Post-traumatic stress reactions and doctor-certified sick leave after a workplace terrorist attack: Norwegian cohort study.

OBJECTIVE: To explore the association between the psychosocial work environment and the risk of sick leave among governmental employees with symptom-defined post-traumatic stress disorder (PTSD) after a workplace bomb attack. DESIGN: A prospective study on employees who met the symptom criteria for PTSD. Questionnaire data on the psychosocial work environment 10 months after the terrorist attack was linked to registry data on doctor-certified sick leave in the period 12-22 months after the attack. SETTING: The bombing of the government ministries in Oslo, Norway, 22 July 2011. PARTICIPANTS: The study sample consists of 94 Norwegian governmental employees, all with symptom-defined PTSD from the Norwegian version of the PTSD checklist (Post-traumatic Stress Disorder Checklist-Specific) measured 10 months after the attack. RESULTS: After adjustment for sex and severity of PTSD symptoms, predictability at work reduced the odds of sick leave (adjusted OR=0.62, 95% CI 0.40 to 0.98). Sense of control over decisions at work was associated with fewer absence days for employees with sick leave (adjusted rate ratio=0.61, 95% CI 0.38 to 0.98). CONCLUSIONS: Employees with PTSD after workplace terrorism would benefit from control over their workplace conditions and increased predictability to reduce the risk of sick leave. The findings suggest that the work environment can facilitate employees' work ability after stressful events, independent of severity of PTSD symptoms.

Using the Haddon matrix to explore medical response strategies for terrorist subway bombings.

BACKGROUND: Since the 1970s, terrorist bombings in subways have been frequently occurring worldwide. To cope with this threat and to provide medical response countermeasures, we analyzed the characteristics of subway bombing terrorist attacks and used the Haddon matrix to explore medical response strategies. METHODS: First, we analyzed 111 subway bombings from 1970 to 2017 recorded in the Global Terrorism Database to provide a reference for the strategy exploration. Then, we convened an expert panel to use the Haddon matrix to explore the medical response strategies to subway bombings. RESULTS: In recent decades, at least one bombing attack occurs every 3 years. Summarized by the Haddon matrix, the influencing factors of medical responses to conventional subway bombings include the adequacy of first-aid kits and the medical evacuation equipment, the traffic conditions affecting the evacuation, the continuity and stability of communication, as well as the factors exclusively attributed to dirty bomb attacks in subways, such as ionizing radiation protection capabilities, the structure of the radiation sickness treatment network based on the subway lines, and the disposal of radioactive sewage. These factors form the basis of the strategy discussion. CONCLUSION: Since subway bombings are long-term threats, it is necessary to have proper medical response preparation. Based on the Haddon matrix, we explored the medical response strategies for terrorist subway bombings, especially dirty bomb attacks. Haddon matrix can help policymakers systematically find the most important factors, which makes the preparations of the response more efficient.

Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program.

BACKGROUND: Violent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population. METHODS AND FINDINGS: We developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria's northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities. CONCLUSIONS: The use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.

Thinking that one's life was in danger: perceived life threat in individuals directly or indirectly exposed to terror.

BACKGROUND: Perceived life threat is associated with post-traumatic stress disorder (PTSD). Still, it is not known whether perceived threat may be important for PTSD in people indirectly exposed to trauma. AIMS: To examine the prevalence of perceived life threat and the association with PTSD in individuals directly or indirectly exposed to terror. METHOD: Data are cross-sectional from a survey 10 months after the 2011 Oslo bombing. Perceived life threat was measured by the question: 'How great do you think the danger was that you would die?' scored on a five-point scale. PTSD was measured with the PTSD Checklist (PCL). RESULTS: The retrospective belief that one's life was in great or overwhelming danger was reported by 65% and 22% of employees who had been present or not present, respectively, at the site of the bomb explosion (n = 1923). A high perceived life threat was associated with PTSD among those present (odds ratio (OR) = 5.7, 95% CI 1.9-16.9) and not present (OR = 5.2. 95% CI 3.0-9.0), even after adjusting for objective exposure, demographics and neuroticism. CONCLUSIONS: Perceived life threat may play a central role in the development and maintenance of PTSD in people directly as well as indirectly exposed to terror. Moderating perceptions of having been in serious danger may be an appropriate approach to the prevention and treatment of PTSD.

