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Table 1 Characteristics of included publications by disease type: Cardiovascular Disease

From: Systematic review on chronic non-communicable disease in disaster settings

Territory of Interest
WHO region Type of study Target Population Years of observation Number of study participants Major findings
Abukhdeir (2013) [32] Palestinian Territories: West Bank/Gaza EMRO Cross sectional Palestinian households in the West Bank and Gaza Strip May 2004—July 2004 4,456 households in the West Bank and 2118 in the Gaza Strip Being a refugee was a significant risk factor for CVD while being married/engaged or divorced/separated/ widowed was a risk factor for hypertension. Non-refugees were 46% less likely to have CVD than refugees. Gender was a risk factor for hypertension with females being 60% more likely to have hypertension than males. Age was a significant risk factor for hypertension and CVD(p < 0.0001)
Ahmad (2015) [33] Syria EMRO Situational analysis using document analysis, key informant interviews, and direct clinic observation Syrian national health system October 2009 -August 2010 53 semi-structured interviews The rebuilding of a post-conflict heath care system in Syria may benefit from insights into the structural problems of the pre-crisis system. Weaknesses that existed before the crisis are compounded by the current conflict
Armenian (1998) [34] Armenia Europe Retrospective cohort Employees of the Armenian Ministry of Health and their immediate families who survived the 1988 Earthquake in Armenia 1990–1992 35,043 persons (7,721 employees who had survived the disaster and their family members) The nested case–control analysis of 483 cases of newly reported heart disease and 482 matched non-heart-disease controls revealed that people with increasing levels of loss of material possessions and family members had significant increases in heart disease risk (OR for “loss scores” of 1, 2, and 3 were 1.3, 1.8, and 2.6, respectively)
Ben Romdhane (2015) [35] Tunisia EMRO Situational analysis Tunisian national health system 2010 12 key informants were interviewed and eight documents were reviewed Weaknesses that existed before the 2011 Revolution (Arab Spring) were compounded during the revolution. This study was conducted prior to political conflict but written post-conflict. Growth of the private sector fostered unequal access by socioeconomic status and reduced coordination and preparedness of the health system
Bergovec (2005) [36] Bosnia and Herzegovina Europe Retrospective chart review The population that lived in Mostar and the nine neighboring districts prior to the Bosnian War(1992–1995) Five consecutive years (1987–1991) before the war and 5 consecutive years (1992–1996) during the war were analyzed 182,000 persons per the 1991 census There was a wartime increase in acute myocardial infarctions(AMI) for the total population (p = 0.025). There was a statistically significant increase (p = 0.001) in the total number of unstable angina pectoris(UA) cases during the war (185 cases, compared with 125 prewar cases). Females experienced a statistically significant increase in UA and AMI(p = 0.001, 0.007 respectively) whereas the increase among men was not statistically significant (p = 0.072, p = 0.354 respectively)
Chen (2009) [37] China Western Pacific Case series Adults who were in the West China Hospital on the day of the 2008 Sichuan (Wenchuan) earthquake May 2008 11 patients Mean blood pressure and heart rate increased immediately after the earthquake, regardless of gender or pre-existing hypertension. BP gradually declined within 6 h after the earthquake and increased again during aftershocks. Circadian variation was absent in all cases
Ebling (2007) [38] Croatia Europe Multipart study including both a retrospective cohort study and an uncontrolled before-after study Refugee-returnees of the 1991–1992 war operations in Eastern Slavonia from Osjek-Baranga County, Croatia 2003 retrospective cohort study: 589 participants
uncontrolled before-after study 202 participants
Single counseling session aimed at lifestyle changes can be effective at decreasing CVD risk factors. The participation of subjects with high blood pressure in the population of displaced returnees, exceeded the values for both Slavonia and Croatia census data
