Open Access Research Death, injury and disability from kinetic impact projectiles in crowd- control settings: a systematic review Rohini J Haar,1 Vincent Iacopino,2 Nikhil Ranadive,3 Madhavi Dandu,4 Sheri D Weiser5 To cite: Haar RJ, Iacopino V, ABSTRACT Strengths and limitations of this study Ranadive N, et al. Death, Objective We conducted a systematic review of the injury and disability from available literature on deaths, injuries and permanent ► The review methodology incorporates all published kinetic impact projectiles disability from rubber and plastic bullets, as well as from in crowd-control settings: a and relevant information on various types of kinetic bean bag rounds, shot pellets and other projectiles used in systematic review. BMJ Open impact projectiles (KIPs) including rubber and plastic arrests, protests and other contexts from 1 January 1990 2017;7:e018154. doi:10.1136/ bullets and shotgun pellets. until 1 June 2017. bmjopen-2017-018154 ► The review allows understanding of the range of Data sources PubMed, Scopus, JSTOR and grey injuries and disabilities, these weapons can cause ► Prepublication history for literature. in myriad contexts. this paper is available online. Data synthesis We report on descriptive statistics as To view these files, please visit ► The review is limited by the limited quality and well as data on injury severity, permanent disability and the journal online (http:// dx. doi. number of published data on injuries secondary to death. We analysed potential risk factors for injury severity, org/ 10. 1136/ bmjopen- 2017- KIPs. including the site of impact, firing distance and access to 018154). ► Meta-analysis of the data is not possible secondary medical care. to the heterogeneity of the studies. Received 8 June 2017 Results Of 3228 identified articles, 26 articles met Revised 22 September 2017 inclusion criteria. These articles included injury data on Accepted 28 September 2017 1984 people, 53 of whom died as a result of their injuries. 300 people suffered permanent disability. Deaths and the unnecessary and disproportionate use permanent disability often resulted from strikes to the of force.3–5 Such use of force often involves head and neck (49.1% of deaths and 82.6% of permanent crowd-control weapons (CCWs) that cause disabilities). Of the 2135 injuries in those who survived preventable injury, disability and death. their injuries, 71% were severe, injuries to the skin and to the extremities were most frequent. Anatomical site of Kinetic impact projectiles (KIPs), impact, firing distance and timely access to medical care commonly called rubber or plastic bullets, were correlated with injury severity and risk of disability. are CCWs that are designed to incapacitate Conclusions Kinetic impact projectiles (KIPs), often individuals by inflicting pain or sublethal called rubber or plastic bullets, are used commonly in injury. Some KIPs target an individual with a crowd-control settings. We find that these projectiles have single projectile, while others target a group caused significant morbidity and mortality during the past by scattering multiple projectiles.6–8 Manu- 27 years, much of it from penetrative injuries and head, facturers produce more than 75 different neck and torso trauma. Given their inherent inaccuracy, 1School of Public Health, types of bullets and launchers in many coun- potential for misuse and associated health consequences Division of Epidemiology, tries, including Brazil, China, Israel, South of severe injury, disability and death, KIPs do not appear University of California, Berkeley, Africa, South Korea and the USA,9 10 and are California, USA to be appropriate weapons for use in crowd-control 2 marketed to military, police and private secu- Physicians for Human Rights, settings. There is an urgent need to establish international 11 New York, New York, USA guidelines on the use of crowd-control weapons to prevent rity forces throughout the world. Despite 3Emory University School of unnecessary injuries and deaths. the widespread use of KIPs and the numerous Medicine, Atlanta, Georgia, USA types available, there is limited regulation 4Department of Medicine, of the development of these weapons and University of California, San limited public information provided by Francisco, California, USA 5 BACKGROUND manufacturers on their design and guidelines Division of HIV, ID and 12 13 Global Medicine, Department In recent years, there has been significant for use. of Medicine, University of attention to the number of popular protests All projectile weapons function by trans- California, San Francisco, challenging governments and other powerful ferring kinetic energy from a weapon California, USA actors.1 2 In many cases, police and