The use of computer modelling and simulation is allowing researchers to test operational assumptions in a virtual but controlled experimental environment. Developing a valid computer simulation model allowing (1) to model complex medical response systems with several types of victims, (2) to test different aspects of the medical response. The SIMEDIS ( Si mulation for the Assessment and Optimization of Me dical Dis aster Management) computer simulator consists of 3 interactive components: the victim creation model, the victim monitoring model, and the medical response model. The objectives of the study were to create a disaster medical response simulation model in the case of an aircraft crash and in a CBRN incident simulation, to test and to optimize existing and future medical disaster response plans, to develop a victim model, to develop a victim creation model and a victim monitoring model, and to produce a pre-hospital medical response model. The case studies showed that the SIMEDIS simulator is offering a valuable tool for testing the impact of several interventional factors on the disaster medical response in specific scenarios including more complex situations such CBRN-incidents. This study reflects the potential of SIMEDIS to model complex systems, to test different aspects of the disaster medical response and to potentially inform changes in practices. This might be of potential interest for disaster response planners allowing them to make the best choices in composing their medical teams and adapting the medical response system.

A scenario of casualty evacuations from the frontlines in Ukraine was simulated in SIMEDIS, incorporating persistent drone threats that restricted daytime evacuations. A stochastic discrete-event approach modeled casualty location and health progression. Casualties from a First-Person View drone explosion in a trench were simulated, incorporating controlled versus uncontrolled bleeding in rescue and stabilization efforts. Two evacuation strategies were compared: (A) transport to a nearby underground hospital with delays and (B) direct transport to a large hospital with potential targeting en route. Results showed that strategy A was safer for transport, but effective hemorrhage control was crucial for survival. Strategy A led to lower mortality than strategy B only when hemorrhage control was sufficient. Without it, both strategies resulted in similar mortality, emphasizing that blood loss was the primary cause of death in this simulation.

IntroductionMass casualty incidents (MCIs) involving nerve agents pose major challenges for emergency medical response due to rapid symptom onset, hazardous environments, and operational uncertainties. Several gaps remain in the knowledge about the prehospital response to nerve agent MCI treatment strategies and logistical decision-making. To address these gaps, this study uses Discrete Event Simulation to evaluate the impact of advanced medical stabilization (AMS) team arrival time, antidote availability, and evacuation policy on patient survival during an urban chemical-traumatic MCI with a subway sarin release scenario.MethodsA validated simulation model (SIMEDIS) was adapted to represent the full prehospital response chain, including triage, antidote administration, AMS, dry decontamination, further on-site stabilization in the forward medical post and transport to categorized hospitals. Two transport policies were modeled: Scoop&Run (rapid transport of victims to hospitals) and Stay&Play (on-site stabilization before transport). We simulated various AMS team arrival times and antidote availability scenarios to assess their impact on survival. Locations of deaths were analyzed to identify critical points of failure in the medical response chain.ResultsAMS team arrival time, antidote availability, and evacuation policy significantly influenced mortality among the 25 salvageable victims. The number of deaths ranged from 8.0 (32%) in the most favorable case to 23.8 (95.2%) in the least favorable. Earlier AMS team arrival and greater antidote availability were associated with fewer deaths, particularly under the Scoop&Run policy. Stay&Play resulted in more deaths unless medical and transport capacity were significantly enhanced. Location-of-death analysis revealed preventable bottlenecks, especially during decontamination and hospital transport under the Stay&Play model.DiscussionThe results highlight the importance of rapid hospital transport, swift antidote availability and administration during urban chemical MCIs. AMS team arrival time emerged as the strongest predictor of preventable mortality, showing a sigmoid-shaped curve where delays beyond 11 min led to sharp increases in death. Antidote supply showed a dose-dependent effect, but the impact diminishes with delayed administration, underscoring the need for timely delivery over sheer volume. To reduce preventable deaths in chemical MCIs, policy makers should focus on streamlining AMS team deployment, prioritizing rapid evacuation, and addressing logistical bottlenecks in decontamination and transport.

