2005 Kashmir earthquake caused widespread contamination of drinking water sources and contributed to a rotavirus outbreak between October and December 2005. Rotavirus is the leading cause of severe diarrhea worldwide among children younger than 5 years and is responsible for around 40% of related deaths, estimated at over 500,000 per year . In KashHepatitis A and E infections remain an important public health concern in many developing countries, where poor socioeconomic conditions and high population density contribute to the transmission of these viral infections . HoweverSencan et al.  investigKaya et al.  assessedVector-borne diseases are infections transmitted by the bite of infected arthropod species, such as mosquitoes, midges, ticks, and mites. They were detected in areas affected by the 1991 Costa Rica , 2003 BaOrientia tsutsugamushi and is transmitted to humans through bites of infected mites found in forests, bushland, gardens, and beaches. Most cases are recorded in rural areas of Southeast Asia, Indonesia, Japan, China, India, and northern Australia [Scrub typhus is caused by ustralia .O. tsutsugamushi and consequently increased the likelihood of human exposure to these infected vectors. The detection of O. tsutsugamushi in humans, rodents, and mites in the affected areas, as well as the widespread reports of scrub typhus cases across the country for 3 consecutive years, confirms the ongoing transmission of O. tsutsugamushi with a firmly established ecology in Nepal [A few months after the 2015 Gorkha earthquake in Nepal and the subsequent strong aftershocks, scrub typhus outbreaks were reported in different parts of the country, particularly in earthquake-affected areas ,141. Ovein Nepal . The 201In 1991, a huge increase in malaria cases was recorded following the earthquake and floods in Costa Rica because of an increase in the mosquito population caused by deforestation and changes in river flow patterns . Sáenz ePlasmodium falciparum is endemic in Haiti and the main mosquito vector is Anopheles albimanus, which is mainly active at dawn and dusk and prefers to live and feed outdoors. Consequently, populations living outdoors or in temporary shelters, as well as thousands of first responders in Haiti, are at significant risk of developing malaria from P. falciparum. During the period 12 January to 25 February 2020, CDC received reports of 11 laboratory-confirmed cases of P. falciparum malaria occurring in Haiti  [Malaria caused by raveler) .Leishmania tropica and L. major, respectively [Cutaneous leishmaniasis is a disease with a wide range of clinical manifestations and occurs mainly in seven countries: Afghanistan, Algeria, Algeria, Brazil, Iran, Iran, Peru, Saudi Arabia, and Syria . Two forectively .Detecting and reporting of cutaneous leishmaniasis cases in the rural town of Zarindasht in the southern Iranian province of Fars from April 2002 to April 2004 showed that 2003 earthquakes may have led to an outbreak of the disease as the annual incidence increased from 58.6 confirmed cases/100,000 in the 12 months before the earthquakes to 864 confirmed cases/100,000 (at the peak of the outbreak) in the following 12 months . Most ofLeishmania species. Since 2004, the epidemiology of cutaneous leishmaniasis has changed with the emergence of new outbreaks and non-healing clinical forms that persist for a long time [Construction of new settlements, expansion of villages, development of previously uninhabited areas, and poor management of waste and debris piles are risk factors that have contributed to the increase of the disease incidence . The 200ong time ,148.All age groups were affected, especially children aged 10 years, which probably suggests the existence of (a) acquired immunity in older city dwellers and (b) behavioral patterns of children, such as outdoor play, that increase their exposure to sandflies .It is noteworthy that although both earthquakes accounted for only one human loss, they caused huge ecological changes, disrupted the normal activities of residents, and forced many of them to sleep outdoors until the threat of aftershocks and further damage to buildings was reduced. The ecological changes that created an ideal environment for the development of the sandflies population and the aftershock behavior of the city residents  contributed to the increased exposure of the affected population to the sandflies bites .Despite considerable efforts and implementation of various approaches to reduce transmission of the disease, cases of cutaneous leishmaniasis increased to epidemic proportions after the earthquake, particularly during 2006–2008 in Bam city ,136. DurIt is worth noting that, although the prevalence of cutaneous leishmaniasis cases has increased after the earthquake , the sevMost cases of cutaneous leishmaniasis occurred in unimmunized men. In the post-earthquake period, the Bam population increased significantly, mainly due to the massive movement of workers and contractors undertaking large-scale construction projects. After the earthquake, men aged >20 years were mainly infected, the majority of them with skin lesions located on the extremities (hands or feet) ,138. JobThe Sichuan earthquake in China occurred in May 2008, when the hot and humid weather