Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the Global Burden of Disease 2015 study

Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the Global... Int J Public Health (2018) 63 (Suppl 1):S39–S46 https://doi.org/10.1007/s00038-017-1005-2 ORIGINAL ARTICLE Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the Global Burden of Disease 2015 study GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators Received: 1 May 2017 / Revised: 6 June 2017 / Accepted: 21 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract Afghanistan, and Libya; they account for 49.7% of total Objectives We used GBD 2015 findings to measure the DALYs in Syria. burden of intentional injuries in the Eastern Mediterranean Conclusions Our findings call for increased efforts to sta- Region (EMR) between 1990 and 2015. bilize the region and assist in rebuilding the health systems, Methods The Global Burden of Disease (GBD) study as well as increasing transparency and employing preven- defines intentional injuries as a combination of self-harm tive strategies to reduce self-harm and interpersonal (including suicide), interpersonal violence, collective vio- injuries. lence (war), and legal intervention. We estimated number of deaths, years of life lost (YLLs), years lived with dis- Keywords Intentional injuries  Eastern mediterranean ability (YLDs), and disability-adjusted life years (DALYs) region  Burden of disease for each type of intentional injuries. Results In 2015, 28,695 individuals (95% UI: 25,474–37,832) died from self-harm, 35,626 (95% UI: Introduction 20,947–41,857) from interpersonal violence, and 143,858 (95% UI: 63,554–223,092) from collective violence and Intentional injuries accounted for more than 1.4 million legal interventions. In 2015, collective violence and legal deaths and about 4% of total years of life lost (YLLs) in intervention was the fifth-leading cause of DALYs in the 2015 globally (GBD 2015 Mortality and Causes of Death EMR and the leading cause in Syria, Yemen, Iraq, Collaborators 2016). The Global Burden of Disease (GBD) study defines intentional injuries as a combination of self- harm (including suicide), interpersonal violence (such as This article is part of the supplement ‘‘The state of health in the homicide and physical and sexual assault), collective vio- Eastern Mediterranean Region, 1990–2015’’. lence (or war), and legal intervention (such as police enforcement). Intentional injuries are important because, in The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Intentional Injuries Collaborators are listed at theory, intentional injuries can be avoided by intention of the end of the article. Ali H. Mokdad, on behalf of GBD 2015 Eastern human beings; this is not the case for most of the other Mediterranean Region Intentional Injuries Collaborators, is the injuries and diseases. In spite of this fact, about 30% of all corresponding author. global deaths from injuries in 2015 were intentional, and Electronic supplementary material The online version of this suicide and homicide were among the top 10 leading article (doi:10.1007/s00038-017-1005-2) contains supplementary causes of deaths in 15–49-year-old individuals (GBD 2015 material, which is available to authorized users. Mortality and Causes of Death Collaborators 2016; Insti- & GBD 2015 Eastern Mediterranean Region Intentional tute for Health Metrics and Evaluation (IHME) 2017). Injuries Collaborators Conflict obviously increases deaths and injuries on the mokdaa@uw.edu battlefield, and also affects health due to the displacement of populations, the breakdown of health and social Institute for Health Metrics and Evaluation, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USA 123 S40 GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators services, and the heightened risk of disease transmission information on input sources of data are available else- (Murray et al. 2002). where (GBD 2015 Mortality and Causes of Death Col- The Eastern Mediterranean Region (EMR) has had laborators 2016). We used the standard CODEm modeling several conflicts and unrests in the past years; such events approach to estimate deaths due to intentional causes of have huge impact on all types of intentional injuries. A injuries, excluding collective violence and legal interven- study in Tunisia showed an increase by 1.7 times in self- tion. This cause was modeled solely outside of the CODEm harm and 1.3 times in homicide after the Tunisian Revo- process as fatal discontinuities estimation (or mortality lution in 2011 (Ben Khelil et al. 2016). The effect of shock regression). conflicts and social unrest on collective violence and legal The output mortality estimates were used to calculate intervention is obvious. Intentional injuries such as suicide years of life lost (YLLs) for each cause of death. are usually underreported due to cultural and religious norms. Previous studies reported on the burden of disease Cause-of-injury incidence; input data and modeling in the region but did not focus on intentional injuries (Mokdad et al. 2014, 2016). To better estimate the burden The majority of incidence data exist at the external cause- of intentional injures, we used the GBD 2015 study to of-injury level, i.e., E-codes. Incidence for cause-of-injury report the mortality, morbidity, and burden of intentional categories was modeled using DisMod-MR 2.1 for self- injuries in EMR countries from 1990 to 2015. harm and interpersonal violence. DisMod-MR 2.1 is a descriptive epidemiological meta- regression tool that uses the integrative systems modeling Methods approach to produce simultaneous estimates of disease incidence, prevalence, remission, and mortality. Multiple The 2015 Global Burden of Disease (GBD 2015) covered datasets from hospital, emergency/outpatient departments, 249 causes of death and 310 non-fatal diseases and injuries. and survey datasets are fed into these incidence models. GBD 2015 reported the burden for 195 countries or terri- We separately estimated inpatient and outpatient injuries. tories, 21 regions, and seven super-regions for the To estimate incidence from the shock cause-of-injury 1990–2015 time period. The general methodology of GBD categories (collective violence and legal intervention), the 2015 has been detailed elsewhere (GBD 2015 DALYs and mortality rate for these cause-of-injury categories was HALE Collaborators 2016; GBD 2015 Disease and Injury multiplied by the average country-year-age-sex-specific Incidence and Prevalence Collaborators 2016; Haagsma incidence-to-mortality ratios within several cause-of-in- et al. 2016; GBD 2015 Mortality and Causes of Death jury categories that likely exhibit similar case fatality ra- tios (such as road injuries, fires, interpersonal violence, and Collaborators 2016). The EMR contains 22 countries: Afghanistan, Bahrain, other unintentional injuries) (GBD 2015 Disease and Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Injury Incidence and Prevalence Collaborators 2016; Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Haagsma et al. 2016). Arabia, Somalia, Sudan, Syria, Tunisia, United Arab We imposed a hierarchy to select the nature-of-injury Emirates, and Yemen. category that leads to the largest burden when an individual We classified intentional injuries as self-harm, inter- experiences multiple injuries. Then, we separated matrices personal violence (which includes physical violence by (for inpatient and outpatient injuries) to estimate the pro- firearm, sharp objects, or other means) and ‘‘collective portions of incident cases in each of the cause-of-injury violence and legal intervention.’’ Collective violence categories that resulted in each of the nature-of-injury includes wars, terrorism, and other violent political con- categories (N-codes). We produced incidence of inpatient flicts within or between states, state-perpetrated violence and outpatient injuries by cause and nature of injury. Then (such as genocide, repression, disappearances, torture, and we estimated short-term disability by nature-of-injury cat- other abuses of human rights), and organized violent egory for all incident cases of inpatient and outpatient crimes such as gang warfare (WHO 2014). We estimated injuries. We estimated the average duration for each nat- fatal and non-fatal intentional injuries to calculate dis- ure-of-injury category and derived short-term prevalence ability-adjusted life years (DALYs). by multiplying incidence and duration. We then applied DisMod-MR 2.1 to estimate the long- Mortality input data and cause of death models term prevalence for each combination of cause-of-injury and nature-of-injury from incidence and the long-term We estimated injury mortality from different sources (vi- mortality risk in cases with long-term disability. After tal registration, verbal autopsy, mortality surveillance, correction for comorbidity with other non-fatal diseases, censuses, surveys, and police record data). More YLDs were calculated as prevalence times a disability 123 