The earthquake risk assessment in Bulgaria by regions (sources: BAS).
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"8188",leadTitle:null,fullTitle:"Ion Beam Techniques and Applications",title:"Ion Beam Techniques and Applications",subtitle:null,reviewType:"peer-reviewed",abstract:"A wide variety of ion beam techniques are being used in several versatile applications ranging from environmental science, nuclear physics, microdevice fabrication to materials science. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"63380",title:"Introductory Chapter: Ion Channels",doi:"10.5772/intechopen.80597",slug:"introductory-chapter-ion-channels",body:'Ion channels are remarkable proteins, present in the lipid bilayer membrane of both animal and plant cells and their organelles, such as nucleus, endoplasmic reticulum, Golgi apparatus, mitochondria, chloroplasts, and lysosomes.
When we google the word “ion channel,” about 80,000,000 results pop up within 0.45 s. Scientists have been working on these amazing transmembrane proteins since the beginning of the last century, which has resulted in three sets of Nobel prizes in 1963, 1991, and 2003.
Sir John Carew Eccles, Alan Lloyd Hodgkin, and Andrew Fielding Huxley in 1963 received Nobel Prize for Physiology and Medicine for their discoveries concerning the ionic mechanisms involved in excitation and inhibition in the peripheral and central portions of the nerve cell membrane [1, 2]. Similarly, Erwin Neher and Bert Sakmann in 1991 proved that cell membranes have individual ion channels through which tiny currents can pass, which are big enough to generate communications between pre- and postsynaptic neurons by converting chemical or mechanical events into electrical signals [3, 4]. The Nobel Prize in Chemistry for 2003 was shared between two scientists Agre [5] and Roderick MacKinnon [6] who have made fundamental discoveries concerning how water and ions move through cell membranes.
In this book, we have nine very diverse and informative chapters including this introductory chapter on the importance of both cations and anions passing through these ion channels.
First chapter is the introductory chapter which briefly overview the other eight chapters included in this book, as well as discusses the diversity and classification of ion channels, nature and number of gating for these ion channels along with shedding some light on Channellopathies. Second chapter deals with the voltage-gated sodium channels in drug discovery. Sodium channels are the very first one to be discovered when Hodgkin and Katz were performing their experiments on squid axons showing that there would be no action potential if sodium ions are not present in the extracellular fluid. In this chapter, genetic evolution and subtype distribution of this super family of voltage-gated sodium (Nav) channels are introduced, and there is a discussion about how the changes in the structure alter their functions. Third chapter argues the modulation of Nav by small and large molecules, along with the discussion on the major challenges for the Nav-targeted drug discoveries. Fourth chapter is taking us to a striking journey about how the genetic mutations bring change in their product proteins and resultant disorders such as Dravet syndrome. SCN1A gene is responsible for this condition and there is a word of caution for the medical practitioners to not prescribe sodium channel blockers for the epileptic patients with this mutation, as the medicine will aggravate their condition. Fifth chapter is about potassium channels: there are many different types of the potassium channels (many more than sodium ion channels). In this chapter, authors have discussed the role of two gap junction proteins—connexins and pannexins—in maintaining the homeostasis of potassium ions, taking cochlea as an example. Mutation in gap junction gene results in 50% of prelingual, recessive deafness. Authors developed a novel method for the early detection of the genetic mutations for the inner ear impairment. Sixth chapter is dealing with the structure and function of L-type calcium channels and how voltage-gated calcium channels (VGCCs) manage the electrical signaling of cells by allowing the selective-diffusion of calcium ions in response to the changes in the cellular membrane potential. Among the different VGCCs, the long-lasting or the L-type calcium channels (LTCCs) are prevalently expressed in a variety of cells, such as skeletal muscles, ventricular myocytes, smooth muscles, and dendritic cells and form the largest family of the VGCCs. Their wide expression pattern and significant role in diverse cellular events have made these channels the major targets for drug development. Seventh chapter is about the regulation of pain through calcium channels. In this chapter, authors present a large body of clinical, biochemical, biophysical, pharmacological, and genetic evidences pointing toward calcium-permeable channels as the key players in pain conditions. The primary goal of this chapter is to present an overview of the different classes of calcium-permeable channels and how they change to modulate the sensation of pain in acute and chronic states. Eighth chapter deals with the transient receptor potential (TRP) ion channels, from their distribution to their assembly. TRP ion channel superfamily is widely distributed from neuronal to nonneuronal tissues by serving as cellular sensors. TRP subunits can form both homomeric and heteromeric channels which are present either in the same subfamily or in the different subfamilies and diversify TRP channel functions. Ninth chapter discusses about the types of anionic and chloride channels present in the mitochondria. There are many types of chloride channels present in mitochondria, but two types are of major interest, i.e., one which is present in the inner mitochondrial membrane, responsible for the oscillations of membrane potential and the chloride intracellular ion channel (CLIC) localized in the cardiac mitochondrial membranes. These anion channels are very important both in health and diseased conditions. These channels are important for the regulation of PH and ROS along with the synchronization of the mitochondrial membrane potential.