was beneficial for insect breeding and multiplication. Zhang et al.  examinedAedes aegypti and Aedes albopictus, as well as by other routes of transmission, including sexual transmission [Zika virus (ZIKV) is an arbovirus transmitted to humans by the mosquitoes smission . Despitesmission .The 2016 Ecuador earthquake contributed to the increase of reported Zika virus infection cases . BuildinAs of 16 April 2016, a total of 92 cases of ZIKV had been recorded across the country. In the aftermath of the earthquake, this number rose rapidly to 1106 total cases in just 3 months. In total, 80% of these cases were reported in Manabi province, the area most affected by the earthquake . Reina OThe ZIKV outbreak in the city of Manabi, Ecuador, after the 2016 earthquake, demonstrates the negative impact of natural hazards in socially vulnerable areas where climatic conditions are not considered normal for the region. An extremely strong El Niño event created environmental conditions that favored the proliferation of mosquito vectors just as ZIKV first appeared in Ecuador .The increase in ZIKV incidence may be associated with the movement of population groups and overcrowding that may increase exposure to virus vectors. Destruction of property and sewage and water management systems may increase the number of Aedes aegypti breeding sites. Stressful conditions alter the immune status and increase the susceptibility of the population to developing symptomatic disease .Wound and skin infection refers to the infection of tissues by one or more types of microorganisms. The type of wound infection depends mainly on the environment in which the injury took place, the extent of the injury, the microorganisms present on the skin of the injured person, the microorganisms to which the person has been exposed during wound healing, and the general health and immune status of individuals.Traumatic injuries that occur after an earthquake disrupt the balance of the immune system and increase the predisposition to infectious complications. Being trapped under rubble for a long period of time can cause severe crush injuries, leading to an increased risk of exposure to pathogens.Wound and skin infections were reported after the 1999 Izmit (Turkey) ,152,153,Staphylococcus aureus, but only 24.4% of all isolated microorganisms were Gram-positive bacteria and 73.2% were Gram-negative, such as Escherichia coli, Acinetobacter baumannii, Enterobacter cloacae, and Pseudomonas aeruginosa [Most patients in the 2008 Sichuan earthquake were buried under rubble with soil, bricks, or stone. Time under debris and time from injury to treatment was associated with the wound infection occurrence. Victims who survived the earthquake were often severely injured. The incidence of wound infections was high due to inadequate provision of medical personnel, surgical equipment and antibiotics, subsequent rainfall, and high temperature in earthquake-affected areas . The mosruginosa ,168,169.A. baumannii (27%), E. cloacae (18%), and P. aeruginosa (13%). However, this distribution of pathogens differed from that in hospitalized cases in the year before the earthquake. The pathogens most frequently isolated in the pre-earthquake period were E. coli (27%), S. aureus (23%), and coagulase-negative staphylococci (9%) [A similar picture was seen in the studies by Kang et al.  and Zhancci (9%) . Meanwhicci (9%) .After the 2010 Haiti earthquake, the majority of earthquake victims were admitted to hospitals for limb injuries requiring orthopedic surgery and treatment of infected wounds. Overall, 77% of the wound infections were polymicrobial and involved predominantly Gram-negative bacteria, which were resistant to the antimicrobials recommended in current CDC and WHO guidelines .P. aeruginosa, Enterobacter spp., and Acinetobacter spp.) were the most common microorganisms isolated from polymicrobial wound infections [After the 2005 Kashmir earthquake in Pakistan, Gram-negative bacteria (fections . The prefections .Recording these changes in the spectrum and resistance of pathogens isolated after earthquakes can contribute to the timely administration of effective treatment after similar seismic events like the 2008 Sichuan (China) earthquake . EarthquAcinetobacter was the main bacterial isolate identified from patients with wound infections attributed to the 1999 Izmit earthquake compared to the almost non-existent prevalence of Acinetobacter infections in the ICU of the same hospital. S. aureus and E. coli were the most common pathogens at the initial stage of hospitalization. With a prolonged ICU stay, A. baumannii and Klebsiella pneumoniae gradually became the dominant pathogens [Crush syndrome can lead to prolonged hospitalization and is associated with an increased risk of subsequent infection . A high athogens .Aeromonas spp., E. coli, K. pneumoniae, P. aeruginosa, and Proteus spp. [It is noteworthy that the aforementioned isolated bacteria differed significantly from the isolation pattern recorded in the 2004 Indian Ocean earthquake and tsunami, where the most commonly reported infectious agents were eus spp. ,158,159.The high frequency of Gram-negative bacilli isolation from wound cultures is probably explained by the mode of wounding. Gram-negative