Conflict-related intentional injuries in Baghdad, Iraq, 2003-2014: A modeling study and proposed method for calculating burden of injury in conflict.

BACKGROUND: Previous research has focused on the mortality associated with armed conflict as the primary measure of the population health effects of war. However, mortality only demonstrates part of the burden placed on a population by conflict. Injuries and resultant disabilities also have long-term effects on a population and are not accounted for in estimates that focus solely on mortality. Our aim was to demonstrate a new method to describe the effects of both lives lost, and years of disability generated by a given conflict, with data from the US-led 2003 invasion and subsequent occupation of Iraq. METHODS AND FINDINGS: Our data come from interviews conducted in 2014 in 900 Baghdad households containing 5,148 persons. The average household size was 5.72 persons. The majority of the population (55.8%) were between the ages of 19 and 60. Household composition was evenly divided between males and females. Household sample collection was based on methodology previously designed for surveying households in war zones. Survey questions were answered by the head of household or senior adult present. The questions included year the injury occurred, the mechanism of injury, the body parts injured, whether injury resulted in disability and, if so, the length of disability. We present this modeling study to offer an innovative methodology for measuring "years lived with disability" (YLDs) and "years of life lost" (YLLs) attributable to conflict-related intentional injuries, using the Global Burden of Disease (GBD) approach. YLDs were calculated with disability weights, and YLLs were calculated by comparing the age at death to the GBD standard life table to calculate remaining life expectancy. Calculations were also performed using Iraq-specific life expectancy for comparison. We calculated a burden of injury of 5.6 million disability-adjusted life years (DALYs) lost due to conflict-related injuries in Baghdad from 2003 to 2014. The majority of DALYs lost were attributable to YLLs, rather than YLDs, 4.99 million YLLs lost (95% uncertainty interval (UI) 3.87 million to 6.13 million) versus 616,000 YLDs lost (95% UI 399,000 to 894,000). Cause-based analysis demonstrated that more DALYs were lost to due to gunshot wounds (57%) than any other cause. Our study has several limitations. Recall bias regarding the reporting and attribution of injuries is possible. Second, we have no data past the time of the interview, so we assumed individuals with ongoing disability at the end of data collection would not recover, possibly counting more disability for injuries occurring later. Additionally, incomplete data could have led to misclassification of deaths, resulting in an underestimation of the total burden of injury. CONCLUSIONS: In this study, we propose a methodology to perform burden of disease calculations for conflict-related injuries (expressed in DALYs) in Baghdad from 2003 to 2014. We go beyond previous reports of simple mortality to assess long-term population health effects of conflict-related intentional injuries. Ongoing disability is, in cross section, a relatively small 10% of the total burden. Yet, this small proportion creates years of demands on the health system, persistent limitations in earning capacity, and continuing burdens of care provision on family members.

Injury and death during the ISIS occupation of Mosul and its liberation: Results from a 40-cluster household survey.