Ebrahimi (2014) [39] Iran EMRO Cross sectional Patients with cardiovascular and respiratory diseases who received medical services from the Center for Disaster and Emergency Medicine in Sanandaj, Iran during dust event days March 2009—June 2010 A statistically significant increase in emergency admissions for cardiovascular diseases was demonstrated during dust storm episodes in Sanandaj, Iran(correlation coefficient (r) = 0.48, p < 0.05)
Huerga (2009) [40] Liberia Africa Retrospective chart review Patients of the medical and pediatric wards of Mamba Point Hospital, Monrovia, Liberia, one year after the end of the Liberian civil war January 2005—July 2005 1,034 adult patients
1,509 children
Non- infectious diseases accounted for 56% of the adult deaths. The main causes of death were meningitis (16%), stroke (14%) and heart failure (10%).Cardiovascular diseases caused half of deaths due to non-infectious diseases: 25% stroke, 18% heart failure, and 10% severe hypertension. No cases of ischemic heart disease were identified
Hult (2010) [41] Nigeria Africa Retrospective cohort 40 year old Nigerians with fetal exposure to famine in Biafra, Nigeria during the Nigerian civil war (1967–1970) June 2009–July 2009 1,339 study participants Fetal-infant exposure to famine was associated with elevated systolic (+ 7 mmHg; p < 0.001) and diastolic (+ 5 mmHg; p < 0.001) blood pressure, waist circumference (+ 3 cm, p < 0.001), increased risk of systolic hypertension (adjusted OR 2.87; 95% CI 1.90–4.34), and overweight status (OR 1.41; 95% CI 1.03–1.93) as compared to people born after the famine
Hung (2013) [42] China Western Pacific Retrospective chart review Patients treated by Hong Kong Red Cross three weeks after the 2008 Sichuan earthquake June 2008 2,034 patient encounters There was a high prevalence of chronic disease after the earthquake, especially hypertension. 43.4% of the 762 patients with blood pressure measurements were above the recognized criteria for hypertension
Kadojic (1999) [43] Croatia Europe Cohort study Displaced persons aged 20-60y with signs of PTSD and a history of traumatic war experience living in a displaced persons camp since 1991 120 displaced persons Displaced persons in Croatia residing in camps had a significantly higher prevalence (p < 0.05) of hypertension, hyperlipidemia, and obesity when compared to age-matched controls in settlements adjacent to the study population not impacted by the war. Total risk for stroke was higher in the exposed group(p < 0.05
Kallab (2015) [44] Country of Asylum: Lebanon
Country of Origin: Syria
EMRO Program implementation reflection Syrian refugees and vulnerable Lebanese being treated in 8 health facilities run by Amel Association International November 2014- May 2015 1,825 patients Of the 1,825 patients enrolled in the program hypertension and diabetes accounted for 46% and 27% of cases respectively, with the remaining 27% of patients presenting with both diseases. Major challenges included medications shortages and cost, insecurity, patient transportation cost, and high workload for providers
Khader (2014) [45] Country of Asylum: Jordan
Country of Origin: Palestinian Territories
EMRO Retrospective cohort study with program and outcome data collected and analyzed using E-Health Palestine refugees living in Jordan October 2009- June 2013 18,881 patients 50% of patients were diagnosed with both hypertension and diabetes and 50% had hypertension alone. There were significantly more patients with hypertension and diabetes (N = 966, 13%) who had disease- related complications than patients who had hypertension alone (N = 472, 6%) [OR 2.2, 95% CI 2.0–2.5]. Most common risk factors included smoking, physical inactivity, and obesity
Marjanovic (2003) [46] Croatia Europe Retrospective chart review Patients examined at Beli Manastir Health Center Department of Emergency in Baranya, Croatia post- war November 1997 (the time of Baranya reintegration into the legal system of the Republic of Croatia after the war)—December 2001 513 stroke patients Stroke patients presenting to the emergency department at a single site had an average of 68.4y, with an age range from 25-91y, and a near equal distribution between men and women (51.7% male). Only 50.6% of patients presented within 6 h, another 16.2% presented after 24 h. Paresis, speech impairment and vision impairment were the most common presenting symptoms. 85.8% of patients had hypertension, 27% had diabetes, 44.6% had hyperlipidemia and 46% also had cardiac disease. 38.4% of patients presenting to the hospital died