Introduction: Earthquakes can have a significant impact on imaging modalities available in the surrounding hospitals. Ultrasound can offer several advantages in earthquake response scenarios but is underrepresented in the bibliometric analysis on imaging modalities after earthquake. This scoping review aims to analyse the gap in literature by examining the possible roles of ultrasound during different timeframes after an earhtquake. Methods: A scoping review was carried out using the PRISMA method searching Pubmed, Scopus and Web of Science. Grey literature was searched and snowballing was performed on the reference list. Results were extracted into 3 time cathegories for use during the first 72 hours after, during the first 6 weeks after, and follow up of patients during the years after the earthquake. Results: A total of 13034 studies were put into COVIDENCE TM, 69 references were found in Grey literature, 24 articles were witheld for extraction. Limitations: Articles were excluded based on language exclusion criteria so valuable information may be missing from the final selection. Discussion: During the first 72 hours after the earthquake ultrasound has been proven usefull for IO placement during rescuscitation, triaging patiens using Focussed Assessment with Sonography in Trauma, diagnosis of rhabdomyalisis and nerve injuries, evaluation of the need for renal replacement therapy, regional anesthesia through ultrasound guided nerve blocks and ultrasound guided procedures like evacuation of abcedations. During the first 6 weeks after the earthquake it can be primarily used in the hospital for regional anesthesia and procedures, and in remote shelters for Deep Venous Trombosis screening. In the years after the earhtquake the main use is follow up of stress cardiomyopathy and nerve injuries. Conclusion: Ultrasound has demonstrated diverse applications, ranging from triaging patients, detecting injuries, guiding procedures, and providing long-term follow-up. Its portability, real-time visualization, and rapid accessibility make it a valuable tool in resource-constrained and post-disaster settings. [SJEMed 2024; 5(1.100): S72-S72]

The increasing use of suicidal and explosive Unmanned Aerial Vehicles (UAVs) poses a significant threat in both battlefield and urban environments, as evidenced by recent events in Ukraine. This study employs the SIMEDIS Simulator to simulate a triple UAV strike in Brussels City Centre, comparing two evacuation strategies: "Stay and Play" versus "Scoop and Run." The simulation incorporates medical facility locations, bed capacities, and evolving patient conditions. Findings highlight the importance of rapid patient transport to surgical facilities, emphasizing the effectiveness of the “Scoop and Run” approach alongside timely medical interventions and adequate blood supply. Challenges such as hemorrhage control and managing multiple disaster sites are also discussed. This study underscores the necessity of efficient evacuation protocols and medical responses to mitigate casualties in urban disaster scenarios involving UAV attacks.

INTRODUCTION: Disasters have existed for many ages and although they are known to threaten health, there is still lack of evidence regarding the effectiveness of health disaster response interventions. Indicators are primordial for the evaluation of such interventions. The main objective of this study was to map the output, outcome and impact indicators used to evaluate health interventions in disasters and to identify gaps in the existing peer-reviewed literature. METHODS: A scoping review of the peer-reviewed literature was performed. Scopus, Web of Science and Pubmed were the 3 databases in which the search was launched. All references published in the peer-reviewed literature in English, Dutch or French since 1990 were eligible for inclusion if they met all the inclusion criteria. Characteristics of the studies, the interventions and indicators identified were charted. Interventions were categorized using an extraction template. RESULTS: A total of 8329 articles were identified. After removal of duplicates, 5578 unique studies were screened of which 56 met all inclusion criteria. The selected articles contained 86 interventions and 1387 indicators which could be grouped into 619 unique indicators. Of these indicators the majority were output indicators (70,8%). Of the remaining indicators 28,8% were outcome indicators and only 2 (0,3%) were impact indicators. For almost half (47,7%) of the interventions, no outcome or impact indicators were identified. The highest proportions of outcome indicators were found in medical care interventions and overall response interventions. CONCLUSION: This scoping review identified the existence of many indicators, however most of them were output indicators. In order to generate evidence on the effectiveness of interventions, the priority should lie on determining outcome and impact indicators. If health disaster management wants to become a scientific discipline, several steps must be undertaken. First, there is an urgent need for the standardization of definitions and the development of a glossary. Second, the identification of indicators should begin with the determination of interventions needed in disaster response after which systematic scoping reviews should be performed in order to identify the most appropriate indicators. Lastly, data collection should be standardized, and a universally accepted reporting template should be implemented.

The field of discrete-event simulation for medical disaster management is relatively new. In such simulations, human victims are generated using pre-determined transitions from one health state to the next, based on a set of triggers that correspond to treatment or the clinical progression of untreated injuries or diseases. However, this approach does not account for subtle differences in clinical progression. We propose a parameter-based model to characterize the evolution of symptoms at first for physical and nerve agent chemical injuries. We used a Gompertz function to predict the time of death in trauma based on forensic data. Then we separately considered the effects of the chemical warfare agent sarin (GB) being the origin of the chemical injuries for the purpose of modelling a GB attack in a metro station. We emphasize that our approach can be extended to other CBRN threats pending knowledge of clinical progressions available in the literature for the purpose of casualty estimations. The intent is to provide an estimate of time to death without any treatment and overlay this model with a treatment model, improving the evolution of the health state. A modification for non-life-threatening injuries is included without losing generality. Improvement functions modelling medical treatment are proposed. We argue that the availability of injury scores vs mortality can greatly enhance the validity of the model.