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the… S41 weight. More details on the process are available elsewhere (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016; Haagsma et al. 2016). Disability-adjusted life years (DALYs) were calculated for each type of injury through summation of YLLs and YLDs (GBD 2015 DALYs and HALE Collaborators 2016). Uncertainty We have propagated uncertainty from all different sources 5 such as input data or adjustment process, using standard GBD methods of repeating all calculations 1000 times, African Eastern European Americas South-East Asia Western Pacific Mediterranean each time drawing from distributions rather than point WHO regions estimates for all the relevant parameters in our models. We Self-harm Interpersonal violence Collecve violence and legal intervenon then used 2.5th and 97.5th percentiles as the lower and Fig. 1 Age-standardized death rates (ASDR) per 100,000 from self- upper bounds of the 95% uncertainty interval (UI). For the harm, interpersonal violence, and collective violence and legal injury mortality estimates, the estimation of model uncer- intervention (Global Burden of Disease 2015 study, WHO Regions, tainty is inherent to the ensemble modeling method. Some 2015) of the rates that we present are age-standardized using the GBD standard population (GBD 2015 DALYs and HALE the Americas and African regions, and higher than the Collaborators 2016; GBD 2015 Disease and Injury Inci- other WHO regions. However, the ASDR of collective dence and Prevalence Collaborators 2016; Haagsma et al. violence and legal intervention (21.5 per 100,000 popula- 2016; GBD 2015 Mortality and Causes of Death Collab- tion, 95% UI: 9.3–33.5) was much higher in the EMR than orators 2016). other WHO regions (Fig. 1). The patterns for all-age death rates were relatively similar. Total number of deaths due to intentional injuries (self- Results harm, interpersonal violence, collective violence and legal intervention) showed an increasing trend between 1990 and In 2015 in the EMR, 28,695 individuals (95% UI: 2015 in the EMR (Fig. 2); the most important increase was 25,474–37,832) died from self-harm, 35,626 individuals observed between 2010 and 2015, and was mainly due to (95% UI: 20,947–41,857) from interpersonal violence, and collective violence and legal intervention. 143,858 individuals (95% UI: 63,554–223,092) from col- Figure 3 shows the age–sex distribution of deaths due to lective violence and legal intervention. These numbers different types of intentional injuries in the EMR (2015). show a significant increase from those in 1990, accounting Males had higher rates, except for the youngest and oldest for a 100% increase in self-harm, 152% increase for age groups. Among males, the mortality was considerably interpersonal violence, and 1027% increase for collective higher in people aged 20–24 years. Girls under 5 years old violence and legal intervention. In comparison, during the had a higher mortality from intentional injuries (Fig. 3) same time, the number of deaths in other parts of the world The highest ASDR of self-harm was observed in men of due to self-harm and interpersonal violence increased by 19 Djibouti, Somalia, and Afghanistan, and women of and 12%, respectively, and decreased by 67% for collective violence and legal intervention. Male to female ratio of 250,000 deaths in 2015 in EMR was 2.4 for self-harm, 4.0 for 200,000 interpersonal violence, and 3.3 for collective violence and legal interventions. 150,000 Among the total number of deaths in the EMR due to 100,000 interpersonal violence, firearms and sharp objects accoun- ted for 14,158 (8782–17,306) and 7195 (3758–10,864) 50,000 deaths, respectively, in 2015. In 2015, the age-standardized death rate (ASDR) of self- 1990 1995 2000 2005 2010 2015 Years harm in the EMR (5.1 per 100,000, 95% UI: 4.6–6.6) was Self-harm Interpersonal violence Collecve violence and legal intervenon lower than that of all other World Health Organization regions (Fig. 1), and the ASDR of interpersonal violence in Fig. 2 Number of deaths due to intentional injuries (Global Burden the EMR (5.7 per 100,000, 95% UI: 3.8–6.6) was less than of Disease 2015 study, Eastern Mediterranean Region, 1990–2015) Number of deaths ASDR per 100,000 S42 GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators Female Male Fig. 5 Age-standardized death rates (ASDR) from interpersonal violence (per 100,000 population), for men and women in the countries of the Eastern Mediterranean Region (Global Burden of Fig. 3 Age–sex distribution of deaths due to intentional injuries Disease 2015 study, Eastern Mediterranean countries, 2015) (Global Burden of Disease 2015 study, Eastern Mediterranean Region, 2015) Female Male Fig. 6 Age-standardized death rates (ASDR) for collective violence and legal intervention (per 100,000 population), for men and women in the countries of the Eastern Mediterranean Region (Global Burden Female Male of Disease 2015 study, Eastern Mediterranean countries, 2015) Fig. 4 Age-standardized death rates (ASDR) from self-harm per Afghanistan, and Palestine. The lowest median percentage 100,000 men and women in the countries of the Eastern Mediter- was in Saudi Arabia, followed by Egypt and Oman (e- ranean Region (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 2015) Table 1). In 2015, collective violence and legal intervention was Somalia, Djibouti, and Iraq (Fig. 4). Afghanistan, Iraq, and the fifth-leading cause of DALYs in the EMR, the first- Somalia had the highest ASDR of interpersonal violence leading cause of DALYs in five countries (Syria, Yemen, for both men and women (Fig. 5). The highest ASDR of Iraq, Afghanistan, and Libya), and the second-leading collective violence and legal interventions was observed in cause in Lebanon. In Syria, 49.7% of total DALYs (95% Syria, Afghanistan, and Iraq for both sexes (Fig. 6). Syria UI: 30.8–62.2) in 2015 were due to collective violence and had an ASDR of 138.2 per 100,000 for women (95% UI: legal intervention. 48.8–228.2) and 478.0 per 100,000 for men (168.8–789.0) for collective violence and legal intervention in 2015. DALYs from self-harm, interpersonal violence, and Discussion collective violence and legal intervention in 2015 totaled 1,425,494 (95% UI: 1,258,222–1901,949), 1,997,224 (95% Our study showed that the burden of intentional injuries is UI: 1,184,027–2,325,345), and 10,107,643 (95% UI: increasing rapidly in the EMR. It is not a surprise that the 5,381,404–14,787,629), respectively. YLLs were the main burden of collective violence and legal intervention has component of DALYs for all kinds of intentional injuries; increased dramatically in the last few years and is currently YLLs accounted for more than 98.5% of DALYs for self- higher than rest of the world due to the unrest in the region. harm and interpersonal violence and 85.9% of DALYs for However, our study showed a rise in self-harm and inter- collective violence and legal intervention. personal violence during the same time period that was Lebanon had the highest median percentage of total much faster than in other parts of the world. Clearly the DALYs from intentional injuries, followed by Iraq, unrest and conflicts are causing deaths due to collective ASDR of self-harm per 100,000 ASDR of collecve violence and legal ASDR of interpersonal violence per 100,000 intervenons per 100,000 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the… S43 violence and legal interventions, but they are also corre- show some differences from other regions of the world. lated with increased burden from self-harm and other dis- Hanging and poisoning are the most common methods of eases (Murray et al. 2002; Ben Khelil et al. 2016). All suicide; however, there are also differences between and countries with the highest mortality rates of self-harm and even within countries (Morovatdar et al. 2013). These are interpersonal violence (Afghanistan, Somalia, Djibouti, important because there are specific interventions to pre- and Iraq) have been affected by multiple episodes of civil vent each type of suicide. Many of the preventive strategies or inter-state wars and social unrest, as well as terrorism focus on finding individuals who are at higher risk of during 1990–2015. Our study calls for efforts to stabilize suicide attempts, such as those with mental illness after the region politically and reduce the burden of disease due discharge from a hospital (Ghanbari et al. 2015). In Iran, to the current situations. some trials have been done to integrate suicide prevention Young men are the most typical victims of intentional services into primary health care (PHC), which increases injuries, especially interpersonal and collective violence. universal access to and sustainability of these services This pattern is relatively similar to other regions of the world (Malakouti et al. 2015b, c). (Degutis 2013). Girls and boys under 5 years old had a large Interpersonal violence is an important cause of DALYs in