http://www.keelpno.gr info@keelpno.gr

VOL. 30

e_bulletinHellenic Center for Disease Control and PreventionAgrafon 3- 5, Maroussi, 15123, Tel: +30 210 5212000,info@keelpno.gr, http://www.keelpno.gr

August 2013 ISSN 1792-9016Vol. 30/ Year 3rd

MINISTRY OF HEALTH

HCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH

Accidents and childhood injuries constitute a major public health issue world-wide. These accidents and types of injuries are responsible for causing a significant proportion of premature mortalities and disabilities. They can be prevented by the co-ordinated implementation of effective strategies. The extent of the problem and some prevention strategies are presented in the main article.

More on page 2

This month’s interview, Eleni Petridou, Professor of Preventive Medicine and Epidemiology, Medical School of Athens University, offers her views regarding physical injuries and accidents. The professor discusses appropriate methods for prevention and offers advice to young professionals who intend to engage in the fields of epidemiology and prevention of disease.

More on page 20

Contents

Main article: Unintentional injuries in childhood 2

Surveillance data 6

Invited articles 9

Recent publications 17

Conferences and meetings 19

Interview 20

Myths and truths 25

Outbreaks around the world 30

Quiz of the month 31

World day 32

Highlights

How feasible is the prevention of injuries?Intentional and unintentional injuries account for more than 6 million deaths world-wide (1/10 deaths) and are the cause of multiple severe injuries and disabilities. Despite the prevailing view that unintentional injuries are mainly caused by bad luck, the vast majority could be avoided with the implementation of both passive safety measures, such as the separation of pedestrians from vehicle lanes, and active safety measures, such as not drinking and driving. On the other hand, the risk of permanent disability and post-traumatic stress disorder remains high, despite the implementation of costly therapeutic interventions. The descriptive epidemiology of injuries varies by type of accident, e.g. within the European Union the burden of intentional injuries has been estimated to exceed that of traffic accidents.In the treaty of Maastricht (1993), an explicit commitment to action in the sector of public health is included. The European Commission prioritizes injuries in the public health agenda, and countries pioneering the field of injury prevention, such as Sweden, have included traffic accidents in the ‘zero vision’ policy agenda.In Greece, during the last 20 years there have been notable initiatives led by the Center for Research and Prevention of Injuries (CEREPRI), Athens Medical School and related institutions to improve injury surveillance and explore their causal factors, with the aim of improving the dismal statistics, especially with regard to road traffic injuries. It is also worth noting our injury research contribution, along with efforts to raise public awareness and implement interventions targeting high-risk groups, such as young motor vehicle drivers and pedestrians, and campaigns for the prevention of drowning. Concerns about steeply rising trends in poisoning have been expressed, and recently Greek researchers have published intensively on the alarming increase of suicides associated with the financial crisis.Given the reduction in staff and resources related to public health interventions, health-care providers, as advocates of the value of prevention, and socially aware private organizations are expected to take the lead in reducing premature mortality due to injuries and prevent unjustified human suffering.

Eleni Petridou

Main article 2

http://www.keelpno.gr info@keelpno.gr

Unintentional injuries in childhood

Introduction Unintentional injuries in childhood are a major public health problem worldwide. They are responsible for causing premature mortality and disability in a significant proportion, but could be prevented by the coordinated implementation of preventive strategies. According to the World Health Organization, “while for each injury category there are proven methods for reducing both the potential for and severity of injury, identification of the problem and commitment to the policy on actions designed to prevent injuries involving children remain at unacceptably low levels.”

The extent of the problem According to the World Health Organization, injuries are among the top causes of death in children aged 18 years and account for 40% of deaths in this age group. After the first year of life, they are the leading cause of death in our country, while traffic accidents alone are recognized as the primary cause of death in those aged between 15 and 18 years, and secondary in those aged between 10 and 14 years. Specific types of injuries often associated with death in childhood are: road traffic accidents, suffocation, drowning, poisoning and burns. Although the rate of child injury death is higher in low- and middle-income countries, economically developed countries are also affected, especially their weaker socioeconomic population.

Every year in Europe, 40,000 children die as a result of an injury. It is estimated that for each death there are also several thousands of children who continue to live with physical disabilities of varying severity and psychological trauma. Similarly in the U.S., more than 9000 children are killed and more than 225,000 require hospitalization due to injury each year, while the number of visits to emergency departments is more than 9,000,000. The annual estimated economic and social costs amounts to $ 87 billion. The indicator YPLL (Years of Potential Life Lost), which estimates the approximate years that a person would have lived if she or he had not died prematurely, for unintentional injuries among children aged 1–19 years in the period 2000–2009, accounted for 42% of all YPLL. It is even five times higher than the rate for cancer, 13 times higher than the rate for heart disease and 31 times higher than the rates for pneumonia and influenza.