In the following pages of Chapter 1, we will be looking at the role of gating in ion channels for the maintenance of normal physiology and how any of these alterations in the gating result in the channelopathies.
Before going any further, we would like to acknowledge the sculpture called the birth of an idea. It is a 1.5-m tall figurine of KcsA potassium channel, made up of wires and blown glass, representing the channel’s lumen [7, 8]. This statue was commissioned to Julian Voss-Andreae by Nobel Prize winner Roderick Mackinnon.
There are three main types of ion channels, i.e., voltage-gated, extracellular ligand-gated, and intracellular ligand-gated along with two groups of miscellaneous ion channels. These ion channels are responsible for the transmission of signals between nerve and other types of electrically active cells [9, 10] through synapses and gap junctions [11, 12]. Alterations in the electrical potential of presynaptic neurons initiate the release of neurotransmitters from the vesicles in the synaptic cleft [13]. These chemicals move toward the postsynaptic cells through the diffusion and occupy their specific receptor sites on membranes and generate the electrical potential by opening ion channels [14]. Removal of neurotransmitters from the synaptic cleft is essential to avoid any effect on the nearby cells [14, 15, 16]. Cell signaling by neurotransmitters is far more adaptable and versatile as compared to the gap junctions [17].
More than 106 ions are transported in a second through the ion channels without the help of metabolic energy like ATP, cotransport, or the active transport mechanism [18]. There are two types ion channels, nonselective or large pore and selective (archetypal) or small pores [19, 20]. Ions typically pass through the channel pores in the form of a single file almost as fast as they move through a free solution. In most of the ion channels, the passage across the pores is governed by a “gate.” The gate may be opened or closed in response to different factors such as: electrical signals, chemical signals, temperature, and the mechanical force [14, 15, 18]. In summary, ion channels are the integral membrane proteins which are usually present as assemblies of many subunit proteins [16, 19]. In most voltage-gated ion channels, α subunit is the pore-forming subunit, while β and γ are the auxiliary subunits [21].
There are many different types of ion channels distributed in each cell of our body; for example, in the cells of inner ear alone, there are about 300 ion channels [22]. Ion channels are mainly classified [23, 24] on the basis of the following:
The nature of gating;
The types of ions passing through the said gates;
The number of the gates.
Ion channels could be classified on the basis of gating, i.e., type of stimuli responsible for their opening and closing. Electrical gradient across the plasma membrane are responsible for the opening and closing of voltage-gated ion channels [25, 26]; however, binding of the ligands to the channels is responsible for the activation and deactivation of ligand-gated ion channels [29].
The opening and closing of the voltage-gated ion channels are dependent on the membrane potential, which can be divided into the following subtypes [25, 26, 27, 28].
These channels are also known as the ionotropic receptors and get opened in response to specific ligand molecules binding to the extracellular domain of the receptor proteins [28, 29, 30]. Binding of the ligand causes a conformational change in the channel protein that ultimately leads to the opening of the channel gate and subsequent ion flux across the plasma membrane occurs [31, 32]. Cation-permeable “nicotinic” acetylcholine receptors, ionotropic glutamate-gated receptors, acid-sensing ion channels (ASICs), ATP-gated P2X receptors, and the anion-permeable γ-aminobutyric acid-gated GABA receptors are a few examples of ligand-gated channels [29, 31, 33].
Activation and inactivation of ion channels by second messengers are included under this heading. Some examples are:
Photon-mediated light-gated channels are activated and deactivated in response to light and are synthesized in the laboratory. Some light-sensitive channels are present in nature such as channelrhodopsin. Photoreceptor proteins are also sensitive to light and are G protein gated too.
Cyclic nucleotide-gated channels are activated by hyperpolarization and are permeable to monovalent and divalent cations such as K+, Na+, and Ca2+.
Temperature-gated channels are the members of the transient receptor potential ion channel superfamily and are opened by hot or cold temperatures.