BACKGROUND: Measurement of mortality and injury in conflict situations presents many challenges compared with stable situations. However, providing information is important to assess the impact of conflict on populations and to estimate humanitarian needs, both in the immediate and longer term. Mosul, Iraq's second largest city, was overrun by fighters of the Islamic State of Iraq and Syria (ISIS) on June 4, 2014. In this study, we conducted household surveys to measure reported deaths, injuries, and kidnappings in Mosul, Iraq, both during the occupation of the city by fighters of ISIS and the months of Iraqi military action known as the liberation. METHODS AND FINDINGS: Mosul was overrun by ISIS forces on June 4, 2014, and was under exclusive ISIS control for 29 months. The military offensive by Iraqi forces, supported by coalition artillery and airstrikes, began on October 17, 2016, in east Mosul and concluded in west Mosul with the defeat of ISIS on June 29, 2017. We conducted a 40-cluster population-based survey as soon as the security forces permitted access for the survey team. The objective of the survey was to measure reported deaths, injuries, and kidnappings in Mosul households during 29 months of ISIS-exclusive control (June 2014-October 2016) and the nine months of Iraqi military action known as the liberation (October 2016-June 2017). In east Mosul, the survey was conducted from March 23 to March 31, 2017, and in west Mosul from July 18 to July 31, 2017. Sampling was based on pre-ISIS population distribution, with revisions made following the extensive destruction in west Mosul. The 1,202 sampled households included 7,559 persons: 4,867 in east Mosul and 2,692 in west Mosul. No households declined to participate. During the time from June 4, 2014, to the time of the survey, there were 628 deaths reported from the sampled households, of which 505 were due to intentional violence, a mortality rate of 2.09 deaths per 1,000 person-months. Over the entire time period, the group with the highest mortality rates from intentional violence was adults aged 20 to 39: 1.69 deaths per 1,000 person-months among women and 3.55 among men. In the 29 months of ISIS-exclusive control, mortality rates among all males were 0.71 reported deaths per 1,000 person-months and for all females were 0.50 deaths per 1,000 person-months. During the nine months of the military liberation, the mortality rates jumped to 13.36 deaths per 1,000 person-months for males and 8.33 for females. The increase was particularly dramatic in west Mosul. The leading cause of reported deaths from intentional violence was airstrikes-accounting for 201 civilian deaths-followed by 172 deaths from explosions. Reported deaths from airstrikes were most common in west Mosul, while reported deaths from explosions were similar on both sides of Mosul. Gunshots accounted for 86 cases, predominantly in west Mosul where ISIS snipers were particularly active. There were 35 persons who were reported to have been kidnapped, almost entirely prior to the military offensive. By the time of the survey, 20 had been released, 8 were dead, and 7 still missing, according to household reports. Almost all of the 223 injuries reported were due to intentional violence. Limitations to population-based surveys include a probable large survivor bias, the reliance on preconflict population distribution figures for sampling, and potential recall bias among respondents. CONCLUSIONS: Death and injuries during the military offensive to liberate Mosul considerably exceeded those during ISIS occupation. Airstrikes were the major reported cause of deaths, with the majority occurring in west Mosul. The extensive use of airstrikes and heavy artillery risks an extensive loss of life in densely populated urban areas. The high probability of survivor bias in this survey suggests that the actual number of injuries, kidnappings, and deaths in the neighborhoods sampled is likely to be higher than we report here.

Sex Differences in Civilian Injury in Baghdad From 2003 to 2014: Results of a Randomized Household Cluster Survey.

OBJECTIVE: To examine sex differences in injury mechanisms, injury-related death, injury-related disability, and associated financial consequences in Baghdad since the 2003 invasion of Iraq to inform prevention initiatives, health policy, and relief planning. BACKGROUND: Reliable estimates of injury burden among civilians during conflict are lacking, particularly among vulnerable subpopulations, such as women. METHODS: A 2-stage, cluster randomized, community-based household survey was conducted in May 2014 to determine the civilian burden of injury in Baghdad since 2003. Households were surveyed regarding injury mechanisms, healthcare required, disability, deaths, connection to conflict, and resultant financial hardship. RESULTS: We surveyed 900 households (5148 individuals), reporting 553 injuries, 162 (29%) of which were injuries among women. The mean age of injury was higher among women compared with men (34 ±â€Š21.3 vs 27 ±â€Š16.5 years; P < 0.001). More women than men were injured while in the home [104 (64%) vs 82 (21%); P < 0.001]. Fewer women than men died from injuries [11 (6.8%) vs 77 (20%); P < 0.001]; however, women were more likely than men to live with reduced function [101 (63%) vs 192 (49%); P = 0.005]. Of intentional injuries, women had higher rates of injury by shell fragments (41% vs 26%); more men were injured by gunshots [76 (41%) vs 6 (17.6%); P = .011). CONCLUSIONS: Women experienced fewer injuries than men in postinvasion Baghdad, but were more likely to suffer disability after injury. Efforts to improve conditions for injured women should focus on mitigating financial and provisional hardships, providing counseling services, and ensuring access to rehabilitation services.

Electricity and generator availability in LMIC hospitals: improving access to safe surgery.