Why are children so vulnerable to injuries? Children are not small adults. Lacking in physical and developmental skills, they exhibit varying degrees of dependence on adults, depending on age, character and cultural characteristics.

Their type of activity and behaviour inherently puts them at risk of injuries, and this behaviour changes as they grow. Curiosity and exploratory tendencies that characterize children are usually inconsistent with the maturity required for risk assessment and capacity building to avoid them.

High-risk groups Injuries in childhood and adolescence are far more prevalent in boys than girls, with an average risk of 25% higher in boys. Possible explanations include biological parameters, the tendency of boys to engage in more risky and impulsive behaviours and socialize in different ways than girls, and the increased likelihood of not meeting inhibitory admonitions of parents and playing unsupervised. Regarding the type of injury, there are variations from country to country, but generally infants have a higher risk of choking/suffocating, while in toddlers the most frequent incidents recorded are of drowning. Falls are the most frequent injury in children up to 3 years of age, but the objects involved in the fall vary with age, e.g. furniture, stairs, playground equipment etc. Poisoning seems to show an upward frequency from the age of 9 months up to 23 months of age, and then shows a gradual reduction. As age increases so does the incidence of road traffic injuries. Low socioeconomic status, young maternal age, single-parent and large families, and low educational level of the mother, are factors that contribute to increased risk of injuries involving children.

Main article 4

http://www.keelpno.gr info@keelpno.gr

Childhood injuries in Greece The primary cause of fatalities among children aged 0–14 years is recorded to be road traffic injuries, which account for 55% of total deaths from known causes of injuries in this age group. The highest mortality rates are found in ages 10–14 years, while the lowest are in those aged 0–4. Noteworthy is the increased mortality in boys at the age of 10–14 years. Drowning is the second leading cause of death from unintentional injuries in children 0–14 years in Greece. In our country (1992–2004) there were 10 recorded deaths per year from drowning on average, in this age group. The third cause of death from unintentional injuries is falls, with six deaths on average each year, followed by burns and poisoning. (Source: National Action Plan for Injuries, 2008–2012).

Prevention Children’s accidents are predictable and preventable when appropriate prevention strategies are applied by combining three approaches that have been repeatedly tested successfully in countries that followed them typically and consistently:

1. Legal security context and political commitment of legislation: it can, in conjunction with education/public information, influence and shape the conditions for safe environment and people’s attitudes – attitudes that promote child safety and protection from injuries. Examples are laws and regulations for the mandatory use of child safety car seats and helmets for cycling as well as speed limits. If we ensure their implementation we can increase their effectiveness.

2. Specialists’ training and public awareness: This is the cornerstone, since it offers both awareness and the knowledge necessary to timely identify potential hazards and implement appropriate preventive measures. A typical example is information – education of couples that will become parents for the need and the proper use of car safety seats for baby’s transportations, even for the first “walk” from maternity hospital to home.

3. Engineering – technological interventions: they strive towards passive safety, and through environmental and product design they aim to reduce the chance of an injury event or the amount of energy to which a person can be exposed during an injury. These measures include, for example, the use of non-flammable fabrics for children’s clothing, the use of smoke detectors, appropriate protective material to cover surfaces and soil in playgrounds, and toys without small parts that can be detached and cause choking. In combination with the active safety measures aimed to amend human behaviour, engineering interventions and the introduction to the market of safer consumer products have yielded spectacular injury prevention in children. Huge reductions in fatal poisoning after the introduction of secure lids on packages of aspirin and other pharmaceuticals or reduction of deaths from falls after installing railings on the windows of flats in Singapore are the most typical examples.

The role of supervision Supervision of children is a fundamental parameter of protection against injuries and towards safety in general. It is estimated that 90% of childhood injuries occur in or near the home environment and while children are supervised by caregivers. The characteristics of “quality” surveillance include particular attention with constant visual and auditory contact with the child, closeness enabling direct physical intervention and removal of dangerous hazards, and continuous monitoring. The level of supervision depends on the child’s age, personality type, development of skills and the environment that determines the exposure to risk factors for injuries. On behalf of the supervisor it requires judgment, quick reflexes and training on methods that could influence child’s behaviour. In this area, the contribution of education of the parents by the paediatric community is crucial. It can guide parents both in creating a safe living environment and encourage safe children’s entertainment as well as address the need for systematic monitoring, awareness, capacity building and direct effective intervention for the prevention of injuries. Equally effective seems to be the role of teachers in preschool and school, with educational programs that are targeted directly to the child in “sensitive” time and age periods of his life, as far as the adoption of safe behaviour patterns is concerned.