bacilli are naturally present in soil and water and people are probably exposed to these bacteria at the time of injury. It is also likely that these infections are hospital-acquired because most patients come from front-line hospitals, where drug resistance rates can be high ,173.Laboratory microbiological analysis is essential for the optimal selection of antibiotics to treat infection, as well as for preventing and possibly reducing the risk of hospital-acquired infection. In addition, effective management of infection contributes to better wound care and therefore leads to lower mortality and disability rates .S. aureus and S. epidermidis. Gram-negative bacteria (35.6%), including E. cloacae, K. pneumoniae, and Serratia rubidaea, were detected in a smaller number of samples in contrast to the pattern seen in wound infections in other body areas [Craniocerebral injuries are rarely vulnerable to infection due to the abundant blood supply. However, among individuals injured in the Sichuan earthquake, scalp wound infections were recorded quite frequently . Gram-pody areas .Certain measures can improve the prognosis of patients with severe infection, including early recognition of infection, early identification of microorganisms, rational use of antimicrobial agents with the guidance of infectious disease experts, targeted therapy to boost the immune system, necessary surgical removal of infected foci, early debridement, and strict surveillance for hospital-acquired infections .Clostridium tetani. The bacterial spores are mainly found in soil, human feces, and on the surface of rusty objects [Tetanus is an acute infectious disease caused by the exotoxin of  objects .Despite being easily preventable with a highly effective vaccine, tetanus remains a major source of morbidity and mortality worldwide. The death rate from tetanus remains high in developing countries affected by natural hazards, where tetanus vaccination coverage is often low or non-existent. Successful treatment of tetanus depends on prompt diagnosis, timely administration of treatment, administration of sedative and muscle relaxant drugs, maintaining an open airway, and mechanical respiratory support in the management of respiratory failure . TetanusIn January 2005, an epidemic of tetanus was detected among the tsunami survivors in Indonesia. Of the 106 cases, 79% were over 25 years old (the median age was 40 years) and 62% were male . The casThe tetanus cases detected following the 2004 Indian Ocean earthquake and tsunami was the largest cluster reported after a natural disaster or an event with huge number of casualties, surpassed only by the 2005 Kashmir earthquake after which 139 cases were recorded . The enoFollowing the 2006 Yogyakarta earthquake, 26 tetanus cases were recorded, including 8 fatalities. Significant predictors of death included the distance from the patient’s residence to the hospital and the type of hospital .Clostridium perfringens. A prerequisite for the occurrence of gas gangrene is wound contamination in such a way that anaerobic conditions are created, i.e., either the wound is deep or the tissues from the injury have been necrosed. Gas gangrene cases were detected in victims of the Sichuan earthquake and several of these were confirmed after culture to have resulted from Clostridium perfringens infection [Gas gangrene or myonecrosis is a highly fatal deep soft tissue infection caused by nfection ,171.In the first three months after the 1999 Izmit earthquake, registrations to the outpatient clinic of a dermatology department included infections/infestations and dermatoses mainly due to damaged infrastructures and unhygienic life conditions. In the following 3 months, erythematous squamous, pruritus, neurocutaneous dermatoses, and eczemas predominated and were due to psychoemotional factors related to the earthquake .The evaluation of skin problems recorded at a general hospital in Banda Aceh after the 2004 Indian Ocean earthquake showed that the most common skin problems were infections/infestations, followed by eczemas and traumatic skin disorders, which were more common in men . The preEarthquakes alter existing environmental conditions, resulting in direct public health impacts, including occurrence of sporadic cases, outbreaks, and epidemics of infectious diseases in the affected population and those involved in emergency response and recovery actions.Coccidioides immitis were transferred to Ventura County with dust clouds generated during the 1994 Northridge, California earthquake [Strong ground motion alters the stability conditions on slopes, resulting in slides and rockfalls on natural and artificial slopes. The resulting dust clouds have a high potential to adversely affect public health, especially when carried by prevailing winds to residential rural and urban areas. A typical example of such an effect is the outbreak of coccidioidomycosis that occurred when airborne spores of rthquake ,69.The vertical displacement of the seabed and offshore earthquake-triggered landslides can generate large tsunamis with significant impacts on infrastructure and the population of coastal areas. Typical examples are tsunamis generated in individual parts of the Ring of Fire, including the Indian Ocean