share of total deaths due to collective violence. This might be some of the countries of the EMR, especially Afghanistan, due to their generally higher vulnerability in emergency Iraq, Somalia, and Djibouti. It is not always easy to separate situations. Like the pre-conflict state, mortality is higher interpersonal violence from collective violence, especially among children than individuals over 5 years during a con- when a civil war is taking place. In this study, firearms had a flict; however, individuals over 5 are usually affected more major contribution to total deaths from interpersonal inju- than young children. In other words, while the general ries. Although having a gun is illegal in most of the countries mortality rate of children under 5 is around ten times that of of the region, having access to weapons is not difficult in individuals over 5 in pre-conflict states, it decreases to countries such as Afghanistan and Iraq (after being involved around double during a conflict state (Guha-Sapir and Pan- in civil wars for several years). huis 2004). The age pattern of deaths due to collective vio- Our study has some limitations. First, reports on inten- lence might be related to several factors such as type of war tional injuries (especially self-harm and legal intervention) (for instance, civil wars versus inter-state wars) and main are subject to underreporting or even being covered up in types of arms involved (individual light weapons compared many countries. We used the general GBD methodology to to heavy artillery and weapons of mass destruction). address underreporting of deaths; however, underreporting The absolute and relative importance of direct injuries might be different for specific causes of deaths. Second, the from collective violence and legal intervention has number of war victims is not usually accurate due to poor health information systems and political considerations of increased significantly in the region in recent years. Although the region has experienced several conflicts in reporting; many of the countries involved in conflicts do not recent decades, the Syrian war has increased deaths and have a reliable health information system even in their pre- burden of collective violence significantly in recent years. conflict states. Third, we did not evaluate the indirect effects The total burden imposed by war is certainly higher of collective violence (war) on health workforce, infras- because it also indirectly increases death and disability tructure, and food security. These factors can considerably from other diseases. On the other hand, the number of increase the attributable burden to war. Finally, we did not people who died from a war is not limited to the time account for the impact of the influx of refugees on the health period of its occurrence. Previous studies show that several systems and disease burden of the host countries. years after termination of wars, people are at higher risk of death due to its consequences such as remaining land Conclusions mines. In addition, some people suffer from the long-term complications of injuries such as amputations and spinal Our study documented the burden of intentional injuries cord injury for years after war and are at risk of premature due to the conflicts and unrest in the EMR. Moreover, we death for the same reasons (Mousavi et al. 2014). showed an increased burden from other intentional injuries In this study, mortality and burden of self-harm in the at the same time. Our findings call for increased efforts to EMR were lower than in other regions of the world. stabilize the region and assist in rebuilding the health Although religious and cultural beliefs might have con- systems, as well as increasing transparency and employing tributed to these low rates, the burden of self-harm also preventive strategies to reduce self-harm and interpersonal might be affected by cultural and religious barriers, social injuries. stigma, and legal punishments that encourage victims, GBD 2015 Eastern Mediterranean Region Intentional Injuries families, and governments to hide the information Collaborators: Ali H. Mokdad, PhD (corresponding author), (Malakouti et al. 2015a). Methods of suicide in the EMR 123 S44 GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators Institute for Health Metrics and Evaluation, University of Washing- Observatory, Instituto Nacional de Salud, Bogota, Colombia, Epi- ton, Seattle, Washington, United States. Maziar Moradi-Lakeh, MD, demiology and Public Health Evaluation Group, Public Health Department of Community Medicine, Preventative Medicine and Department, Universidad Nacional de Colombia, Bogota, Colombia. Public Health Research Center, Gastrointestinal and Liver Disease Koustuv Dalal, PhD, Centre for Injury Prevention and Safety Pro- Research Center (GILDRC), Iran University of Medical Sciences, motion, School of Health and Medical Sciences, Orebro University, Tehran, Iran. Raghid Charara, MD, American University of Beirut, Orebro, Sweden. Hadi Danawi, PhD, Walden University, Min- Beirut, Lebanon. Charbel El Bcheraoui, PhD, Institute for Health neapolis, Minnesota, United States. Diego De Leo, DSc, Griffith Metrics and Evaluation, University of Washington. Ibrahim Khalil, University, Brisbane, Queensland, Australia. Samath D. Dharmaratne, PhD, Institute for Health Metrics and Evaluation, University of MD, Department of Community Medicine, Faculty of Medicine, Washington. Ashkan Afshin, MD, Institute for Health Metrics and University of Peradeniya, Peradeniya, Sri Lanka. Shirin Djalalinia, Evaluation, University of Washington, Seattle, WA, United States. PhD, Undersecretary for Research & Technology, Ministry of Health Nicholas J. Kassebaum, MD, Institute for Health Metrics and Eval- & Medical Education, Tehran, Iran. Kerrie E. Doyle, PhD, RMIT uation, University of Washington, Seattle, Washington, United States, University, Bundoora, VIC, Australia; Australian National Univer- Department of Anesthesiology & Pain Medicine, Seattle Children’s sity, Canberra, ACT, Australia. Alireza Esteghamati, MD, Hospital, Seattle, Washington, United States. Michael Collison, BS, Endocrinology and Metabolism Research Center, Tehran University Institute for Health Metrics and Evaluation, University of Washing- of Medical Sciences, Tehran, Iran. Andre´ Faro, PhD, Federal ton, Seattle, Washington, United States. Adrienne Chew, ND, Insti- University of Sergipe, Aracaju, Sergipe, Brazil. Maryam S. Farvid, tute for Health Metrics and Evaluation, University of Washington. PhD, Department of Nutrition, Harvard T. H. Chan School of Public Kristopher J. Krohn, BA, Institute for Health Metrics and Evaluation, Health, Harvard University, Boston, MA, United States, Harvard/ University of Washington, Seattle, Washington, United States. Farah MGH Center on Genomics, Vulnerable Populations, and Health Daoud, BA/BS, Institute for Health Metrics and Evaluation, Univer- Disparities, Mongan Institute for Health Policy, Massachusetts Gen- sity of Washington. Danny Colombara, PhD, Institute for Health eral Hospital, Boston, MA, United States. Seyed-Mohammad, Metrics and Evaluation, University of Washington. Nicholas Graetz, Fereshtehnejad, PhD, Department of Neurobiology, Care Sciences MPH, Institute for Health Metrics and Evaluation, University of and Society (NVS), Karolinska Institutet, Stockholm, Sweden. Flo- Washington, Seattle, Washington, United States. Michael Kutz, BS, rian Fischer, PhD, School of Public Health, Bielefeld University, Institute for Health Metrics and Evaluation, University of Washing- Bielefeld, Germany. Tsegaye Tewelde Gebrehiwot, MPH, Jimma ton. Haidong Wang, PhD, Institute for Health Metrics and Evaluation, University, Jimma, Ethiopia. Reyna A. Gutierrez, PhD, National University of Washington, Seattle, Washington, United States. Foa- Institute of Psychiatry Ramon de la Fuente, Mexico City, Mexico. d Abd-Allah, MD, Department of Neurology, Cairo University, Nima Hafezi-Nejad, MD, Endocrinology and Metabolism Research Cairo, Egypt. Laith J. Abu-Raddad, PhD, Infectious Disease Epi- Center, Tehran University of Medical Sciences, Tehran, Iran. Randah demiology Group, Weill Cornell Medical College in Qatar, Doha, Ribhi Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. Qatar. Aliasghar Ahmad Kiadaliri, PhD, Department of Clinical Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund Dubai, United Arab Emirates. Josep Maria Haro, MD, Parc Sanitari University, Lund, Sweden. Muktar Beshir Ahmed MPH, College of Sant Joan de De´u—CIBERSAM, Sant Boi de Llobregat (Barcelona), Health Sciences, Department of Epidemiology, ICT and e-Learning Spain. Delia Hendrie, MA, Centre for Population Health Research, Coordinator, Jimma University, Jimma, Ethiopia. Khurshid Alam, Curtin University, Bentley, Western Australia, Australia. Guoqing PhD, Murdoch Childrens Research Institute, The University of Mel- Hu, PhD, Department of Epidemiology and Health Statistics, School bourne, Parkville, Victoria, Australia, The