Traumatic injuries and outcomes during the Libyan Civil War: a systematic review

Abstract

Introduction

The Libyan Civil War (LCW) is an ongoing internal armed conflict that started as a peaceful protest in February 2011, resulting in a power vacuum after the regime collapsed and an uncontrolled spread of arms, which caused a significant increase in violence and trauma. Our review aims to investigate the war-related epidemiology and mortality in patients who have been injured during this conflict.

Methods

A systematic review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Embase, Web of Science and Cochrane Library databases were searched for studies published between February 2011 and May 2024. Studies were included if they involved patients with trauma during the LCW and outcomes of interest were type and anatomical distribution of injuries and mortality. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation.

Results

Thirteen studies met the eligibility criteria, with a total sample size of 4665 patients. There were seven studies (n=4378 patients) that reported mortality rate, with 438 (10%) who died. 13 out of the 14 studies documented the mechanism of injury of their participants with a total number of 4543 injuries, most commonly from firearm-related trauma (60.3%). 12 studies recorded the anatomical distribution of their sample of 4123 anatomical sites, with extremities being the most affected part, accounting for 54.5% of injuries.

Conclusion

The LCW has caused a high burden of morbidity and mortality among the Libyan population. This review provides an insight into the adverse health consequences of this active war and highlights the difficulties in collecting reliable information on the wounded during conflicts.

PROSPERO registration number

CRD42024527289.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• There is scattered published research of war-related epidemiology and mortality of the Libyan Civil War (LCW), but there is no systematic review to evaluate it.

WHAT THIS STUDY ADDS

• This study provides research evidence for healthcare professionals and policymakers within Libya about common traumatic injuries to be able to plan and allocate resources.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This review advocates for an urgent need for a trauma registry within Libya to monitor the impact of the ongoing LCW on the affected individuals.

Introduction

The Libyan Civil War (LCW) is an ongoing internal armed conflict that started as a peaceful protest in early 2011 as citizens sought to end decades of authoritarian rule and establish a democratically elected government.^{1 2} What started as non-violent demonstrations escalated into an 8-month armed struggle, resulting in the fall of the ruling regime later that year.^{2 3} The failure to establish a new ruling government after the fall of the previous regime created a power vacuum with an uncontrolled spread of arms, which resulted in a significant increase in violence and trauma as subsequent Libyan governments were unable to assert authority.^{2 4}

This long-standing on–off conflict between armed groups coupled with the failure of Libya’s political administrations to form a united government has resulted in a devastating humanitarian crisis with a high burden of death, physical disabilities, population displacement and destruction of healthcare facilities.^{2 5 6} The ongoing nature of this conflict has depleted the country’s resources and prevented the recovery of the healthcare infrastructure⁶ and as such international organisations have advocated for an urgent need to resolve this crisis and end the suffering of ordinary citizens.^{4 7} The United Nations (UN) have attempted to introduce enforcement measures for arms embargo to reduce the war-related mortality and civilian injuries.^{4 7}

This prolonged urban conflict with its cumulative traumatic events was also linked to considerable psychological damage to the affected Libyan population.¹ An increase in common mental health disorders like depression, anxiety and post-traumatic stress disorder was documented, but there was not enough epidemiological data, especially from war-affected areas of Libya to make definitive conclusions.¹ Therefore, our study tackled the lack of epidemiological data regarding the psychological impact of this conflict, by focusing on conflict hotspots with a high prevalence of war-related injuries, as these casualties are likely to benefit from psychological support.

This conflict has also resulted in an increase in the prevalence and severity of traumatic injuries, which have become one of the leading causes of morbidity and mortality.⁸ Consequently, it is critical for policymakers and healthcare professionals in war-torn countries like Libya to have accurate and reliable data about the extent of traumatic injuries in their affected populations.⁹ The current systematic review aimed to analyse the injury epidemiology and outcomes in this conflict in order to provide guidance in allocating available resources depending on the need of affected communities.

Methods

Study design

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO (Ref: CRD42024527289).¹⁰ The full literature search was achieved using Medline (via Ovid), Embase (via Ovid), Web of Science (Core Collection) and Cochrane Library on 31 May 2024 with relevant medical subject headings (MeSH) search terms such as (Libya OR Libyan) AND (War OR Conflict) AND (Injury or Trauma).

Search strategy

Studies were eligible for inclusion if they included data regarding traumatic injuries in patients in Libya after February 2011 (the start of the LCW). Language, age or location restrictions were not applied as long as they reported on patients affected by exposure to this conflict. We included all types of research studies apart from case studies with fewer than six patients. Studies without a clear timeline of data collection were excluded if there was no response from the corresponding author and the relevant data remained unavailable via any other means.

