IntroductionMost epidemiological studies from conflicts are restricted to either combatants or civilians. It is largely unknown how the epidemiology differs between the two groups. In 2016, an Iraqi-led coalition began retaking Mosul from the terrorist group Islamic State of Iraq and Syria. One key institution that received trauma patients from Mosul was Emergency Management Center (EMC) in Erbil, 90 km away. The aim of this study was to describe the epidemiology, morbidity, and mortality of civilians and combatants admitted during the ongoing conflict.MethodThis retrospective cohort study utilized routinely collected data on patients with conflict-related injuries who were admitted to EMC between October 16, 2016, and July 10, 2017. Data processing and analysis was carried out using JMP 13. Categorical variables were compared using Fisher’s exact test.ResultsThe analysis included 1725 patients, out of which 46% were civilian. Ordnance accounted for most injuries (68%), followed by firearms (18%) and improvised explosive devices (IEDs) (14%). The proportion of IED-related injuries among combatants were almost three times that of civilians. The proportions of abdominal injuries, need for surgery, laparotomies, and amputations were significantly higher among civilians than among combatants. The mortality rate was 0.5%.DiscussionThe fact that civilians had greater surgical needs than combatants may be explained by several factors including a lack of ballistic protection. The extremely low mortality rate indicates significant gaps in prehospital care and transport. Our results may provide useful information to guide medical preparedness and response during future conflicts.Clinicaltrials.gov IDNCT03358758.

Background In Iraq, where Islamic State of Iraq and Syria (ISIS) and other groups have contributed to escalating violence in recent years, understanding the epidemiology of intentional firearm-related fatalities is essential for public health action. Methods The Iraqi Ministry of Health (MoH; Baghdad, Iraq) compiles surveillance of fatal injuries in eight of Iraq's 18 governorates (Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya). Information is collected from coroner's reports and interviews with family members. Analysis was performed on intentional firearm-related injuries, excluding injuries from intentional self-harm or negligent discharges, that occurred during 2010-2013, a subset of all fatal injuries, and compared to previously published explosive-related fatalities. Results Overall, the dataset included 7,985 firearm-related fatalities. Yearly fatalities were: 2010 = 1,706; 2011 = 1,642; 2012 = 1,662; and 2013 = 2,975. Among fatalities, 86.0% were men and 13.7% women; 83.4% were adults and 6.2% children <18 years of age. Where age and sex were both known, men aged 20-39 years accounted for 56.3% of fatalities. Three “high-burden” governorates had the highest fatality rate per 100,000 population—Baghdad (12.9), Ninevah (17.0), and Al-Anbar (14.6)—accounting for 85.9% of fatalities recorded in the eight governorates. Most fatalities occurred in the street (56.3%), followed by workplace (12.2%), home (11.3%), and farm/countryside (8.4%). Comparing the ratio of firearm-related fatalities to explosives-related fatalities revealed an overall ratio of 2.8:1. The ratio in Baghdad more than doubled from 2.9 in 2010 to 6.1 in 2013; the highest ratios were seen outside the high-burden governorates. Conclusions Firearm-related fatalities remained relatively stable throughout 2010-2012, and almost doubled in 2013, correlating with increased ISIS activity. Three governorates contributed the majority of fatalities and experienced the highest fatality rates; these saw high levels of conflict. Firearm-related fatalities disproportionately affected younger men, who historically are over-represented as victims and perpetrators of violence. More than one-half of fatalities occurred in the street, indicating this as a common environment for conflict involving firearms. Firearms appear to account for more fatalities in Iraq than explosives and largely accounted for escalating violence in Baghdad during the study period. The high ratio observed outside the high-burden governorates is reflective of very low numbers of explosives-related fatalities; thus, violence in these governorates is likely non-conflict-related. These observations provide valuable public health information for targeted intervention to prevent violence.

Introduction There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. Materials and Methods This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. Results Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). Conclusion Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.

Background : Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts. Objective : This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict. Methods : During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant. Results : The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately onethird of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED. Conclusions : The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflictrelated injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.