Genetic and autoimmune disorders of the ion channels cause channelopathies. If a mutant gene encodes an ion channel protein that is present on the cell membrane of heart, muscles, or brain, it results in the development of diseases in these organs [34, 35]. For example, if a gene encoding Na+ channel is mutated, then the protein for that channel will be defected and will be incapable to function properly; for example, in myotonia, there is delayed muscle relaxation after voluntary contraction. The abnormal Na+ channels are not able to deactivate, thus initiating repeated membrane depolarizations and resultant muscle contractions. Similarly, abnormality of the K+ and Ca2+ channels in the brain can cause epilepsy. The repeated nerve firings result in convulsions and fits, known as epileptic seizures [36]. Generally, the cell repolarization is effected due to a defect in the voltage-gated ion channels such as K+, Ca2+, Cl−, and Na+. Similarly, any impediment in the Nav can lead to hyperkalemic periodic paralysis [36, 37]. Stress, alarm, or strenuous activity can stimulate paramyotonia congenital (PC), potassium-aggravated myotonia (PAM), generalized epilepsy with febrile seizures plus (GEFS₊), and episodic ataxia (EA), marked by acute bouts of extreme discoordination with or without myokymia [36, 37]. Similarly, familial hemiplegic migraine (FHM) and spinocerebellar ataxia are due to mutation in one or more of the 10 different genes encoding the potassium channels, which also causes a ventricular arrhythmia syndrome called the Long QT syndrome. This mutation ultimately affects the cardiac repolarization [38]. Another type of ventricular arrhythmia is caused by the mutations in genes coding for the voltage-gated sodium channels, and is known as the Brugada syndrome. Likewise, a mutation in the CFTR gene, which encodes for the chloride channel, causes cystic fibrosis [39].
Defect in the transient receptor potential cation channel, mucolipin subfamily (TRPML1) channel, due to a mutation in any of its genes results in mucolipidosis type IV [34, 40, 41]. Some very vital events occur in the cancer cells due to the mutations and overexpression of genes encoding the ion channels; for example, glioblastoma multiform is marked by an increase in the number of receptors for glioma big potassium (gBK) channels and the CIC-3 chloride channels enabling the glioblastoma cells to move within the brain causing the diffuse growth patterns of these tumors.
The medical provision of the injured population (MPIP) is a key task in the activity plan of the health system (HS) in case of emergencies and disastrous situations (EDS) [1, 2, 3]. This is regulated and specified for each level of government and for each type of structural unit within the HS of the country [2]. The timely and correct updating of the action plan of EDS by the healthcare leaders and health risk managers is a consistent, up-to-date annual task in order to maintain a highly optimal readiness for rapid response [2, 3, 4]. According to the type of EDS for each individual critical care potion the availability of action protocols guarantees not only confident firmness but also readiness for effective operational response and good medical practices. The productive operational activities at each stage of the MPIP with responsible and expert risk health management in a dynamically changing environment at the EDS require mobile flexibility and maneuverability in the development of the plan and its implementation [2, 5, 6, 7]. The provision with sufficient resources and their maneuver contextually according to the specific EDS is the basis for a good organizational culture [7, 8] Essential step for rescuing and providing successful medical care to the affected population is a practical interaction with other emergency systems and organization [8, 9]. Coordination of the EDS activities on a large scale is a solid fundament principle for the correct direction of the actions [7, 8, 9]. In case of the destructive EDS with a serious territorial scope and severely affected available resources the participation of international organizations, rescue teams and means of medical specialist is a possible option [10].
\nAs a particular type of EDS, large magnitude earthquakes are characterized not only with mass casualty but also with the diversity of damage among the population of any natural community [2, 7, 8, 9].
\nAccording to the World Health Organization (WHO) evidence-based databases, around the world more than million earthshakings annually are occured, of which about 100,000 have a magnitude of 3–8 Richter and are felt by humans. Some of the strongest earthquakes in the world are: the Assam (June 12, 1897) in Northeast India; The Japanese (September 1923), in which the cities of Tokyo and Yokohama were destroyed; Gobi - Altai (December 4, 1957); Chilean (May 29, 1960); the Alaska Earthquake (March 28, 1964); the Armenian Earthquake (December 7, 1988); the earthquake of December 26, 2004 after which almost 230,000 missing and presumed dead [11]; the earthquake in Haiti (January 12, 2010) that killed more than 230,000 people and another 300,000 were injured [12]; the earthquake in Japan (March 11, 2011), which killed more than 15,800 people, injured more than 6000 and disappeared more than 2500 people [13]. The earthquake risk assessment in Bulgaria is made by regions. The number of regions in Bulgaria is 28 in total (Table 1).
