Beyond major earthquakes: cardiovascular health impact of Low-magnitude seismic activity and the need for preventive strategies

Introduction

Disaster medicine has historically focused on the immediate management of traumatic injuries, mass casualties, and infectious disease outbreaks following natural catastrophes (1). Earthquakes, in particular, are commonly conceptualized through the lens of collapsed infrastructure, acute trauma, and emergency surgical care (2). While this focus is clinically essential, it captures only part of the health burden associated with seismic events. Globally, CVDs are the leading cause of death, responsible for an estimated 17.9 million deaths per year and roughly 32% of all-cause mortality (3), and they are increasingly recognized as major contributors to disaster-related morbidity and mortality (3–5).

Cardiovascular complications during and after disasters are typically attributed to acute psychoemotional stress (6–8), disruption of healthcare services (9), and interruption of chronic disease management (9, 10). Most existing research in this area has concentrated on major earthquakes, where the temporal association between a catastrophic event and a surge in cardiovascular events is relatively easy to identify (4, 11, 12). For example, in the days following the 1995 Hanshin-Awaji and 2011 Great East Japan earthquakes, increases in acute coronary syndromes, stroke, and decompensated heart failure of 30% or more were observed in affected regions (12–14), and similar patterns were reported in the immediate aftermath of the 2023 Türkiye–Syria earthquake (15). However, this event-centered approach overlooks a critical reality in many seismically active regions: seismic exposure is often chronic rather than episodic (16, 17).

Low-magnitude earthquakes and background seismic activity occur frequently in geodynamically unstable areas, with hundreds to thousands of detectable events per year in tectonically active belts (16). Although such events rarely cause structural damage or trigger formal disaster responses, they may exert persistent psychological and physiological stress on exposed populations (7, 18). From a disaster medicine perspective, these low-level hazards are particularly challenging because they fall below traditional thresholds for emergency preparedness (1) yet may contribute meaningfully to population-level cardiovascular risk through repeated activation of stress-response pathways (5, 6).

According to WHO estimates, noncommunicable diseases account for approximately 89% of all-cause mortality in Azerbaijan, with cardiovascular diseases alone responsible for roughly 60% of total deaths—among the highest age-standardized CVD mortality rates in the WHO European Region (19). Country-level Global Burden of Disease estimates similarly identify ischaemic heart disease and stroke as the two leading causes of premature mortality in Azerbaijan and the wider South Caucasus, providing a quantitatively robust baseline against which any environmental contributor to cardiovascular risk including chronic seismic exposure must be evaluated (20).

This Mini Review shifts the focus beyond major earthquakes to examine the cardiovascular health impact of low-magnitude seismic activity. By integrating insights from seismology, environmental cardiology (8, 21), and disaster risk reduction (2, 22), we aim to highlight an underrecognized dimension of disaster-related health risk and to outline the need for preventive strategies tailored to chronically seismically active regions (9, 17). An exclusive focus on catastrophic events risks overlooking a substantial burden of disaster-related cardiovascular morbidity arising outside formally recognized disaster periods (11, 16). A conceptual overview of the proposed pathways linking chronic low-magnitude seismic exposure to cardiovascular morbidity and health-system burden is presented in Figure 1.

In Azerbaijan, where cardiovascular diseases account for approximately 60% of all-cause mortality (19) and where the population is chronically exposed to several hundred low-magnitude (M < 5) earthquakes per year (16, 23), even the conservative 10%–30% relative increases in cardiovascular hospitalizations reported during periods of measurable seismic activity (16) would translate into thousands of additional, potentially preventable acute cardiovascular events annually establishing low-magnitude seismic activity as a quantitatively important, modifiable component of regional cardiovascular risk that warrants explicit inclusion in disaster medicine practice, surveillance, and policy (2, 22).

Seismic activity beyond catastrophic events: a regional perspective

Seismic activity is a continuous geophysical process rather than a discrete series of catastrophic events (16). In many regions worldwide, low-magnitude earthquakes occur regularly as part of ongoing tectonic adjustment along active faults and plate boundaries (17). Although these events are frequently perceived as routine or insignificant by both the public and emergency services (1), their cumulative impact on human health warrants closer examination from a disaster medicine perspective (3, 16).