ConclusionAccording to the published data of the Centre for Research and Prevention of Injuries for EU countries, the reduction of injuries involving children by 33% is possible if we follow consistent and sustained prevention policies in our country, similarly to those already followed by the Nordic countries, the Netherlands and Great Britain. In basic numbers, every year there could be with us at least 100 children aged 0–14 years who died unnecessarily, mainly due to factors related to human behaviour and the lack of care at family, community or state level.

REFERENCES

1. World report on child injury prevention, WHO 2008, http://www.who.int/violence_injury_prevention/child/injury/world_report/en/

2. European report on child injury prevention, WHO 2008http://www.euro.who.int/en/what-we-do/health-topics/Life-stages/child-and-adolescent-health/publications/2008/european-report-on-child-injury-prevention

3. National Action Plan for child injury prevention. An agenda to prevent injuries and promote the safety of children and adolescents in the United States, CDC 2012 http://www.cdc.gov/safechild/nap/

4. http://www.childsafetyeurope.org/reportcards/info/greece-country-profile.pdf

5. http://www.childsafetyeurope.org/reportcards/info/greece-report-card.pdf

6. Unintentional injury mortality in the European Union: how many more lives could be saved? Petridou ET al, Scand J Public Health 2007;35(3):278–87

7. Childhood injuries in the European Union: can epidemiology contribute to their control? Petridou E, Acta Paediatr. 2000 Oct;89(10):1244–9

8. National Action Plan for Injuries, 2008–2012.

Xanthi DedoukouHead of Hospital Infectious Diseases Office, HCDCP

Surveillance data

http://www.keelpno.gr info@keelpno.gr

6

SURVEILLANCE DATA, JULY 2013, GREECE

Table 1: Number of notified cases in July 2013, median number and range of notified cases in July for the years 2004−2012, Mandatory Notification System, Greece

Disease Number of notified cases

July 2013

Median number July 2004−2012

Min. number July 2004-

2012

Max. numberJuly 2004-

2012

Botulism 0 0 0 1Chickenpox with complications 0 1 0 16Anthrax 0 0 0 2Brucellosis 33 17 8 72Diphtheria 0 0 0 0Arbo-viral infections 0 0 0 1Malaria 4 5 2 17Rubella 0 0 0 1Smallpox 0 0 0 0Echinococcosis 1 1 1 3Hepatitis Α 17 3 0 19Hepatitis B, acute & HBsAg(+) in infants <12 months 1 6 0 15

Hepatitis C, acute & confirmed anti-HCV positive (1st diagnosis) 3 1 0 4

Measles 0 1 0 34Haemorrhagic fever 0 0 0 3Pertussis 1 3 0 6Legionellosis 5 2 0 8Leishmaniasis 5 5 1 7Leptospirosis 3 2 0 5Listeriosis 2 0 0 2EHEC infection 0 0 0 0Rabies 0 0 0 0Melioidosis/glanders 0 0 0 0Meningitis

aseptic 36 27 16 220bacterial (except meningococcal disease) 14 18 7 23unknown etiology 1 1 0 5

Meningococcal disease 2 2 0 6Plague 0 0 0 0Mumps 0 0 0 11Poliomyelitis 0 0 0 0Q fever 3 0 0 1Salmonellosis (non-typhoid/paratyphoid) 59 113 42 166Shigellosis 19 5 0 8Severe acute respiratory syndrome 0 0 0 0Congenital rubella 0 0 0 0Congenital syphilis 1 0 0 1Congenital toxoplasmosis 0 0 0 1Cluster of foodborn /waterborne disease cases 8 8 2 10Τetanus/neonatal tetanus 0 0 0 3Tularaemia 0 0 0 0Trichinosis 0 0 0 0Typhoid fever/paratyphoid 0 1 0 3Tuberculosis 42 50 35 78Cholera 0 0 0 0

Table 2: Number of notified cases by place of residence (region), July 2013, Mandatory Notification System, Greece (place of residence is defined as the home

address of patients)