\nRegion | \nProbability (low, moderate, high) | \nPower (low, moderate, high) | \nExpected losses (low, moderate, high) | \n||
---|---|---|---|---|---|
People | \nFinance | \nEcology | \n|||
Blagoevgrad | \nHigh | \nHigh | \nModerate | \nModerate | \nHigh | \n
Burgas | \nLow | \nLow | \nLow | \nModerate | \nModerate | \n
Varna | \nModerate | \nModerate | \nModerate | \nHigh | \nHigh | \n
Veliko Tarnovo | \nHigh | \nHigh | \nModerate | \nModerate | \nModerate | \n
Vidin | \nLow | \nLow | \nLow | \nLow | \nLow | \n
Vratsa | \nLow | \nModerate | \nLow | \nModerate | \nModerate | \n
Gabrovo | \nModerate | \nModerate | \nLow | \nModerate | \nLow | \n
Dobrich | \nHigh | \nHigh | \nModerate | \nModerate | \nModerate | \n
Kardzhali | \nModerate | \nLow | \nLow | \nModerate | \nModerate | \n
Kyustendil | \nModerate | \nModerate | \nLow | \nLow | \nModerate | \n
Lovech | \nLow | \nModerate | \nLow | \nLow | \nLow | \n
Montana | \nLow | \nLow | \nLow | \nLow | \nLow | \n
Pazardzhik | \nHigh | \nHigh | \nModerate | \nModerate | \nModerate | \n
Pernik | \nModerate | \nModerate | \nModerate | \nHigh | \nHigh | \n
Pleven | \nModerate | \nModerate | \nModerate | \nModerate | \nHigh | \n
Plovdiv | \nHigh | \nHigh | \nModerate | \nHigh | \nHigh | \n
Razgrad | \nModerate | \nModerate | \nLow | \nLow | \nLow | \n
Ruse | \nHigh | \nHigh | \nModerate | \nHigh | \nHigh | \n
Silistra | \nHigh | \nHigh | \nModerate | \nLow | \nModerate | \n
Sliven | \nModerate | \nModerate | \nModerate | \nModerate | \nModerate | \n
Smolyan | \nModerate | \nModerate | \nLow | \nLow | \nLow | \n
Sofia-city | \nHigh | \nHigh | \nHigh | \nHigh | \nHigh | \n
Sofia | \nModerate | \nModerate | \nLow | \nModerate | \nLow | \n
Stara Zagora | \nHigh | \nHigh | \nModerate | \nHigh | \nModerate | \n
Targovishte | \nHigh | \nModerate | \nLow | \nLow | \nLow | \n
Haskovo | \nHigh | \nHigh | \nModerate | \nHigh | \nHigh | \n
Shumen | \nModerate | \nModerate | \nLow | \nModerate | \nModerate | \n
Yambol | \nHigh | \nModerate | \nModerate | \nModerate | \nLow | \n
The earthquake risk assessment in Bulgaria by regions (sources: BAS).
The data indicate that the probability is low in only five regions in Bulgaria (almost 18%). In contrast, the probability is high in 12 regions (almost 43%) and moderate level in 11 regions (around 39%). It is interesting to note that in 12 regions the risk of a strong earthquake is rated as high and only in 4 is indicated as low. According to prognostic data, human losses are assessed as high only in Sofia-city region. On the one hand only in Sofia-city region is reported high values prognosis for each of the indicators. On the other hand in two of them (Montana and Vidin) a low risk assessment is given.
\nThe medical provision of the population (MPP) is an element of activity of the health system especially due to EDS. In case of emergencies it is based as much as possible on the existing health care system and only with an organizational approach moves to a new mode of work with available staff and sources. MPP according to real practice, results of an epidemiological survey and documentary research is defined as a complex of interconnected organizational, medical and hygienic-anti-epidemic measures [7, 8, 9, 10, 14].
\nIt seems that the Aim of MPP is organized in a few groups of actions:
\nPreservation of the health and strengthening of the physical condition and working capacity of the population.
\nSaving the lives of the affected people and reducing mortality and disability and the fastest recovery of health and work ability.
\nPrevention of long-term and infection diseases.
The occurrence of different types of traumatic defeat due to huge EDS, which are characterized by diverse in nature injuries and mass effect determine the main principles of MPP [1, 2, 7, 8, 9, 10, 14, 15].
\nThe main Principles of MPP due to contemporary scientific knowledge are collected in some main key points [1, 2, 7, 8, 9, 10, 14, 15, 16]:
\nUniversality of using of medical resources.
\nMaximum allowable economy of using of available resources.
\nImplementation of the medical evacuation into a MPP activity.
To use correctly Unified rescue system with unified emergency number for providing MPP.
To use unified doctrine for rendering medical aid and treatment from the epicenter of defeat to the ends in the multi-profile and specialized medical establishments until the final outcome.