The South Caucasus represents a region of persistent geodynamic instability, situated at the convergence of the Eurasian, Arabian, and Anatolian lithospheric plates (23). Azerbaijan, located within this active tectonic zone, experiences frequent seismic events of varying magnitude, with national seismological monitoring routinely registering several hundred low-magnitude (M < 4) earthquakes per year, the majority of which fall below thresholds typically associated with disaster declarations or formal emergency response activation (16). In parallel, the country carries a substantial burden of cardiovascular disease: in Azerbaijan and neighboring countries of the South Caucasus and Eastern Europe, age-standardized CVD mortality rates exceed 400–600 deaths per 100,000 population annually, among the highest in the WHO European Region (3, 21). This intersection of chronic seismic exposure and high baseline cardiovascular risk creates a population particularly susceptible to seismically-related cardiovascular destabilization (8, 13).

From a disaster medicine standpoint, such regions challenge conventional risk-assessment models that prioritize rare, high-impact events over chronic, low-intensity hazards (1). Persistent seismic exposure may contribute to a sustained state of population-level alertness, uncertainty, and psychosocial stress (7, 18). Unlike major earthquakes, which are followed by clearly delineated response and recovery phases (2), background seismic activity represents an ongoing exposure with no defined beginning or end, complicating traditional surveillance, triage, and resource-allocation paradigms (9, 23, 24).

Recognizing this regional context is essential for reframing seismic risk as a chronic, disaster-related stressor rather than an exclusively acute phenomenon (16, 17). Such a shift is necessary to align disaster-medicine practice with the realities of populations living in chronically seismic regions, where the cardiovascular health burden may accumulate silently over years of recurrent low-level exposure (6, 16).

Cardiovascular healthcare utilization during periods of low seismic activity

Observations from seismically active regions indicate that cardiovascular healthcare utilization may remain elevated even in the absence of major earthquakes (11, 16). Ecological analyses of earthquake-prone regions beginning with the classic natural experiment of the 1981 Athens earthquake, which documented a marked, transient rise in fatal cardiovascular events in the absence of significant structural damage (16) have shown that periods of measurable seismic activity are associated with measurable increases in cardiovascular hospitalizations and acute events, with reported short-term relative risks typically rising on the order of tens of percent above baseline in vulnerable populations (11, 16, 25). Comparable signals emergency department visits and hospital admissions for acute coronary syndromes (12, 15), hypertensive crises (5, 26), arrhythmias and decompensated heart failure (13, 14), and cerebrovascular events (4) have been documented during periods characterized by low-magnitude or background seismic activity (16, 27). These patterns suggest that cardiovascular destabilization is not limited to catastrophic seismic events but may also occur in response to chronic geophysical stress (8).

Recurrent minor tremors and ongoing tectonic instability may act as continuous stressors capable of precipitating clinical deterioration in vulnerable individuals, particularly those with pre-existing cardiovascular disease (5, 10, 13). Importantly, such increases in cardiovascular healthcare utilization often occur without triggering formal disaster alerts or emergency response mechanisms (1, 22), resulting in limited preparedness at the health system level (9). Cardiovascular admissions occurring under conditions of background seismicity are therefore typically classified as routine clinical workload rather than as disaster-related health outcomes (2, 9).

This misclassification has important implications for disaster medicine. Failure to recognize low-level seismic activity as a relevant health stressor may lead to underestimation of the true cardiovascular burden associated with seismic exposure (16), delayed resource mobilization (9), and insufficient preparedness of emergency and cardiology services (9). From a systems perspective, these observations challenge the traditional binary distinction between “disaster” and “non-disaster” periods (23) and instead support a continuum-based model in which chronic low-level hazards exert sustained pressure on population health and healthcare infrastructure (1, 9).

The spectrum of cardiovascular outcomes reported in association with different seismic contexts including: major earthquakes, aftershock periods, and chronic low-magnitude seismicity together with representative effect estimates and supporting studies, is summarized in Table 1. Across the seismic intensity continuum, the magnitude of the cardiovascular signal appears to scale with the duration and intensity of exposure rather than with the occurrence of any single discrete event (11, 16). Recognizing cardiovascular healthcare utilization during periods of low seismic activity as part of the disaster-related health spectrum (3) therefore underscores the need to broaden disaster surveillance and preparedness frameworks to include non-traumatic cardiovascular outcomes in chronically seismically active regions (2, 22).

Table 1. Cardiovascular outcomes reported across the seismic-intensity continuum, with representative effect estimates, key populations, and supporting studies.

