The lasting legacy of war: epidemiology of injuries from landmines and unexploded ordnance in Afghanistan, 2002-2006.

INTRODUCTION Due to several decades of armed conflict and civil unrest, Afghanistan is one of the countries most affected by landmines and unexploded ordnance worldwide. OBJECTIVE The study was performed to assess the magnitude of injuries due to landmines and unexploded ordnance in Afghanistan during 2002-2006 and to describe epidemiological patterns and potential risk factors for these events. METHODS Surveillance data including 5,471 injuries caused by landmines and unexploded ordnance in Afghanistan during 2002-2006 were analyzed. The International Committee of the Red Cross collects data on such injuries from 490 reporting health facilities and volunteers throughout the country. These surveillance data were used to describe injury trends, victim demographics, injury types, risk behaviors, and explosive types related to landmine and unexploded ordnance accidents. RESULTS The largest number of injuries (1,706) occurred in 2002. The number declined sharply to 1,049 injuries in 2003, and remained relatively stable with slight decline thereafter. Overall, 92% of victims were civilians, 91% were males, and 47% were children <18 years of age. The case-fatality ratio was 17%. Approximately 50% of all injuries were caused by unexploded ordnance and 42% by landmines. Among children, 65% of injuries were caused by unexploded ordnance and only 27% by landmines, whereas in adults, most injuries (56%) were caused by landmines. The most common risk behaviors among children were tending animals, playing, and tampering with explosive devices. In adults, most common risk behaviors were traveling, performing activities of economic necessity, and tampering with explosives. Twenty-eight percent of the surviving victims who received mine awareness training and 2% of those who did not receive such training reported that the area where event occurred was marked. CONCLUSIONS The large number of injuries and high proportion of child victims suggest that clearance and risk education activities fall short of achieving their goals, and must be substantially improved or expanded. Especially concerning is the high proportion of injuries caused by unexploded ordnance, and the high number of injuries sustained while tampering with explosive devices. Because unexploded ordnance is more visible than are landmines, and ordnance-contaminated areas are cheaper to clear than are minefields, these injuries are highly preventable and should be a priority for clearance and risk education efforts.