For the correct understanding and optimization of the activities connected with EDS the tasks of the MPP are divided into three groups depending on the time for their implementation – before, during and after disaster strike [1, 2, 7, 8, 9, 10, 14, 15, 16, 17, 18]:
Before a disaster occurs:
Study of the devastating effect of various factors in EDS and the means for prevention, diagnosis and treatment.
Planning the activities of the health system for MPP.
Construction and maintenance of formations and resources of the MPP.
Creation of the medical and sanitary property.
Training, drills, workshops for preparing medical staff to react as better as possible.
Constant and regular current hygienic control.
In case of threatening and an ongoing EDS:
Deployment of the medical formations according to the operational plan, keeping them ready for work and protection.
Bringing the health risk management system into readiness.
Strengthening the medical provision (MP) system and teams and start MP of the evacuated population from epicenter, during transport to emergency room.
Strengthening and targeting the operational and special preparation of medical staff to starting and working into epicenter.
Strengthening the epidemiological surveillance of the territory.
After a disaster occurs:
Medical reconnaissance.
Introduction of the formations in the center of defeat.
Organization and rendering of timely first medical aid in the center of defeat.
Removal and evacuation of the victims for appropriate medical care and subsequent treatment.
Provision of complex of hygienic and anti-epidemic measures.
Continuous management and maneuver for the most appropriate use of the medical forces and means.
Conducting a forensic medical examination of the victims and their identification.
Proper performance of these tasks is a prerequisite for providing in the shortest possible time the optimal amount of medical care to the largest possible number of victims [2, 7, 8, 9, 10, 11, 14, 16, 17, 18]. The good success of medical provision of the effected population is guaranteed with a clear goal, streamlined tasks and by following the basic principles (Figure 1).
\nMain interconnected components of successful medical provision of the population.
\nAffecting large areas with mass destruction and mass loss is a typical effect after hug magnitude earthquakes. A typical example of possible consequences in large-magnitude earthquakes is presented in Figure 2 as number of victims and financial losses due to some of the most destructive earthquakes in XX century (Figure 2) [2, 3, 4, 5, 6]. Industrial sites, homes, hospitals, public buildings, utilities, underground and aboveground technical facilities, transport hubs, etc., are damaged or destroyed [2, 7, 8, 9, 10, 13, 19, 20, 21, 22]. This significantly impedes rescue operations, effective enough immediately after the earthquake occurs.
\nVictims and financial losses (USD) due to some of the most destructive earthquakes in XX century (resources: Primary data from USGS, 2005 г.)
Analysis of primary and secondary statistical data shows that occurrence of secondary defeats after an earthquake is a common effect. This increases number of risks factors and character of injuries among the affected population. According to analysis some of possible secondary disasters after earthquakes are [2, 7, 8, 9, 10, 13, 19, 20, 21, 23, 24, 25, 26]:
\nAn outbreak of chemical contamination by industrial poisons. Observed in the area of the incident due to the destruction of chemical enterprises, warehouses with agricultural or industrial poisons. The chemicals produce not only acute intoxication but also long-term heath effect and cancer diseases as well [7, 10, 19].
Occurrence of explosions and fires due to destruction of flammable or explosive objects as petrol station after large magnitude earthquakes. They can develop dangerous additional consequences as fire burn, chemical burn, traumas, toxicological injuries etc. [7, 10].
Destruction of buildings and severe air pollution with fine dust particles in large enough areas because of an earthquake leading to casualties, poisoning and suffocation [7, 10, 13, 19, 23, 24, 25, 26].
\nAn outbreak of nuclear damage such as Fukushima Daiichi nuclear accident, 2011 due to the large earthquake and tsunami is a real possible consequences. Radiation as danger risk factor produce some particular health problems, which can be acute, or chronic, somatic or genetic, stochastic and non-stochastic diseases, and long-term effects [7, 10, 13, 23, 24, 25, 26].
\nA tsunami is generated when undersea earthquakes occurs. Fukushima 2011 and Haiti 2010 are significant examples and it is shows that many health problems influence not only primary effected county, but also much more people around the world for many years [1, 7, 8, 9, 10, 11, 12, 13].
Occurrence of catastrophic floods [1, 7, 8, 9, 11, 12, 13] after earthquakes can increase number of traumas due to new risk factors with leading place and role for the speed and depth of the water flow. On the other hand can cause hypothermia [7, 10, 27] especially for infants, adults, for the chronically ill and for people with special needs like people with compromised vision or limbs. Can be formed a new defeat of waterborne disease such as Cholera as well (like Haiti, 2010) [1, 7, 8, 9, 10, 11, 12].