tsunami on 26 December 2004, the Samoa Islands (South Pacific Ocean) tsunami on 29 September 2009, and the Japan tsunami on 11 March 2011, which have flattened extensive coastal areas with thousands of human casualties and widespread post-event public health impacts .Apart from the above direct effects of secondary seismic phenomena on public health, there are also indirect effects, mainly resulting from damage and malfunction of the main elements of the built environment. The strong ground shaking and the resulting severe structural damage to residential buildings create an emergency need for immediate sheltering of thousands of people in places, whether organized or not, where overcrowding prevails and sanitary conditions deteriorate.Damage to health care facilities causes problems and delays in providing first aid and immediate medical care to the affected people. The destruction of parts of the road network causes temporary disruption to transport services and difficulties in accessing essential supplies and emergency services immediately. These effects on lifelines are characterized by high potential to induce the occurrence of infectious diseases and even result in human casualties among earthquake survivors.Heavy structural damage to critical healthcare infrastructure, including facilities and buildings, remained unfixed during the emergency response and the subsequent recovery, causing delayed management and treatment of severe infectious diseases cases.Lack of awareness and provision of early or real-time warning for the upcoming and the ongoing events, resulting in little time for preparedness or evacuation.Severely injured earthquake and tsunami survivors highly exposed to high pathogen densities in soil and water.Immense changes in climate and aggravating weather conditions in the emergency response phase including dramatic temperature changes.○airborne particulate matter due to large dust clouds formed by earthquake-triggered landslides.○airborne particulate matter due to contaminated ejecta dust formed by earthquake-triggered liquefaction phenomena with a destructive impact on water and sewage systems.Prolonged physical exposure to and inhalation of:Prolonged physical exposure to and aspiration of contaminated water due to tsunami generation and impact on the coastal residential zones.○High population density and overcrowding.○Poor living conditions comprising small places for individuals and families and insufficient equipment for the homeless and evacuees .○Lack of clean running water due to damage and contamination of the water supply systems and water sources, respectively.○Unsanitary conditions (poor hand hygiene) due to a shortage of personal hygiene items.○Malnutrition due to insufficient food provision and shortage of long-lasting food supplies.○Insufficient equipment comprising essentials and poor heating, ventilation and air conditioning systems among others.○Rodent/vector infestation.Emergency shelters and evacuation camps with:Increased exposure to vectors and rodents due to earthquake-triggered ecological changes, leading to extensive formation of potential breeding and feeding sites of vectors and rodents.The weak immune system of vulnerable groups of the affected population comprising the elderly, the chronically ill individuals, and young children.The dependency of young children, people with disabilities, and elders of the affected communities seeking assistance with daily activities.Poor socio-economic conditions, including large percentage of low education level, a large part of the population living below the national poverty line leading to insufficient personal hygiene and denial of risk, disinterest, and ignorance of risk, as well as poorly constructed buildings and infrastructures.Poor health education and training on infectious disease prevention and control.Lack of emergency preparedness and training of residents and medical staff for infectious disease prevention.Insufficient or low vaccination coverage due to limited vaccination campaigns and short supplies.Close contact with cases and activities and interaction in areas where clusters of infectious disease cases have been observed.As concluded from the above literature review on earthquake-triggered infectious diseases, the risk factors that can lead to the occurrence of sporadic cases, outbreaks, and epidemics of infectious diseases in an earthquake-affected area are summarized as follows ,183,184:The knowledge of factors underlying earthquake-triggered infectious diseases can contribute to the adoption and application of effective prevention strategies. These measures should be taken in the light of a more multihazard approach to environmental, disaster, and crisis management, related to different types of hazards. This need has begun to emerge in recent decades as the interactions between mainly natural hazards became increasingly evident ,186. It One of the widely proposed measures for the prevention of infectious diseases after an earthquake and its effects is the establishment of a proper disease surveillance system. The main purpose of the surveillance system is initially to immediately and effectively identify the pre- and post-disaster infectious disease cases and trends through the