In the last decades, Chemical, Biological, Radiological and Nuclear (CBRN) threats have become serious risks prompting countries to prioritize preparedness for such incidents. As CBRN scenarios are very difficult and expensive to recreate in real life, computer simulation is particularly suited for assessing the effectiveness of contingency plans and identifying areas of improvement. These computer simulation exercises require realistic and dynamic victim profiles, which are unavailable in a civilian context. In this paper we present a set of civilian nerve agent injury profiles consisting of clinical parameters and their evolution, as well as the methodology used to create them. These injury profiles are based on military injury profiles and adapted to the civilian population, using sarin for the purpose of illustration. They include commonly measured parameters in the prehospital setting. We demonstrate that information found in military sources can easily be adjusted for a civilian population using a few simple assumptions and validated methods. This methodology can easily be expanded to other chemical warfare agents as well as different ways of exposure. The resulting injury profiles are generic so they can also be used in tabletop and live simulation exercises. Modeling and simulation, if used correctly and in conjunction with empirical data gathered from lessons learned, can assist in providing the evidence practices for effective and efficient response decisions and interventions, considering the contextual factors of the affected area and the specific disaster scenario.

The escalation of the Russian invasion in Ukraine, characterized by the deployment of conventional weapon systems, inflicts significant morbidity and mortality on the victims. It is imperative to ascertain optimal medical practices and disaster response strategies throughout the battlefield to minimize casualties and safeguard the well-being of medical and disaster responders. The challenges posed by large-scale battlefield threats can rapidly overwhelm healthcare providers due to the sheer number of victims, which can result in the depletion of medical supplies and insufficient training and resources. To address these issues, we utilized the SIMEDIS simulator to establish and implement a battlefield scenario involving an open-air artillery strike in a field. Mortality rates were calculated based on the application of bleeding control measures and the distribution policy for allocating victims to medical treatment facilities. Controlling hemorrhage remains the most crucial factor influencing mortality outcomes.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has revealed a gap in disaster preparedness of health workers globally. Disaster medicine education is a key element to fill this gap. Objectives: This study evaluated the involvement of the European Master in Disaster Medicine (EMDM) Alumni in the current COVID-19 pandemic response and their self-perceived value of the EMDM educational program in accomplishing their tasks during the disaster. Methods: An online survey targeting the EMDM Alumni was conducted from January through March 2021. Quantitative data were described using percentages or means, as appropriate, while qualitative data were categorized using deductive thematic analysis. Results: In total, 259 Alumni completed the survey. Most of the Alumni (88.03%; standard error of the proportion [SEp] = 0.02) participated directly in the COVID-19 pandemic response - nationally or internationally - with different roles and responsibilities at different levels and sectors. Around 25% of the Alumni reported an increase in their tasks and responsibilities due to COVID-19 response, but few worked beyond their main specialization (5.26%) or expertise (2.19%). Moreover, Alumni shifted their role from clinical practice to managerial, public health, education and training, and policymaking roles during COVID-19 (P <.001). Participants believed that the EMDM study program and the competencies acquired during the course were relevant and useful to perform their tasks during the COVID-19 pandemic response (mean = 5.26; 5.17 standard error of the mean [SEM] = 0.108, 0.107), respectively. Around 36% (SEp = 0.03) of the participants deemed that some contents were not sufficient for COVID-19 response. Conclusion: Most of the EMDM Alumni were involved in the COVID-19 pandemic response, playing diverse roles with an increased level of responsibility compared to those played before the pandemic. Moreover, the Alumni perceived the EMDM curriculum as relevant for accomplishing their tasks. However, they also reported gaps within the curriculum, especially topics related to outbreak and pandemic response. The findings of the study stress the value of investing in disaster medicine education world-wide and of pushing to update and standardize post-graduate disaster medicine curricula.

