The blast wounded of Raqqa, Syria: observational results from an MSF-supported district hospital

Abstract

Background In June 2017, the U.S.-backed Syrian Democratic Forces (SDF) launched a military operation to retake the city of Raqqa, Syria, from the so-called Islamic State. The city population incurred mass numbers of wounded. In the post-offensive period, the population returned to a city (Raqqa) contaminated with improvised explosive devices (IEDs) and explosive remnants of war (ERWs), resulting in a second wave of wounded patients. Médecins Sans Frontières (MSF) supported a hospital in Tal-Abyad (north of Raqqa) and scaled up operations in response to this crisis. We describe the cohort of blast-wounded cases admitted to this hospital in order help prepare future humanitarian responses. Methods We retrospectively extracted data from clinical charts in the MSF-supported hospital. We included all new admissions for blast-wounded patients with key data elements documented. We performed comparative analyses from the offensive period (June 6, 2017 to October 17, 2017) and the post-offensive period (October 18, 2017 to March 17, 2018). Results We included 322 blast related injuries. There were more than twice the number of cases with blast injuries in the post-offensive period as the offensive period (225 vs. 97, p = <.001). The offensive period saw a significantly higher proportion of female patients (32.0%, n = 31 vs. 11.1%, n = 25, p < 0.001) and paediatric patients (42.3%, n = 41 vs 24.9%, n = 56, p = 0.002). Blast-injured patients in the post-offensive period included more cases with multiple traumatic injuries (65.8%, n = 148 vs. 39.2%, n = 38, p < 0.001). The treatment of the blast-injured cases in the post-offensive period was more labor intensive with those patients having a higher median number of interventions (2 vs 1, p = <0.001) and higher median number of days in hospital (7 vs 4, p = < 0.001). Conclusions In the wake of the Raqqa offensive, the MSF-supported district hospital received an unpredicted second, larger and more complex wave of blast-wounded cases as the population returned to a city strewn with IEDs and ERWs. These findings indicate the high risk of traumatic injury to the population even after warring factions have vacated conflict zones. Medical humanitarian actors should be prepared for a continued and scaled up response in areas known to be highly contaminated with explosive ordnance.

Conflict-Related Population Health Research in Syria, 2011-2019: An Assessment of Information Gaps, Research Needs and Challenges, for The Lancet - AUB Commission on Syria

“…Other direct health effects of con ict receive comparatively little research attention. For example, injury epidemiology is covered in just ve papers, three of which described a cohort of inpatients with abdominal (Arafat, Alsabek et al 2017), paediatric chest (Darwish, Mahfouz et al 2018) or blast injuries (Okeeffe, Vernier et al 2019). Understanding injury epidemiology is critical to informing health and social system needs, both to address immediate acute care needs but also to inform estimates of likely disability burden in future and requirements for health and social infrastructures and adaptive measures.…”

Conflict-related health research in Syria, 2011–2019: a scoping review for The Lancet - AUB Commission on Syria

“…Health status is the most frequently researched theme, examined in 38 research papers covering nutrition [ 10 , 94 ], communicable diseases and/or vaccination status [ 8 , 18 , 23 , 26 , 28 , 30 , 38 , 41 , 47 , 54 , 61 , 88 , 94 , 95 ], mental health [ 20 , 27 , 39 , 55 , 56 , 60 , 79 , 83 , 91 , 94 ], child [ 22 , 41 , 57 , 92 ] and maternal [ 93 ] health, oral health [ 44 , 72 , 75 , 83 ], gender-based violence [ 76 ], anaemia [ 43 ] and non-communicable diseases [ 39 , 84 , 94 ]. Of studies examining injuries, three are studies of hospital patients [ 29 , 46 , 89 ], one examines injury burden among children surveyed at home and in camps for internally displaced persons (IDPs) [ 41 ] and one reports injury counts among children and the general population as provided by key informants [ 32 ]. One additional study reports reasons for patient encounters at health facilities [ 28 ].…”