BACKGROUND: Access to reliable energy has been identified as a global priority and codified within United Nations Sustainable Goal 7 and the Electrify Africa Act of 2015. Reliable hospital access to electricity is necessary to provide safe surgical care. The current state of electrical availability in hospitals in low- and middle-income countries (LMICs) throughout the world is not well known. This study aimed to review the surgical capacity literature and document the availability of electricity and generators. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search for surgical capacity assessments in LMICs in MEDLINE, PubMed, and World Health Organization Global Health Library was performed. Data regarding electricity and generator availability were extracted. Estimated percentages for individual countries were calculated. RESULTS: Of 76 articles identified, 21 reported electricity availability, totaling 528 hospitals. Continuous electricity availability at hospitals providing surgical care was 312/528 (59.1%). Generator availability was 309/427 (72.4%). Estimated continuous electricity availability ranged from 0% (Sierra Leone and Malawi) to 100% (Iran); estimated generator availability was 14% (Somalia) to 97.6% (Iran). CONCLUSIONS: Less than two-thirds of hospitals providing surgical care in 21 LMICs have a continuous electricity source or have an available generator. Efforts are needed to improve electricity infrastructure at hospitals to assure safe surgical care. Future research should look at the effect of energy availability on surgical care and patient outcomes and novel methods of powering surgical equipment.

Perceptions, experiences and expectations of Iraqi medical students.

BACKGROUND: The environment for medical education in Iraq has been difficult for many years. The 2003 invasion of Iraq accelerated a steady emigration of faculty and graduates. Kidnappings and deaths of doctors became commonplace. To understand current career plans, expectations and perceptions of medical students, three Baghdad medical schools were surveyed. METHODS: Written questionnaires were completed by 418 medical students variously in their 4th, 5th and 6th (final)years of training. We asked about perceptions of the quality of their medical education, the quality of health services in Iraq generally, and about deaths, injuries and migration of faculty, classmates and family. RESULTS: The average age of students was 22 years, with 59% women. Most students (90%) were originally from Baghdad. Although there were some positive responses, many students (59%) rated the overall quality of their medical education as fair or poor. Three-fourths of students believed the quality of hospital care in Iraq to be only fair or poor. A majority of students (57%) stated they were thinking frequently or all the time about leaving Iraq after graduation. Reasons given for leaving included the desire for further education, seeking a better lifestyle and fleeing conflict. Leading reasons for staying included the pull of friends and family, familiarity with the health system, and a sense of responsibility to the country. Nearly one in five (18%) students reported the death of a family member attributable to intentional violence, and 15% reported the violent death of a medical school classmate or faculty member since the 2003 invasion. Half the students reported at least one school faculty members had left Iraq because of the war. CONCLUSION: Medical students hold a mediocre view of the quality of their medical education and of Iraq's health system. Many of their faculty members have left the country. The majority of students may leave Iraq after graduation, afforded the opportunity. This poses a significant problem for staffing an already demoralized and stressed health system. Current circumstances suggest the situation will continue to deteriorate.

Mortality and kidnapping estimates for the Yazidi population in the area of Mount Sinjar, Iraq, in August 2014: A retrospective household survey.