Psychiatric disorders after terrorist bombings among rescue workers and bombing survivors in Nairobi and rescue workers in Oklahoma City.

BACKGROUND: To examine the prevalence of psychopathology in 52 male rescue workers responding to the 1998 U.S. Embassy bombing in Nairobi, Kenya, comparing them with 176 male rescue workers responding to the 1995 Oklahoma City, Oklahoma, bombing and with 105 directly exposed male civilian survivors of the Nairobi bombing. METHODS: The Diagnostic Interview Schedule/Disaster Supplement assessed pre-disaster and post-disaster psychiatric disorders and variables related to demographics, exposure, disaster perceptions, and coping in all 3 disaster subgroups. RESULTS: The most prevalent post-disaster disorders were posttraumatic stress disorder (PTSD) (22%) and major depressive disorder (MDD) (27%) among Nairobi rescue workers, which were more than 2 and 4 times higher, respectively, than among Oklahoma City rescue workers. Alcohol use disorder was the most prevalent pre- and post-disaster disorder among Oklahoma City rescue workers. Nairobi rescue workers had a prevalence of PTSD and MDD not significantly different from Nairobi civilian survivors. CONCLUSIONS: Nairobi rescue workers were more symptomatic than Oklahoma City rescue workers and were as symptomatic as Nairobi civilian survivors. The vulnerability of Nairobi rescue workers to psychological sequelae may be a reflection of their volunteer, rather than professional, status. These findings contribute to understanding rescue worker mental health, especially among volunteer rescue workers, with potential implications for the importance of professional status of rescue workers in conferring protection from adverse mental health outcomes.

40 years of terrorist bombings - A meta-analysis of the casualty and injury profile.

INTRODUCTION: Terrorists have used the explosive device successfully globally, with their effects extending beyond the resulting injuries. Suicide bombings, in particular, are being increasingly deployed due to the devastating effect of a combination of high lethality and target accuracy. The aim of this study was to identify trends and analyse the demographics and casualty figures of terrorist bombings worldwide. METHODS: Analysis of the Global Terrorism Database (GTD) and a PubMed/Embase literature search (keywords "terrorist", and/or "suicide", and/or "bombing") from 1970 to 2014 was performed. RESULTS: 58,095 terrorist explosions worldwide were identified in the GTD. 5.08% were suicide bombings. Incidents per year are increasing (P<0.01). Mean casualty statistics per incidents was 1.14 deaths and 3.45 wounded from non-suicide incidents, and 10.16 and 24.16 from suicide bombings (p<0.05). The kill:wounded ratio was statistically higher in suicide attacks than non-suicide attacks, 1:1.3 and 1:1.24 respectively (p<0.05). The Middle East witnessed the most incidents (26.9%), with Europe (13.2%) ranked 4th. The literature search identified 41 publications reporting 167 incidents of which 3.9% detailed building collapse (BC), 60.8% confined space (CS), 23.5% open space (OS) and 11.8% semi-confined space (SC) attacks. 60.4% reported on suicide terrorist attacks. Overall 32 deaths and 180 injuries per incident were seen, however significantly more deaths occurred in explosions associated with a BC. Comparing OS and CS no difference in the deaths per incident was seen, 14.2(SD±17.828) and 15.63 (SD±10.071) respectively. However OS explosions resulted in significantly more injuries, 192.7 (SD±141.147), compared to CS, 79.20 (SD±59.8). Extremity related wounds were the commonest injuries seen (32%). DISCUSSION/CONCLUSION: Terrorist bombings continue to be a threat and are increasing particularly in the Middle East. Initial reports, generated immediately at the scene by experienced coordination, on the type of detonation (suicide versus non-suicide), the environment of detonation (confined, open, building collapse) and the number of fatalities, and utilising the Kill:Wounded ratios found in this meta-analysis, can be used to predict the number of casualties and their likely injury profile of survivors to guide the immediate response by the medical services and the workload in the coming days.

