Introduction
On February 6, 2023, there were 2 consecutive earthquakes measuring 7.8 and 7.7 on the Richter scale in the southeastern part of Turkey, near the Syrian border. The epicenters of these earthquakes were 100 kilometers apart, and they were followed by subsequent aftershocks.Reference Armitage1 As of March 1, there were nearly 6000 deaths in the affected areas of the northwest region of Syria—1414 within the territory controlled by the Syrian government, and 4518 in parts of Syria not under government control.Reference Alkhalil, Ekzayez and Rayes2 The earthquake has significantly exacerbated the existing humanitarian problems in the region, including the ongoing internal conflict between territories with different subordination, the presence of internally displaced populations, the current cholera outbreak, and difficulties with the health system in the area.Reference Alkhalil, Ekzayez and Rayes2-Reference Tarnas, Karah and Almhawish4 For these reasons, the response during the acute period was only one aspect of the larger issue of the earthquake’s consequences in the Syrian Arab Republic (SAR). Considering the humanitarian situation in the region and the difficulties in operating the existing medical infrastructure, medical care to the population during the delayed period after the earthquake, when the disease spectrum and incidence changes, but the number of victims is still high, becomes equally significant as during the acute phase, as previous studies have shown.Reference Tamariz, Cely and Palacio5, Reference Gao and Wang6
To provide medical care for victims in the affected area in the delayed period of the earthquake, a field hospital (FH) from the Federal Center for Disaster Medicine (FCDM) of the Ministry of Health of Russia was deployed. After the preparation phase, FH arrived in Syria on March 1, 2023, and began providing medical care in Aleppo city on March 10, 2023.
The main purpose of this study was to describe the work of the field hospital during a deployment in Aleppo and the disease spectrum among the affected population.
Materials and Methods
FH is a division of FCDM that provides medical care in the field based on pneumatic frame modules, which can be deployed in different variants. In Aleppo, FH was deployed as a daytime outpatient clinic, placed in the 6 pneumatic frame modules, organizing a triage area, physicians’ offices, manipulation room for surgical procedures not requiring general anesthesia, intensive care unit with 1 bed, ultrasound diagnostic room, and daytime hospital. The team included doctors from various specialties: general practitioner, internist, pediatricians, surgeon, trauma specialist, infectious disease specialists, cardiologist, neurologist, dermatologist, gynecologist, anesthesiologist, ophthalmologist, psychiatrist, and ultrasound diagnostic specialist (a total of 17 doctors). In addition, there were nurses and engineers in the team. The total number of people in the team was 29.
Patients were free to visit the triage area. After a security check, nurses conducted an initial examination, and based on complaints and identified symptoms, referred them to a specialist doctor. For each patient, a medical record with an individual identifier (with end-to-end numbering) was created and informed consent for treatment was obtained. All patients underwent a detailed examination by specialists. Instrumental studies (electrocardiography, ultrasound), laboratory studies (urine analysis, glucometry) were performed in place. If it was necessary to perform radiography or other laboratory tests, patients were referred to other medical facilities with a further repeat visit to the FH. Clinical diagnosis was made by the specialists according to ICD-10, based on clinical examination and, when necessary, results of laboratory and instrumental investigation. All identified diagnoses and conditions of the patient that required medical care (if there were two or more) were recorded in the medical record. In case of need for hospitalization, the transfer to other organizations was carried out with the help of local ambulances. Interpreters assisted in communicating with the local population.
A retrospective analysis of the FH database, describing the structure of patients and their diagnoses, included data from all patients who received treatment at the FH during the entire period from March 10 to April 13, 2023. On each day, data from all newly registered medical cards were entered into the electronic database for daily reports. According to the decision of the ethics committee, the patient’s informed consent for the retrospective analysis was not required, and all data have been anonymized. The data from the daily reports, including gender, age, results of specialist consultations (diagnosis and treatment), and instrumental and laboratory tests, were de-identified using unique identifiers and then summarized in a database for retrospective analysis. The end-to-end numbering in the database was checked for missing numbers, and there were no missing data. If the diagnosis was changed following a further examination, the updated diagnosis was entered into the database as conclusive.