BACKGROUND: In August 2014, the so-called Islamic State of Iraq and Syria (ISIS) attacked the Yazidi religious minority living in the area of Mount Sinjar in Nineveh governorate, Iraq. We conducted a retrospective household survey to estimate the number and demographic profile of Yazidis killed and kidnapped. METHODS AND FINDINGS: The survey covered the displaced Yazidi population from Sinjar residing in camps in the Kurdistan Region of Iraq. Fieldwork took place between 4 November and 25 December, 2015. A systematic random sample of 1,300 in-camp households were interviewed about the current household composition and any killings and kidnappings of household members by ISIS. Of the 1,300 interviewed households, 988 were Yazidi from Sinjar. Yazidi households contained 6,572 living residents at the time of the survey; 43 killings and 83 kidnappings of household members were reported. We calculated the probability of being killed and kidnapped by dividing the number of reported killings and kidnappings by the number of sampled Yazidis at risk, adjusting for sampling design. To obtain the overall toll of killings and kidnappings, those probabilities were multiplied by the total Yazidi population living in Sinjar at the time of the ISIS attack, estimated at roughly 400,000 by the United Nations and Kurdish officials. The demographic profile of those killed and kidnapped was examined, distinguishing between children and adults and females and males. We estimated that 2.5% of the Yazidi population was either killed or kidnapped over the course of a few days in August 2014, amounting to 9,900 (95% CI 7,000-13,900) people in total. An estimated 3,100 (95% CI 2,100-4,400) Yazidis were killed, with nearly half of them executed-either shot, beheaded, or burned alive-while the rest died on Mount Sinjar from starvation, dehydration, or injuries during the ISIS siege. The estimated number kidnapped is 6,800 (95% CI 4,200-10,800). Escapees recounted the abuses they had suffered, including forced religious conversion, torture, and sex slavery. Over one-third of those reported kidnapped were still missing at the time of the survey. All Yazidis were targeted regardless of age and sex, but children were disproportionately affected. They were as likely as adults to be executed but constituted 93.0% (95% CI 71.9-98.6) of those who died on Mount Sinjar. Moreover, children only accounted for 18.8% (95% CI 8.4-36.9) of those who managed to escape captivity. A sensitivity analysis suggests that the actual toll of killings and kidnappings may be underestimated in our data because of survival bias. The uncertainty associated with inference from a small sample of in-camp households and the reliance on a rough figure of 400,000 for extrapolation to the total Yazidi population of Sinjar at the time of the ISIS attack are the main limitations of this study. CONCLUSIONS: Consistent with other existing evidence, our data provide a clear indication of the severity of the ISIS attack against the Yazidis in terms of both the number and demographic profile of those targeted.

Health service access and utilization among Syrian refugees in Jordan.

BACKGROUND: The influx of Syrian refugees into Jordan presents an immense burden to the Jordanian health system. Changing lifestyles and aging populations are shifting the global disease burden towards increased non-infectious diseases including chronic conditions, co-morbidities, and injuries which are more complicated and costly to manage. The strain placed on health systems threatens the ability to ensure the health needs of both refugees and host country populations are adequately addressed. In light of the increasing challenges facing host governments and humanitarian actors to meet health needs of Syrian refugees and affected host communities, this study was undertaken to assess utilization of health services among Syrian refugees in non-camp settings. METHODS: A survey of Syrian refugees in Jordan was undertaken in June 2014 to characterize health seeking behaviors and issues related to accessing care. A cluster design with probability proportional to size sampling was used to attain a nationally representative sample of 1550 non-camp Syrian refugee households. Differences in household characteristics by geographic region, facility type, and sector utilized were examined using chi-square and t-test methods. RESULTS: Care-seeking was high with 86.1 % of households reporting an adult sought medical care the last time it was needed. Approximately half (51.5 %) of services were sought from public sector facilities, 38.7 % in private facilities, and 9.8 % in charity/NGO facilities. Among adult care seekers, 87.4 % were prescribed medication during the most recent visit, 89.8 % of which obtained the medication. Overall, 51.8 % of households reported out-of-pocket expenditures for the consultation or medications at the most recent visit (mean US$39.9, median US$4.2). CONCLUSIONS: Despite high levels of care-seeking, cost was an important barrier to health service access for Syrian refugees in Jordan. The cessation of free access to health care since the time of the survey is likely to have worsened health equity for refugees. Dependence of refugees on the public facilities for primary and specialist care has placed a great burden on the Jordanian health system. To improve accessibility and affordability of health services in an equitable manner for both refugees and Jordanian host communities, strategies that should be considered going forward include shifting resources for non-communicable diseases and other traditional hospital services to the primary level and creating strong health promotion programs emphasizing prevention and self-care are strategies.

Global Estimation of Surgical Procedures Needed for Forcibly Displaced Persons.