collection, compilation, and analysis of information related to the number of cases of various diseases.Through this rapid identification of infectious disease cases, it is possible to contribute effectively to improvement of disease trends monitoring, validity of early warnings, support for vaccine development, the development of more effective prevention strategies and thus to a more complete assessment of the public health burden of infectious diseases. Among the key structural elements of this surveillance system are the alert and response components.One of the most important prerequisites for strengthening the early warning component of a surveillance system is the regular exchange of information between the competent authorities. Proper disease surveillance after a disaster is further enhanced by prompt diagnosis and subsequent treatment, which should be expanded to all high-risk parts of the earthquake-affected areas in order to prevent the acquisition of infectious diseases and the subsequent emergence of outbreaks and epidemics.The significance of the infectious disease surveillance systems should be emphasized in emergency shelters for the implementation of infection prevention and control measures. The emergency shelters are critical post-disaster infrastructures, providing immediate temporary shelter to those who leave their homes due to severe structural damage or evacuation of an area affected by both the earthquake and its accompanying phenomena. However, in the first days or hours after the earthquake occurrence that has led to a surge of evacuees and internal displaced people and heavy structural damage of the healthcare facilities and life lines in affected areas, emergency shelters are the places where the first cases of infectious diseases may occur, leading to related outbreaks or even epidemics.Typical examples of sporadic cases, outbreaks, and epidemics of infectious diseases come from Japan and the emergency shelters that were set up to accommodate those in need of immediate shelter and food after the 2011 earthquake and the subsequent tsunami that hit much of the coastal zone in the eastern part of the country ,184. EmeIn order to prevent such adverse effects during staying in emergency shelters, it is necessary to conduct actions to mainly cover the gaps in the organization and operation of these places. Thus, ample amounts of bottled water and canned and dry food should be available, adequate ventilation (heating and air-conditioning) should be provided, personal protective equipment  should be distributed to prevent the spread of respiratory tract infections, mosquito nets and insect repellents should be distributed and spraying should be carried out to prevent vector-borne diseases, and appropriate pharmaceutical material and effective vaccines should be available in sufficient quantities. As regards the awareness-raising and information of evacuees and staff, material comprising posters and leaflets should be posted in several sites of the shelters for enhanced prevention of infectious diseases not only in the emergency shelters but also in the affected community.In order to avoid overcrowding in emergency shelters, more shelters of the same or different type should be constructed. This approach was successfully used in the case of devastating earthquakes that hit Greece during the COVID-19 pandemic, where maintaining physical distance between evacuees was a measure to limit the spread of SARS-CoV-2 in the earthquake-affected communities ,188,189.Infectious disease mitigation measures in emergency shelters can be divided into (i) measures for first responders and personnel involved in the emergency response, (ii) mitigation measures for accommodated staff and visitors in emergency shelters, (iii) administrative and engineering controls in emergency shelters, including changes in the layout of facilities and distribution practices of supplies, and (iv) designation of isolation facilities to separate suspected cases of infectious diseases .When an earthquake causes extensive structural damage to the built environment and a major impact on the population of the affected area, search and rescue teams are mobilized not only from the services of the affected country and neighboring countries but also from other countries on other continents with different epidemiological characteristics. In order to avoid sporadic cases, outbreaks, or even epidemics of infectious diseases in non-endemic countries or the addition of epidemic risk factors to existing ones, all people involved and responding to disaster management comprising rescuers, volunteer teams, and aid organizations should respect the fundamental principle of all assistance, which is initially not to harm. With this in mind, measures should be taken to protect the health of both first responders and the affected population. With regard to the first aspect of protecting those involved in the immediate response, strict adherence to personal hygiene and safety and environmental sanitation protocols should be applied in areas where SAR operations are conducted and in emergency shelters. Furthermore, adherence to good hygiene practice in the handling, preparation, and distribution of food should also be applied in the areas