The statistical analysis was conducted using the IBM SPSS 23.0 software package. The average values were calculated after a preliminary analysis to determine the distribution’s normality. Proportion comparisons were performed using the χ2 criterion. The study was approved by the local review board of the Pirogov Russian National Research Medical University (protocol No. 244, dated 21.10.2024). De-identified data may be made available from the corresponding author upon reasonable request.
Results
During the 35-day deployment of the FH in Aleppo, medical specialists examined 6812 patients. Of these, 622 patients (8.4%) were re-examined on other days. Out of the 6812 patients, 2767 (40.6%) were children under the age of 18. The age distribution (Figure 1) of the patients ranged from 4 days old to 93 years old. The median age for children under 18 was 4 years [1; 9], and for adults it was 46 years [33; 57]. Women predominated among the patients (3898, 57.3%, 95%CI 56.1-58.4). However, there was a significant difference in gender distribution across different age groups (Figure 1).
Distribution of patients (n = 6812) by gender in different age groups.
Except for the first day, the number of examined patients varied from 333 per day in the middle of the deployment to 141 on the last day. The average number of patients per day was 225.6 ± 34.4. The graphic distribution of the workload by day, divided into primary and repeat visits, is shown in supplement Figure 1. Due to the request from the local security service, the clinic was closed on Sundays—on the 8th, 15th, 22nd, and 29th days of deployment.
A total of 9016 consultations were provided by various specialists. Of these, 8328 (92.3%) were initial consultations, and 688 (7.7%) were repeated. At the initial visit, 5399 (79.3%) of the 6812 patients were seen by 1 specialist based on their complaints. However, 1413 (20.7%) patients required examination by two or more specialists. The number of consultations provided by each specialist is shown in supplement Table 1.
In most cases, based on the results of the examination, one disease or condition was diagnosed in patients. However, 532 (7.8%) patients were diagnosed with two or more diseases. Specifically, 2 diseases were diagnosed in 514 patients, 3 in 16 patients, and 4 in only 2 patients. Due to the fact that some patients were diagnosed with multiple diseases, which led them to seek medical care, a more detailed analysis of the diagnostic structure was conducted by counting the “number of diagnoses” rather than the number of patients. The distribution of these diseases or conditions (n = 7364 diagnoses) among adults (n = 4487 diagnoses) and children (n = 2877 diagnoses) is shown in Figure 2. These diseases are grouped according to sections of the International Classification of Diseases, 10th Revision (ICD-10).
Frequency of various diagnosed diseases/conditions in adults (n = 4487 diagnoses) and children (n = 2877 diagnoses); total diagnoses n = 7364.
As can be seen in Figure 2, diseases from 5 main groups were most commonly diagnosed (65.1% of all cases): diseases of the respiratory system, musculoskeletal system and connective tissues, eye diseases, infectious diseases, and diseases of the circulatory system. A more detailed analysis of the specific diagnoses among children and adults can be found in supplement Table 2.
Respiratory, infectious, and ear diseases were significantly more common among children (p < 0.001) compared to adults. In contrast, adults were more likely (p < 0.05) to be diagnosed with musculoskeletal and connective tissue disorders, circulatory, eye, genitourinary, nervous system disorders, injuries, wounds, and mental and behavioral disorders, as well as for other groups of disorders (codes C00-E90, O00-R99, V01-Y98, according to ICD-10) not listed in the histogram.
According to the results of the consultations, 1310 patients were referred to a FH daytime hospital for further treatment, and 61 patients were redirected to a local hospital due to an acute condition or a severe exacerbation of their existing chronic diseases. Among the hospitalized patients, there were 21 children (34%) and 40 adults (66%). Most often, patients with circulatory (n = 16), respiratory (n = 9), and digestive (n = 7) system diseases needed hospitalization. Information about all hospitalized patients can be found in supplementary Table 3.