CV, cardiovascular; CVD, cardiovascular disease; M, moment magnitude; BP, blood pressure. Effect estimates are indicative ranges synthesized from the cited primary studies and meta-analyses (4, 8, 9, 16, 22, 24, 25, 29) and are intended to illustrate the direction and approximate magnitude of association rather than to represent pooled meta-analytic values. Numbers in parentheses correspond to references in the bibliography.

Taken together, Table 1 highlights a graded, continuum-based pattern of cardiovascular response across seismic exposures: from short-lived but large-magnitude surges after catastrophic earthquakes, to persistent blood-pressure and autonomic effects in aftershock periods, to subtler but cumulative increases in admissions associated with low-magnitude recurrent seismicity and chronic residence in seismically active regions (10, 11, 16).

Low-magnitude seismic activity as an underrecognized disaster hazard

Disaster medicine traditionally prioritizes sudden, high-impact hazards that produce immediate casualties and infrastructure damage (1). Low-magnitude seismic activity does not fit neatly within this paradigm: such events rarely cause visible destruction (23), attract limited media attention, and seldom activate emergency response mechanisms (24). Nevertheless, their cumulative health impact may be substantial when exposure is frequent and prolonged ecological data suggest that even sub-felt seismic activity is associated with modest but measurable increases in cardiovascular event rates in exposed populations (16).

In geodynamically active regions, background seismicity represents a form of chronic hazard exposure. Unlike major earthquakes, which are temporally discrete (4), low-magnitude seismic events occur repeatedly and unpredictably, generating persistent uncertainty and anticipatory stress (18). This pattern aligns with contemporary disaster risk reduction concepts that emphasize the cumulative effects of small but frequent hazards (1, 2, 17).

Despite this relevance, low-magnitude seismicity remains largely absent from disaster health frameworks (16). Most disaster-related cardiovascular studies focus on single catastrophic events (4, 12), short-term mortality (3), or trauma-dominated outcomes (2). Consequently, the cardiovascular consequences of chronic seismic exposure remain poorly characterized, representing a significant blind spot in disaster medicine research (1, 16).

Pathophysiological and psychosocial mechanisms

The cardiovascular effects of low-magnitude seismic activity are likely mediated through a combination of biological and psychosocial mechanisms (5, 6, 30). Acute and chronic stress responses play a central role. Even minor seismic events can trigger sympathetic nervous system activation and hypothalamic–pituitary–adrenal axis stimulation, leading to surges in circulating catecholamines and cortisol (6). Post-earthquake studies have documented average systolic blood pressure elevations of 10–25 mmHg lasting several weeks among hypertensive patients, with proportionally greater increases in those with poorly controlled disease (5, 12, 26). These responses also produce transient increases in heart rate and myocardial oxygen demand, providing a plausible substrate for acute coronary events (8).

Repeated exposure to such stress responses may contribute to sustained autonomic imbalance, endothelial dysfunction, and prothrombotic states (6, 8, 33). In individuals with pre-existing atherosclerosis or impaired cardiovascular reserve, these changes may increase susceptibility to acute events; case-crossover and registry data have linked post-disaster periods to a several-fold short-term rise in sudden cardiac death and myocardial infarction (4, 11, 13). Importantly, the absence of overt disaster cues during periods of low-magnitude seismicity may prolong uncertainty and anxiety, amplifying psychosocial stress without triggering the protective social mobilization that often follows major events (18, 27).

Psychological factors are particularly relevant in regions with chronic seismicity, where anticipatory stress and hypervigilance may persist over long periods (7, 27, 28). Population-based surveys after major earthquakes have reported clinically significant anxiety or post-traumatic stress symptoms in 15%–40% of exposed adults, and similar though less well-quantified symptoms have been documented in communities experiencing recurrent low-magnitude activity (18, 27, 28). This continuous stress burden can adversely affect cardiovascular health through behavioral pathways, including reduced physical activity, poor sleep quality, and diminished adherence to medical therapy (6, 7, 10).

Taken together, these mechanisms support the concept of low-magnitude seismic activity as a biologically meaningful stressor with measurable cardiovascular consequences (5, 6, 8, 30).

