BRIEF REPORT Death and Injury From Landmines and Unexploded Ordnance in Afghanistan Oleg O. Bilukha, MD, PhD Context Afghanistan is one of the countries most affected by injuries due to land- Muireann Brennan, MD, MPH mines and unexploded ordnance. Bradley A. Woodruff, MD, MPH Objective To understand the epidemiological patterns and risk factors for injury due to landmines and unexploded ordnance. ANDMINES AND UNEXPLODED ORD- Design and Setting Analysis of surveillance data on landmine and unexploded ord- nance pose a significant public nance injuries in Afghanistan collected by the International Committee of the Red Cross health risk and economic threat in 390 health facilities in Afghanistan. Surveillance data were used to describe injury worldwide.1,2 Approximately 60 trends, injury types, demographics, and risk behaviors of those injured and explosive Lmillion to 70 million landmines are types related to landmine and unexploded ordnance incidents. placed in about 70 countries,3 and an esti- Participants A total of 1636 individuals injured by landmines and unexploded ord- mated 24000 individuals, mostly civil- nance, March 2001 through June 2002. ians, are killed or injured by landmines Results Eighty-one percent of those injured were civilians, 91.6% were men and boys, and unexploded ordnance worldwide and 45.9% were younger than 16 years. Children were more likely to be injured by every year.4 Unexploded ordnance unexploded ordnance (which includes grenades, bombs, mortar shells, and cluster mu- includes military explosive munitions nitions), whereas adults were injured mostly by landmines. The most common risk be- such as grenades, bombs, mortar shells haviors for children were playing and tending animals; for adults, these risk behaviors and cluster munitions, which have been were military activity and activities of economic necessity (eg, farming, traveling). The deployed or scattered during military case-fatality rate of 9.4% is probably underestimated because surveillance predomi- nantly detects those who survive long enough to receive medical care. activities but have failed to detonate. During 2000 and 2001, Afghanistan Conclusions Landmine risk education should focus on hazards due to unexploded had the most reported landmine and un- ordnance for children and on landmine hazards for adults and should address age- specific risk behaviors. Expanding community-based and clinic-based reporting will exploded ordnance casualties in the improve the sensitivity and representativeness of surveillance. world.5 Most of the 7 million to 8 mil- JAMA. 2003;290:650-653 www.jama.com lion landmines in Afghanistan were laid during the Soviet occupation between 1978 and 1989 and the subsequent civil nance injury surveillance in Afghani- the Red Cross. There are an estimated war.3 The coalition air strikes in the fall stan, to document the magnitude of 905 functioning health facilities in Af- of 2001 exacerbated the problem by these injuries and deaths between ghanistan.7 Among these 905, the In- deploying a new type of ordnance— March 2001 and June 2002, and to de- ternational Committee of the Red Cross cluster bomblets.5,6 Because the bomb- scribe epidemiological patterns of and identified those facilities most likely to lets were bright yellow, concerns ex- risk factors for injury. see injuries caused by landmines and isted that children might mistake them unexploded ordnance. These include for the humanitarian daily rations air- METHODS major referral hospitals, provincial and dropped during the early stages of the We obtained data on landmine and un- district hospitals, specialized surgical conflict. Another feature of recent con- exploded ordnance casualties from flicts in Afghanistan and Iraq has been March 2001 through June 2002 from Author Affiliations: Epidemic Intelligence Service, Epi- the aerial bombardment of munitions the International Committee of the demiology Program Office (Dr Bilukha) and Interna- dumps. This resulted in scattering of ex- Red Cross. Duplicate entries were ex- tional Emergency and Refugee Health Branch, Divi- sion of Emergency and Environmental Health Services, plosives over wide areas. In such situa- cluded, and statistical analyses were National Center for Environmental Health (Drs Bi- tions, injuries due to unexploded ord- performed using JMP software (Re- lukha, Brennan, and Woodruff ), Centers for Disease Control and Prevention, Atlanta, Ga. nance may be as much of a public health lease 5.0, SAS Institute Inc, Cary, NC). Corresponding Author and Reprints: Oleg O. Bi- threat as those due to landmines. These data were obtained from a lukha, MD, PhD, National Center for Environmental Health, Centers for Disease Control and Prevention, We undertook this study to evalu- clinic-based surveillance system oper- 4770 Buford Hwy, Mailstop F-48, Atlanta, GA 30341 ate landmine and unexploded ord- ated by the International Committee of (e-mail: [email protected]). 