\nAn outbreak of biological contamination and infectious diseases can be created after a destructive earthquake within or without a tsunami wave (Like Haiti, 2010; like Nepal, 2015). [1, 7, 8, 9, 10, 11, 12, 21, 22].
Occurrence of landslides and avalanches (like Nepal, 2015) [1, 7, 8, 9, 10, 11, 12, 21, 22].
\nAn ecological disaster and even local environment can be changed totally (like Kresna, Bulgaria, April, 1904, with 7,8 M). [7, 8, 9].
\nA volcano generated by an earthquake. It is believed that mixed of danger toxic substances after that can affect society due to discarded volcanic ash into the environment. [7, 8, 9].
\nSocial related and financial crisis due to earthquakes. [1, 7, 8, 9, 10, 13, 17].
It seems that after huge earthquakes, a large number of victims and injuries are occurred. According to experts, many numbers of victims need emergency medical care at the same time. [7, 8, 9, 10] Nature and structure of the injuries can be very diverse. [7, 13] Injuries to the musculoskeletal system, extensive burns, prolonged compression syndrome due to prolonged compression of individual limbs or parts of the body, injuries to large blood vessels predominate. [7, 8, 9, 10] Significant percentage of victims may be in a state of shock [7, 10, 27], with acute respiratory and cardiovascular insufficiency, in need of urgent respiratory and cardiovascular resuscitation [7, 10], neuropsychiatric disorder due to the experienced mental stress and others. According to scientific research [7, 10], by severity, medical losses are divided into the following groups: lightly injured (40%), moderately severely and severely injured (60%), of which 20% need specialized medical care.
\nCreating a severe hygienic-epidemiological situation on the territory of the outbreak of traumatic defeat is defined as a big health risk factor. Prerequisite for this is the pollution of the territory from the destruction of water supply and sewerage systems, difficulties in finding the corpses of dead people and animals, the appearance of rodents, insects etc. The appearance of diseases of infectious and non-infectious origin is possible, as well as the appearance of epidemics - typhoid fever, paratyphoid fever A and B, salmonellosis, hepatitis, cholera etc. [7, 8, 9, 10].
\nUsually the signals for victims of an accident or disaster are received by the medical director (manager) of the emergency room and emergency hospitals as medical institution from ECS. Firstly, emergency medical care center (EMCC) as a front line of health system is informed by Unified rescue and emergency number 112. The teams of EMCC are the first to go to the place and take place of the scene of the EDS as event. [7, 8, 9, 10, 14, 16, 17, 18, 27].
\nIn large-scale disasters, the EMCC teams are not enough to provide the necessary amount of medical care to those in need. This requires in advance formation, preparation and equipment additional teams of staff of medical institutions for their inclusion in the provision of medical care. In addition to these medical teams for the population, especially in earthquake-prone areas or areas with chemical sites in anticipation of numerous medical losses, emergency hospital medical teams and emergency military teams can be used. These are medical formations built on a functional principle with opportunities to provide emergency qualified therapeutic and surgical care for vital indications. [7, 14, 16, 17, 18, 27].
\nThe main tasks of the hospitals in EDS are the provision of medical care and treatment of the victims and hygienic and anti-epidemic provision of the affected regions, and by order of the chairman of the respective commission (district, municipal) and neighboring regions. [7].
\nThe network of health facilities and their infrastructure must be ready to provide timely emergency and specialized medical care to the population in emergency and disaster situations. [2, 7, 8, 9, 16, 17, 18, 27].
\nKnowledge of the factors that can lead to damage to health or endanger the lives of people in EDS allows them to predict the medical consequences, to clarify ways to combat them, to take the necessary preventive measures to limit the medical consequences, to organizing emergency medical measures and eliminating the consequences of emergencies. [7, 8].
\nThe hospitals provide the necessary human and material-technical resources, create an effective organization and keep in constant readiness the forces for immediate action in EDS. [2, 8].
\nBefore the occurrence of the disaster, the head of the medical institution – hospital must make a comprehensive assessment of the condition and the ability of the health institution to work in such a situation. During this period, the action plan for the EDS and the work of the medical institution for the medical provision of the population of the respective territorial unit must be developed, in accordance with the plan of the Ministry of Health. [2, 8, 16, 17, 18, 27].
\nThe plan is developed in different variants depending on the expected nature and severity of the medical losses and includes the following [7, 8]:
Creation and maintenance of a system for notification of the employees of the hospital.
Calculation of the medical losses and of the necessary forces and means for rendering medical aid to the victims.