University of Melbourne, of Public Health, Central South University, Changsha, China. Jost B. Melbourne, VIC, Australia, The University of Sydney, Sydney, NSW, Jonas, MD, Department of Ophthalmology, Medical Faculty Man- Australia. Suliman Alghnam, PhD, King Abdulah International nheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany. Medical Research Center, Riyadh, Saudi Arabia; Center For Injury Amir Kasaeian, PhD, Hematology-Oncology and Stem Cell Trans- Research and Policy, Bloomberg School of Public Health, Johns plantation Research Center, Tehran University of Medical Sciences, Hopkins University, Baltimore, MD, United States. Reza Alizadeh- Tehran, Iran; Endocrinology and Metabolism Population Sciences Navaei, PhD, Gastrointestinal Cancer Research Center, Mazandaran Institute, Tehran University of Medical Sciences, Tehran, Iran. Peter University of Medical Sciences, Mazandaran, Iran. Rajaa Al-Raddadi Njenga Keiyoro, PhD, Institute of Tropical and Infectious Diseases, PhD, Joint Program of Family and Community Medicine, Jeddah, Nairobi, Kenya, School of Continuing and Distance Education, Saudi Arabia. Khalid A. Altirkawi, MD, King Saud University, Nairobi, Kenya. Yousef Saleh Khader, ScD, Department of Com- Riyadh, Saudi Arabia. Nahla Anber, PhD, Mansoura University, munity Medicine, Public Health and Family Medicine, Jordan Mansoura, Egypt. Palwasha Anwari, MD, Self-employed, Kabul, University of Science and Technology, Irbid, Jordan. Ejaz Ahmad Afghanistan. Leticia Avila-Burgos, PhD, National Institute of Public Khan, MD, Health Services Academy, Islamabad, Pakistan. Jagdish Health, Cuernavaca, Mexico. Ashish Awasthi, PhD, Sanjay Gandhi Khubchandani, PhD, Department of Nutrition and Health Science, Postgraduate Institute of Medical Sciences, Lucknow, India. Alek- Ball State University, Muncie, Indiana, United States. Jacek A. sandra Barac, PhD, Faculty of Medicine, University of Belgrade, Kopec, PhD, University of British Columbia, Vancouver, BC, Belgrade, Serbia. Suzanne L. Barker-Collo, PhD, School of Psy- Canada. Heidi J. Larson, PhD, Department of Infectious Disease chology, University of Auckland, Auckland, New Zealand. Neeraj Epidemiology, London School of Hygiene & Tropical Medicine, Bedi, MD, College of Public Health and Tropical Medicine, Jazan, London, United Kingdom; Institute for Health Metrics and Evalua- Saudi Arabia. Zulfiqar A. Bhutta, PhD, Centre of Excellence in tion, University of Washington, Seattle, Washington, United States. Women and Child Health, Aga Khan University, Karachi, Pakistan, Asma Abdul Latif, PhD, Department of Zoology, Lahore College for Centre for Global Child Health, The Hospital for Sick Children, Women University, Lahore, Pakistan. Cheru Tesema Leshargie, Toronto, ON, Canada. Rohan Borschmann, PhD, The University of MPH, Debre Markos University, Debre Markos, Ethiopia. Raimundas Melbourne, Melbourne, VIC, Australia, Murdoch Childrens Research Lunevicius, PhD, Aintree University Hospital National Health Ser- Institute, Melbourne, VIC, Australia. Soufiane Boufous, PhD, vice Foundation Trust, Liverpool, United Kingdom, School of Med- Transport and Road Safety (TARS) Research, University of New icine, University of Liverpool, Liverpool, United Kingdom. South Wales, Sydney, New South Wales, Australia. Zahid A. Butt, Mohammed Magdy Abd El Razek, MBBCH, Aswan University PhD, Al Shifa Trust Eye Hospital, Rawalpindi, Punjab, Pakistan. Hospital, Aswan Faculty of Medicine, Aswan, Egypt. Azeem Majeed, Carlos A. Castan˜eda-Orjuela, MSc, Colombian National Health MD, Department of Primary Care & Public Health, Imperial College 123 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the… S45 London, London, England, United Kingdom. Reza Malekzadeh, MD, Anesthesiology, University of Virginia, Charlottesville, VA, United Digestive Diseases Research Institute, Tehran University of Medical States, Department of Anesthesiology, King Fahad Medical City, Sciences, Tehran, Iran; Digestive Diseases Research Institute, Tehran Riyadh, Saudi Arabia; Outcomes Research Consortium, Cleveland University of Medical Sciences, Tehran, Iran. Ziad A. Memish, MD, Clinic, Cleveland, OH, United States. RomanTopor-Madry, PhD, Saudi Ministry of Health, Riyadh, Saudi Arabia, College of Medicine, Institute of Public Health, Faculty of Health Sciences, Jagiellonian Alfaisal University, Riyadh, Saudi Arabia. Tuomo J. Meretoja, PhD, University Medical College, Krako´w, Poland; Faculty of Health Sci- Comprehensive Cancer Center, Breast Surgery Unit, Helsinki ences, Wroclaw Medical University, Wroclaw, Poland. Kingsley University Hospital, Helsinki, Finland; University of Helsinki, Hel- Nnanna Ukwaja, MD, Department of Internal Medicine, Federal sinki, Finland. Ted R. Miller, PhD, Pacific Institute for Research & Teaching Hospital, Abakaliki, Ebonyi State, Nigeria. Olalekan A. Evaluation, Calverton, MD, United States; Centre for Population Uthman, PhD, Warwick Medical School, University of Warwick, Health, Curtin University, Perth, Western Australia, Australia. Shafiu Coventry, United Kingdom. Mehdi Yaseri, PhD, Tehran University of Mohammed, PhD; Health Systems and Policy Research Unit, Ahmadu Medical Sciences, Terhan, Iran, Ophthalmic Research Center, Shahid Bello University, Zaria, Kaduna, Nigeria, Institute of Public Health, Beheshti University of Medical Sciences, Tehran, Iran. Naohi- Heidelberg University, Heidelberg, Germany. Carla Makhlouf Ober- roYonemoto, MPH, Department of Biostatistics, School of Public meyer, DSc, Center for Research on Population and Health, Faculty of Health, Kyoto University, Kyoto, Japan. Mustafa Z. Younis, DrPH, Health Sciences, American University of Beirut, Beirut, Lebanon. Jackson State University, Jackson, MS, United States. Aisha O. Felix Akpojene Ogbo, MPH, Centre for Health Research, Western Jumaan, PhD, Independent Consultant, Seattle, Washington, United Sydney University, Sydney, New South Wales, Australia. Michael States. Theo Vos, PhD, Institute for Health Metrics and Evaluation, Robert Phillips, MD, Shanghai Jiao Tong University School of Med- University of Washington, Seattle, Washington, United States. Simon icine, Shanghai, China; Emory University, Atlanta, Georgia, United I. Hay, DSc, Oxford Big Data Institute, Li Ka Shing Centre for Health States. Farshad Pourmalek, PhD, University of British Columbia, Information and Discovery, University of Oxford, Oxford, United Vancouver, British Columbia, Canada. Mostafa Qorbani, PhD, Non- Kingdom, Institute for Health Metrics and Evaluation, University of communicable Diseases Research Center, Alborz University of Washington, Seattle, Washington, United States. Mohsen Naghavi, Medical Sciences, Karaj, Iran. Amir Radfar, MD, A T Still University, PhD, Institute for Health Metrics and Evaluation, University of Kirksville, MO, United States. Anwar Rafay, MS, Contech Interna- Washington, Seattle, Washington, United States. Christopher J. tional Health Consultants, Lahore, Pakistan, Contech School of Public L. Murray, DPhil, Institute for Health Metrics and Evaluation, Health, Lahore, Pakistan. Afarin Rahimi-Movaghar, MD, Iranian University of Washington, Seattle, Washington, United States. National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran. Vafa Rahimi-Movaghar, MD, Sina Compliance with ethical standards Trauma and Surgery ResearchCenter, Tehran University of Medical Sciences, Tehran, Iran. Rajesh Kumar Rai, MPH, Society for Health Ethical standards This manuscript reflects original work that has not and Demographic Surveillance, Suri, West Bengal, India. David Laith previously been published in whole or in part and is not under con- Rawaf, MD, WHO Collaborating Centre, Imperial College London, sideration elsewhere. All authors have read the manuscript and have London, United Kingdom; North Hampshire Hospitals, Basingstroke, agreed that the work is ready for submission and accept responsibility United Kingdom, University College London Hospitals, London, for its contents. United Kingdom. Salman Rawaf, MD, Imperial College London, London, United Kingdom. Satar Rezaei, PhD, School of Public Ethics statements The authors of this paper have complied with all Health, Kermanshah University of Medical Sciences, Kermanshah, ethical standards and do not have any conflicts of interest to disclose Iran. Mohammad Sadegh Rezai, MD, Mazandaran University of at the time of submission. The funding source played no role in the Medical Sciences, Sari, Iran. Gholamreza Roshandel, PhD, Golestan design of the study, the analysis and interpretation of data, and the Research Center of Gastroenterology and Hepatology, Golestan writing of the paper. The study did not involve human participants University of Medical Sciences, Gorgan, Iran; Digestive Diseases and/or animals; therefore, no informed consent was needed. Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Mahdi Safdarian, MD, Sina Trauma & Surgery Research Center, Funding This research was funded by the Bill & Melinda Gates Tehran, Iran. Saeid Safiri, PhD, Managerial Epidemiology Research Foundation. Center, Department of Public Health, School of Nursing and Mid- wifery, Maragheh University of Medical Sciences, Maragheh, Iran. Conflict of interest The authors declare that they have no conflicts of Payman Salamati, MD, Sina Trauma and Surgery Research Center, interest at this time. Tehran University of Medical Sciences, Tehran, Iran. Abdallah M. Samy, PhD, Ain Shams University, Cairo, Egypt Lawrence Kansas, Open Access This article is distributed under the terms of the United States. Benn Sartorius, PhD, Public Health Medicine, School of Creative Commons Attribution 4.0 International License (http://crea Nursing and Public Health, University of Kwa Zulu-Natal, Durban, tivecommons.org/licenses/by/4.0/), which permits unrestricted use, South Africa; UKZN Gastrointestinal Cancer Research Centre, South distribution, and reproduction in any medium, provided you give African Medical Research Council (SAMRC), Durban, South Africa. appropriate credit to the original author(s) and the source, provide a Soraya Seedat, PhD, Stellenbosch University, Cape Town, South link to the Creative Commons license, and indicate if changes were Africa. Sadaf G. Sepanlou, PhD, Digestive Diseases Research Insti- made. tute, Tehran University of Medical Sciences, Tehran, Iran. Masood Ali Shaikh, MD, Independent Consultant, Karachi, Pakistan. Badr H. A. Sobaih, MD, King Saud University, Riyadh, Saudi Arabia. Karen References M. 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Collective compare data visualization. http://vizhub.healthdata.org/gbd- violence, Chap 8. http://www.who.int/violence_injury_preven compare. Accessed 24 Mar 2017 tion/violence/world_report/chapters/en/. Accessed 12 Jul 2017 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Public Health Springer Journals

Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the Global Burden of Disease 2015 study

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Abstract

Int J Public Health (2018) 63 (Suppl 1):S39–S46 https://doi.org/10.1007/s00038-017-1005-2 ORIGINAL ARTICLE Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the Global Burden of Disease 2015 study GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators Received: 1 May 2017 / Revised: 6 June 2017 / Accepted: 21 June 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract Afghanistan, and Libya; they account for 49.7% of total Objectives We used GBD 2015 findings to measure the DALYs in Syria. burden of intentional injuries in the Eastern Mediterranean Conclusions Our findings call for increased efforts to sta- Region (EMR) between 1990 and 2015. bilize the region and assist in rebuilding the health systems, Methods The Global Burden of Disease (GBD) study as well as increasing transparency and employing preven- defines intentional injuries as a combination of self-harm tive strategies to reduce self-harm and interpersonal (including suicide), interpersonal violence, collective vio- injuries. lence (war), and legal intervention. We estimated number of deaths, years of life lost (YLLs), years lived with dis- Keywords Intentional injuries  Eastern mediterranean ability (YLDs), and disability-adjusted life years (DALYs) region  Burden of disease for each type of intentional injuries. Results In 2015, 28,695 individuals (95% UI: 25,474–37,832) died from self-harm, 35,626 (95% UI: Introduction 20,947–41,857) from interpersonal violence, and 143,858 (95% UI: 63,554–223,092) from collective violence and Intentional injuries accounted for more than 1.4 million legal interventions. In 2015, collective violence and legal deaths and about 4% of total years of life lost (YLLs) in intervention was the fifth-leading cause of DALYs in the 2015 globally (GBD 2015 Mortality and Causes of Death EMR and the leading cause in Syria, Yemen, Iraq, Collaborators 2016). The Global Burden of Disease (GBD) study defines intentional injuries as a combination of self- harm (including suicide), interpersonal violence (such as This article is part of the supplement ‘‘The state of health in the homicide and physical and sexual assault), collective vio- Eastern Mediterranean Region, 1990–2015’’. lence (or war), and legal intervention (such as police enforcement). Intentional injuries are important because, in The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Intentional Injuries Collaborators are listed at theory, intentional injuries can be avoided by intention of the end of the article. Ali H. Mokdad, on behalf of GBD 2015 Eastern human beings; this is not the case for most of the other Mediterranean Region Intentional Injuries Collaborators, is the injuries and diseases. In spite of this fact, about 30% of all corresponding author. global deaths from injuries in 2015 were intentional, and Electronic supplementary material The online version of this suicide and homicide were among the top 10 leading article (doi:10.1007/s00038-017-1005-2) contains supplementary causes of deaths in 15–49-year-old individuals (GBD 2015 material, which is available to authorized users. Mortality and Causes of Death Collaborators 2016; Insti- & GBD 2015 Eastern Mediterranean Region Intentional tute for Health Metrics and Evaluation (IHME) 2017). Injuries Collaborators Conflict obviously increases deaths and injuries on the mokdaa@uw.edu battlefield, and also affects health due to the displacement of populations, the breakdown of health and social Institute for Health Metrics and Evaluation, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USA 123 S40 GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators services, and the heightened risk of disease transmission information on input sources of data are available else- (Murray et al. 2002). where (GBD 2015 Mortality and Causes of Death Col- The Eastern Mediterranean Region (EMR) has had laborators 2016). We used the standard CODEm modeling several conflicts and unrests in the past years; such events approach to estimate deaths due to intentional causes of have huge impact on all types of intentional injuries. A injuries, excluding collective violence and legal interven- study in Tunisia showed an increase by 1.7 times in self- tion. This cause was modeled solely outside of the CODEm harm and 1.3 times in homicide after the Tunisian Revo- process as fatal discontinuities estimation (or mortality lution in 2011 (Ben Khelil et al. 2016). The effect of shock regression). conflicts and social unrest on collective violence and legal The output mortality estimates were used to calculate intervention is obvious. Intentional injuries such as suicide years of life lost (YLLs) for each cause of death. are usually underreported due to cultural and religious norms. Previous studies reported on the burden of disease Cause-of-injury incidence; input data and modeling in the region but did not focus on intentional injuries (Mokdad et al. 2014, 2016). To better estimate the burden The majority of incidence data exist at the external cause- of intentional injures, we used the GBD 2015 study to of-injury level, i.e., E-codes. Incidence for cause-of-injury report the mortality, morbidity, and burden of intentional categories was modeled using DisMod-MR 2.1 for self- injuries in EMR countries from 1990 to 2015. harm and interpersonal violence. DisMod-MR 2.1 is a descriptive epidemiological meta- regression tool that uses the integrative systems modeling Methods approach to produce simultaneous estimates of disease incidence, prevalence, remission, and mortality. Multiple The 2015 Global Burden of Disease (GBD 2015) covered datasets from hospital, emergency/outpatient departments, 249 causes of death and 310 non-fatal diseases and injuries. and survey datasets are fed into these incidence models. GBD 2015 reported the burden for 195 countries or terri- We separately estimated inpatient and outpatient injuries. tories, 21 regions, and seven super-regions for the To estimate incidence from the shock cause-of-injury 1990–2015 time period. The general methodology of GBD categories (collective violence and legal intervention), the 2015 has been detailed elsewhere (GBD 2015 DALYs and mortality rate for these cause-of-injury categories was HALE Collaborators 2016; GBD 2015 Disease and Injury multiplied by the average country-year-age-sex-specific Incidence and Prevalence Collaborators 2016; Haagsma incidence-to-mortality ratios within several cause-of-in- et al. 2016; GBD 2015 Mortality and Causes of Death jury categories that likely exhibit similar case fatality ra- tios (such as road injuries, fires, interpersonal violence, and Collaborators 2016). The EMR contains 22 countries: Afghanistan, Bahrain, other unintentional injuries) (GBD 2015 Disease and Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Injury Incidence and Prevalence Collaborators 2016; Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Haagsma et al. 2016). Arabia, Somalia, Sudan, Syria, Tunisia, United Arab We imposed a hierarchy to select the nature-of-injury Emirates, and Yemen. category that leads to the largest burden when an individual We classified intentional injuries as self-harm, inter- experiences multiple injuries. Then, we separated matrices personal violence (which includes physical violence by (for inpatient and outpatient injuries) to estimate the pro- firearm, sharp objects, or other means) and ‘‘collective portions of incident cases in each of the cause-of-injury violence and legal intervention.’’ Collective violence categories that resulted in each of the nature-of-injury includes wars, terrorism, and other violent political con- categories (N-codes). We produced incidence of inpatient flicts within or between states, state-perpetrated violence and outpatient injuries by cause and nature of injury. Then (such as genocide, repression, disappearances, torture, and we estimated short-term disability by nature-of-injury cat- other abuses of human rights), and organized violent egory for all incident cases of inpatient and outpatient crimes such as gang warfare (WHO 2014). We estimated injuries. We estimated the average duration for each nat- fatal and non-fatal intentional injuries to calculate dis- ure-of-injury category and derived short-term prevalence ability-adjusted life years (DALYs). by multiplying incidence and duration. We then applied DisMod-MR 2.1 to estimate the long- Mortality input data and cause of death models term prevalence for each combination of cause-of-injury and nature-of-injury from incidence and the long-term We estimated injury mortality from different sources (vi- mortality risk in cases with long-term disability. After tal registration, verbal autopsy, mortality surveillance, correction for comorbidity with other non-fatal diseases, censuses, surveys, and police record data). More YLDs were calculated as prevalence times a disability 123 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the… S41 weight. More details on the process are available elsewhere (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016; Haagsma et al. 2016). Disability-adjusted life years (DALYs) were calculated for each type of injury through summation of YLLs and YLDs (GBD 2015 DALYs and HALE Collaborators 2016). Uncertainty We have propagated uncertainty from all different sources 5 such as input data or adjustment process, using standard GBD methods of repeating all calculations 1000 times, African Eastern European Americas South-East Asia Western Pacific Mediterranean each time drawing from distributions rather than point WHO regions estimates for all the relevant parameters in our models. We Self-harm Interpersonal violence Collecve violence and legal intervenon then used 2.5th and 97.5th percentiles as the lower and Fig. 1 Age-standardized death rates (ASDR) per 100,000 from self- upper bounds of the 95% uncertainty interval (UI). For the harm, interpersonal violence, and collective violence and legal injury mortality estimates, the estimation of model uncer- intervention (Global Burden of Disease 2015 study, WHO Regions, tainty is inherent to the ensemble modeling method. Some 2015) of the rates that we present are age-standardized using the GBD standard population (GBD 2015 DALYs and HALE the Americas and African regions, and higher than the Collaborators 2016; GBD 2015 Disease and Injury Inci- other WHO regions. However, the ASDR of collective dence and Prevalence Collaborators 2016; Haagsma et al. violence and legal intervention (21.5 per 100,000 popula- 2016; GBD 2015 Mortality and Causes of Death Collab- tion, 95% UI: 9.3–33.5) was much higher in the EMR than orators 2016). other WHO regions (Fig. 1). The patterns for all-age death rates were relatively similar. Total number of deaths due to intentional injuries (self- Results harm, interpersonal violence, collective violence and legal intervention) showed an increasing trend between 1990 and In 2015 in the EMR, 28,695 individuals (95% UI: 2015 in the EMR (Fig. 2); the most important increase was 25,474–37,832) died from self-harm, 35,626 individuals observed between 2010 and 2015, and was mainly due to (95% UI: 20,947–41,857) from interpersonal violence, and collective violence and legal intervention. 143,858 individuals (95% UI: 63,554–223,092) from col- Figure 3 shows the age–sex distribution of deaths due to lective violence and legal intervention. These numbers different types of intentional injuries in the EMR (2015). show a significant increase from those in 1990, accounting Males had higher rates, except for the youngest and oldest for a 100% increase in self-harm, 152% increase for age groups. Among males, the mortality was considerably interpersonal violence, and 1027% increase for collective higher in people aged 20–24 years. Girls under 5 years old violence and legal intervention. In comparison, during the had a higher mortality from intentional injuries (Fig. 3) same time, the number of deaths in other parts of the world The highest ASDR of self-harm was observed in men of due to self-harm and interpersonal violence increased by 19 Djibouti, Somalia, and Afghanistan, and women of and 12%, respectively, and decreased by 67% for collective violence and legal intervention. Male to female ratio of 250,000 deaths in 2015 in EMR was 2.4 for self-harm, 4.0 for 200,000 interpersonal violence, and 3.3 for collective violence and legal interventions. 150,000 Among the total number of deaths in the EMR due to 100,000 interpersonal violence, firearms and sharp objects accoun- ted for 14,158 (8782–17,306) and 7195 (3758–10,864) 50,000 deaths, respectively, in 2015. In 2015, the age-standardized death rate (ASDR) of self- 1990 1995 2000 2005 2010 2015 Years harm in the EMR (5.1 per 100,000, 95% UI: 4.6–6.6) was Self-harm Interpersonal violence Collecve violence and legal intervenon lower than that of all other World Health Organization regions (Fig. 1), and the ASDR of interpersonal violence in Fig. 2 Number of deaths due to intentional injuries (Global Burden the EMR (5.7 per 100,000, 95% UI: 3.8–6.6) was less than of Disease 2015 study, Eastern Mediterranean Region, 1990–2015) Number of deaths ASDR per 100,000 S42 GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators Female Male Fig. 5 Age-standardized death rates (ASDR) from interpersonal violence (per 100,000 population), for men and women in the countries of the Eastern Mediterranean Region (Global Burden of Fig. 3 Age–sex distribution of deaths due to intentional injuries Disease 2015 study, Eastern Mediterranean countries, 2015) (Global Burden of Disease 2015 study, Eastern Mediterranean Region, 2015) Female Male Fig. 6 Age-standardized death rates (ASDR) for collective violence and legal intervention (per 100,000 population), for men and women in the countries of the Eastern Mediterranean Region (Global Burden Female Male of Disease 2015 study, Eastern Mediterranean countries, 2015) Fig. 4 Age-standardized death rates (ASDR) from self-harm per Afghanistan, and Palestine. The lowest median percentage 100,000 men and women in the countries of the Eastern Mediter- was in Saudi Arabia, followed by Egypt and Oman (e- ranean Region (Global Burden of Disease 2015 study, Eastern Mediterranean countries, 2015) Table 1). In 2015, collective violence and legal intervention was Somalia, Djibouti, and Iraq (Fig. 4). Afghanistan, Iraq, and the fifth-leading cause of DALYs in the EMR, the first- Somalia had the highest ASDR of interpersonal violence leading cause of DALYs in five countries (Syria, Yemen, for both men and women (Fig. 5). The highest ASDR of Iraq, Afghanistan, and Libya), and the second-leading collective violence and legal interventions was observed in cause in Lebanon. In Syria, 49.7% of total DALYs (95% Syria, Afghanistan, and Iraq for both sexes (Fig. 6). Syria UI: 30.8–62.2) in 2015 were due to collective violence and had an ASDR of 138.2 per 100,000 for women (95% UI: legal intervention. 