Using Hamburg as an example of a city with a major port and points of entry, the current planning and rescue equipment provision for MCI-ID and thus the implementation of civil protection was shown for both perspectives, administrative as well as operational. The created organizational chart shows how many different organizations would be involved in an MCI-ID in the Port of Hamburg and concurrently reflects the complexity. It can be assumed that if more parties are involved in such a situation, they will have more challenges on the communicational and operational level (47). Cooperation between different organizations in an emergency situation can only be efficient if existing concepts are brought together, coordinated, and most importantly tested regularly.
In 2012, an analysis of an operation on the high seas showed that the preparation, the determination and provision of resources, as well as training, are important factors for effectively coping with an MCI in the maritime setting (22). Another study shows that also regular refreshments of seafarers' medical skills are also important in order to achieve a training effect and to be able to initiate appropriate treatment in emergencies (48). Current studies still warn about lack of adequate preparations, in this example about analog mis-triages in an MCI on the high seas (24). European projects such as SHIPSAN ACT, SHIPSAN Trainet, and subsequently the Healthy Gateways Joint Action, provide initial approaches on the preparation and prevention, as well as the occupational health practices, of possible outbreaks of infectious diseases (4, 33, 49). In this regard, the linking of medical concepts to a special infrastructure, like that of a port, not only appears very useful and necessary for current events such as the COVID-19 pandemic.
It should be kept in mind that medical standards on ships are dependent on the country and the flag under which the ships sail. Therefore, there are discrepancies, and it might be not possible that same standards are being used overall. This affects both medical resources and staffing (33, 35, 36). Regionally different MCI concepts must also be taken into account (11–14, 17). Thus, we recommend carrying out large-scale infection disaster exercises in the port that have not been implemented so far. Several organizations such as the HPHC, rescue services and all those involved ship and port workers are able to test and develop common processes in order to become reliable and resilient against an MCI-ID.
A cross-organizational task force that can be alerted in medical emergencies, such as the "Fachstab Seuchenschutz" (Disease Control Unit) in Hamburg, has various advantages (32, 33). Through quick identification and assessment of the situation, decisions can be made quickly, which would serve to better deal with such a situation. In this way, the city of Hamburg aims at clarify competencies in advance and guarantee security of action in infectious emergencies.
The selection criteria made by an intensive care unit and internal specialist department in clinics can be extended to surgical clinics in the event of resource shortages. This is possible in Hamburg as a city of over a million inhabitants with over 12,000 fully inpatient beds (43). However, such a selection cannot be made everywhere, especially with regard to smaller municipalities and cities. Additionally, the distribution of patients could be optimized via a central (or regional) register of available beds for infectious patients, whereas in Germany IVENA (IVENA by mainis IT-Service GmbH, Offenbach am Main, Germany) is a potential system that is already used in a similar way and is the most widespread. By expanding this system, existing resources for COVID-19 patients can be displayed (50). This can be linked and used analogously to the national register for intensive care capacities, which was implemented in the course of the COVID-19 pandemic and has gained in importance in Germany (51, 52).
The Port of Hamburg can be approached in any emergency due to its special function as one of five designated ports in Germany. This port was chosen as an example, since it is infrastructural embedded in an industrialized urban area. However, our findings are not completely transferable to other national or even international ports. Individual adaptation to the local situation and different local or national conditions make transferability more difficult. In contrast to Hamburg, and all other designated ports (in Germany), smaller port cities cannot offer such a comprehensive rescue service and at least 14 clinics available to treat a large number of infectious patients (18, 26, 27, 41–43). Nevertheless, the basic patterns of the analyzed influencing factors should be the same and could be applied to other ports. We assume, that this enables a future transfer of coping strategies to similar facilities.
Based on this analysis and the gained knowledge due to the COVID-19 pandemic and the outbreaks on ships, where ports had to deal with an MCI-ID and, if necessary, adapt their emergency plans, an operational strategy that integrates existing concepts will be adapted to the special infrastructure of the port. One aim of the ARMIHN project is to practice and to test the operational strategy through the modeling of damage scenarios and disease patterns, in three theoretical exercises and one practical exercise with all involved parties, so that a first training effect can be achieved. The developed operative strategy can be expanded in a future-oriented way to deal with a new type of pathogen such as SARS-CoV-2. Finally, the results of the project should be adapted to other port facilities. Although our analysis and future concept will be created for the Port of Hamburg, we assume that our final recommendations are going to be widely universally applicable and could be adapted by most of the major ports in Europe (and worldwide) to improve their prevention against MCI-ID. The need for standardized cross-organizational concepts and the preparation for MCI-ID was underlined by the COVID-19 pandemic and associated outbreaks on ships.