Markoglou (2005) [47] Kosovo Europe Cross sectional Patients under the care of the NATO forces who provided medical services to the civilians of Kosovo during the Yugoslav Wars January 2000—July 2000 830 patients 30.6% patients were diagnosed with hypertension (188 female and 66 male). More than half of the patients (51.2%) had severe hypertension, 31.5% modest and 17.3% mild. Only 5.5% of patients were on regular antihypertensive treatment (9.09% men and 4.24% women). Concomitant diseases in our patients (62% of patients) were in descending order by incidence rheumatic, cardiovascular and COPD disorders. Hypertension due to increased sympathetic activity(attributed to war stress) was present in 35 patients, (13.78%, 32 – 17.02% women and 3 – 4.55% men, p < 0.05), and hypertension secondary to the use of NSAIDs or cortisone in 15 patients (5.91%, 8 women – 4.26% and 7 men – 10.6%, p > 0.1)
Mateen (2012) [48] Country of Asylum: Jordan
Country of Origin: Iraq
EMRO Retrospective Cohort Iraqi refugees receiving UNHCR health assistance in Jordan January 2010-December 2010 7,642 registered Iraqi refugees For adults 18y and older, primary hypertension was the top diagnosis(22%). Diagnoses requiring the greatest number of visits per refugee were cerebrovascular disease (average of 1.46 visits per refugee); senile cataract (1.46); glaucoma (1.44); urolithiasis (1.38); prostatic hyperplasia(1.36); and angina pectoris (1.35). Concomitant disease was common (60% has more than one diagnosis)
Miric (2001) [49] Croatia Europe Retrospective chart review Patients hospitalized in coronary care units of Clinical Hospital Split prior to, during, and following the Croatian War of Independence 1989—1997 3,454 patients In the 3-year period preceding the war, from 1989 to 1991, 1,024 patients were hospitalized because of MI. During the 3 years of full war activities, from 1992 to 1994, there were 1,257 patients (significantly more; p < 0.05). And in the 3-year period after the war, from 1995 to 1997, there were 1,173 patients. Older age was a risk factor for greater morbidity and mortality, however the number of smokers was greater among patients younger than 45 years (75% vs. 51%; p < 0.001)
Mousa (2010) [50] Country of Asylum: Jordan, Lebanon, Syria, West Bank/Gaza
Country of Origin: Palestinian Territories
EMRO Case series Refugees registered by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) June 2007 7,762 refugees Overall 18.7% of the screened population presented with high blood pressure (≥ 140/ ≥ 90 mmHg). People were referred for screening most commonly because of age (both sexes), followed by smoking (males) and family history (females). More females over 40 years of age were screened than men (p < 0.01)
Otoukesh (2012) [51] Country of Asylum: Iran
Country of Origin: Afghanistan
EMRO Retrospective cross sectional Afghan refugees in Iran 2005 -2010 23,152 refugees Ischemic heart diseases constituted the fourth leading cause of referrals (10.4% of referrals). Referrals by Pashtun group were mostly for neoplasms (17%), among Uzbek group it was nephropathies (26%), and in Baluch group hematopoietic disorders (25%)
Sibai (2001) [52] Lebanon EMRO Retrospective cohort study Lebanese aged 50 years and over residing in Beirut, Lebanon in 1983 1983–1993 1,567 cases The most important causes were non-communicable diseases, mainly circulatory disease (60%); and cancer (15%). Among circulatory diseases, ischaemic heart disease accounted for the majority of the mortality burden (68%) followed by cerebrovascular diseases (21%). In countries that lack reliable sources of mortality data, the utility of verbal autopsy can be viably extended to cohort studies for assessing causes of death
Sibai (2007) [30] Lebanon EMRO Retrospective cohort study Lebanese aged 50 years and over residing in Beirut, Lebanon 1984–1994 1,567 cases Most important causes of death were CVD and Cancer. High adjusted risk of CVD mortality associated with being single (never-married) versus married among men and women. Outcomes were self-reported
