2 tables omitted
Landmines and unexploded ordnance (UXO) pose a substantial public health
risk.1,2 Approximately 60-70
million landmines are scattered in approximately 70 countries,3 and
an estimated 24,000 persons, mostly civilians, are killed or injured annually
by landmines and UXO.4 In Afghanistan, approximately
5-7 million landmines are scattered throughout the country.4 During
2000-2001, Afghanistan had the highest number of reported landmine and UXO
casualties in the world.5 This report presents
analyses of surveillance data on landmine- and UXO-related injuries in Afghanistan
during January 1997–September 2002, which indicate that the proportion
of victims injured by UXO increased during this time, compared with the proportion
injured by landmines. The majority (61%) of adult victims were injured by
landmines, and the majority (66%) of children and adolescents were injured
by UXO. Mine-risk education programs should focus on UXO hazards for children
and on landmine hazards for adults and should address age-specific risk behaviors.
Data on landmine- and UXO-related injuries were obtained from the United
Nations Mine Action Center for Afghanistan (UN MACA), which conducts surveillance
for these injuries in Afghanistan. The data include geographic location of
incident, victim demographics, type of injury, type of explosive involved,
activity at the time of injury, and other information about the circumstances
of the incident. Approximately 70% of records in the database came from the
clinic-based surveillance system operated by the International Committee of
the Red Cross (ICRC), which uses both active and passive data-collection methods.
ICRC clinic-based surveillance began in 1998 and has expanded during the observation
period to include approximately 390 health clinics and hospitals in Afghanistan.6 The remaining data on landmine- and UXO-related
injuries were collected from mine-clearance teams and community mine-risk
education programs operated by the nongovernment organizations working in
mine clearance, mine-risk education, and victim assistance under the auspices
of UN MACA. Rates were not calculated because no reliable data were available
on large population changes during 1997-2002 and the sensitivity of the system
is unknown. Duplicate entries were excluded, and statistical analyses were
performed by using JMP (version 5.0) software from SAS Institute. Statistical
significance of associations was tested by using chi-square tests.
During January 1997–September 2002, a total of 6,114 injuries
from landmines and UXO were reported to UN MACA in Afghanistan. The number
of reported victims of landmines and UXO was highest in 1999 and decreased
gradually; sex and age distributions of victims remained relatively stable.
Injuries in males were approximately 10 times higher than in females. In each
year during 1997-2002, approximately half of all injuries occurred in persons
aged <18 years. The greatest number (1,830 [29%]) of injuries occurred
in children aged 10-14 years, followed by persons aged 15-19 years (891 [14%])
and children aged 5-9 years (834 [13%]). During this period, the proportion
of UXO-related injuries increased, and that of landmine-related injuries decreased
(chi square for linear trend = 114.8; p<0.001). The proportion of children
injured by UXO was 2.3 times as high as that of adults (chi square = 729.7;
p<0.001). The proportion of adult victims sustaining amputation was 1.3
times higher than that of child victims (chi square = 67.7; p<0.001). The
case-fatality rate was the same (approximately 7%) in both age groups. Children
were injured most often while playing or tending animals; adults were injured
most often while traveling or engaging in military activities.
M Wennerstrom, United Nations Mine Action Center for Afghanistan, Kabul;
S Baaser, P Salama, MD, United Nations Children's Fund, Kabul, Afghanistan.
M Brennan, MD, BA Woodruff, MD, National Center for Environmental Health;
O Bilukha, MD, EIS Officer, CDC.
The data presented in this report demonstrate that injuries from landmines
and UXO remain a public health concern in Afghanistan. The majority of landmines
were laid during the Soviet occupation in the 1980s3;
however, many areas have been newly contaminated with UXO during recent episodes
of fighting between Taliban and allied forces.5 Mines
often are laid around objects of economic importance (e.g., industrial buildings,
roads, water sources, and fertile land), resulting in injuries among persons
who are traveling or performing activities of economic necessity (e.g., farming,
collecting wood or water, and tending animals). UXO often lie on the surface
of the ground and thus are more visible and easier to avoid. However, because
of their visibility, UXO pose a particular threat to children and adolescents
who like to play or tamper with strange objects.
The findings in this report are subject to at least four limitations.
First, because surveillance for landmine- and UXO-related injuries is predominantly
clinic-based, it probably undercounts victims who die before reaching the
clinic, whose injuries are too minor to seek medical care, or who do not have
access to medical facilities. The overall sensitivity of the system is unknown
but is thought to be <50%.5,7 Second,
the reported case-fatality rate probably is underestimated because surveillance
detects predominantly victims who survive long enough to receive medical care.
Survey data from Afghanistan and other countries have shown case-fatality
rates as high as 50%-55%.8,9 Third,
the time trends in recorded injuries should be interpreted with caution because
of the low sensitivity of the system and variability in system coverage over
time depending on the availability of resources, the security situation, and
other factors. However, sensitivity of the system to landmine-related injuries
versus sensitivity to UXO-related injuries probably has not changed substantially
over time, suggesting that the data reflect a true increase in the proportion
of UXO-related injuries among all recorded injuries. Finally, although this
surveillance system identifies acute injuries, it does not monitor long-term
disability or psychological impact on victims and their families, which can
add substantially to the public health burden.
The more restricted mobility of Afghan women and the resulting lower
likelihood that women engage in activities that put them at risk for landmine-
and UXO-related injuries might account for the low proportion of female victims.
In addition, because of cultural restrictions, women, if injured, might be
less likely to receive medical care or to be interviewed and recorded by the
surveillance system. Among children aged ≤5 years, sex-specific differences
in mobility generally do not apply, and the proportion of female victims is
The increasing proportion of injuries from UXO and the high proportion
of such injuries among children and adolescents underscore the need for effective
mine-risk education programs for children and adolescents that focus on UXO
hazards and address age-specific risk behaviors, such as playing, tending
animals, and tampering with explosives. Mine-risk education programs for adults
should focus more on hazards from landmines. Such programs also should address
the approximately two million refugees who returned to Afghanistan in 2002
and who might be at higher risk for landmine- and UXO-related injuries because
they are unaware of dangerous areas.
Surveillance data about the incidence and types of injury sustained
by victims of landmines and UXO should be instrumental in planning and implementing
victim-assistance programs. Similarly, mine-clearance programs should use
surveillance data to prioritize areas for clearance. Expansion of community-based
reporting will improve sensitivity and representativeness of surveillance.
This report is based on data provided by the United Nations Mine Action
Center for Afghanistan and the International Committee of the Red Cross.
Injuries Associated With Landmines and Unexploded Ordnance—Afghanistan, 1997-2002. JAMA. 2003;290(14):1846-1848. doi:10.1001/jama.290.14.1846