Chemical terrorist attacks in closed areas are a serious threat to national security. In order to deduct the best reponse with regard to treatment and protective measures, simulation is the best tool, either in-silico or as a real-life exercise. The difficulty of the latter is the great number of resources necessary to set up a large-scale realistic exercise while the limitation of the former is that the model needs to be as realistic as possible to draw relevant conclusions. The complexity in designing and running a realistic and large-scale computer simulation model with pedestrian movement and air/gas flows renders studies near-impossible with current computers. To address the complexity issue, agent-based simulation is usually preferred over a Computational Fluid Dynamics (CFD) approach. The aim of this contribution is to present a method to generate a list of victims with both inhaled doses of the chemical warfare agent sarin (NATO designation GB) and traumatic injuries in an emergency subway evacuation scenario. The method couples a simple gas diffusion model with a crowd dynamics model. The interaction of the crowd follows a social force model (SFM) where the overlaps are used to determine a physical injury distribution.

Discrete-event simulation for health disaster management is a relatively new field. Human victims in these models are usually created with predetermined transitions from one health state to the next, based on a set of triggers which can correspond to treatment procedures performed by physicians, stabilization by paramedics or follow the normal clinical progression of untreated injuries or diseases. In this approach, clinical progression is predetermined and subtle differences are not accounted for. A simulator developed by a team from the Royal Military Academy and the Vrije Universiteit Brussel has successfully implemented a discrete victim model in the past to describe an airport crash scenario. The next step is to generalize this simulator for diverse scenarios where a combination of chemical and physical injuries can happen. To do so, a novel approach to the generation of victims is adopted. In this contribution, the development of a continuous victim model is presented. In this victim model, victims can be assigned both physical and chemical injuries. The dynamic evolution of the health state of the victims follows established injuries models based on trauma registries. Concerning the chemical injuries, a set of existing victim profiles developed by the North Atlantic Treaty Organization are used as a starting set of data, modified for civilian application. The use of a continuous victim model represents a significant advancement over the use of a discrete-based clinical transition model where small changes in timelines of care will have more realistic impacts on the victims health states.To the best of our knowledge, this is the first time that a continuous victim model is used for disaster management simulations.

Introduction: The aim of this study was to determine if school personnel can understand and apply the Sort, Assess, Life-saving interventions, Treat/Transport (SALT) triage methods after a brief training. The investigators predicted that subjects can learn to triage with accuracy similar to that of medically trained personnel, and that subjects can pass an objective-structured clinical exam (OSCE) evaluating hemorrhage control. Methods: School personnel were eligible to participate in this prospective observational study. Investigators recorded subject demographic information and prior medical experience. Participants received a 30-minute lecture on SALT triage and a brief lecture and demonstration of hemorrhage control and tourniquet application. A test with brief descriptions of mass-casualty victims was administered immediately after training. Participants independently categorized the victims as dead, expectant, immediate, delayed, or minimal. They also completed an OSCE to evaluate hemorrhage control and tourniquet application using a mannequin arm. Results: Subjects from two schools completed the study. Fifty-nine were from a private school that enrolls early childhood through grade eight, and 45 from a public school that enrolls grades seven and eight (n = 104). The average subject age was 45 years and 68% were female. Approximately 81% were teachers and 87% had prior cardiopulmonary resuscitation (CPR) training. Overall triage accuracy was 79.2% (SD = 10.7%). Ninety-six (92.3%) of the subjects passed the hemorrhage control OSCE. Conclusions: After two brief lectures and a short demonstration, school personnel were able to triage descriptions of mass-casualty victims with an overall accuracy similar to medically trained personnel, and most were able to apply a tourniquet correctly. Opportunities for future study include integrating high-fidelity simulation and mock disasters, evaluating for knowledge retention, and exploring the study population's baseline knowledge of medical care, among others.

Globally, the risk of a commercial aircraft accident is low. The fatal accident rate of about 0.65 per million flights at the start of the 1990 s decreased to an average of one per 2.75 million flights for the five-year period 2010-2015. Research related to factors that can impact the health outcomes of occupants and the preparedness and response to aviation mass casualty accidents is rather limited. The aim of the study was to expand this knowledge and to determine the impact of maximum take-off weight (MTOW), flight phases and aircraft damage on the survivability of occupants in commercial passenger aircraft accidents. Two thousand one hundred accidents from the period 1990-2014, included in the accident database of the International Civil Aviation Organization (ICAO), met the inclusion criteria of the study. Results of the study showed that the survivability was lower and the casualty rate and the rate of seriously and fatally injured was higher in accidents that occurred during the approach phase, involving smaller aircrafts and in which the aircraft was destroyed. Approximately two-thirds of the accidents happened at the airport or in its immediate vicinity. Empirical data on the casualty rate, the rate of seriously and fatally injured and the survivability of occupants involved in commercial passenger aircraft accidents can help to optimize the preparedness and response of emergency medical services and hospitals in the accident area.

