Evidence of use of toxic gas chemical weapons in the Syrian war has been reported by governmental and non-governmental international organizations since the war started in March 2011. To date, the profiles of victims of the largest chemical attacks in Syria remain unknown. In this study, we used descriptive epidemiological analysis to describe demographic characteristics of victims of the largest chemical weapons attacks in the Syrian war.We analysed conflict-related, direct deaths from chemical weapons recorded in non-government-controlled areas by the Violation Documentation Center, occurring from March 18, 2011 to April 10, 2017, with complete information on the victim’s date and place of death, cause and demographic group. ‘Major’ chemical weapons events were defined as events causing ten or more direct deaths.As of April 10, 2017, a total of 1206 direct deaths meeting inclusion criteria were recorded in the dataset from all chemical weapons attacks regardless of size. Five major chemical weapons attacks caused 1084 of these documented deaths. Civilians comprised the majority (n = 1058, 97.6%) of direct deaths from major chemical weapons attacks in Syria and combatants comprised a minority of 2.4% (n = 26). In the first three major chemical weapons attacks, which occurred in 2013, children comprised 13%–14% of direct deaths, ranging in numbers from 2 deaths among 14 to 117 deaths among 923. Children comprised higher proportions of direct deaths in later major chemical weapons attacks, forming 21% (n = 7) of 33 deaths in the 2016 major attack and 34.8% (n = 32) of 92 deaths in the 2017 major attack.Our finding of an extreme disparity in direct deaths from major chemical weapons attacks in Syria, with 97.6% of victims being civilians and only 2.4% being combatants provides evidence that major chemical weapons attacks were indiscriminate or targeted civilians directly; both violations of International Humanitarian Law (IHL). Identifying and quantifying chemical weapons violations requires inter-disciplinary collaboration to inform international policy, humanitarian intervention and legal action.

Background In 2015, an earthquake killing 9,000 and injuring 22,000 people hit Nepal. The Tribhuvan University Teaching Hospital (TUTH), a reference tertiary hospital, was operational immediately after the earthquake. We studied the profile of earthquake victims admitted in TUTH and assessed what factors could influence hospital length of stay. Methods An earthquake victim dataset was created based on patient records, with information on sex, age, date of admission and discharge, diagnosis, and surgical intervention. We performed an initial descriptive overview of the earthquake victims followed by a time-to-event analysis to compare length of hospital stay in different groups, using log rank test and cox regression to calculate Hazard Ratios. Results There were in total 501 admitted victims, with the peak of admissions occurring on the fifth day after the earthquake. About 89% had injury as main diagnosis, mostly in lower limbs, and 66% of all injuries were fractures. Nearly 69% of all patients underwent surgery. The median length of hospital stay was 10 days. Lower limb and trunk injuries had longer hospital stays than injuries in the head and neck (HR = 0.68, p = 0.009, and HR = 0.62 p = 0.005, respectively). Plastic surgeries had longer hospital stays than orthopaedic surgeries (HR = 0.57 p = 0.006). Having a crush injury and undergoing an amputation also increased time to discharge (HR = 0.57, p = 0.013, and HR = 0.65 p = 0.045 respectively). Conclusions Hospital stay was particularly long in this sample in comparison to other studies on earthquake victims, indirectly indicating the high burden TUTH had to bear to treat these patients. To strengthen resilience, tertiary hospitals should have preparedness plans to cope with a large influx of injured patients after a large-scale disaster, in particular for the initial days when there is limited external aid.