Study selection

Two reviewers (MA and VDP) independently screened all titles and abstracts and performed full-text evaluation, against pre-determined inclusion/exclusion criteria (online supplemental table 1). If different studies were published from the same patient sample, the study with the most relevant data was selected for inclusion. The screening process was conducted using the Covidence systematic review software (Covidence.org, Melbourne, Australia) and any discrepancies were resolved by discussion.

Study quality assessment

We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidance to assess the certainty of evidence of relevant outcomes and classify studies into (Very low, Low, Moderate or High), as described previously.¹¹ The GRADE assessment was conducted by (MA), which was then reviewed by (VDP) and any disagreements were resolved by discussion.

Data extraction and analysis

Data extraction included characteristics of included studies (eg, study type, duration, trauma location and quality assessment), patients’ demographics and clinical information (eg, sample size, gender, mean age, type of attendees, mechanism of injury, injury anatomical location and mortality). Missing outcome data were handled by directly contacting the corresponding author and if there was no response by 31 August 2024, the study was excluded. Mechanism of injury was categorised into firearms related which encompassed all firearms, stray bullets or blast-related trauma which included explosion, missile, bomb, improvised explosive devices and rocket propellant. Other mechanisms of injuries were blunt instrument, burn, stabbing and unspecified battlefield traumatic injuries.

Outcomes of interest

The outcomes of interest were injury type, anatomical region of injury and mortality.

Data synthesis

All extracted data from included studies were summarised in a narrative form. There was no planned meta-analysis because there was no intervention or control required in included studies. Data are reported verbatim from included studies where applicable, and when summarised, number and percentage were used for categorical data.

Results

Study selection

Our search yielded 170 studies of which 48 were duplicates (figure 1). After title and abstract screening, 89 studies met the eligibility criteria, and 13 studies remained after full-text screening. Two studies used the same population sample,^{12 13} so only the study with the most comprehensive data about traumatic injuries was included.¹² Two other studies contained incomplete data or unclear timelines for data collection, and after sending emails to corresponding authors, raw data was sent by one author,¹⁴ but the other was excluded since the author did not respond in time.¹⁵ Population-based studies were excluded from the analysis because they were ‘whole-population’ studies that clearly overlapped with patients in the remainder of studies.^{5 6}

Figure 1. PRISMA flow diagram of a systematic review of trauma casualty epidemiology during LCW. LCW, Libyan Civil War; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Study characteristics

Seven studies were descriptive, four were cohort studies, one was a retrospective cross-sectional study and one was a prospective descriptive case series (table 1). Four studies collected data from 2011 only^{12 14 16 17} and another five studies that started data collection in 2011.¹⁸,²² Six studies were based in Benghazi city (east of Libya) and its surrounding areas,^{1216 18},²¹ three were based in the western coast of Libya and involved casualties from the capital city, Tripoli, and the city of Misurata,^{14 17 23} and four²²²⁴,²⁶ were from unspecified locations. Six studies involved participants who were injured and treated at the same location within Libya,^{1216 17 19},²¹ while seven studies involved foreign healthcare professionals stationed on the ground during the start of this conflict or abroad.^{1418 22},²⁶ Two out of these seven studies^{14 18} were conducted by staff from the Jordanian military field hospital in Benghazi city and the International Medical Corps field hospital in Misurata city. The remaining five studies²²²⁴,²⁶ involved the treatment of Libyan casualties in healthcare facilities outside Libya (eg, four in Turkey and one in Germany).

Table 1. Characteristics of included studies and GRADE evaluation of its certainty.