ObjectiveIn 2013, the Philippines was struck by typhoon Haiyan, which damaged local hospitals and disrupted health care. The Belgian First Aid and Support Team erected a field hospital and water purification unit in Palo. This study aims to describe the diagnoses encountered and treatment provided.MethodsIn this cross-sectional study, medical records of 1267 field hospital patients were reviewed for gender, age, complaints, diagnoses, and management and referral information.ResultsAlmost 28% of the patients suffered from injury, but most presented with nonsurgical diseases (64%), particularly of respiratory (31%), dermatological (11%), and digestive (8%) origin. Only 53% presented with disaster-related pathology, and 59% showed signs of infection. Patients needed wound care (47%), pain relief (33%), or antibiotics (29%); 9% needed procedures, 8% needed fluid therapy, and 5% needed psychological support. Children under 5 years of age were more at risk for infections (OR, 18.8; CI, 10.6-33.3) and injuries (OR, 10.3; CI, 6.3-16.8). Males were more prone to injuries than females (OR, 2.1; CI, 1.6-2.6).ConclusionsOne week after the acute phase of a typhoon, respiratory, dermatological, and digestive problems emerge to the prejudice of trauma. Only 53% of patients presented with disaster-related conditions. Young children are more at risk for injury and infectious diseases. These trends should be anticipated when composing Emergency Medical Teams and medical resources to be sent to disaster sites. (Disaster Med Public Health Preparedness. 2019;13:265-278)

Introduction:Egypt has been and continues to be at risk of a multitude of natural and man-made disasters and mass casualty incidents (MCIs).In spite of the essential and integral role of the emergency medical services in MCIs management, there is abundant literature indicating that healthcare providers lack adequate education and training in responding to MCIs.Aim of work: The objectives of the study were to assess the current level of education, training, experience, preparedness and satisfaction with knowledge and training of the Egyptian emergency medical technicians (EMTs) in responding to MCIs.Materials and Methods: A cross-sectional and questionnairebased survey that recruited 177 EMTs working within the Egyptian Ambulance Authority.Planning, education and training scores were calculated in order to determine a possible correlation with self-confidence and preparedness in responding to MCIs. Results:The results of the study demonstrated that about one-third of the surveyed EMTs found that they had a high MCIs planning level and about two-thirds had a high MCIs training level.However, about 70% of EMTs had no training regarding terrorism response and about half of them had never participated in MCIs exercises.Both the MCIs training level and the participation in MCIs exercises were correlated with the perception of the EMTs' confidence and preparedness for their role during MCIs response.The surveyed EMTs ranked the administrative obstacles as the most frequent barriers to MCIs medical education or training.Conclusion: The educational strategy should include mechanism that substitute for practice and experience and should ensure that the identified training needs and the required competencies are met.