INTRODUCTION: Sixty million people were displaced from their homes due to conflict, persecution, or human rights violations at the end of 2014. This vulnerable population bears a disproportionate burden of disease, much of which is surgically treatable. We sought to estimate the surgical needs for forcibly displaced persons globally to inform humanitarian assistance initiatives. METHODS: Data regarding forcibly displaced persons, including refugees, internally displaced persons (IDPs), and asylum seekers were extracted from United Nations databases. Using the minimum proposed surgical rate of 4669 procedures per 100,000 persons annually, global, regional, and country-specific estimates were calculated. The prevalence of pregnancy and obstetric complications were used to estimate obstetric surgical needs. RESULTS: At least 2.78 million surgical procedures (IQR 2.58-3.15 million) were needed for 59.5 million displaced persons. Of these, 1.06 million procedures were required in North Africa and the Middle East, representing an increase of 50 % from current unmet surgical need in the region. Host countries with the highest surgical burden for the displaced included Syria (388,000 procedures), Colombia (282,000 procedures), and Iraq (187,000). Between 4 and 10 % of required procedures were obstetric surgical procedures. Children aged <18 years made up 52 % of the displaced, portending a substantial demand for pediatric surgical care. CONCLUSION: Approximately three million procedures annually are required to meet the surgical needs of refugees, IDPs, and asylum seekers. Most displaced persons are hosted in countries with inadequate surgical care capacity. These figures should be considered when planning humanitarian assistance and targeted surgical capacity improvements.

Road traffic injuries in Baghdad from 2003 to 2014: results of a randomised household cluster survey.

INTRODUCTION: Around 50 million people are killed or left disabled on the world's roads each year; most are in middle-income cities. In addition to this background risk, Baghdad has been plagued by decades of insecurity that undermine injury prevention strategies. This study aimed to determine death and disability and household consequences of road traffic injuries (RTIs) in postinvasion Baghdad. METHODS: A two-stage, cluster-randomised, community-based household survey was performed in May 2014 to determine the civilian burden of injury from 2003 to 2014 in Baghdad. In addition to questions about household member death, households were interviewed regarding crash specifics, healthcare required, disability, relatedness to conflict and resultant financial hardship. RESULTS: Nine hundred households, totalling 5148 individuals, were interviewed. There were 86 RTIs (16% of all reported injuries) that resulted in 8 deaths (9% of RTIs). Serious RTIs increased in the decade postinvasion and were estimated to be 26 341 in 2013 (350 per 100 000 persons). 53% of RTIs involved pedestrians, motorcyclists or bicyclists. 51% of families directly affected by a RTI reported a significant decline in household income or suffered food insecurity. CONCLUSIONS: RTIs were extremely common and have increased in Baghdad. Young adults, pedestrians, motorcyclists and bicyclists were the most frequently injured or killed by RTCs. There is a large burden of road injury, and the families of road injury victims suffered considerably from lost wages, often resulting in household food insecurity. Ongoing conflict may worsen RTI risk and undermine efforts to reduce road traffic death and disability.

Operative procedures in the elderly in low-resource settings: a review of Médecins Sans Frontières facilities.

BACKGROUND: As the demographic transition occurs across developing countries, an increasing number of elderly individuals are affected by disasters and conflicts. This study aimed to evaluate the elderly population that underwent an operative procedure at MSF facilities. METHODS: A retrospective review of prospectively collected operative cases performed at MSF-Operational Centre Brussels (MSF-OCB) facilities between June 2008 and December 2012 was completed. Baseline demographic data, American Society of Anesthesiologists (ASA) physical status and surgical indications were collected for each patient. For each procedure, the degree of urgency, anesthesia type, and intra-operative mortality were noted. All patients aged 50 and over at the time of the procedure were considered elderly, as proposed by the World Health Organization (WHO). Comparisons were made with the 18-49 age group in order to elucidate differences between older and younger individuals. RESULTS: We reviewed a total of 93,385 procedures performed on 83,911 patients in 21 different countries. Patients aged 50 and over comprised 11.5% (9,628/83,911) of all patients. While most procedures (57.6%) in the comparison group were urgent, this proportion decreased substantially in the elderly. Intra-operative mortality was considerably lower in the 50-59 group (0.12%) but increased with each age stratum. The most commonly performed surgical procedures in the elderly included herniorrhaphies, simple and extensive wound debridements, abscess incision and drainages, minor tumorectomies, and urological procedures. CONCLUSIONS: In light of the increasing elderly population in developing countries, efforts should be made to better quantify and address their surgical needs.

Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan.

BACKGROUND: There are currently more people displaced by conflict than at any time since World War II. The profile of displaced populations has evolved with displacement increasingly occurring in urban and middle-income settings. Consequently, an epidemiological shift away from communicable diseases that have historically characterized refugee populations has occurred. The high prevalence of non-communicable diseases (NCDs) poses a challenge to in terms of provision of appropriate secondary and tertiary services, continuity of care, access to medications, and costs. In light of the increasing burden of NCDs faced by refugees, we undertook this study to characterize the prevalence of NCDs and better understand issues related to care-seeking for NCDs among Syrian refugees in non-camp settings in Jordan. METHODS: A cross-sectional survey of 1550 refugees was conducted using a multi-stage cluster design with probability proportional to size sampling to obtain a nationally representative sample of Syrian refugees outside of camps. To obtain information on chronic conditions, respondents were asked a series of questions about hypertension, cardiovascular disease, diabetes, chronic respiratory disease, and arthritis. Differences by care-seeking for these conditions were examined using chi-square and t-test methods and characteristics of interest were included in the adjusted logistic regression model. RESULTS: Among adults, hypertension prevalence was the highest (9.7%, CI: 8.8-10.6), followed by arthritis (6.8%, CI: 5.9-7.6), diabetes (5.3%, CI: 4.6-6.0), chronic respiratory diseases (3.1%, CI: 2.4-3.8), and cardiovascular disease (3.7%, CI: 3.2, 4.3). Of the 1363 NCD cases, 84.7% (CI: 81.6-87.3) received care in Jordan; of the five NCDs assessed, arthritis cases had the lowest rates of care seeking at 65%, (CI:0-88, p = 0.005). Individuals from households in which the head completed post-secondary and primary education, respectively, had 89% (CI: 22-98) and 88% (CI: 13-98) lower odds of seeking care than those with no education (p = 0.028 and p = 0.037, respectively). Refugees in North Jordan were most likely to seek care for their condition; refugees in Central Jordan had 68% (CI: 1-90) lower odds of care-seeking than those in the North (p = 0.047). CONCLUSION: More than half of Syrian refugee households in Jordan reported a member with a NCD. A significant minority did not receive care, citing cost as the primary barrier. As funding limitations persist, identifying the means to maintain and improve access to NCD care for Syrian refugees in Jordan is essential.

Cross-sectional assessments of participants' characteristics and loss to follow-up in the first Opioid Substitution Therapy Pilot Program in Kabul, Afghanistan.

BACKGROUND: Kabul has over 12,000 people who inject drugs (PWID), most of them heroin users, and opioid substitution therapy has recently been introduced as an effective method to reduce opioid use. We aimed to evaluate a pilot Opioid Substitution Therapy Pilot Program (OSTPP) in Kabul, Afghanistan, particularly to (1) describe characteristics of the participants enrolled in the program and (2) identify factors associated with client retention in the OSTPP. FINDINGS: Two cross-sectional surveys evaluated participants attending the OSTPP at baseline (n = 83) and 18 months after (n = 57). Questionnaires assessed socio-demographic, drug use behavior, and general and mental health factors. After 18 months, 57 participants remained in the OSTPP. Participants lost to follow-up were younger (p < 0.01) and married (p < 0.01) and had no family contact (p < 0.01). Participants at 18 months reported no criminal activity in the last month and only two (3.5 %) reported heroin use in the last month, constituting significant decreases from baseline. CONCLUSIONS: While preliminary results are promising, further evaluation is needed to determine the feasibility of implementing OSTPP in this setting and effectiveness in reducing injection risk behaviors in Afghanistan.

Health services in Iraq.

After decades of war, sanctions, and occupation, Iraq's health services are struggling to regain lost momentum. Many skilled health workers have moved to other countries, and young graduates continue to leave. In spite of much rebuilding, health infrastructure is not fully restored. National development plans call for a realignment of the health system with primary health care as the basis. Yet the health-care system continues to be centralised and focused on hospitals. These development plans also call for the introduction of private health care as a major force in the health sector, but much needs to be done before policies to support this change are in place. New initiatives include an active programme to match access to health services with the location and needs of the population.

