Correction to: Injury-related deaths before and during the Islamic State insurgency - Baghdad, Iraq, 2010-2015.

[This corrects the article DOI: 10.1186/s13031-020-0252-7.].

Injury-related deaths before and during the Islamic State insurgency - Baghdad, Iraq, 2010-2015.

Background: Following a period of low intensity conflict during 2009-2012, the emergence of the Islamic State of Iraq and Levant (or Islamic State) in 2013 was associated with a resurgence of violence in Baghdad, Iraq's capital and largest city. We evaluated trends in injury-related deaths in Baghdad before and during the Islamic State insurgency. Methods: Iraqi National Injury Mortality Surveillance System prospectively collects information on fatal injuries from governorate coroner offices using standardized reporting forms. Trained coroner clerks collect information on victim demographics, intention of injury and mechanism of injury during medical examinations using reports from police and families. We analyzed data on all deaths reported by the Baghdad Forensic Institute from January 1, 2010 to December 31, 2015. Results: There were 17,555 injury-related deaths with documented intent and mechanism (range 2385-3347 per year): 6241 from gunfire (36%), 1381 explosions (8%), 1348 non-gunfire assaults (8%), 3435 traffic accidents (20%), and 5150 other unintentional injuries (29%). Rates of gunfire (23.45 per 100,000) and explosion (5.90 per 100,000) deaths were significantly higher in 2014 than in all other years during the review period (p < 0.001 and p = 0.03, respectively). During the same period from 2010 to 2015, traffic accident deaths declined significantly from 13.29 to 6.35 (p = 0.002), with declines observed primarily among pedestrians. Trends in the rate of non-gunfire-assault and unintentional deaths, comparing 2010 and 2015, were not significant (p = 0.12 and p = 0.63, respectively). Unintentional deaths were mostly attributed to burns (46%) and electricity-related injuries (31%). The proportion of both females and children was highest in unintentional injury deaths. Conclusions: During the study period, deaths from both gunfire and explosions in Baghdad peaked in 2014, corresponding with emergence of the Islamic State. Trends suggest a potential impact of insurgency-related activity on other injuries as evidenced by a decrease in the death rate from traffic accidents. The decreased traffic-related death rate could be from decreased vehicle and pedestrian activity during times of violence. Monitoring trends in injury mortality during conflict allows Iraq to identify priority injury causes to inform public health interventions.

Fatalities from Firearm-Related Injuries in Selected Governorates of Iraq, 2010-2013.

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. Nerlander MP , Leidman E , Hassan A , Sultan ASS , Hussain SJ , Browne LB , Bilukha OO . Fatalities from firearm-related injuries in selected governorates of Iraq, 2010-2013. Prehosp Disaster Med. 2017;32(5):548-555.

Injury-related fatalities in selected governorates of Iraq from 2010 to 2013: Prospective surveillance.

OBJECTIVE: After several years of relative stability in Iraq, the emergence of the Islamic State militant group has spurred a resurgence of violence. This study explores the impact of the conflict on the overall injury profile to estimate the proportion of injury fatalities related to conflict and better understand how violence has affected nonconflict-related injuries. DESIGN: Routine prospective injury surveillance operated by the Iraqi Ministry of Health. SETTING: Surveillance data were collected from coroner offices in eight pilot governorates: Al-Anbar, Baghdad, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. PARTICIPANTS: We analyzed all fatalities from external injury causes recorded between January 1, 2010 and December 31, 2013. Analysis included 32,664 fatal injuries. RESULTS: Of all injury fatalities reported, 27.1 percent were conflict-related fatalities, approximately the same proportion as road traffic-related fatalities (24.4 percent) and other unintentional injuries (27.5 percent). The proportion of fatalities from conflict was approximately three times higher among males than females (33.0 percent and 10.3 percent, respectively) and four times higher among adults than children (29.8 percent and 7.3 percent, respectively). The total number of injury fatalities remained stable between 2010 and 2012; an increase in injury fatalities in 2013 was driven primarily by increases in fatalities from both interpersonal violence and conflict. CONCLUSIONS: From 2010 to 2013, nearly one in four injury fatalities in Iraq was attributable to conflict, a notably higher proportion than other conflict-affected countries in the region. The overall profile of nonconflict injuries in Iraq is also distinct from other countries of similar socioeconomic level that have not experienced violence.

Road traffic fatalities in selected governorates of Iraq from 2010 to 2013: prospective surveillance.