BACKGROUND:Heavy rain hit Sudan in August 2013 with subsequent flash floods in different parts of the country. This study investigated the impact of the flooding on incidence of malaria in Almanagil Locality in central Sudan.METHODS:This observational retrospective study compared malaria data sets during rainfall seasons in the Almanagil Locality in the year of flooding (2013) with those of corresponding rainfall seasons of previous two non-flood years (2011 and 2012).RESULTS:A marked increase of new malaria cases and incidence rate was observed in the 13 sentinel malaria notification sites in the locality  (IR increased from 6.09 per 100,000 person-days in 2011 [95 % CI: 5.93-6.26] and 6.48 in 2012 [95 % CI: 6.31-6.65] to 8.24 in 2013 [95 % CI: 8.05-8.43] ; P< 0.0001), with a peaking of the incidence rate in the under-5-years age group (IR for this age group jumped from 9.80 per 100,000 person-days in 2011 [95 % CI: 9.29-10.32] and 10.00 in 2012 [95 % CI: 9.52-10.49] to 15.02 in 2013 [95 % CI: 14.41-15.64]). A noticeable increase in the slide positivity rate (P< 0.0001) was observed in the 12-week period of 2013 (SPR = 20.86% [95 % CI: 20.40 -21.32%]) compared with the same periods in 2011 (SPR = 8.72% [95 % CI: 8.36 -9.08%]) and 2012 (SPR = 12.62% [95 % CI: 12.24 -13.01%]), with a more marked rise of the SPR in the under-5-year age group. Hospital data showed increase in both the inpatient and outpatient incidence proportions in the study period of 2013 compared to those of the years 2011 and 2012. Hospital OPD incidence proportion in 2013 was 19.7% (95% CI: 19.24-20.18%) compared to 12.85% (95% CI: 12.48-13.23%) in 2011, and 12.16% (95% CI: 11.82-12.51%) in 2012. The < 5 year old groups were responsible for the overall rise in the proportion of malaria cases in 2013 , particularly the < 1 year old group which more than doubled in the 2013 period compared to both 2011 and 2012 periods (Age-specific proportion of the outpatient malaria cases of the < 1 year old group in 2013 was19.5% [95% CI: 18.5-20.6%]  compared to 7.7% [95% CI: 6.9-8.6%] in 2011 and 8.1% [95% CI: 7.3-8.9%] in 2012. Incidence proportion of severe malaria cases (inpatients) increased to 22.5 % (95 % CI: 21.5 to 23.6 %) in the study period of 2013 compared to 19.8 % (95 % CI: 18.6 to 21.0 %) in 2011 and 18.4 % (95 % CI: 17.4 to 19.5) in 2012. The increase in the proportion of severe malaria cases was mainly due to a higher proportion of children < 5 years of age and especially to a higher proportion of children < 1 year of age.CONCLUSION:The study revealed a significant increase in the incidence rate of malaria in Almanagil Locality following the flash flood of August 2013. The flooding had the highest impact on the malaria incidence of the under-5-years age group, and particularly of the under-1-year age group.

Mass casualty incidents still cause a huge amount of deaths and injuries in the 21 st century. Research on these events is challenging due to inherent ethical and logistical difficulties. Computer simulation models can overcome these difficulties, and offer evidence on which to base policy and decisions. In this paper a discrete event simulation model is described, designed to analyze prehospital policies and commonly made decisions. We studied an airplane crash scenario and analyzed mortality as a primary and treatment and transport times as secondary outcome measures. We implemented resource dispatching, search and rescue at the disaster site, triage, treatment and evacuation of victims to healthcare facilities. Overall we conclude that for this particular scenario - where treatment capacity is sufficient - the best outcome for victims can be achieved by the combination of triage, pre-triage and quick distribution of victims to regional hospitals.

BackgroundThe civil war in Syria including the deliberate targeting of healthcare services resulted in a complex humanitarian emergency, seriously affecting children's health. The objectives of this study are to document diagnoses and disease categories in Northern Syrian children after four years of conflict, and to document infectious diseases and injuries in this vulnerable population.MethodsIn a prospective cross-sectional observational sample study conducted in May 2015, healthcare workers registered demographics, comorbidities, and diagnoses (categorised according to the International Classification of Diseases version 10) in children visited at home and in internally displaced persons camps in four Syrian governorates.ResultsOf 1080 filled-out records, 1002 were included. Children originated from Aleppo (41%), Idleb (36%), Hamah (15%) and Lattakia (8%). Median age was 6 years (0-15; IQR 3-11), 61% were boys, 40% were younger than 5 years old. Children suffered from respiratory (29%), neurological (19%), digestive (17%), eye (5%) and skin (5%) diseases. Clinical malnutrition was seen in 4%, accidental injury in 3%, intentional injury in 1%, and mental disorders in 2%. Overall, 64% had features of infectious diseases (OR 0.635; CI 0.605-0.665). Most common comorbidities were chronic respiratory diseases (14, malnutrition (5%), acute flaccid paralysis (5%), and epilepsy (4%). Logistic regression analysis indicated that the risk for children to have communicable diseases was higher in Aleppo than in Idleb (OR 1.7; CI 1.2-2.3), Hamah (OR 4.9; CI 3.3-7.5), or Lattakia (OR 5.5; CI 3.3-9.3). Children in Aleppo and Lattakia were more at risk to be injured than in Idleb (OR 5.6; CI 2.1-14.3), or in Hamah (OR 5.9; CI 1.4-25.6), but more often from intentional violence in Lattakia. Mental problems were more prominent in Hamah.ConclusionsFour years far in the conflict, 64% of the studied children in four Northern Syrian governorates suffer from infections, mostly from respiratory, neurological and digestive origin, while 4% was injured or victim of intentional aggression. Substandard living conditions and the lack of paediatric healthcare put Syrian children at risk for serious infections, epidemics and morbidity, and ask for urgent international humanitarian relief efforts.