where these teams operate ,188,190.In the affected area where the SAR team was deployed, due to the absence of running water, abundant amounts of mineral water and baby wipes were used for washing. Food for the team was limited to prepackaged or canned field rations . The use of local products in meal preparation and their consumption was prohibited. Close medical guidance was given to all food handlers and environmental hygiene supervision was continuously carried out during the mission. These methods, combined with immunization, kept morbidity to a minimum. In another region, where all of the above was not strictly followed, there was a 48% gastroenteritis infection rate .Ensuring the safety of drinking water and sewerage systems not only in either temporary or permanent relief camps but also in areas characterized by high riskCompliance with the existing safety and hygiene measuresWhere existing measures are not sufficient, educational activities for hygiene and sanitation awareness raising should be conducted, aiming for the integration of safe water and hand hygiene best practices into households, communities, and countriesLarge-scale preventive vaccination and medicine programs for several infectious diseases should be implemented, along with the establishment of a proper disease surveillance program and a long–term empowering and strengthening of the public-sector health system.As far as the protection of the local population is concerned, the same strict adherence should be applied to personal and environmental hygiene rules. The example of the cholera epidemic following the 2010 Haitian earthquake, which caused human losses greater than those attributed to the earthquake’s impact on the country’s buildings and infrastructure, is typical. Many researchers have addressed this epidemic ,195,196.In order to provide relief efforts to a region systematically, data and information on the prevalent endemic and epidemic infectious diseases in the disaster-affected area should be collected shortly after the earthquake occurrence. A quick evaluation of the existing infectious disease patterns should be also assessed, along with the demographic conditions of the affected area, including the number, size, and location of residential areas and population density, the availability of safe clean running water and adequate personal and environmental sanitation facilities, as well as the nutrition status and the immunization coverage of the disaster-affected population .With regard to respiratory infections caused by secondary earthquake environmental effects, mainly including landslides and liquefaction, measures deal with limiting the exposure of affected people to dust clouds generated during landslides and the clearance of areas covered from extensive liquefied deposits ,197,198.2 per person. The UN Refugee Agency (UNHCR) [2 per person in cold climates and 3.5 m2 per person in tropical, warm climates. These recommendations could facilitate emergency evacuation planning and result in the reduction of ARI incidence at emergency shelters.Increased incidence of respiratory infections could be attributed to seasonal variations and overcrowding conditions in emergency shelters in the earthquake-affected areas. The correlation between shelter crowding and an increased ARI incidence rate was demonstrated by Kawano et al.  followin (UNHCR)  developeTo avoid the occurrence of waterborne diseases during the emergency in earthquake-affected areas, one of the most effective proposed measures is the examination of water and sewage systems for detecting non-structural and structural damage with potential to affect public health. It is a practice that has been applied in all developed countries for decades. If non-structural and structural damage is found in these systems, chlorination or even an initial supply from a different source is applied and then disinfection follows ,202. IndTo reduce the risk of vector- and rodent-borne diseases throughout the earthquake-affected areas, public health authorities should give priority to surveillance. The implementation of response activities and control measures, as well as the improvement of preparedness efforts aimed at emerging vector- and rodent-borne diseases, depends on the immediate recognition and identification of local vector and rodent species, environmental factors, and breeding habitats that influence local disease transmission.Information on how to avoid contact with water, especially if skin abrasion happens, avoid touching eyes, nose, or mouth, identify rodent- and vector-borne infection symptoms, and seek immediate medical help and advice if you become ill should be distributed to the general public and disaster management officials. Since misdiagnosis or delayed diagnosis has serious clinical implications, early detection of signs and symptoms, appropriate treatment, and application of disease-specific therapies are essential to reduce morbidity and mortality. The earthquake-affected population should also stay away from places like uncontrolled waste disposal sites, garbage dumps, and areas with stagnant water where they might come into contact with contaminated surface water or infected animal urine.A rapid risk assessment should be performed within