Vulnerable populations in chronically seismic regions

Disaster medicine places strong emphasis on identifying vulnerable populations (2, 22). In the context of chronic seismic exposure, individuals with established cardiovascular disease represent a key at-risk group (11, 13). Hypertension, which affects approximately 30%–40% of adults globally and exceeds 45% in many parts of Eastern Europe and the South Caucasus (3, 21, 31), is consistently associated with heightened sensitivity to stress-related triggers and shows pronounced blood pressure variability under disaster conditions (5, 26). Ischemic heart disease, heart failure, and cerebrovascular disease similarly demonstrate stress-related exacerbation patterns in post-disaster cohorts (4, 8, 13, 14).

Age further modifies vulnerability. Adults aged 65 years and older account for the majority of post-earthquake cardiovascular hospitalizations and deaths, reflecting reduced physiological reserve and a higher prevalence of comorbidities in this group (3, 10, 13). Sex-specific differences in stress perception, coping strategies, and healthcare utilization may also influence cardiovascular outcomes in seismically active settings, with women reporting higher levels of anxiety and post-traumatic stress but men exhibiting greater short-term increases in cardiac event rates after disasters (27, 28).

Socioeconomic and psychosocial factors compound these risks. Limited access to healthcare (9), low health literacy (28), and weak social support networks (23) may reduce resilience to chronic environmental stress (8, 17). In disaster medicine, such layered vulnerability underscores the importance of integrating chronic disease management into preparedness planning, even when hazards are perceived as low intensity (2, 9, 22).

Knowledge gaps in disaster medicine

Despite growing recognition of environmental determinants of cardiovascular health (8, 32), low-magnitude seismic activity remains insufficiently studied within disaster medicine (16). Most existing literature focuses on major earthquakes (4, 12), short-term mortality (3), and trauma-dominated outcomes (2). This event-centric approach leaves several critical gaps in understanding the broader cardiovascular consequences of seismic exposure (16).

First, there is limited understanding of the cumulative cardiovascular impact of recurrent minor seismic events; published studies are predominantly cross-sectional or short-window time-series analyses, with few cohorts followed for more than 12–24 months (16). Second, non-traumatic outcomes—such as cardiovascular destabilization and increased healthcare utilization are systematically underrepresented in disaster health assessments, where mortality and trauma metrics dominate (2, 3). Third, patterns of cardiovascular healthcare utilization during periods of background seismicity are rarely examined through a disaster medicine lens, despite their potential implications for preparedness and health-system resilience (9).

Another important limitation of the current literature is the lack of standardized definitions and exposure metrics for low-magnitude seismic activity (16). Studies vary widely in how seismic exposure is characterized, including differences in magnitude thresholds (often ranging from M 2.5 to M 5.0 in published analyses), temporal windows of analysis (hours to months), and selected clinical endpoints (17). This heterogeneity limits comparability across studies and hampers the synthesis of evidence relevant to disaster risk reduction (1).

Furthermore, relatively few investigations explicitly frame cardiovascular outcomes of seismic exposure within disaster medicine or disaster risk reduction paradigms (1, 24). As a result, evidence remains fragmented across cardiology (21), environmental health (8, 32), and geophysical disciplines (23). Longitudinal data addressing cumulative exposure and long-term cardiovascular trajectories are particularly scarce, with most available studies relying on short-term observational designs (3, 9).

The principal gaps in the current disaster medicine literature related to low-magnitude seismic activity and cardiovascular health, together with the corresponding implications for research and practice, are summarized in Table 2. Addressing these gaps will require interdisciplinary collaboration linking cardiology, environmental health, seismology, and disaster risk science (8, 9, 17), and is essential for developing prevention-oriented, resilience-based strategies that adequately reflect the full spectrum of health risks associated with chronic seismic exposure (2, 22, 28).

Table 2. Gaps in the current literature on low-magnitude seismic activity and cardiovascular health, with recommended research directions and key supporting references for each domain.

CVD, cardiovascular disease; DRR, disaster risk reduction. Each row links a domain of weakness in the current evidence base to a concrete research direction; the rightmost column lists representative references that substantiate both the existing focus and the identified gap.

Collectively, the six domains summarized in Table 2 outline a coherent research agenda: harmonized exposure and outcome definitions, prospective longitudinal cohorts, mechanistic studies in chronically exposed populations, and explicit framing within Sendai-aligned disaster risk reduction frameworks (1, 2, 9, 16, 17, 22).