Providing Hemodialysis in Unstable Areas: An Assessment and Framework for Effective Care.

Introduction: Providing hemodialysis to patients with kidney failure (KF) in conflict-affected areas poses a significant challenge. Achieving and sustaining reasonable quality hemodialysis operations in such regions necessitates a comprehensive approach. Methods: In the conflict area of Northwest (NW) Syria, a 3-phase project was initiated to address the quality of hemodialysis operations. The assessment phase involved the examination of infection prevention and control (IPC) protocols, staff training, medical protocols, individualized hemodialysis prescriptions, and laboratory testing capabilities. The second phase involved activities toward capacity building and implementing an action plan based on feasibility and sustainability. Results: The assessment phase revealed that only 7 of 14 centers had IPC protocols, and 8 centers provided IPC training for their staff. Furthermore, only 7 centers had medical protocols, and 5 used individualized hemodialysis prescriptions. Difficulties in testing for potassium was reported in 7 centers and the inability to perform hepatitis B and C serologies was reported in 3 centers. Only 2 centers adhered to machine and water treatment system maintenance guidelines, and 4 conducted daily water quality checks. Recommendations were formulated, and an action plan was developed for implementation in the second phase. The plan encompassed enhancements in IPC practices, medical protocols, record-keeping, laboratory testing, and equipment maintenance. Conclusion: This project underscores that hemodialysis services in conflict-affected areas do not meet the standards for quality care. It emphasizes the necessity of implementing a comprehensive framework that engages relevant stakeholders in defining and upholding quality care, a model that should be extended to other protracted conflict-affected regions.

Mortality in Iraq associated with the 2003-2011 war and occupation: findings from a national cluster sample survey by the university collaborative Iraq Mortality Study.

BACKGROUND: Previous estimates of mortality in Iraq attributable to the 2003 invasion have been heterogeneous and controversial, and none were produced after 2006. The purpose of this research was to estimate direct and indirect deaths attributable to the war in Iraq between 2003 and 2011. METHODS AND FINDINGS: We conducted a survey of 2,000 randomly selected households throughout Iraq, using a two-stage cluster sampling method to ensure the sample of households was nationally representative. We asked every household head about births and deaths since 2001, and all household adults about mortality among their siblings. We used secondary data sources to correct for out-migration. From March 1, 2003, to June 30, 2011, the crude death rate in Iraq was 4.55 per 1,000 person-years (95% uncertainty interval 3.74-5.27), more than 0.5 times higher than the death rate during the 26-mo period preceding the war, resulting in approximately 405,000 (95% uncertainty interval 48,000-751,000) excess deaths attributable to the conflict. Among adults, the risk of death rose 0.7 times higher for women and 2.9 times higher for men between the pre-war period (January 1, 2001, to February 28, 2003) and the peak of the war (2005-2006). We estimate that more than 60% of excess deaths were directly attributable to violence, with the rest associated with the collapse of infrastructure and other indirect, but war-related, causes. We used secondary sources to estimate rates of death among emigrants. Those estimates suggest we missed at least 55,000 deaths that would have been reported by households had the households remained behind in Iraq, but which instead had migrated away. Only 24 households refused to participate in the study. An additional five households were not interviewed because of hostile or threatening behavior, for a 98.55% response rate. The reliance on outdated census data and the long recall period required of participants are limitations of our study. CONCLUSIONS: Beyond expected rates, most mortality increases in Iraq can be attributed to direct violence, but about a third are attributable to indirect causes (such as from failures of health, sanitation, transportation, communication, and other systems). Approximately a half million deaths in Iraq could be attributable to the war. Please see later in the article for the Editors' Summary.

Chronic disease and disability among Iraqi populations displaced in Jordan and Syria.