650 JAMA, August 6, 2003—Vol 290, No. 5 (Reprinted) ©2003 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 LANDMINES AND UNEXPLODED ORDNANCE or rehabilitation clinics, facilities sup- Figure. Individuals With Injuries From Landmines and Unexploded Ordnance per Month, by ported by nongovernmental organiza- Explosive Type, in Afghanistan, March 2001-June 2002 tions, and basic health centers in areas contaminated by landmines or unex- Explosive Type ploded ordnance. The current surveil- Other/Unknown Landmine∗ Unexploded Ordnance† Other Unexploded Cluster Munition‡ lance system includes 390 clinics and Than Landmines and Cluster Munition 8 hospitals throughout the country and 200 is believed to include most facilities 180 likely to see injuries due to landmines 160 and unexploded ordnance. Not in- 140 cluded in the system are specialized fa- 120 cilities, such as tuberculosis or ma- 100 laria treatment centers, facilities located in areas with no known landmine or un- 80 exploded ordnance problems, facili- No. of Injured 60 ties in which access is difficult or the 40 situation is insecure, and facilities not 20 0 wishing to participate in the system. Mar May Jul Sep Nov Jan Mar May Jul Surveillance uses a standard data col- 2001 2002 lection form compatible with the In- formation Management System for Asterisk indicates landmine includes antipersonnel and antitank landmines. Dagger indicates munitions such as grenades, bombs, or mortar shells. Double dagger indicates weaponized containers that are intended to Mine Action, recommended and widely break open in mid air and disperse smaller munitions or submunitions. used by the United Nations Mine Ac- tion Service worldwide.5 Those sus- taining injuries from landmines and un- month; the lowest number was re- farming were the most common risk be- exploded ordnance, or their family ported in October 2001 (FIGURE). A haviors among persons 16 years or members, are interviewed by trained pronounced increase in injuries from older. About 11% of those injured, staff at the health facility, and the forms unexploded cluster munitions began in mostly adults, reported that they know- are forwarded to International Com- October 2001, when the conflict be- ingly took the risk of going into a dan- mittee of the Red Cross headquarters gan between the Taliban government gerous area. About 11% of injured per- in Kabul each month. and coalition forces. Cluster muni- sons reported having received some As participating health facilities were tions are weaponized containers that are landmine risk education before the in- considered neither a random nor rep- intended to break open in mid air and jury (Table 1). resentative sample of all health facili- disperse smaller munitions or submu- A stratified analysis assessed the re- ties in Afghanistan, the injuries detected nitions that are intened to explode just lationship of age and activity to explo- are likewise not considered representa- before or at impact. sive type. For each of the activities of eco- tive of all relevant injuries. Nonethe- Forty-six percent of those injured nomic necessity (ie, farming; tending less, for participating facilities, reported were younger than 16 years. The high- animals; traveling; collecting wood, food, injuries are considered a complete list est number of injuries was seen among or water), children were more likely to of all injuries due to landmines and unex- those aged 7 to 15 years. Reported in- be injured by unexploded ordnance and ploded ordnance seen in those facili- juries in all age groups were mostly adults were more likely to be injured by ties. For these reasons, measures of pre- among males (91.6%) and civilians landmines. On the other hand, both chil- cision, such as confidence intervals, were (81.2%) (TABLE 1). dren and adults injured while playing or not calculated nor was hypothesis test- Children were more likely to be tampering with explosives were in- ing performed to test the statistical sig- injured by unexploded ordnance; jured predominantly by unexploded nificance of differences between sub- injuries among adults were caused ordnance (TABLE 2). groups. Therefore only substantial predominantly by landmines. The case- observed differences between sub- fatality rate was 9.4% and varied little COMMENT groups are highlighted in this article. across the age groups (Table 1). The results of this study demonstrate Among injuries to children and ado- that landmines and unexploded ord- RESULTS lescents younger than 16 years for nance remain a serious public health