The need for preventive strategies in disaster medicine

Recognizing low-magnitude seismic activity as a chronic, disaster-related stressor has important implications for prevention (1, 16). Within disaster medicine, prevention does not imply eliminating the geophysical hazard itself, which is not feasible, but rather reducing underlying biological, behavioral, and structural vulnerabilities (2). For cardiovascular health, this translates into optimizing primary and secondary prevention among populations residing in chronically seismically active regions (5, 21) and embedding cardiovascular protection within broader disaster risk reduction strategies (22). Given that even modest reductions in population blood pressure are estimated to substantially decrease cardiovascular mortality (3, 21), such measures are likely to yield large public-health gains in high-burden, seismically active regions.

At the individual level, preventive measures include the effective control of established cardiovascular risk factors: hypertension (5, 26), dyslipidemia (21), diabetes (8), smoking, and obesity alongside ensured continuity of essential pharmacotherapy (9) and reinforcement of evidence-based lifestyle interventions, such as physical activity, dietary modification, and sleep hygiene (6). Targeted psychosocial support and structured stress-management education may further enhance resilience by mitigating the cardiovascular impact of chronic anxiety, anticipatory stress, and uncertainty associated with recurrent seismic events (6, 7, 18, 28).

At the health-system level, preparedness frameworks should explicitly account for predictable, sustained increases in non-traumatic cardiovascular emergencies during periods of heightened seismic instability (9, 16). This may involve early-warning indicators based on seismic monitoring data (16), surge capacity planning for cardiology and emergency services (9), protected supply chains for essential cardiovascular medications (9), and the integration of cardiovascular destabilization into disaster surveillance systems (3, 13). Embedding cardiovascular considerations into disaster planning, training, simulation exercises, and recovery frameworks aligns with contemporary disaster risk reduction principles (2, 22) and supports more resilient, context-sensitive health services in chronically seismic regions (1, 24).

At the policy and community level, prevention should be conceptualized as continuous rather than event-bound (1, 22). Public health communication strategies should foster realistic risk awareness without amplifying anxiety (18, 27), while community-based interventions can promote adherence to chronic disease management (28) and strengthen social support networks (23). Such an integrated, multilevel approach, outlined in Table 3, reframes cardiovascular risk reduction as an inherent component of disaster preparedness in seismically active settings (2, 9, 22, 24).

Table 3. Proposed multilevel preventive strategies for cardiovascular risk reduction in chronically seismically active regions.

CV, cardiovascular; CVD, cardiovascular disease; DRR, disaster risk reduction. Strategies are structured according to the three levels of action emphasized in contemporary disaster risk reduction frameworks (2, 22), and align with current guideline-based cardiovascular prevention (21). Numbers in parentheses correspond to references in the bibliography.

Table 3 frames cardiovascular risk reduction in chronically seismic regions as a multilevel, continuous intervention rather than an event-bound emergency response, connecting individual clinical care, health-system preparedness, and population-level policy within a single coherent prevention model (1, 2, 21, 22, 24).

Discussion

Moving beyond major earthquakes allows for a more nuanced and operationally relevant understanding of seismic risk within disaster medicine (1, 11, 16). While catastrophic seismic events understandably dominate emergency preparedness and response planning (4, 15), growing evidence suggests that low-magnitude seismic activity may exert meaningful effects on cardiovascular health through cumulative biological and psychosocial stress mechanisms (5, 6, 8). The persistence of elevated cardiovascular healthcare utilization in chronically seismically active regions with reported short-term increases in CV hospitalizations of approximately 10%–30% during periods of measurable but sub-catastrophic seismic activity (16) highlights the limitations of disaster models focused exclusively on rare, high-impact events (8, 16).

Comparison with existing literature

The findings reviewed here are broadly consistent with three distinct but converging bodies of evidence. First, classical post-earthquake cardiovascular studies, including those from Hanshin-Awaji (1995), Northridge (1994), L'Aquila (2009), Great East Japan (2011), and Türkiye–Syria (2023), consistently document acute surges in sudden cardiac death, acute coronary syndromes, and stroke in the days to weeks after a major event (4, 12–15). Second, longer follow-up cohorts, most notably from Fukushima Prefecture, demonstrate that adverse cardiovascular risk-factor changes (e.g., increases in blood pressure, weight, and dyslipidemia) can persist for years after the inciting disaster, indicating a chronic rather than purely acute biological footprint (10, 14). Third, ecological analyses of low-magnitude or background seismic exposure, although still few in number, report measurable increases in cardiovascular hospitalizations during periods that fall well below conventional disaster thresholds (11, 16). Taken together, these strands of evidence suggest a continuum of cardiovascular risk extending from sub-felt seismic activity to catastrophic events, rather than a sharp dichotomy between disaster and non-disaster states (8, 11, 16). However, direct comparisons across studies are constrained by substantial heterogeneity in exposure definitions, outcome ascertainment, and follow-up durations (1, 16, 17).

