Managing infectious mass casualty incidents in port environments strategy development and evaluation within the ARMIHN project.

Background: The ARMIHN project ("Adaptives Resilienz Management im Hafen"/"Adaptive Resilience Management in the Port") aims to develop an operational strategy for managing mass casualty incidents involving infectious diseases (MCI-ID) in port environments. The strategy considers structural, organizational, and technical measures, accounting for end-user needs and local infrastructural characteristics, with the aim of optimizing patient care and facilitating a rapid transition back to individual-level standards of care. Methods: A selective literature review identified existing national concepts, guidelines, and frameworks related to major incident management in Germany. Port infrastructural conditions were assessed through on-site inspections and stakeholder engagement. To evaluate the strategy, structured crisis management exercises were conducted, comprising three command-level tabletop exercises and one full-scale field exercise. Participant self-assessments were collected via a five-point Likert scale questionnaire before and after each exercise; pre-to-post differences were analyzed using Pearson's chi-square and Fisher's exact test where appropriate. Results: A MCI-ID operational strategy for the Port of Hamburg was developed in alignment with existing frameworks, integrating local infrastructural capacities and the expected temporal sequence of emergency resource deployment. The strategy comprises four phases: phase 1 (initial notification), Phase 2 (vessel arrival), Phase 3 (on-site rescue and medical response), and Phase 4 (transport and handover to preclinical emergency services). Exercise evaluations demonstrated statistically significant improvements across all domains, including basic MCI skills, incident management quality, confidence, and perceived team preparedness. Mean Likert scores increased from 3.33 to 4.03 in the command exercise ( Conclusion: The developed strategy addresses a structural gap in existing MCI frameworks by providing a port-and maritime-specific response concept for infectious mass casualty incidents. Grounded in disaster medicine principles and refined through stakeholder engagement and repeated exercises, the framework enhances operational preparedness among involved organizations. Its phase-based architecture offers a transferable foundation adaptable to diverse MCI scenarios and pathogen types, contributing to the long-term resilience of port-based emergency management systems.