First author (year)	Study design	Study duration	Trauma location—country	Treating centre—country	Stated inclusion/exclusion criteria	GRADE quality assessment
Al-Tarshihi and Al-Basheer18 2013	Descriptive study	November 2011– February 2012	Benghazi city—Libya	Military Jordanian field hospital in Benghazi city—Libya	Study looked at celebratory stray bullet injuries. Any patient with a known source of the bullet was excluded from the study	Very low ⊕
Bodalal and Mansor12 2013	Descriptive study	2011	Benghazi city, Almarj city, Alwahat and Misrata city) —Libya	Benghazi city—Libya	Patient with gunshot injuries were analysed for various parameters	Moderate ⊕⊕⊕
Mansor et al16 2014	Descriptive study	February 2011– December 2011	Benghazi city—Libya	Benghazi city—Libya	Patients presented with gunshot injury in the abdomen and sustained colon injury.	Low ⊕⊕
Elfaedy et al19 2015	Cohort study	February 2011– December 2014	Benghazi city—Libya	Benghazi city—Libya	All patients admitted to this health facility with gunshot wounds to the colon	Very low ⊕
Etabbal et al20 2018	Prospective descriptive case series	February 2011– August 2017	Benghazi city—Libya	Benghazi city—Libya	All patients who presented with a shotgun, gunshot or explosive penile injury	Low ⊕⊕
Mansor et al21 2022	Cohort study	February 2011– December 2016	Benghazi city—Libya	Benghazi city—Libya	Patient presented with proximal and distal anatomical half of the brachial artery. The diagnosis of brachial artery injuries depended mainly on clinical examinations.	Very low ⊕
Dau et al17 2013	Descriptive study	March 2011 - October 2011	Tripoli and surrounding cities—Libya	Tripoli city—Libya	All patients with surgical wounds that were sustained during LCW	Very low ⊕
Dootz et al23 2021	Cross-sectional study	July 2016– November 2017	Tripoli city—Libya	Frankfurt city— Germany	All patients who presented to this health facility were selected by the Libyan War Casualties’ Committee (Tripoli).	Very low ⊕
Levine and Shetty14 2012	Descriptive study	June 2011– August 2011	Misurata city—Libya	International Medical Corps field hospital in Misurata city—Libya	Any patient presented to this field hospital	Very low ⊕
Sertbas and Karatay24 2020	Descriptive study	February 2015– March 2017	Libya (unspecified)	Istanbul—Turkey	Patients treated at this hospital for cranial and spinal penetrating gunshot injuries during LCW.	Low ⊕⊕
Karakoc et al25 2020	Descriptive study	November 2013– Oct 2015	Libya (unspecified)	Istanbul—Turkey	Patients discharged within 48 hours of admittance, those with surveillance cultures sampled after 48 hours of admittance, and those with missing surveillance culture samples were excluded	Low ⊕⊕
Biçen et al22 2020	Cohort study	November 2011– April 2020	Libya (unspecified)	Izmir—Turkey	Patients treated at this hospital for extremity injuries caused in the LCW	Moderate ⊕⊕⊕
Onuk et al26 2022	Cohort study	October 2014– September 2016	Libya (unspecified)	Istanbul—Turkey	Patients acquired various injuries during LCW who then were transferred to this facility with genitourinary trauma for further assessment and treatment.	Low ⊕⊕

GRADE, Grading of Recommendations Assessment, Development and Evaluation; LCW, Libyan Civil War.

Quality assessment

All included studies were scored low at the initial GRADE assessment (table 1), but two studies^{12 22} were upgraded to ‘moderate’ due to large effects or lack of plausible confounding factors. Five studies^{1620 24},²⁶ remained at an overall GRADE score of ‘low’ due to common themes of poor study design or lack of bias control measures. The remaining six studies¹⁴¹⁷,^{19 21 23} were downgraded to ‘very low’ due to serious concerns such as inconsistency and imprecision. For example, one study contained a small sample size (n=23) with no randomisation or bias control,¹⁸ while another showed bias prior to treatment since selection for their treatment abroad was done by the Libyan War Casualties’ Committee, who were affiliated with a certain political group and only sent patients from a specific militia.²³

Patient characteristics

There were 4665 patients across all included studies (range 21–1761), summarised in table 2 (for full table, see online supplemental table 2). One study provided gender distribution of their fatalities (table 2) and reported that out of 98 documented deaths, male: female mortality was 18.6:1 with a mean age of 26.¹² Three studies^{12 18 24} described their fatalities’ anatomical sites of injuries, with head and chest trauma associated with the highest proportion of deaths (29.8% and 24%, respectively). However, 21.2% of casualties did not have documentation of their anatomical sites of injury, while the remaining casualties had severe injuries to their abdomen, extremities and spine, accounting for 12.5%, 7.7% and 4.8%, mortality, respectively. Firearms were the only documented cause of death in four studies,^{12 18 19 24} with a total number of 120 fatalities due to gunshot wounds.

Table 2. Summary table of patient characteristics in included studies during the LCW from February 2011 to May 2024.