Effects of Blast Exposure on Subjective and Objective Sleep Measures in Combat Veterans with and without PTSD.

STUDY OBJECTIVES: This study examined the extent to which self-reported exposure to blast during deployment to Iraq and Afghanistan affects subjective and objective sleep measures in service members and veterans with and without posttraumatic stress disorder (PTSD). METHODS: Seventy-one medication-free service members and veterans (mean age = 29.47 ± 5.76 years old; 85% men) completed self-report sleep measures and overnight polysomnographic studies. Four multivariate analyses of variance (MANOVAs) were conducted to examine the impact of blast exposure and PTSD on subjective sleep measures, measures of sleep continuity, non-rapid eye movement (NREM) sleep parameters, and rapid eye movement (REM) sleep parameters. RESULTS: There was no significant Blast × PTSD interaction on subjective sleep measures. Rather, PTSD had a main effect on insomnia severity, sleep quality, and disruptive nocturnal behaviors. There was no significant Blast × PTSD interaction, nor were there main effects of PTSD or Blast on measures of sleep continuity and NREM sleep. A significant PTSD × Blast interaction effect was found for REM fragmentation. CONCLUSIONS: The results suggest that, although persistent concussive symptoms following blast exposure are associated with sleep disturbances, self-reported blast exposure without concurrent symptoms does not appear to contribute to poor sleep quality, insomnia, and disruptive nocturnal disturbances beyond the effects of PTSD. Reduced REM sleep fragmentation may be a sensitive index of the synergetic effects of both psychological and physical insults.

Combat-related facial burns: analysis of strategic pitfalls.

PURPOSE: Burns constitute approximately 10% of all combat-related injuries to the head and neck region. We postulated that the combat environment presents unique challenges not commonly encountered among civilian injuries. The purpose of the present study was to determine the features commonly seen among combat facial burns that will result in therapeutic challenges and might contribute to undesired outcomes. MATERIALS AND METHODS: The present study was a retrospective study performed using a query of the Burn Registry at the US Army Institute of Surgical Research Burn Center for all active duty facial burn admissions from October 2001 to February 2011. The demographic data, total body surface area of the burn, facial region body surface area involvement, and dates of injury, first operation, and first facial operation were tabulated and compared. A subset analysis of severe facial burns, defined by a greater than 7% facial region body surface area, was performed with a thorough medical record review to determine the presence of associated injuries. RESULTS: Of all the military burn injuries, 67.1% (n = 558) involved the face. Of these, 81.3% (n = 454) were combat related. The combat facial burns had a mean total body surface area of 21.4% and a mean facial region body surface area of 3.2%. The interval from the date of the injury to the first operative encounter was 6.6 ± 0.8 days and was 19.8 ± 2.0 days to the first facial operation. A subset analysis of the severe facial burns revealed that the first facial operation and the definitive coverage operation was performed at 13.45 ± 2.6 days and 31.9 ± 4.1 days after the injury, respectively. The mortality rate for this subset of patients was 32% (n = 10), with a high rate of associated inhalational injuries (61%, n = 19), limb amputations (29%, n = 9), and facial allograft usage (48%, n = 15) and a mean facial autograft thickness of 10.5/1,000th in. CONCLUSIONS: Combat-related facial burns present multiple challenges, which can contribute to suboptimal long-term outcomes. These challenges include prolonged transport to the burn center, delayed initial intervention and definitive coverage, and a lack of available high-quality color-matched donor skin. These gaps all highlight the need for novel anti-inflammatory and skin replacement strategies to more adequately address these unique combat-related obstacles.

Homemade chemical bomb incidents - 15 states, 2003-2011.

