Long Term Risks to Neonatal Health from Exposure to War-9 Years Long Survey of Reproductive Health and Contamination by Weapon-Delivered Heavy Metals in Gaza, Palestine.

Introduction: High levels of environmental contaminants with long term effects and teratogenic and carcinogenic potential, such as heavy metals, were introduced by weaponry in war areas in the last decades. Poorer reproductive health and increases in non-communicable diseases were reported after wars and are the suspected long term effects of contamination by stable war remnants. Although potentially affecting millions of people, this is still an understudied issue of public health. Background: Gaza, Palestine since 2006 has been an object of repeated severe military attacks that left heavy metals remnants in the environment, in wound tissues and that were assumed by the population. Retrospective studies showed a progressive increase in birth defects since the 2006 attacks. In 2011 we started surveillance at birth alongside analysis of the heavy metals load carried by pregnant women and their babies. Methods: We used protocols for birth registration which also document the extent of exposures to attacks, war remnants and to other environmental risks that allow comparison of 3 data sets-2011, 2016 and 2018-2019 (4000-6000 women in each set). By ICP/MS analysis we determined the content of 23 metals in mothers' hair. Appropriate statistical analysis was performed. Results: Comparison of data in birth registers showed a major increase in the prevalence in birth defects and preterm babies between 2011 and 2016, respectively from 1.1 to 1.8% and from 1.1 to 7.9%, values remaining stable in 2019. Negative outcomes at birth in 2016 up to 2019 were associated with exposure of the mothers to the attacks in 2014 and/or to hot spots of heavy metals contamination. Metal loads since the attacks in 2014 were consistently high until 2018-2019 for barium, arsenic, cobalt, cadmium, chrome, vanadium and uranium, pointing to these metals as potential inducers for the increased prevalence of negative health outcomes at birth since 2016. Conclusions: Bodily accumulation of metals following exposure whilst residing in attacked buildings predispose women to negative birth outcomes. We do not know if the metals act in synergy. Trial for mitigation of the documented negative effects of high metal load on reproductive health, and ensuing perinatal deaths, could now be done in Gaza, based on this documentary record. High load of heavy metals may explain recent increases in non-communicable diseases and cancers at all ages in Gaza. Modern war's legacy of diseases and deaths extends in time to populations and demands monitoring.

Hospital centered surveillance of births in Gaza, Palestine, 2011-2017 and heavy metal contamination of the mothers reveals long-term impact of wars.

Prevalence of preterm, low birth weight and birth defects increased significantly since 2011 in Gaza, Palestine. No change in known co-factors of reproductive health justified this rise. Two military attacks in 2012 and 2014 introduced novel risk factors for outcomes at birth: contamination by teratogenic and carcinogenic heavy metals weapon-remnants, ongoing impoverishment, and impaired rehabilitation of waste management. It was previously shown that mothers exposed to military attacks had higher metal load than those unexposed and mother's heavy metals trans-pass placenta. We investigated association in time of heavy metal contamination and reproductive health using hospital-based surveillance (2011-2016-2017) of births, accompanied by assessment in 2016 of metal load in mother and newborn hair. Mother's housing proximal to unmanaged waste predicted preterm birth and birth defects, and these women had highest load of heavy metals. Poor diet predicted low birth weight. Circumstances prevent investigation of heavy metals molecular impact(s) during fetal development.