Study	Sample size (n)	Mean age (years)	Mechanism of injury (n)	Injury sites (n)	Mortality rate (per 1000)
Al-Tarshihi and Al-Basheer18	23	N/A	Gunshots (23)	Head/neck (2) Chest (8) Abdomen/pelvis (1) Extremities (12)	87.0
Bodalal and Mansor12	1761	28	Gunshots (1761)	Head (116) Vertebra (57) Chest (203) Abdomen (127) Extremities (1526)	55.7
Mansor et al16	63	29	Gunshots (63)	Abdomen (63)	NA
Elfaedy et al19	172	28	Gunshots (172)	Abdomen (172)	70.0
Etabbal et al20	29	31	Shotgun (2) Gunshot (18) IED/personal landmine (7) Projectile explosion (2)	Gentile (29)	NA
Mansor et al21	51	29	Gunshots (31) Explosive (12) Stab (4) RTA (4)	Vascular injury (51)	NA
Dau et al17	1200	30	Gunshot (343) Shrapnel (283) Blunt instrument (197) Blast (171) Burn (89) Other (117)	Head and neck: (202) Chest and back (379) Abdomen (239) Extremity (189) Loss of limb (93) Polytrauma (98)	258.3
Dootz et al23	78	30	Gunshot (48) Explosion (37) Gunshot and explosion (11) Burning (3) RTA (3)	Head (16) Spine (12) Extremities (53) Thoracoabdominal (14)	NA
Levine and Shetty14	869	NA	Blast (367) Burn (19) Gunshot (7) Unspecific battle trauma (151) RTA (25) Non-battle trauma (6) Medical illness (147)	NA	6.9
Sertbas and Karatay24	63	27	Gunshots (63)	Head (35) Spine (28) Chest (8) Abdomen (20)	127.0
Karakoc et al25	45	30	Firearms (30) Bomb (9) Shrapnel (5) Rocket propellant (1)	Extremities (34) Non-extremity (3) Polytrauma (8)	NA
Biçen et al22	290	28	Gunshot (172) Explosive (56) Missile (8) Fight (9) Fall (25) RTA in conflict (21)	Extremities (290)	6.9
Onuk et al26	21	26	Explosive weapons (13) Gunshot (8)	Gentile (21)	NA

For full table, see online supplemental table 2.

IED, improvised explosive device; LCW, Libyan Civil War; NA, not available; RTA, road traffic accident.

Characteristics of injured patients

There were 3787 injured patients in the included studies with 12 studies that reported gender (3699 male, 98 female) (table 2). Of these studies, 11 reported ages,^{1216 17 19},²⁶ with a calculated overall mean age of 29, while two studies^{12 18} included data on 29 children (<18 years). The type of participants was either separated into civilians,^{18 25} combatants,^{17 23} mixed^{12 14 21 22} or unspecified.^{16 19 20 24 26}

Mortality rate

Seven studies reported the number of deaths per its collected sample, which reached a combined total of 438 from a total population of 4,378^{1214 17},^{19 22 24} (table 2). This gave an overall calculated mortality rate of 100 in 1000 (range from 6.9 to 258.3 between studies). Six studies did not document the number of deaths or only stated ‘low mortality’ without specific figures, so it was not possible to use their samples in the calculation of the overall mortality rate.^{16 20 21 23 25 26}

Anatomical distribution of injuries

Some studies specified the injured body part in their populations,¹²¹⁶,²⁶ with five focusing on one specific body region¹⁶¹⁹,^{21 24} (table 3). The total number of injuries to specific anatomical sites was 4123, with the most affected body part being the extremities, accounting for 54.5% of the total affected anatomical regions. The second most injured body parts were the abdomen and pelvis, with 686 injuries (16.6%). Two studies also reported 50 injuries specifically on male external genitalia,^{20 26} but there were no details about 502 injuries, which were documented as ‘other’.

Table 3. Anatomical site of injury of patients who were exposed to the LCW.

	N	%
Extremities	2248	54.5
Abdomen/pelvis	686	16.6
Head/neck	371	9
Chest	219	5.3
Spine/back	97	2.4
Other	502	12.2

LCW, Libyan Civil War.

Mechanism of injury

Thirteen studies reported the mechanism of injury, with a total documented mechanism of injury of 4543 (table 4).^{1214 16},²⁶ Firearm-related injuries accounted for 2741 patients, representing 60.3% of the total mechanism of injury. Blast-related trauma affected around 15.6% of casualties, whereas only 6.8% of injuries were due to blunt instrument, burn or stabbings. There were also 151 unspecified forms of battlefield injuries and 344 injuries were unrelated to military combat.

Table 4. Mechanism of injury of patients who were exposed to the LCW.