Literature on earthquake impact on hospital admissions is lacking, particularly in low-resource settings. Our aim was to study the pattern of admissions before and after the 2015 earthquake in a tertiary hospital in Nepal. We used routine hospital data from 9,596 admissions, and defined four periods: pre-earthquake (pre-EQ), acute (EQ1), post-acute (EQ2), and post-earthquake (post-EQ). We compared length of hospital stay (LOS) across the study periods using negative binomial regressions. We used logistic regressions to study changes in probability of admission for diagnostic categories, and Generalized Additive Models to model the difference in number of admissions compared to pre-EQ baseline. LOS was longer in EQ1 than during pre-EQ, in particular for injury-related admissions. In EQ1, the odds of injury admissions increased, while they decreased for the majority of other diagnoses, with the odds of pregnancy-related admissions remaining low until post-EQ. The number of admissions dropped in EQ1 and EQ2, and returned to pre-EQ trends in post-EQ, accumulating 381 admissions lost (CI: 206-556). Our findings suggest that hospital disaster plans must not only foresee injury management after earthquakes, but also ensure accessibility, in particular for pregnant women, and promote a quick return to normality to prevent additional negative health outcomes. Violent, sudden-onset disasters, such as hurricanes or earthquakes, cause considerable damage in communities, leading to widespread destruction 1. While deaths and direct injuries are immediate and expectable consequences of such disasters, drastic changes in the surrounding environment may have longer-term health effects 2-7. These disasters also heavily disturb health systems, which must provide healthcare in a context of sudden increase of health needs, radical change of priority conditions, infrastructural and material damage, and staff shortages 8. While most of the victims in need of care during and after a disaster are managed in an outpatient basis at emergency departments, a considerable amount of people will require hospitalization 9. However, there is inconsistent evidence on the impact on hospital admissions immediately after and in the months following violent, sudden-onset disasters 3,10-12. Earthquakes are the most destructive type of natural disaster, having killed nearly 720,000 people globally between 2000 and 2018. About two thirds of all events worldwide occurred in Asia, where earthquakes affect much more people than earthquakes in all the other continents 13. Rapid population growth, urbanization, poverty, and geological risks contribute to Asia's seismic vulnerability. Nepal is located on the boundaries of two colliding tectonic plates. On April 25 th 2015, an earthquake with a moment magnitude of 7.8 severely hit the country. The epicenter was in Gorkha district, and heavy infrastructural damage occurred in neighbouring regions, including in the capital city of Kathmandu located 76 km away. There were several aftershocks, the strongest occurri...

Background: Seasonal patterns of mortality have been identified in Sub-Saharan Africa but their changes over time are not well documented. Objective: Based on death notification data from Antananarivo, the capital city of Madagascar, this study assesses seasonal patterns of all-cause and cause-specific mortality by age groups and evaluates how these patterns changed over the period 1976-2015. Methods: Monthly numbers of deaths by cause were obtained from death registers maintained by the Municipal Hygiene Office in charge of verifying deaths before the issuance of burial permits. Generalized Additive Mixed regression models (GAMM) were used to test for seasonality in mortality and its changes over the last four decades, controlling for long-term trends in mortality. Results: Among children, risks of dying were the highest during the hot and rainy season, but seasonality in child mortality has significantly declined since the mid-1970s, as a result of declines in the burden of infectious diseases and nutritional deficiencies. In adults aged 60 and above, all-cause mortality rates are the highest in the dry and cold season, due to peaks in cardiovascular diseases, with little change over time. Overall, changes in the seasonality of all-cause mortality have been driven by shifts in the hierarchy of causes of death, while changes in the seasonality within broad categories of causes of death have been modest. Conclusion: Shifts in disease patterns brought about by the epidemiological transition, rather than changes in seasonal variation in cause-specific mortality, are the main drivers of trends in the seasonality of all-cause mortality. ARTICLE HISTORY

Background The COVID-19 pandemic has led to major shocks in mortality trends in many countries. Yet few studies have evaluated the heterogeneity of the mortality shocks at the sub-national level, rigorously accounting for the different sources of uncertainty. Methods Using death registration data from Belgium, we first assess change in the heterogeneity of districts’ standardized mortality ratios in 2020, when compared to previous years. We then measure the shock effect of the pandemic using district-level values of life expectancy, comparing districts’ observed and projected life expectancy, accounting for all sources of uncertainty (stemming from life-table construction at district level and from projection methods at country and district levels). Bayesian modelling makes it easy to combine the different sources of uncertainty in the assessment of the shock. This is of particular interest at a finer geographical scale characterized by high stochastic variation in annual death counts. Results The heterogeneity in the impact of the pandemic on all-cause mortality across districts is substantial: while some districts barely show any impact, the Bruxelles-Capitale and Mons districts experienced a decrease in life expectancy at birth of 2.24 (95% CI:1.33–3.05) and 2.10 (95% CI:0.86–3.30) years, respectively. The year 2020 was associated with an increase in the heterogeneity of mortality levels at a subnational scale in comparison to past years, measured in terms of both standardized mortality ratios and life expectancies at birth. Decisions on uncertainty thresholds have a large bearing on the interpretation of the results. Conclusion Developing sub-national mortality estimates taking careful account of uncertainty is key to identifying which areas have been disproportionately affected.