BACKGROUND: The insurgency tactics that characterize modern warfare, such as suicide car bombs and roadside bombs, have the potential to significantly impact road traffic injuries in conflict affected-countries. As road traffic incidents are one of the top ten causes of death in Iraq, changes in incidence have important implications for the health system. We aimed to describe patterns of road traffic fatalities for all demographic groups and types of road users in Iraq during a period characterized by a resurgence in insurgency activity. METHODS: Iraqi Ministry of Health routine prospective injury surveillance collects information on all fatal injuries in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. From all injury fatalities documented at the coroner office, we analyzed only those attributed to road traffic that occurred between 1 January 2010 and 31 December 2013. Coroners ascertain information from physical examinations, police reports and family members. RESULTS: Analysis included 7,976 road traffic fatalities. Overall, 6,238 (78.2 %) fatalities were male and 2,272 (28.5 %) were children under 18 years of age. The highest numbers of road traffic fatalities were among males 15 to 34 years of age and children of both sexes under 5 years of age. 49.2 % of fatalities occurred among pedestrians. Among children and females, the majority of road traffic fatalities were pedestrians, 69.0 % and 56.6 %, respectively. Fatalities among motorcyclists (3.7 %) and bicyclists (0.4 %) were least common. Rates of road traffic fatalities ranged from 8.6 to 10.7 per 100,000 population. CONCLUSIONS: The injury surveillance system provides the first data from a conflict-affected country on road traffic fatalities disaggregated by type of road user. The highest numbers of fatalities were among children and young men. Nearly half of fatalities were pedestrians, a proportion nearly double that of any neighboring country. As insurgency activity increased in 2013, the number of road traffic fatalities declined.

Deaths due to Intentional Explosions in Selected Governorates of Iraq from 2010 to 2013: Prospective Surveillance.

INTRODUCTION: The aim of this study was to describe the most recent trends and epidemiologic patterns of fatal injuries resulting from explosions in Iraq, one of the countries most affected by violence from explosive devices. METHODS: Iraqi Ministry of Health (MoH) routine prospective injury surveillance collects information on all fatal injuries recorded by coroners from physical examinations, police reports, and family members in eight governorates of Iraq: Baghdad, Al-Anbar, Basrah, Erbil, Kerbala, Maysan, Ninevah, and Al-Sulaimaniya. This study analyzed explosive-related fatal injuries that occurred from January 1, 2010 through December 31, 2013. RESULTS: Analysis included 2,803 fatal injuries. The number of fatal injuries declined from 2010 through 2012, followed by an increase in 2013. One-thousand one-hundred and one explosion-related fatalities were documented in 2013, more than twice as many as in 2012 or in 2011. Most fatalities were among men aged 20-39 years. Of all causalities, 194 (6.9%) were among females and 302 (10.8%) were among children aged less than 18 years. The majority of fatalities were caused by improvised explosive devices (IEDs): car bombs (15.3%), suicide bombs (4.0%), and other IEDs (29.6%). The highest number of fatalities occurred in streets and roads. Of all deaths, 95.6% occurred in three governorates: Baghdad, Ninevah, and Al-Anbar. CONCLUSIONS: Explosives continue to result in a high number of fatal injuries in Iraq. Following a period of declining violence from explosives, in 2013, fatalities increased. Most explosion-related injuries resulted from IEDs; males aged 20-39 years were at greatest risk.

Medicine in the 21st century: the situation in a rural Iraqi community.

OBJECTIVE: To describe the health beliefs and practice in a rural Iraqi community. METHODS: Personal observations and practice; narratives of colleagues. RESULTS: Rural Iraqi society has remained unchanged in beliefs and practices in many ways since the Babylonian and Sumerian eras over four millennia ago. Like other rural societies, it has a culture that includes values, beliefs, customs, communication style, and behaviors. Those beliefs often invoke supernatural agents such as evil, jinni, witchcraft and the results of sin, bad luck and envy. Primitive and current religious beliefs join with the effects of poverty and illiteracy. These rural people view health and disease quite differently from the views of their physicians and these cultural beliefs and practices confound current patient-clinician communication. Although physicians view the medical encounter as the main tool of diagnosis and therapy, especially when biomedical technology is lacking, ignorance of the characteristics of the rural society and people may make physicians' work all the more difficult. CONCLUSIONS: As with all cross-cultural interactions, better understanding of the patient or family's beliefs allow the clinician to find compromises and reach agreements that ignorance of their beliefs would deny. PRACTICE IMPLICATIONS: Simply asking the patient and the family how they view the illness, what they consider to be the cause, what treatments they have already tried and what treatments they hope you will use, may go a long way toward building a therapeutic relationship.