the first week of the earthquake’s occurrence by gathering data on the earthquake-affected area and population, with a focus on internally displaced people, as well as the risk of infectious disease outbreaks and disruptions to the public health infrastructure. The establishment of adequate disease surveillance systems and the identification of suitable interventions for managing and mitigating the negative effects of infectious disease outbreaks that happen concurrently with or after an earthquake disaster are both made possible by recorded data.The improvement of health surveillance systems, the maintenance and provision of effective and efficient health care services, and the reduction of associated mortality and morbidity may all be aided by education, training, and awareness-raising initiatives for the identification and management of infectious diseases.It may be possible to prevent the onset of an infectious disease outbreak during the post-disaster phase or to mitigate and eliminate the negative effects on the public health after the onset of an infectious disease outbreak by taking awareness-raising and informational actions in areas with high seismic risk and susceptibility to seismic effects. In addition to making it simple to implement personal protective measures to prevent infection, these actions allow for effective management of an impending outbreak.Flexible preparedness planning and measures that can quickly and effectively incorporate unforeseen circumstances and associated negative effects are required in terms of long-term prevention. This strategy necessitates expanding our understanding of the connection between infectious diseases and disasters induced by natural hazards. Planning for emergency response to disasters by natural hazards should include measures for preventing infectious disease outbreaks and mitigating their effects on the affected population and the staff involved in emergency response and recovery.The public, in particular residents belonging to particular groups within communities who may be more susceptible than others to the negative effects of earthquakes and may therefore suffer the most from the generation of such events and subsequent infectious disease outbreaks, should also be informed of these measures in a timely and effective manner, in addition to the staff involved in the prevention and management of these emergencies. The elderly, people with disabilities, children, women, people with low incomes, the homeless, and migrants are some of these groups.Earthquakes occur in specific zones where active faults have been formed. A rupture along these active faults results in primary and secondary effects with considerable impact on the built environment and the local population of the affected areas.The synergy of pre-existing conditions and changes caused by the earthquake and its primary and secondary effects, combined with the physiographic characteristics of the affected area and the socio-economic characteristics of the affected communities, have high potential to cause public health impacts, including sporadic cases, outbreaks, and epidemics of infectious diseases, which may lead to human losses, resulting in a delay of the recovery process in the earthquake-affected area.This study shows that earthquake-triggered infectious diseases have occurred not only in areas devastated by destructive earthquakes with hundreds to thousands of human casualties, thousands to tens of thousands injured, and tens of thousands to millions internally displaced people, but also in areas affected by earthquakes with an extensive impact on elements of the built environment (buildings and lifelines) but with no direct impact on human life, including losses and injuries.The risk factors that favor the incidence of infectious diseases in earthquake-affected areas are related to the earthquake magnitude and intensity, the extent of its primary and secondary effects, the demographic and epidemiological characteristics of the affected area, and the level of education and living conditions of the affected communities, as well as the damage to public health structures and facilities.The infectious diseases that have been recorded to date following the occurrence of earthquakes around the world are classified into (a) respiratory infections, (b) gastrointestinal diseases (water- and food-borne diseases), (c) vector-borne diseases, and (d) wound and skin infections.Regarding measures for the prevention and management of earthquake-triggered infectious diseases, the most effective and widely recommended measure by almost all relevant published research is the establishment of an appropriate disease surveillance system. Such a system should be able to effectively identify infectious disease trends before and after the earthquake and contribute to a full assessment of the public health burden of the infectious diseases and their management. This system should be governed by a multiparametric, interdisciplinary, and multihazard approach. This approach is considered imperative, especially in recent years, where the parallel occurrence and evolution of geophysical and biological hazards and related disasters with public health implications is more frequent than ever before.