Discussion
This study presents the structure of diseases among patients treated in the FH for periods ranging from 33 to 67 days after the earthquake. Both this study and the works of Gao and Wang and Broach et al. (where the structure of diseases up to 30 days after an earthquake was presented) found that respiratory system diseases were the most common.Reference Gao and Wang6, Reference Broach, McNamara and Harrison7 In contrast, in this study, the next most common diseases were those of the musculoskeletal system, followed by infectious diseases and circulatory diseases.
When analyzing the morbidity structure by age group, we found significant differences between children and adults. For example, the top three causes of complaints among adults included musculoskeletal, circulatory, and eye diseases. This differs from the data presented by Gao and Wang and Broach et al.Reference Gao and Wang6, Reference Broach, McNamara and Harrison7 The most common diseases among children were infectious diseases—respiratory infections, infectious diarrhea, acute otitis media, and skin infections. These findings are consistent with the data from Ding et al., which were obtained within 1-10 days after an earthquake, except for a lower frequency of injuries in this study.Reference Ding, Fan and Lv8
The difference in results of this study compared to the literature data could be due to several factors: the variability in morbidity due to the specific characteristics of the region, the time period of this study (33-67 days after the earthquake), and the possible errors in the morbidity structure due to the limitations of the study.
Patients mainly associated exacerbations of musculoskeletal diseases and some respiratory illnesses with hypothermia. Given that a significant number of patients were living in temporary shelters and the temperature in Aleppo at the time of this study (March 10, 2023) was +18°C during the day and +5°C at night, prolonged exposure to cold may explain the findings we observed.
In comparison with the literature data, a large number of patients with eye diseases attracted our attention. These eye diseases were mainly long-term chronic conditions, and we believe that they reflect not only the effects of the earthquake, but also a long-term humanitarian crisis in the region. An additional factor contributing to the high number of eye-related diseases in morbidity pattern may be the presence of an ophthalmologist on our medical team itself.
From groups A and B according to ICD-10, leishmaniasis was the most common type of infectious disease. This emphasizes the need to analyze the endemicity of the area for infectious diseases prior to deployment. In our experience, acute otitis media is quite common. Therefore, it is essential that the team includes doctors trained in otoscopy or otorhinolaryngologists.
As seen in the study by Bakkaloğlu et al., during the early response period, when injuries are more common, there is a high need for surgical care and intensive care, including hemodialysis for patients with crush syndrome.Reference Bakkaloğlu, Delibaş and Sürmeli Döven9 Based on the morbidity data we have collected, in the delayed period after the earthquake, the primary need of the population shifts from surgical to therapeutic care, which must be taken into account when planning deployment.
Limitations
This study had several limitations. The presented data on morbidity reflects only outpatient work in one district of the city, and does not fully represent the true morbidity. Additionally, the limited availability of diagnostic resources contributed to the distorted morbidity structure. Radiography, complete blood count, biochemical, and microbiological tests were significantly limited in availability, and these tests were only performed to confirm diagnoses rather than for screening purposes. Only a small number of patients were able to attend the final visit and long-term follow-up was not feasible, which limited our ability to assess disease outcomes and outcome data was not collected. Also, due to communication difficulties with patients, we were unable to accurately determine the correlation between the disease and the earthquake, so this type of data was excluded from the analysis.
Conclusions
In conclusion, the needs of the population for different types of medical care during disasters can vary significantly. The main reasons for this variability, in our opinion, are: the timing of the response (days 33-67), the situation in the country before the disaster, particularly in the healthcare system, climatic conditions during the response, and local endemicities of certain diseases.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/dmp.2025.10222.
Author contribution
Study conception and design—Sayfullin R.F., collection and processing of material—Sayfullin R.F., Kolodkin A.A., statistical processing—Sayfullin R.F., text writing—Sayfullin R.F., Kolodkin A.A., editing the text—Sayfullin R.F., Zamyatin M.N., Plutnitskiy A.N.
Funding statement
The study had no financial support.
Competing interests
None.