security into the body of an individual. Ballis- Correspondence to forces have responded in ways that funda- tics data indicate that denser objects and Dr Rohini J Haar; mentally undermine freedom of peaceful faster projectile speeds increase the force rohinihaar@ berkeley. edu assembly and often lead to escalation through of impact.14 KIPs have a wide range of Haar RJ, et al. BMJ Open 2017;7:e018154. doi:10.1136/bmjopen-2017-018154 1 Open Access variables that can impact injury patterns and severity, Table 1 Search terms including the material composition, shape, number, muzzle velocity (projectile speed exiting the weapon) area round less-lethal ballistics and flight path of projectiles, the firing distance and attenuated energy projectiles nonlethal gun the location of impact on the body.15 It is important ballistics and injuries nonlethal projectiles to note that many KIPs have muzzle velocities equal to baton rounds peacekeeper bullet those of live ammunition. Most KIPs are designed with bean bag rounds pepper ball a large surface area to produce a rapid loss of speed bird shot plastic bullets during flight and reduce the chance of skin pene- tration, but this also results in unpredictable flight blunt force rounds projectile round paths and reduced accuracy.16 Newer weapons include buck shot protest projectiles with a hard outer shell coating, tear gas or bullets protest bullet pepper spray that explodes on impact, and ‘attenuated civil disturbance riot energy projectiles’ with hollow tips to limit the risk of crowd control riot control ricochet or penetration.17 KIPs can cause blunt and penetrative injuries, crowd control munition rubber ball ranging from localised contusions to severe organ crowd control projectiles rubber bullets damage and death.18–20 While there has been much deaths AND protest rubber coated bullets recent media attention globally on the significant extended range impact weapons shotgun 21–28 dangers of misusing these weapons, efforts to Flash ball sponge bullet provide systemic documentation on injuries is limited foam bullet sponge rounds for a number of reasons. There are limited regulations on the development of weapons, and manufacturers foam coated bullet Sting ball are not required to keep records on injuries from their injuries AND protest wooden bullets products in development, field trials or actual use,17 In kinetic impact projectiles most countries, there is no legal requirement for law enforcement to collect data on injuries from KIPs.11 Though police may record related deaths, these data METHODS are often not publicly available or complete.29 Simi- Search strategy larly, military data on both international and domestic We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and use of these weapons is confidential. There is often 33 limited communication between the healthcare Meta-Analyses guidelines. We searched JSTOR, PubMed providers who treat and manage injuries and police and Scopus using search terms cross-referenced with who typically use the weapons.30 While non-govern- the MeSH database without any language restrictions. mental organisations and human rights groups may We included varied terminology for ‘rubber bullets,’ report injuries or deaths in specific incidents, they ‘plastic bullets,’ ‘bean bag rounds,’ ‘baton rounds’ and have not established surveillance mechanisms to other projectiles used in crowd-control and other settings 11 31 around the world (see table 1). systematically collect injury data. In addition, most of the medical literature on KIPs is sourced in case Study selection 32 reports and case series. Retrospective cohort studies Given the paucity of literature on KIP injuries, we and prospective studies have been conducted but have designed a broad search strategy to identify all potential been limited to specific locations and time frames literature on KIP-related injuries. We included studies and by challenges in developing adequate studies of that documented injuries, deaths or other health conse- weapons injuries in potentially volatile and politically quences of KIPs on any human participants and that were difficult conditions. published between 1 January 1990 and 1 June 2017. In Given the limited knowledge of the health conse- addition to civilian protestors, we included other indi- quences of KIPs, we undertook a systematic review of viduals who may have had exposure to KIPs, including the literature to evaluate the morbidity and mortality sports fans, police officers and prisoners. We included associated with these weapons. We assessed injury all contexts, including peaceful demonstrations, riots, type and severity as well as potential exacerbating and sporting events, prison uprisings, arrests and accidental