Regional implications

The South Caucasus, with Azerbaijan as a representative model region, illustrates how chronic seismic exposure (23) and a high burden of cardiovascular disease (3, 21, 31) may intersect, creating a context in which traditional disaster preparedness frameworks are insufficient (9). In such settings, cardiovascular complications associated with background seismicity may remain largely invisible to disaster surveillance systems (2, 9), despite their relevance to population health and healthcare-system resilience (9). Recognizing low-level seismic activity as a disaster-relevant health stressor supports a shift from event-centered response toward prevention-oriented disaster medicine (1, 2, 22) and is consistent with the broader environmental cardiology agenda, which conceptualizes the cardiovascular system as a sensitive integrator of multiple chronic environmental exposures (8, 17).

Alignment with disaster risk reduction frameworks

Reframing seismic risk in this manner aligns closely with contemporary disaster risk reduction principles, including those articulated in the Sendai Framework for Disaster Risk Reduction 2015–2030, the WHO Health Emergency and Disaster Risk Management Framework, and the UNDRR Global Assessment Report 2022 (2, 22). Emphasizing prevention, preparedness, and resilience over reactive emergency response enables a more comprehensive approach to disaster-related health risk (1, 9, 24). Within this paradigm, cardiovascular disease should be recognized as a major non-traumatic contributor to disaster-related morbidity (4, 5, 11), particularly in regions exposed to chronic environmental hazards (8, 17, 32).

Critical appraisal and remaining knowledge gaps

Several methodological limitations temper the strength of the current evidence base. Most published analyses of low-magnitude seismic exposure rely on retrospective, ecological, or short time-series designs, which are vulnerable to residual confounding by co-occurring environmental exposures (e.g., air pollution, temperature, socioeconomic disruption) and by secular trends in cardiovascular care (16, 17, 32). Outcome definitions are heterogeneous, ranging from all-cause cardiovascular admissions to specific endpoints such as acute coronary syndromes or out-of-hospital sudden cardiac death, limiting cross-study comparability (1, 3, 17). Exposure metrics are equally inconsistent, with magnitude thresholds, distance buffers, and lag windows differing widely across studies (16, 17). Few studies have examined dose–response relationships between cumulative seismic exposure and long-term cardiovascular outcomes, and even fewer have explicitly framed their analyses within a disaster medicine or disaster risk reduction conceptual model (1, 22, 24). Mechanistic data, although biologically plausible (5, 6, 8), remain dominated by post-major-earthquake cohorts and are seldom obtained in populations exposed only to background seismicity (27).

Implications for future research and practice

Future research should prioritize interdisciplinary approaches that integrate seismological data, cardiovascular epidemiology, and disaster risk science (16, 17). Standardized definitions of low-magnitude seismic exposure (16), prospective longitudinal cohorts assessing cumulative cardiovascular effects (9, 10, 16), and health-system–focused analyses linking seismic monitoring data with cardiovascular surveillance (9) are needed to inform evidence-based disaster preparedness strategies (22, 28). Integrating cardiovascular considerations into disaster risk reduction frameworks may enhance the ability of healthcare systems to anticipate non-traumatic surges in demand (3, 11, 13) and to mitigate preventable cardiovascular complications in seismically active regions (5, 21).

Failure to address these gaps risks perpetuating an incomplete disaster health paradigm that overlooks a substantial and potentially preventable component of cardiovascular morbidity associated with chronic seismic exposure (1, 11, 16, 21).

Generative AI statement

The author(s) declared that generative AI was used in the creation of this manuscript. Generative AI was used to assist with language editing and stylistic refinement of the manuscript. All scientific content, interpretation, conclusions, and references were developed, reviewed, and approved by the authors, who take full responsibility for the accuracy and integrity of the work.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Ives Hubloue, Vrije University Brussels, Belgium

Reviewed by: Berna Büşra Ergin, Ministry of Health (Turkey), Türkiye