This study demonstrates that civilians, males and adolescents and young adults constituted the majority of victims hospitalized for landmines injuries in Erbil governorate. It also revealed that a high proportion of these victims sustained limb amputations with lower limbs more commonly involved. However, upper limb amputations were also relatively common particularly among children. Injuries without limb amputations were also common involving mainly head and face. The hospital mortality rate was relatively low and involved mainly those with severe injuries. The number of hospitalized victims witnessed a steadily decreasing trend between July 1998 and July 2001, followed by prominent increase between July 2002 and July 2003. The highest proportion of admissions was reported in the summer months and the incidents have occurred mainly in areas located along the borders with Iran and Turkey.
This study adds to limited existing knowledge about landmine injuries in Iraq. It provides an insight to the problem through defining its magnitude, the number of victims hospitalized for landmine injuries during the study period and identifying a number of potential risk factors for injury. However, the study has a number of limitations. Data on the circumstances of injury, i.e. type of activity that resulted in the incident, occupation and level of education of victims and type of landmines were not available to be included in the study.
Another major limitation is that only hospitalized victims that had access to EMC were captured, while those with minor injuries, fatal injuries and those had no means or resources to be treated at EMC would not have been captured. Ascertainment that the injury was indeed caused by landmine and not UXO is another limitation of this study. The study was limited to Erbil governorate, whereas landmines are also abundant in the other two governorates of Iraqi Kurdistan; Duhok and Sulaimaniya.
Studies from similar and different contexts agree with the findings that the majority of victims of landmines were males and adolescents or young adults [7, 10]. However, a higher percentage of injured children was reported by other studies ranging between 25% to 46%, which is probably attributed to including UXO injuries that are more common among children [1, 8].
The high percentage of victims sustaining amputation to the lower limbs agrees with another study from Iran, which reported that 54.4% of landmine victims sustained amputation to the lower extremities . This study showed a considerably higher percentage of victims sustaining amputation to the upper extremities as well as injury to head, face and eyes than a previous study from Iraq . The low mortality rate at EMC corresponds to that in hospital setting revealed by studies from other countries . This low rate does not necessarily reflect the actual mortality and severity of landmine injuries as injured patients who managed to reach the hospital may have sustained mild injuries and consequently the prehospital mortality, which is expected to be high, was not included in the study. Two other studies from Iran and Iraqi Kurdistan reported a high pre-hospital mortality rate among landmine casualties of 40% and 36.4%, respectively [14, 15].
The median travel time of 5 hours revealed by this study is one of the most extreme reported travel times. While this study reports that around 38% of victims needed 6 hours or more of travel time to reach EMC, other studies from different contexts have reported that only 25% of victims need 6 hours or more to reach a hospital .
The decrease in number of hospitalized victims of landmine injuries between July 1998 and July 2002 might be attributed to landmine clearance activities and implementation of mine risk education programs. These activities started in Iraqi Kurdistan by a number of non-governmental organizations in mid 1990 s and boosted through the United Nations Mine Action Program during the period from 1999 to 2003. The increase in admission between July 2002 and July 2003 is mainly related to 2003 war and its aftermaths in terms of population movement and return of displaced people to areas used to be dispute areas or military bases. However, the continuous occurrence of hospitalization for landmine injured victims between 2004 and July 2007 suggests that landmines continue to represent an important health and humanitarian concern in Iraqi Kurdsitan.
The highest proportion of hospitalization of landmine injured victims noticed during April, July and August and to less extent in June and September was probably attributed to the social and economic activities undertaken in fields, hills and mountains during these months like outing, food collection, animal husbandry and agricultural work. Similarly, the occurrence of high proportion of hospitalization between 6 am and 7 pm could also be attributed to such activities, a finding which further corroborates the demonstration that most of the landmine affected individuals being productive members of the society, which agrees with the findings of other studies [7, 9, 10].
The effect of landmines goes beyond injury and death of victims to permanent disability of victims; this study revealed that around 72% of victims had suffered a limb amputation and 19 victims had suffered eye injury of which 4 developed blindness. Such permanent disability has profound social and economic adverse effects on the victims, their families, their communities and the local health facilities. Sustaining injuries to upper limbs and other parts including injuries to face suggests that these victims had directly dealt with or handled landmines, which could be either through playing with or trying to dismantle landmines. This finding is further corroborated by the demonstration of a high proportion of upper limp amputations among children of 7-12 years of age in comparison with other age groups. These types of injuries were observed throughout the study period indicating the importance of this issue from socioeconomic and public health point of view.
Areas along the borders and other mountainous areas, where previous military bases are abundant, are important sites for and occurrence of accidents. Areas along the former green zone between Iraqi Kurdistan and the southern part of Iraq have witnessed a considerably high number of landmine accidents since the 2003 War.
In spite of the finding that only 48% of casualties have received first aid treatment at Soran first aid post and that Soran is around 2 hours drive from the EMC, the importance of having such centre functioning properly and professionally should be emphasized. However, the travelling time from different sites of landmine accidents to Soran first aid post is around 3-4 hours. Having first aid posts functioning at different districts and sub-districts may significantly contribute to better management of landmine victims and decreasing pre-hospital mortality rate as reported by other studies .