48.8–228.2) and 478.0 per 100,000 for men (168.8–789.0) for collective violence and legal intervention in 2015. DALYs from self-harm, interpersonal violence, and Discussion collective violence and legal intervention in 2015 totaled 1,425,494 (95% UI: 1,258,222–1901,949), 1,997,224 (95% Our study showed that the burden of intentional injuries is UI: 1,184,027–2,325,345), and 10,107,643 (95% UI: increasing rapidly in the EMR. It is not a surprise that the 5,381,404–14,787,629), respectively. YLLs were the main burden of collective violence and legal intervention has component of DALYs for all kinds of intentional injuries; increased dramatically in the last few years and is currently YLLs accounted for more than 98.5% of DALYs for self- higher than rest of the world due to the unrest in the region. harm and interpersonal violence and 85.9% of DALYs for However, our study showed a rise in self-harm and inter- collective violence and legal intervention. personal violence during the same time period that was Lebanon had the highest median percentage of total much faster than in other parts of the world. Clearly the DALYs from intentional injuries, followed by Iraq, unrest and conflicts are causing deaths due to collective ASDR of self-harm per 100,000 ASDR of collecve violence and legal ASDR of interpersonal violence per 100,000 intervenons per 100,000 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the… S43 violence and legal interventions, but they are also corre- show some differences from other regions of the world. lated with increased burden from self-harm and other dis- Hanging and poisoning are the most common methods of eases (Murray et al. 2002; Ben Khelil et al. 2016). All suicide; however, there are also differences between and countries with the highest mortality rates of self-harm and even within countries (Morovatdar et al. 2013). These are interpersonal violence (Afghanistan, Somalia, Djibouti, important because there are specific interventions to pre- and Iraq) have been affected by multiple episodes of civil vent each type of suicide. Many of the preventive strategies or inter-state wars and social unrest, as well as terrorism focus on finding individuals who are at higher risk of during 1990–2015. Our study calls for efforts to stabilize suicide attempts, such as those with mental illness after the region politically and reduce the burden of disease due discharge from a hospital (Ghanbari et al. 2015). In Iran, to the current situations. some trials have been done to integrate suicide prevention Young men are the most typical victims of intentional services into primary health care (PHC), which increases injuries, especially interpersonal and collective violence. universal access to and sustainability of these services This pattern is relatively similar to other regions of the world (Malakouti et al. 2015b, c). (Degutis 2013). Girls and boys under 5 years old had a large Interpersonal violence is an important cause of DALYs in share of total deaths due to collective violence. This might be some of the countries of the EMR, especially Afghanistan, due to their generally higher vulnerability in emergency Iraq, Somalia, and Djibouti. It is not always easy to separate situations. Like the pre-conflict state, mortality is higher interpersonal violence from collective violence, especially among children than individuals over 5 years during a con- when a civil war is taking place. In this study, firearms had a flict; however, individuals over 5 are usually affected more major contribution to total deaths from interpersonal inju- than young children. In other words, while the general ries. Although having a gun is illegal in most of the countries mortality rate of children under 5 is around ten times that of of the region, having access to weapons is not difficult in individuals over 5 in pre-conflict states, it decreases to countries such as Afghanistan and Iraq (after being involved around double during a conflict state (Guha-Sapir and Pan- in civil wars for several years). huis 2004). The age pattern of deaths due to collective vio- Our study has some limitations. First, reports on inten- lence might be related to several factors such as type of war tional injuries (especially self-harm and legal intervention) (for instance, civil wars versus inter-state wars) and main are subject to underreporting or even being covered up in types of arms involved (individual light weapons compared many countries. We used the general GBD methodology to to heavy artillery and weapons of mass destruction). address underreporting of deaths; however, underreporting The absolute and relative importance of direct injuries might be different for specific causes of deaths. Second, the from collective violence and legal intervention has number of war victims is not usually accurate due to poor health information systems and political considerations of increased significantly in the region in recent years. Although the region has experienced several conflicts in reporting; many of the countries involved in conflicts do not recent decades, the Syrian war has increased deaths and have a reliable health information system even in their pre- burden of collective violence significantly in recent years. conflict states. Third, we did not evaluate the indirect effects The total burden imposed by war is certainly higher of collective violence (war) on health workforce, infras- because it also indirectly increases death and disability tructure, and food security. These factors can considerably from other diseases. On the other hand, the number of increase the attributable burden to war. Finally, we did not people who died from a war is not limited to the time account for the impact of the influx of refugees on the health period of its occurrence. Previous studies show that several systems and disease burden of the host countries. years after termination of wars, people are at higher risk of death due to its consequences such as remaining land Conclusions mines. In addition, some people suffer from the long-term complications of injuries such as amputations and spinal Our study documented the burden of intentional injuries cord injury for years after war and are at risk of premature due to the conflicts and unrest in the EMR. Moreover, we death for the same reasons (Mousavi et al. 2014). showed an increased burden from other intentional injuries In this study, mortality and burden of self-harm in the at the same time. Our findings call for increased efforts to EMR were lower than in other regions of the world. stabilize the region and assist in rebuilding the health Although religious and cultural beliefs might have con- systems, as well as increasing transparency and employing tributed to these low rates, the burden of self-harm also preventive strategies to reduce self-harm and interpersonal might be affected by cultural and religious barriers, social injuries. stigma, and legal punishments that encourage victims, GBD 2015 Eastern Mediterranean Region Intentional Injuries families, and governments to hide the information Collaborators: Ali H. Mokdad, PhD (corresponding author), (Malakouti et al. 2015a). Methods of suicide in the EMR 123 S44 GBD 2015 Eastern Mediterranean Region Intentional Injuries Collaborators Institute for Health Metrics and Evaluation, University of Washing- Observatory, Instituto Nacional de Salud, Bogota, Colombia, Epi- ton, Seattle, Washington, United States. Maziar Moradi-Lakeh, MD, demiology and Public Health Evaluation Group, Public Health Department of Community Medicine, Preventative Medicine and Department, Universidad Nacional de Colombia, Bogota, Colombia. Public Health Research Center, Gastrointestinal and Liver Disease Koustuv Dalal, PhD, Centre for Injury Prevention and Safety Pro- Research Center (GILDRC), Iran University of Medical Sciences, motion, School of Health and Medical Sciences, Orebro University, Tehran, Iran. Raghid Charara, MD, American University of Beirut, Orebro, Sweden. Hadi Danawi, PhD, Walden University, Min- Beirut, Lebanon. Charbel El Bcheraoui, PhD, Institute for Health neapolis, Minnesota, United States. Diego De Leo, DSc, Griffith Metrics and Evaluation, University of Washington. Ibrahim Khalil, University, Brisbane, Queensland, Australia. Samath D. Dharmaratne, PhD, Institute for Health Metrics and Evaluation, University of MD, Department of Community Medicine, Faculty of Medicine, Washington. Ashkan Afshin, MD, Institute for Health Metrics and University of Peradeniya, Peradeniya, Sri Lanka. Shirin Djalalinia, Evaluation, University of Washington, Seattle, WA, United States. PhD, Undersecretary for Research & Technology, Ministry of Health Nicholas J. Kassebaum, MD, Institute for Health Metrics and Eval- & Medical Education, Tehran, Iran. Kerrie E. Doyle, PhD, RMIT uation, University of Washington, Seattle, Washington, United States, University, Bundoora, VIC, Australia; Australian National Univer- Department of Anesthesiology & Pain Medicine, Seattle Children’s sity, Canberra, ACT, Australia. Alireza Esteghamati, MD, Hospital, Seattle, Washington, United States. Michael Collison, BS, Endocrinology and Metabolism Research Center, Tehran University Institute for Health Metrics and Evaluation, University of Washing- of Medical Sciences, Tehran, Iran. Andre´ Faro, PhD, Federal ton, Seattle, Washington, United States. 