Homemade chemical bombs (HCBs) are made from commonly found chemicals. The volume of news reports of HCB explosions suggests they are not uncommon. To determine the number of events involving HCBs in the United States and describe the factors associated with them, the Agency for Toxic Substances and Disease Registry (ATSDR) analyzed data from its surveillance system that tracks spills and leaks of hazardous substances. This report describes the results of that analysis, which indicated that, during 2003-2011, a total of 134 events involving HCBs were reported from 15 states. Among those events, 21 (16%) resulted in adverse health effects (i.e., respiratory symptoms, burns, and skin irritation) for 53 persons. The majority (35 [66%]) of these persons were youths.HCBs are hazardous and especially dangerous if detonated in public areas. Increasing awareness of HCBs and their dangers (particularly during summer months) among first-responders, parents, school staff members and others who work with youths might help reduce injuries associated with HCBs.

Injuries and deaths due to victim-activated improvised explosive devices, landmines and other explosive remnants of war in Nepal.

BACKGROUND: Following more than a decade of civil conflict, Nepal is among the countries affected by landmines, victim-activated improvised explosive devices (IED) and other explosive remnants of war (ERW). OBJECTIVES: To assess the magnitude of injuries due to landmines, victim-activated IED and other ERW in Nepal and to describe epidemiological patterns and risk factors for these events. METHODS: Analysis of surveillance data on civilian injuries due to landmines, victim-activated IED and other ERW between July 2006 and June 2010. Data were collected through active community-based prospective surveillance. RESULTS: Of 307 total casualties, 94 (31%) were female and 169 (55%) were children under 18 years of age. The case-fatality ratio was 14%. The highest number of casualties was in the age group 10-14 years. 233 (76%) injuries were caused by victim-activated IED, 13 (4%) by landmines and 44 (14%) by other ERW. Two types of IED, sutali and socket bombs, caused the majority of injuries (28% and 31%, respectively). 117 (38%) of all injuries occurred in victims' homes and 152 (50%) occurred while victims were tampering with explosive devices. CONCLUSIONS: Substantial numbers of civilians, including women and children, were injured and killed following implementation of the Comprehensive Peace Agreement in 2006. The government of Nepal and humanitarian organisations should continue their efforts to reach communities at highest risk through targeted interventions and nationwide media campaigns to convey the risks of tampering with explosive devices or suspicious objects.

Suicide bombings: process of care of mass casualties in the developing world.

In recent times Pakistan's biggest city, Karachi, has witnessed numerous terrorist attacks. The city does not have an emergency response system and only one of the three public sector hospitals has a trauma centre. We describe the pattern of injuries and management of two terror-related mass casualty incidents involving suicide bombers in a developing nation with limited resources. The first incident occurred in May 2002 with 36 casualties, of whom 13 (36%) died immediately and 11 (30.5%) died at the primary receiving hospitals. The second incident was targeted against the local population in May 2004. The blast resulted in 104 casualties, of which 14 (13.46%) died at the site. All patients had their initial assessment and treatment based on Advanced Trauma and Life Support principles and documented on a trauma form.

The 2006 war and its inter-temporal economic impact on agriculture in Lebanon.

The July 2006 war waged by Israel on Lebanon caused an estimated USD 1 billion of direct (financial) damage to infrastructure. However, it generated also significant indirect (economic/inter-temporal) costs. One sector that suffered considerably in this respect was agriculture, the main source of income for 30-40 per cent of Lebanese. This paper's main objective is to develop a methodology to estimate the total-direct and indirect-cost of the war to agricultural crop production, using an area of south Lebanon as a focal point. The indirect loss assessment viewed inter-temporal reductions in crop production values as the opportunity cost of not working fields due to the presence of unexploded ordnance (UXO). Various crops were evaluated for two scenarios (50 and 100 per cent damage due to UXO) over UXO-clearance periods of five and 10 years. The results indicate that any damage estimates that include only direct losses will under-estimate total losses by 80 and 87 per cent for the five- and 10-year periods, respectively.

Effects of land mines and unexploded ordnance on the pediatric population and comparison with adults in rural Cambodia.