Necessary medical teams and formations for rendering emergency and urgent medical aid, as well as inpatient medical care.
Creation of an appropriate structure (restructuring) of the bed base of the medical institution if necessary.
Organizational scheme for providing medical care at the site of the lesion, during transportation and in the medical institution.
The Regional Health Inspectorates (RHI) are developing a work plan for the Hygiene and Epidemiological Provision and Inspectorate in the disaster area. It must be in accordance with the plan for conducting rescue and other urgent works of the regional and municipal commission. [7, 8].
\nIn case of disasters, the director of RHI clarifies the place and nature of the event, then organizes and conducts research and control of environmental hygiene parameters in the affected areas, in industrial and other sites in terms of toxic substances, dust, noise, vibration, microclimate, radiation and other harmful factors. This activity is carried out by pre-formed and trained anti-epidemic teams of RHI on the territory of the disaster. [7, 16, 17, 18, 27].
\nThe main task of the RHI is the organization and implementation of disinfection, disinsection, deratization and control of the degassing and decontamination activities in the affected areas after the normalization of the situation. [8].
\nThe number and nature of foodstuffs affected by the disaster, the type and quantity and the nature of the damage must be clarified, and enhanced sanitary control must be organized over all foodstuffs in the disaster area. This requires organizing and conducting intensive laboratory control over the affected catering establishments and food industry establishments.
\nBased on the conclusions of the analysis, the RHI prescribes measures for compliance with hygiene standards and requirements for all factors of the working environment. After conducting a control for hygienic efficiency of the conducted measures, a conclusion is given for safe working conditions with a view to resuming regular operation of the affected sites. [7].
\nThe relevant clinics from the Multidisciplinary Hospital for Active Treatment (MPHAT) and Hospital for Emergency Medicine, as well as the clinical departments of surgery, orthopedics and traumatology, resuscitation and anesthesiology in the district, regional and municipal hospitals are used as a base. If necessary, the bed capacity of the same hospitals is used. In some cases, staff and facilities from other surgical units (ophthalmology, maxillofacial surgery, etc.) of hospitals can be used. This allows in EDS for a short time and without significant difficulties to be included in the organizational scheme of medical care. About 60% of the inpatients can be discharged and a specialized bed stock can be released for the needs of the victims. For work in a trauma center, if necessary, medical teams (trauma, surgical, etc.) are formed on a functional principle, without seriously violating the readiness of these wards for admission and treatment of victims. These teams must arrive at the scene no later than one hour after the emergency medical teams. At this time, the medical situation, the scope of work and the possible number of required specialized surgical teams should be clarified. If necessary, they can be strengthened with teams from medical institutions in neighboring regions. [7, 8].
\nIn case of accidents at the NPP, in case of incidents with sources of ionizing radiation, in case of cross-border transfer of radioactive substances in the therapeutic wards of the MPHAT, an opportunity must be created to provide radiological assistance to the victims. All therapeutic wards of the medical establishments, in the vicinity of the NPP, must be ready for possible admission of radiation patients and those with combined radiation injuries. For this purpose, it is necessary for physicians-therapists to have radiobiological training and in case of radiation conditions to organize the work of the ward in radiological terms and to conduct radio protective measures in the medical institution. The existing departments of radiotherapy and isotope diagnostics, based most often in oncology dispensaries, oncology hospitals, etc., have a corresponding place in this functional radiological system. The medical staff from these radiology departments are involved in providing radiological assistance to the victims. [7, 20, 21, 22, 23, 24, 25, 26].
\nThe duty and responsibilities according to the International Atomic Energy Agency (IAEA) require doctors to have the relevant knowledge of radiation protection, which enables them to initiate preliminary treatment and provide assistance to specialized units in the event of a radiation accident. Another task of health care in the section of radiological care is the control of the radiation parameters of the working and living environment, which directly affect the person. [22] The radiation control department must organize and conduct the necessary radiation-hygienic measures on the given territory.
\nThe organization of the radiological assistance is related to the plan for radiation protection of the country in case of an accident at the NPP, which ensures the implementation of the plan in its medical section. [7, 20, 21, 22, 23, 24, 25, 26].
\nThe organization of toxicological care uses a mixed approach, including the establishment of staff and functional units. The expanding chemical pathology necessitated the establishment of full-time clinics and toxicology departments in the settlements with large sites of the chemical industry. These units, in addition to providing toxicological assistance to the population, also serve to train medical personnel in this field. In the other hospitals, the therapeutic wards are re-profiled into toxico-therapeutic ones for admission of toxicologically ill patients for emergency toxicological care. Good interaction should be ensured with the intensive care unit of the hospital. [7, 10].