“…Twenty-one papers cover issues of service provision including renal [ 17 ], mental health [ 20 , 24 , 56 ], orthopaedic [ 73 ], cancer [ 40 ], communicable disease surveillance [ 54 ], respiratory [ 87 ], antenatal [ 93 ], and trauma services [ 25 , 74 , 89 ], disruptions to service provision due to attacks on healthcare [ 35 , 36 , 49 , 52 , 67 ], challenges of service provision under siege [ 58 , 80 ], factors enabling sustained UNRWA service delivery [ 85 ], and interplays of local service provision with cross-border humanitarian assistance [ 78 ].…”

“…Other studies included analysis of Qatar Red Crescent surveys of the impacts of the conflict on education, family and public health status [ 22 ] and diagnoses, injuries and comorbidities [ 41 ] among children in Northern Syria in 2015; and household surveys of water, sanitation and hygiene (WASH) and health outcomes in opposition-controlled Daraa and Quneitra in 2016–17 [ 65 ]. Review of humanitarian programmatic data and operations included middle-upper arm circumference screening, survey of living conditions and food security, and nutritional programming administered by Medecins Sans Frontiers (MSF) in Al-Raqqa in 2013 [ 10 ], MSF vaccine-preventable disease risk assessment, pre- and post-vaccine coverage surveys and immunization activity in Aleppo in 2015 [ 47 ], 2012–2014 surgical data from an MSF field hospital in Northwest Syria [ 19 ], blast injuries managed at an MSF-supported facility in Raqqa in 2017–18 [ 89 ], MSF paediatric consultations in Aleppo and Raqqa in 2013–16 [ 57 ], MSF assessment of health status of recently arrived IDPs in Al-Raqqa in 2017 [ 94 ], primary care services delivered by 10 Union of Medical Care and Relief Organisations (UOSSM) centres in opposition-controlled territories in 2014–2015 [ 28 ], and analysis of data from the humanitarian health response in contested and opposition-controlled areas in 2013–14 [ 32 ]. Additional interventions and program evaluations included delivery and evaluation of an intervention through provision of information and follow-up questionnaire in bread packages being distributed by a humanitarian organization in Northern Syria [ 21 ], evaluation of three modes of food assistance programming in Idlib in 2014–15 [ 34 ], evaluation of an International Rescue Committee cash assistance program on violence against women in Raqqa [ 76 ], evaluation of effectiveness of multi-level WASH risk reduction interventions in southern Syria in 2018 [ 64 ] and examination of the impact of a psychosocial support program on the wellbeing of a control and intervention group of farmers [ 96 ].…”

“…attacks on larger facilities may be reported more than those on smaller ones if there is less impact or fewer staff witness it; political agendas of witnesses and those reporting on attacks might influence reporting; restricted access to verify reports [ 35 , 52 , 67 ] • Potential survival bias in retrospective mortality surveys e.g. if all members of a household were killed, will not be captured in household level surveys where participants asked about household deaths [ 94 ] • Selection and respondent biases impacting representativeness; limited generalizability due to restricted geographic access and because not all governorates impacted by war to the same extent and in the same way [ 27 , 33 , 48 , 49 ] • Potential for data collection and categorization to be biased by motivations of researchers, political or advocacy groups [ 51 ] Data availability and quality • Missing data and limited data availability [ 20 , 28 , 74 ] • Impact on data quality and availability due to patient care taking precedence over documentation during crisis [ 89 ] • Difficulties of ascertaining casualty counts in an active conflict [ 90 ] • Extracting additional data on war injuries limited as names were deleted from paper medical records for security reasons [ 74 ] • Difficulties with outcome measurement and follow up data, including inability to return for follow up because of security issues, inability to follow up by phone because of disrupted phone network [ 19 ] • Difficulties ascertaining response rate due to inability to contact participants directly, reliance on third party [ 24 ] • Absence of / difficulties with establishing population denominator [ 32 , 38 , 57 , 61 ] • Inability to validate authenticity of data collected from online video sources [ 11 ] Ethics / Institutional Review Board processes • Lack of formal local ethics committees and governance processes [ 59 , 61 , 80 ] • Concerns with obtaining written consent related to anonymity and potential risks associated with participation [ 61 ] Permissions and permits • Need to secure specific travel permissions for local participa...…”