BACKGROUND: This paper was designed to evaluate and compare the impact of explosive war remnants on children versus adults in rural Cambodia. METHODS: A prospective review of trauma database from November 2003 to January 2006 of the Civilian War Victims Surgical Centre in Battambang, Cambodia, run by an Italian NGO called "EMERGENCY" was performed. Age, female ratio, time of evacuation, type of ordnance, pattern of injury, number of operations, transfused patients, hospitalization, mortality, and residual disability were registered and compared. RESULTS: A total of 356 patients acutely wounded by antipersonnel land mines, antitank land mines, or unexploded ordnances (UXO) were admitted. Among these, 94 (26.4%) were children (younger than aged 16 years). Females were more common among children than adults (31.9% vs. 11.8%); 61.7% of children were injured by UXO, whereas 72.1% of adults were victims of antipersonnel land mines. Antitank mines victims were uncommon in both groups. The majority of adults (49.2%) were injured to lower limbs, whereas 50% of children were injured to upper limbs, face, and torso. Random wounds, typical of an explosion in vicinity, were observed in 32.9% of children and 18.7% of adults. All differences were statistically significant (P < 0.005). Time of evacuation, number of operations, and hospitalization did not statistically differ among groups. Number of transfused patients (23% vs. 7.2%), mortality (6.3% vs. 1.5%), incidence of blindness (21.2% vs. 9.5%), and maimed upper limbs (23.3% vs. 8.8%) were significantly higher in children compared with adults (P < 0.05). CONCLUSIONS: Long after ceasefire, antitank mines, antipersonnel land mines, and UXO continue to injure and kill civilians. Children are commonly injured and sustain more severe injuries.

A review of casualties during the Iraqi insurgency 2006--a British field hospital experience.

BACKGROUND: Following the invasion of Iraq in April 2003, British and coalition forces have been conducting counter-insurgency operations in the country. As this conflict has evolved from asymmetric warfare, the mechanism and spectrum of injury sustained through hostile action (HA) was investigated. METHOD: Data was collected on all casualties of HA who presented to the British Military Field Hospital Shaibah (BMFHS) between January and October 2006. The mechanism of injury, anatomical distribution, ICD-9 diagnosis and initial discharge information was recorded for each patient in a trauma database. RESULTS: There were 104 HA casualties during the study period. 18 were killed in action (KIA, 21%). Of the remaining 86 surviving casualties, a further three died of their wounds (DOW, 3.5%). The mean number of diagnoses per survivor was 2.70, and the mean number of anatomical regions injured was 2.38. Wounds to the extremities accounted for 67.8% of all injuries, a percentage consistent with battlefield injuries sustained since World War II. Open wounds and fractures were the most common diagnosis (73.8%) amongst survivors of HA. Improvised explosive devices (IEDs) accounted for the most common cause of injury amongst casualties (54%). CONCLUSIONS: Injuries in conflict produce a pattern of injury that is not seen in routine UK surgical practice. In an era of increasing surgical sub-specialisation, the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. IEDs have become the modus operandi for terrorists. In the current global security situation, these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries is relevant to both military and civilian surgeons.

Analysis of homicidal deaths in district DI Khan: an autopsy study.

BACKGROUND: One of the oldest crimes in human civilization is homicide which started from murder of Abel by the hands of Cane. With the passage of time manner of homicide have been changing. Study of pattern of homicide in any civil society is the first step towards development of intervention to reduce the impact of homicidal crimes. This study was conducted at the department of forensic medicine and toxicology Gomal Medical College DI Khan to know the pattern of the homicides, taking it as the first step in the prevention of crime. METHODS: The present study was conducted over two years 2007-08. The data collected includes all reported unnatural deaths from the urban and rural areas of district on which autopsies were conducted in the district headquarter teaching hospital DI Khan and department of Forensic Medicine and Toxicology, Gomal Medical College DL Khan. RESULTS: Homicidal deaths constituted 259/341 (76%) of all autopsies. Out of these homicides 59.07% were caused by the firearm. The most common firearm weapons were high velocity rifled weapons (AK-47, rifles and pistols). A total of 304 injuries were found in various body regions giving an average of about two injuries per victim/person. The head, neck and face sustained the highest numbers of injuries 100, (32.90%) followed by chest 91 (29.93%) and abdomen 47 (15.4%); the extremities, buttock and genitalia together sustained 65 (21.38 %) injuries. A part from firearm injuries unfortunately in our this study the second highest cause of homicidal deaths was bomb blasts injuries either due to suicide bombers or remote control bombs. The numbers of deaths due to blast injuries were 82 for the year 2007/08 out of total homicidal deaths and percentage was 32.66%. CONCLUSION: The vast majority of homicidal deaths in this area are caused by firearms like other big cities of the province like Peshawar, which bring up issues related to possession of firearms and change in cultural attitude towards the use of firearm, if a decrease in firearm related homicides is desired.