Strong (2015) [53] Country of Asylum: Lebanon
Country of Origin: Syria
EMRO Cross sectional Syrian refugees over age 60 residing in Lebanon and registered with either Caritas Lebanon Migrant Center (CLMC) or the Palestinian Women’s Humanitarian Organization (PALWHO) March 2011—March 2013 210 refugees Older refugees reported a high burden of chronic illnesses and disabilities. Hypertension was most common (60%), followed by diabetes mellitus (47%), and heart disease (30%). The burden from these diseases was significantly higher in older Palestinians compared to older Syrians, even when controlling for the effects of sex and age (hypertension p < 0.001; diabetes p < 0.001; heart disease p = 0.042). Financial difficulties were given as the primary reason for not seeking care by 79% of older refugees
Sun (2013) [54] China Western Pacific Cross sectional Survivors of Wenchuan earthquake staying in a temporary shelter for more than 1 year March–May 2009 3,230 adults The prevalence rate of hypertension among survivors was 24.08%. Age, family history of hypertension, sleep quality, waist-to-hip ratio, BMI,and blood glucose levels are risk factors for earthquake-induced hypertension. Mental stress was not a risk factor. The rates of hypertension awareness, dosing, and control was 34.58%, 53.43% and 17.84%, respectively
Tomic (2009) [50] Bosnia and Herzegovina Europe Retrospective case control Pregnant women with hypertensive disorders and their neonates hospitalized in the Obstetric/Gynecological and Pediatric Departments of Mostar Hospital during the war and postwar period (Bosnian War 1992–1995) January 1995—December 1999 542 pregnancies with hypertensive disorders The prevalence of hypertensive disorders in pregnancy was higher during wartime, demonstrated by a drop in prevalence during the five years after the war, with the highest prevalence occurring at 8.7% during the first year after the war. Those in the study group had higher odds of placental abruption, cesarean delivery, preterm birth, fetal growth restriction, and fetal death. Those in the study group with hypertensive pregnancy disorders had a lower number of prenatal care visits than controls (p < 0.001)
Vasilj (2006) [55] Bosnia and Herzegovina Europe Retrospective chart review Patients who suffered from the acute coronary syndrome in western Herzegovina pre, during, and post-war (Bosnian War 1992–1995) 1987–2001 2,022 patients There was a higher prevalence of ACS presentations both during (n = 665, p < 0.0005) and after the war (n = 843, p < 0.0005), as compared to prior to the war (n = 365) in both sexes
Vukovic (2005) [56] Serbia Europe Retrospective chart review Patients with ischemic heart disease who were admitted to the Cardiac policlinic for a control check-up immediately after the suspension of air raids June 1999 75 patients The severity of angina pains and nitroglycerin pill usage was associated with timing of air raids, increasing during the first week and initial week after raids when compared to the week before raids
Yusef (2000) [22] Country of Asylum: Lebanon
Country of Origin: Palestinian Territories
EMRO Cross-sectional Diabetic and hypertensive patients attending UNRWA primary health care facilities in Lebanon 1997 2,202 records Presence of both diabetes and hypertension increased the risk for late-stage complications. The major complication was cardiovascular disease followed by retinopathy. Only 18.2% of diabetic patients and 17.7% of diabetic patients with hypertension were managed by lifestyle modification. Medication shortages may drive medication choices for hypertension
Zubaid (2006) [57] Kuwait EMRO Retrospective chart review Catchment area of Mubarak Al Kabeer Hospital March 2003 1 Missile Attack Period (MAP) and 4 control periods Missile attacks were associated with an increase in the incidence of AMI. The number of admissions for AMI was highest during MAP, 21 cases compared to 14–16 cases in the four control periods, with a trend towards increase during MAP (incidence rate ratio = 1.59; 95% CI 0.95 to 2.66, p < 0.07).The number of admissions for AMI during the first 5 days of MAP was significantly higher compared to the first 5 days of the four control periods (incidence rate ratio = 2.43; 95% CI 1.23 to 4.26,p < 0.01)