\nOn the basis of the staff clinics and toxicology departments, specialized medical teams are established, provided with medical and sanitary equipment and transport. These teams must be constantly prepared to work in a chemical outbreak or to strengthen the therapeutic wards of neighboring hospitals where toxicologically ill patients are hospitalized. [7, 8, 9, 10].
\nWhen creating an outbreak of biological infection all types of medical care (first medical, first medical, qualified and specialized) are within the area of the outbreak. For this purpose, the medical and prophylactic establishments on the territory in the OBC mainly are used. [7, 8, 9, 10]
\nThe first medical and qualified medical care for vital indications is provided at the medical center according to various schemes. Most often, two groups of medical forces are created for rescue operations in the center of a combined defeat: in the biologically infected area and outside it. [2, 7, 8, 9, 10].
\nMedical sorting is performed in the OTD. According to the severity of the OTD, the distribution of the victims by sorting groups allows for homogeneous treatment and prevention measures [7, 8, 9, 10, 16, 17, 18, 27].
\nDepending on the severity of the injuries the victims are sorted into two main groups in Bulgaria [7, 10]:
Slightly injured (40%). This group includes victims of soft tissue injuries who do not need hospital treatment;
Moderately and severely injured (60%). These are victims who need urgent medical attention and inpatient treatment. This group can be divided into four subgroups (Figure 3):
Group T4. Dying and agonizing;
Group T3. Injured with some slightly graded cranio-cerebral injuries or some insignificant spinal cord injuries and others slightly injured (20–40%). These are persons with injuries of the small bones of the frontal part of the skull (mandible, nose), medium and small soft tissue injuries, etc.;
Group T 2. Persons to whom medical care can be postponed for 6–8 hours (20%). These victims have an advantage of transportation, but do not need extreme treatment. These include victims with some surface thoracic or abdominal injuries, or some not penetrating injuries to the uro-genital tract, or some negligible blood vessels rupture, burns less than 20% of the body surface in people of active age, but without other injuries;
Group T 1. Persons whose trauma is defined by immediate vital disorders (20–40%). This group includes victims with respiratory failure, cardiac arrest, ventricular fibrillation, huge bleeding, shock, increased intracranial pressure, burns of the face and respiratory tract, or extensive burns occupying more than 20% of the body surface; poly-trauma, etc. The victims of this group receive emergency first aid in order to stabilize the basic vital functions and have the highest priority in treatment.
Triage groups in an OTD. (the worst prognostic option).
Particular attention in medical sorting should be paid to groups dangerous to others and in need of urgent medical attention. Dangerous for others are those infected with poisonous substances, radioactive substances, bacterial agents and patients with particularly dangerous infections (PDI), acutely unlocked or exacerbated chronic psychiatric diseases, some acute mental disorders etc. This danger imposes the need for sanitary treatment of the infected and isolation of patients with PDI, mental disorders as well.
\nPrevention of the population in favor of public health and the future of the nation is fundament for stabilization of the health system in case of EDS. [7, 8, 9, 10, 16, 17, 18, 27]. Prophylaxis measures (PM) used for primary risk reduction is only first group of tasks and primary step for government and national health system. By Figure 4 is presented risk reduction actions before, during and after earthquakes. (Figure 4) Some of the most important groups of methods for prevention of public health are:
Earthquake prognosis.
Establishment of well-equipped and prepared seismic stations and a notification system.
Scientifically based anti-seismic construction.
Compilation and timely updating of a map of OTD threats.
The approaches to the hospitals should be known and organized in case the entrances are covered with destructions. For each hospital, which is located in an area with high seismicity, a helipad should be provided.
Systematic training of medical staff.
Systematic preparation of the population to react and provide main first medical aid steps.
Risk reduction actions before, during and after earthquakes.
Unlike other disasters, earthquakes by sudden onset and rapid flow are characterized. Trough detailed analysis of earthquakes a number of specific features are described. First instance place, unlike other natural risks, in earthquakes the response time is practically a very limited resource. Good preparation and collaboration of various institutions with the healthcare system in case of the OTD with the multi-factorial nature of the risks due to an earthquake and the possible consequences is definitely connected. All levels of health risk management of the health care system for medical provision of the affected population are included. On the EMCC is based the field work on the medical provision of the injured people. A real staged process, but not a condition is proper medical triage and the provision of medical care in OTD. Two-stage system with evacuation by appointment as method for MPIP in case of traumatic defeat of EDS is used. A guarantee for the adequate provision of good medical practices in case of EDS is defined with good enough developed health risk management system, together with the necessary number and structure of resource capacity.
\nThe author declares no conflict of interest.
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