Injury patterns from major urban terrorist bombings in trains: the Madrid experience.

BACKGROUND: Terrorist urban mass casualty incidents (MCI) in the last 3 years have targeted commuter trains at rush hour, producing large numbers of casualties. Civilian care providers are usually not familiar with the types of blast injuries sustained by victims of these MCI. METHODS: We focus on the injury patterns sustained by casualties of the Madrid, 11 March 2004, terrorist bombings, at the seven hospitals that received most victims. Data were gathered of casualties who had injuries other than superficial bruises, transient hearing loss from barotrauma without eardrum perforation, and/or emotional shock. The degree of severity in critical patients was assessed with the ISS. RESULTS: The bombings resulted in 177 immediate fatalities, 9 early deaths, and 5 late deaths. Most survivors had noncritical injuries, but 72 (14%) of 512 casualties assessed had an Injury Severity Score (ISS) >15. The critical mortality rate was of 19.5%. The most frequently injured body regions were the head-neck and face. Almost 50% of casualties had ear-drum perforation, and 60% of them were bilateral. There were 43 documented cases of blast lung injury, with a survival rate of 88.3%. Maxillofacial and open long-bone fractures were most prevalent. Gustillo's grade III of severity predominated in tibia-fibular and humeral fractures. Upper thoracic fractures (D1-6 segment) represented 65% of all vertebral fractures and were associated with severe blast to the torso. Severe burns were uncommon. Eye injuries were frequent, although most were of a mild-to-moderate severity. Abdominal visceral lesions were present in 25 (5%) patients. A multidisciplinary approach was necessary in most operated patients, and orthopedic trauma procedures accounted for 50% of the caseload in the first 24 h. CONCLUSIONS: Ninety-three percent of the fatalities of the Madrid trains terrorist bombings were immediate, and most survivors had noncritical injuries. Closed doors increased the immediate fatality rate in the trains. Severely wounded casualties presented specific patterns of injuries, some of them life-threatening and unusual in other types of trauma mechanisms. Ear-lobe amputations and upper thoracic spine fractures were markers of critical injuries.

Key factors for civilian injuries and deaths from exploding landmines and ordnance.

OBJECTIVE: To identify risk factors for death or injury from landmines and ordnance in Kabul City, Afghanistan, so programs can target preventive actions. METHODS: Active surveillance in hospitals and communities for injuries and deaths from landmine and ordnance explosions in Kabul City. RESULTS: Of the 571 people the authors identified during the 25-month period, 161 suffered a traumatic amputation and 94 were killed from a landmine or ordnance explosion. Of those asked, 19% of victims had received mine awareness education before the incident, and of those, the majority was injured while handling or playing with an explosive device. Most victims were young males with a few years of education. The occupation types most at risk were students and laborers, and unemployment was common among the victims. Collecting wood or paper and playing with or handling an explosive were the most frequent activities associated with injuries and deaths. CONCLUSIONS: From May 1996 to July 1998, explosions from landmines and ordnance claimed 571 victims and were an important preventable cause of injury and death among people in Kabul City. Prevention strategies should focus on high-risk groups and changing risky behaviors, such as tampering with explosive devices.