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Flo- Washington, Seattle, Washington, United States. Michael Kutz, BS, rian Fischer, PhD, School of Public Health, Bielefeld University, Institute for Health Metrics and Evaluation, University of Washing- Bielefeld, Germany. Tsegaye Tewelde Gebrehiwot, MPH, Jimma ton. Haidong Wang, PhD, Institute for Health Metrics and Evaluation, University, Jimma, Ethiopia. Reyna A. Gutierrez, PhD, National University of Washington, Seattle, Washington, United States. Foa- Institute of Psychiatry Ramon de la Fuente, Mexico City, Mexico. d Abd-Allah, MD, Department of Neurology, Cairo University, Nima Hafezi-Nejad, MD, Endocrinology and Metabolism Research Cairo, Egypt. Laith J. Abu-Raddad, PhD, Infectious Disease Epi- Center, Tehran University of Medical Sciences, Tehran, Iran. Randah demiology Group, Weill Cornell Medical College in Qatar, Doha, Ribhi Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. Qatar. Aliasghar Ahmad Kiadaliri, PhD, Department of Clinical Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund Dubai, United Arab Emirates. Josep Maria Haro, MD, Parc Sanitari University, Lund, Sweden. Muktar Beshir Ahmed MPH, College of Sant Joan de De´u—CIBERSAM, Sant Boi de Llobregat (Barcelona), Health Sciences, Department of Epidemiology, ICT and e-Learning Spain. Delia Hendrie, MA, Centre for Population Health Research, Coordinator, Jimma University, Jimma, Ethiopia. Khurshid Alam, Curtin University, Bentley, Western Australia, Australia. Guoqing PhD, Murdoch Childrens Research Institute, The University of Mel- Hu, PhD, Department of Epidemiology and Health Statistics, School bourne, Parkville, Victoria, Australia, The University of Melbourne, of Public Health, Central South University, Changsha, China. Jost B. 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Rohan Borschmann, PhD, The University of MPH, Debre Markos University, Debre Markos, Ethiopia. Raimundas Melbourne, Melbourne, VIC, Australia, Murdoch Childrens Research Lunevicius, PhD, Aintree University Hospital National Health Ser- Institute, Melbourne, VIC, Australia. Soufiane Boufous, PhD, vice Foundation Trust, Liverpool, United Kingdom, School of Med- Transport and Road Safety (TARS) Research, University of New icine, University of Liverpool, Liverpool, United Kingdom. South Wales, Sydney, New South Wales, Australia. Zahid A. Butt, Mohammed Magdy Abd El Razek, MBBCH, Aswan University PhD, Al Shifa Trust Eye Hospital, Rawalpindi, Punjab, Pakistan. Hospital, Aswan Faculty of Medicine, Aswan, Egypt. Azeem Majeed, Carlos A. Castan˜eda-Orjuela, MSc, Colombian National Health MD, Department of Primary Care & Public Health, Imperial College 123 Intentional injuries in the Eastern Mediterranean Region, 1990–2015: findings from the… S45 London, London, England, United Kingdom. Reza Malekzadeh, MD, Anesthesiology, University of Virginia, Charlottesville, VA, United Digestive Diseases Research Institute, Tehran University of Medical States, Department of Anesthesiology, King Fahad Medical City, Sciences, Tehran, Iran; Digestive Diseases Research Institute, Tehran Riyadh, Saudi Arabia; Outcomes Research Consortium, Cleveland University of Medical Sciences, Tehran, Iran. Ziad A. Memish, MD, Clinic, Cleveland, OH, United States. RomanTopor-Madry, PhD, Saudi Ministry of Health, Riyadh, Saudi Arabia, College of Medicine, Institute of Public Health, Faculty of Health Sciences, Jagiellonian Alfaisal University, Riyadh, Saudi Arabia. Tuomo J. Meretoja, PhD, University Medical College, Krako´w, Poland; Faculty of Health Sci- Comprehensive Cancer Center, Breast Surgery Unit, Helsinki ences, Wroclaw Medical University, Wroclaw, Poland. Kingsley University Hospital, Helsinki, Finland; University of Helsinki, Hel- Nnanna Ukwaja, MD, Department of Internal Medicine, Federal sinki, Finland. Ted R. Miller, PhD, Pacific Institute for Research & Teaching Hospital, Abakaliki, Ebonyi State, Nigeria. Olalekan A. Evaluation, Calverton, MD, United States; Centre for Population Uthman, PhD, Warwick Medical School, University of Warwick, Health, Curtin University, Perth, Western Australia, Australia. Shafiu Coventry, United Kingdom. Mehdi Yaseri, PhD, Tehran University of Mohammed, PhD; Health Systems and Policy Research Unit, Ahmadu Medical Sciences, Terhan, Iran, Ophthalmic Research Center, Shahid Bello University, Zaria, Kaduna, Nigeria, Institute of Public Health, Beheshti University of Medical Sciences, Tehran, Iran. Naohi- Heidelberg University, Heidelberg, Germany. Carla Makhlouf Ober- roYonemoto, MPH, Department of Biostatistics, School of Public meyer, DSc, Center for Research on Population and Health, Faculty of Health, Kyoto University, Kyoto, Japan. Mustafa Z. Younis, DrPH, Health Sciences, American University of Beirut, Beirut, Lebanon. Jackson State University, Jackson, MS, United States. Aisha O. Felix Akpojene Ogbo, MPH, Centre for Health Research, Western Jumaan, PhD, Independent Consultant, Seattle, Washington, United Sydney University, Sydney, New South Wales, Australia. Michael States. Theo Vos, PhD, Institute for Health Metrics and Evaluation, Robert Phillips, MD, Shanghai Jiao Tong University School of Med- University of Washington, Seattle, Washington, United States. Simon icine, Shanghai, China; Emory University, Atlanta, Georgia, United I. Hay, DSc, Oxford Big Data Institute, Li Ka Shing Centre for Health States. Farshad Pourmalek, PhD, University of British Columbia, Information and Discovery, University of Oxford, Oxford, United Vancouver, British Columbia, Canada. Mostafa Qorbani, PhD, Non- Kingdom, Institute for Health Metrics and Evaluation, University of communicable Diseases Research Center, Alborz University of Washington, Seattle, Washington, United States. Mohsen Naghavi, Medical Sciences, Karaj, Iran. Amir Radfar, MD, A T Still University, PhD, Institute for Health Metrics and Evaluation, University of Kirksville, MO, United States. Anwar Rafay, MS, Contech Interna- Washington, Seattle, Washington, United States. Christopher J. tional Health Consultants, Lahore, Pakistan, Contech School of Public L. Murray, DPhil, Institute for Health Metrics and Evaluation, Health, Lahore, Pakistan. Afarin Rahimi-Movaghar, MD, Iranian University of Washington, Seattle, Washington, United States. National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran. Vafa Rahimi-Movaghar, MD, Sina Compliance with ethical standards Trauma and Surgery ResearchCenter, Tehran University of Medical Sciences, Tehran, Iran. Rajesh Kumar Rai, MPH, Society for Health Ethical standards This manuscript reflects original work that has not and Demographic Surveillance, Suri, West Bengal, India. David Laith previously been published in whole or in part and is not under con- Rawaf, MD, WHO Collaborating Centre, Imperial College London, sideration elsewhere. All authors have read the manuscript and have London, United Kingdom; North Hampshire Hospitals, Basingstroke, agreed that the work is ready for submission and accept responsibility United Kingdom, University College London Hospitals, London, for its contents. United Kingdom. Salman Rawaf, MD, Imperial College London, London, United Kingdom. Satar Rezaei, PhD, School of Public Ethics statements The authors of this paper have complied with all Health, Kermanshah University of Medical Sciences, Kermanshah, ethical standards and do not have any conflicts of interest to disclose Iran. Mohammad Sadegh Rezai, MD, Mazandaran University of at the time of submission. The funding source played no role in the Medical Sciences, Sari, Iran. Gholamreza Roshandel, PhD, Golestan design of the study, the analysis and interpretation of data, and the Research Center of Gastroenterology and Hepatology, Golestan writing of the paper. The study did not involve human participants University of Medical Sciences, Gorgan, Iran; Digestive Diseases and/or animals; therefore, no informed consent was needed. Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Mahdi Safdarian, MD, Sina Trauma & Surgery Research Center, Funding This research was funded by the Bill & Melinda Gates Tehran, Iran. Saeid Safiri, PhD, Managerial Epidemiology Research Foundation. Center, Department of Public Health, School of Nursing and Mid- wifery, Maragheh University of Medical Sciences, Maragheh, Iran. Conflict of interest The authors declare that they have no conflicts of Payman Salamati, MD, Sina Trauma and Surgery Research Center, interest at this time. Tehran University of Medical Sciences, Tehran, Iran. Abdallah M. Samy, PhD, Ain Shams University, Cairo, Egypt Lawrence Kansas, Open Access This article is distributed under the terms of the United States. Benn Sartorius, PhD, Public Health Medicine, School of Creative Commons Attribution 4.0 International License (http://crea Nursing and Public Health, University of Kwa Zulu-Natal, Durban, tivecommons.org/licenses/by/4.0/), which permits unrestricted use, South Africa; UKZN Gastrointestinal Cancer Research Centre, South distribution, and reproduction in any medium, provided you give African Medical Research Council (SAMRC), Durban, South Africa. appropriate credit to the original author(s) and the source, provide a Soraya Seedat, PhD, Stellenbosch University, Cape Town, South link to the Creative Commons license, and indicate if changes were Africa. Sadaf G. Sepanlou, PhD, Digestive Diseases Research Insti- made. tute, Tehran University of Medical Sciences, Tehran, Iran. Masood Ali Shaikh, MD, Independent Consultant, Karachi, Pakistan. Badr H. A. Sobaih, MD, King Saud University, Riyadh, Saudi Arabia. Karen References M. 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Journal

International Journal of Public HealthSpringer Journals

Published: Aug 3, 2017

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