The Iraq conflict resulted in the largest displacement in the Middle East since the Palestinian crisis, and provision of health services to the displaced population presents a critical challenge. The study aimed to provide information on chronic medical conditions and disability to inform humanitarian assistance planning. Nationally representative cross-sectional surveys of Iraqi populations displaced in Jordan and Syria were conducted in late 2008 and early 2009. Clusters of 10 household were randomly selected using probability-based sampling; a total of 1200 and 813 Iraqi households in Jordan and Syria, respectively, were interviewed. The majority of respondents in both countries perceived healthcare as unaffordable but accessible; cost was an important barrier to care. In Jordan, most routine health expenditures were for medications where in Syria, expenses were divided between medical consultations and medication. Chronic disease prevalence among adults was 51.5% (confidence interval (CI): 49.4-53.5) in Syria and 41.0% (CI: 39.4-42.7) in Jordan, most common were hypertension and musculoskeletal problems. Overall disability rates were 7.1% (CI: 6.3-8.0) in Syria and 3.4% (CI: 3.0-3.9) in Jordan. In both countries, the majority of disability was attributed to conflict, prevalence was higher in men than women, and depression was the leading cause of mental health disability. Chronic illnesses, disabilities and psychological health are key challenges for the Iraqi population and the health systems in Jordan and Syria. Continued attention to the development of systems to manage conditions that require secondary and tertiary care is essential, particularly given reported difficulties in accessing care and the anticipated prolonged displacement.

COVID-19 in Baghdad, Iraq: adaptive and emotional findings in a household cluster survey.

Purpose: The objective of this study was to assess the impact of COVID-19 infection on households in Baghdad, Iraq. Methods: A cross-sectional household survey was conducted in early 2022; 41 clusters were selected proportional to population size from the districts of the Baghdad governorate. Households were randomly selected for inclusion. The head of household or senior female member present was interviewed to obtain a listing of COVID-19 infections, deaths, and vaccinations among members of the household and to understand if social and economic changes occurred during the pandemic. All analyses incorporated the complex survey design and sample weights for clustering. Findings: The findings revealed that there were 1,464 cases of COVID-19 (37.1%) and 34 reported fatalities among the 927 households enrolled in this study. One or more COVID-19 immunizations were received by 50.9% of household members. Preventive measures against COVID-19 were widely reported to be being practiced but were not more commonly reported in households having reported a clinical case of infection. While some households where infections had occurred stated that their household expenses were increased, overall, infections were not associated with significantly increased household costs. In households where COVID-19 had occurred, senior members reported a substantial increase in emotional and psychological problems compared with uninfected households. Implications: COVID-19 deaths were rare, though infections were common, suggesting an effect of vaccination and other efforts. The household economic implications were minimal in houses with and without COVID-19-infected members. COVID-19 had mental health consequences on affected and unaffected populations alike. It is conceivable that the fear and uncertainty generated by the pandemic had an effect on senior household members which was out of keeping with the other effects in the households sampled. This suggests that there may be a persisting need for mental health services for a protracted period to manage the consequences of mental health needs arising from the pandemic.

Correction: Civil war and death in Yemen: Analysis of SMART survey and ACLED data, 2012-2019.

[This corrects the article DOI: 10.1371/journal.pgph.0000581.].

A two-stage cluster sampling method using gridded population data, a GIS, and Google Earth(TM) imagery in a population-based mortality survey in Iraq.

BACKGROUND: Mortality estimates can measure and monitor the impacts of conflict on a population, guide humanitarian efforts, and help to better understand the public health impacts of conflict. Vital statistics registration and surveillance systems are rarely functional in conflict settings, posing a challenge of estimating mortality using retrospective population-based surveys. RESULTS: We present a two-stage cluster sampling method for application in population-based mortality surveys. The sampling method utilizes gridded population data and a geographic information system (GIS) to select clusters in the first sampling stage and Google Earth TM imagery and sampling grids to select households in the second sampling stage. The sampling method is implemented in a household mortality study in Iraq in 2011. Factors affecting feasibility and methodological quality are described. CONCLUSION: Sampling is a challenge in retrospective population-based mortality studies and alternatives that improve on the conventional approaches are needed. The sampling strategy presented here was designed to generate a representative sample of the Iraqi population while reducing the potential for bias and considering the context specific challenges of the study setting. This sampling strategy, or variations on it, are adaptable and should be considered and tested in other conflict settings.