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Bilukha OO, Brennan M, Anderson M. Injuries and Deaths From Landmines and Unexploded Ordnance in Afghanistan, 2002-2006. JAMA. 2007;298(5):516–518. doi:10.1001/jama.298.5.516
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
To the Editor: Afghanistan is among the countries most affected by landmines and unexploded ordnance.1,2 Injury data from 1997-2002 showed an increasing burden of injuries due to unexploded ordnance and a high proportion of children among those injured.2,3 This study examined trends of injuries due to landmines and unexploded ordnance in Afghanistan from 2002 to 2006.
Data on landmine and unexploded ordnance injuries in Afghanistan from January 2002 through December 2006 were obtained from the International Committee of the Red Cross. These data were collected from 490 reporting health facilities and from a network of volunteers in a community-based First Aid program supported by the Afghan Red Crescent Society. Trained staff in the health facilities and community interviewed the injured person or the family of a person who had died. The Information Management System for Mine Action4 form, which conforms to the standard questionnaire recommended by the World Health Organization,5 was used for data collection.
Linear trends were assessed with χ2 tests. P values <.05 were considered statistically significant. Statistical analyses were performed using Epi Info (version 3.4, Centers for Disease Control and Prevention, Atlanta, Georgia) and JMP (release 5.0, SAS Institute Inc, Cary, North Carolina). The Institutional Review Board of the Centers for Disease Control and Prevention exempted this study from review.
There was information on 5471 individuals injured or killed by landmines or unexploded ordnance. Overall, 91.3% of reported injuries were among males, and 47.2% were among children younger than 18 years (Table). Seventeen percent of those injured died as a result of the accident. Unexploded ordnance caused more injuries than did landmines (Table). Most adult injuries (55.8%) were due to landmines, whereas for children the majority (65.4%) were from unexploded ordnance. Children were more likely to sustain upper limb amputation (24.3%) compared with adults (14.8%), whereas a higher proportion of injured adults (25.5%) than children (11.5%) sustained lower limb amputation.
The proportion of injuries due to unexploded ordnance increased from 48.4% in 2002 to 58.8% in 2006 (P < .001), accounting for 70.6% of all injuries in children and 41.9% in adults in 2006. The proportion of injuries sustained while tampering increased from 8.3% in 2002 to 25.6% in 2006 (P < .001). Of injuries sustained while tampering, 89.2% were caused by unexploded ordnance.
Landmines and unexploded ordnance continue to result in death and injury in children and adults in high numbers in Afghanistan. This is in contrast with other affected territories such as Chechnya, where the number of injured subsided rapidly after the end of active fighting.6
Persistent issues compared with previous studies2 include a high percentage of children among those injured and a high percentage of injuries due to unexploded ordnance in children. Amputation patterns suggest that children were more likely to handle an explosive device, whereas adults were more likely to step on it.
Limitations of this study must be considered. The surveillance system is believed to include most facilities likely to see injuries from landmines and unexploded ordnance,2 but its sensitivity is unknown, so these results may be underestimates. These injuries may not be representative of all relevant injuries. Potentially poor training of interviewers could have introduced a bias. Nevertheless, these findings suggest that clearance and risk education activities fall short of achieving their goal and need to be substantially improved or expanded.
Especially concerning is the increasing proportion of injuries due to unexploded ordnance. Because these devices are much more visible than landmines and contaminated areas are much cheaper to clear than minefields, these injuries are preventable. Because of the increase in injuries sustained while tampering with unexploded ordnance, studies should determine whether people take these risks due to economic necessity (eg, collecting scrap metal or clearing fields for farming), curiosity, lack of knowledge, or other factors. This information is necessary to design successful injury prevention programs.
Author Contributions: Dr Bilukha had full access to all of the data and takes responsibility for the integrity and accuracy of the data analysis.
Study concept and design: Bilukha, Brennan, Anderson.
Acquisition of data: Bilukha.
Analysis and interpretation of data: Bilukha.
Drafting the manuscript: Bilukha, Brennan, Anderson.
Critical revision of the manuscript for important intellectual content: Bilukha, Brennan, Anderson.
Statistical expertise: Bilukha.
Administrative, technical or material support: Bilukha, Anderson.
Study supervision: Bilukha.
Financial Disclosures: None reported.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.
Additional Contributions: We thank the International Committee of the Red Cross for providing the data on persons injured or killed by landmines and unexploded ordnance in Afghanistan.
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