	N	%
Firearms related	2741	60.3
Blast	707	15.6
Fragmentation	288	6.3
Blunt	197	4.3
Burns injuries	111	2.4
Stabbing injuries	4	0.1
War (unspecified including fight)	151	3.3
Others (unspecified)	344	7.6

LCW, Libyan Civil War.

Discussion

To our knowledge, this is the first systematic review to investigate the unique epidemiology of traumatic injuries developed during this conflict over its ongoing 13-year period. The main finding from this study was a 10% mortality rate among injured patients. Many injured patients were male, the most common mechanism of injury was gunshot wounds, and extremities were the most injured anatomical region. These findings may help to set the context for the understanding of trauma care during the situation within Libya.

The overall mortality rate determined by this review was higher than the observed rates in the Middle East and North African regions, which experienced or are still experiencing an ongoing war. For example, the Syrian Civil War (SCW) had an overall mortality rate (per 1000) reaching 86.3 while the Iraq war with a violence-related mortality reaching up to 10.25 per 1000^{27 28} (table 5). These comparisons can be helpful in providing context about the severity of the LCW and the devastating impact on its population. However, it is important to highlight that these figures may not necessarily be directly generalisable to the true level of violence due to the considerable variations in time and place, and the difficulty of collecting accurate and timely data.

Table 5. Comparison between Libyan and Syrian Civil Wars.

	Libya/%	Syria/%
Mortality	10	8.6
Injury/killed males	97.7	88.8
Mean age	29	6.3
Firearm-related injury	60.3	66.3
Injury of extremities	54.5	18.8

The conflict is like many other conflicts where males represented the majority of injured or killed individuals. For example, males formed around 88.8% of injured individuals in the SCW and 91% of deaths in the 1991–1992 Croatian War.²⁸ Another study looking at 18 countries that were involved in conflicts, also showed that males were over-represented, accounting for 79.3% of injured individuals.²⁹ There are many proposed explanations for this difference, including studies stating that in most North African societies, men played a bigger role in outdoor activities both in peace and war times.^{12 19} In addition, traumatic injuries in children (defined as <18 years) were under-reported in this conflict with only two studies^{12 18} providing figures for this age group. This could be due to the lack of clear documentation of patients’ demographics as most studies only provided the mean age of their casualties rather than the exact split of their included age groups.

Firearms were the most common cause of injury (60.3%), aligning with other civil wars where gunshot wounds represented up to 66.3% of injuries.²⁷ The increase in gunshot injuries, especially outside the battlefield was most likely linked to the uncontrolled spread of firearms, as civilians were not allowed to own guns prior to 2011.¹² A significant increase in injuries caused by stray bullets was also reported with injuries outside the battlefield attributed to the use of firearms for celebrations such as weddings.¹⁸

Extremities were the most commonly affected body part during this conflict accounting for 54.5% of all injuries. A similar pattern was also identified during other conflicts such as the Second Palestinian Intifada with 50% of injuries localised to extremities.²⁸ However, during the SCW, the head was the most commonly affected anatomical region, accounting for 26.6% of all injuries.²⁸ A possible explanation for the high rate of extremity injuries could be that these weapons and their users were not very accurate, resulting in stray bullets. This finding emphasises the importance of tailoring the surgical training of Libyan doctors towards learning about the overall management of injured extremities.

This conflict is a complex urban war with many internal and external variables that are difficult to control. This, coupled with a lack of documentation from many included studies, made it difficult to conduct further statistical analysis such as age-specific mortality rates or subgroup analysis. A possible solution to address this challenge could be introducing a national trauma registry to record all traumatic injuries and deaths during these sporadic conflicts. This suggestion is one of the chief assessment tools that the WHO has been advocating since 2009 and formed part of its trauma care quality improvement manual.³⁰

Limitations

Our systematic review is limited by the relatively low quality of included studies. Most studies did not follow a rigorous methodology in their study design nor did they have mortality as a primary outcome. Other studies excluded fatalities that happened in the first and second days of admission and did not provide figures of how many of these patients were excluded, lowering the number of recorded deaths in this study.¹⁶ The locations of the conducted studies affected the calculated mortality rate, as three out of five studies looked at casualties who were treated abroad and did not report mortality data.

Conclusion

This conflict has caused a high burden of morbidity and mortality among the Libyan population, which was reflected by the high overall mortality rate and prevalence of traumatic injuries. This review provides an insight into the adverse health consequences of this conflict and highlights the urgent need for further research on these adverse health consequences over the short and long term. This review also highlights the difficulty in collecting accurate data on the types of traumatic injuries and their effects on mortality, during times of conflict.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.