Disease Number of notified cases

Region

Eas

tern

Mac

edonia

and T

hra

ce

Cen

tral

Mac

edonia

Wes

tern

Mac

edonia

Epirus

Thes

salia

Ionia

n isl

ands

Wes

tern

Gre

ece

Ste

rea

Gre

ece

Att

ica

Pelo

ponnes

e

Nort

her

n A

egea

n

South

ern A

egea

n

Cre

te

Unkn

ow

n

Brucellosis 3 7 3 1 6 0 5 2 2 3 0 1 0 0

Malaria 0 0 0 0 1 0 0 0 3 0 0 0 0 0

Echinococcosis 1 0 0 0 0 0 0 0 0 0 0 0 0 0

Hepatitis Α 11 1 0 0 2 0 2 0 0 0 0 0 0 1

Hepatitis B, acute & HBsAg(+) in infants <12 months 0 0 0 0 0 0 0 0 1 0 0 0 0 0

Hepatitis C, acute & confirmed anti-HCV positive (1st diagnosis) 1 0 0 0 0 0 0 0 1 0 0 1 0 0

Pertussis 0 0 0 0 1 0 0 0 0 0 0 0 0 0

Legionellosis 0 1 0 0 0 1 1 0 1 0 0 0 0 1

Leishmaniasis 0 1 0 0 2 0 0 0 2 0 0 0 0 0

Leptospirosis 0 1 0 0 0 1 1 0 0 0 0 0 0 0

Listeriosis 0 0 0 0 0 0 0 1 1 0 0 0 0 0

Meningitis

aseptic 4 5 2 3 3 0 5 0 5 0 0 0 6 3

bacterial (except meningococcal disease) 1 5 0 1 0 0 1 1 3 0 0 0 2 0

unknown etiology 0 0 0 0 0 0 0 0 0 0 0 0 0 1

Meningococcal disease 0 1 0 0 0 0 0 0 0 0 0 0 0 1

Q fever 0 0 0 0 2 0 0 0 1 0 0 0 0 0

Salmonellosis (non-typhoid/paratyphoid) 6 7 2 4 2 1 6 4 21 0 1 1 2 2

Shigellosis 4 0 0 0 0 8 1 2 4 0 0 0 0 0

Cluster of foodborne/waterborne disease cases 1 3 0 0 0 1 2 0 0 1 0 0 0 0

Congenital syphilis 0 0 0 0 1 0 0 0 0 0 0 0 0 0

Tuberculosis 8 10 0 0 1 1 2 0 14 4 0 1 1 0

Invited articles

info@keelpno.grhttp://www.keelpno.gr

8

Table 3: Number of notified cases by age group and gender, July 2013, Mandatory Notification System, Greece (M, male; F, female)

Disease Number of notified cases by age group (years) and gender

<1 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65+ UnM F M F M F M F M F M F M F M F M F M F

Brucellosis 1 0 1 0 1 1 2 2 5 0 3 3 5 3 0 2 2 1 1 0

Malaria 0 0 1 0 0 0 0 0 1 0 2 0 0 0 0 0 0 0 0 0

Echinococcosis 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Hepatitis Α 0 0 2 0 2 3 0 1 2 1 4 2 0 0 0 0 0 0 0 0

Hepatitis B, acute & HBsAg(+) in infants <12 months 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0

Hepatitis C, acute & confirmed anti-HCV positive (1st diagnosis)

0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0

Pertussis 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Legionellosis 0 0 0 0 0 0 0 0 0 1 2 0 1 1 0 0 0 0 0 0

Leishmaniasis 0 0 0 0 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 0

Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 1 0 0

Listeriosis 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 1 0 0

Meningitis

aseptic 3 4 2 1 6 6 1 2 1 0 1 5 1 1 0 0 1 1 0 0

bacterial (except meningococcal disease) 1 3 1 0 1 2 1 0 0 0 0 1 0 1 0 0 2 1 0 0

unknown etiology 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Meningococcal disease 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0

Q fever 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0 0 0

Salmonellosis (non-typhoid/paratyphoid) 4 6 9 2 7 5 3 1 1 2 2 1 2 1 2 2 3 5 1 0

Shigellosis 1 1 3 2 2 2 1 0 1 1 0 0 0 2 0 1 1 0 1 0

Congenital syphilis 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Tuberculosis 2 0 0 0 1 1 5 0 6 2 8 0 6 0 2 2 3 4 0 0

The data presented are derived from the Mandatory Notification System (MNS) of the Hellenic Center for Disease Control and Prevention (HCDCP). Forty-five infectious diseases are included in the list of the mandatory notifiable diseases in Greece. Notification forms and case definitions can be found on HCDCP’s website (www.keelpno.gr).It should be noted that the data for July 2013 are provisional, and could be slightly modified/corrected in the future, and also that data interpretation should be made with caution as there are indications of under-reporting in the system.

Department of Epidemiological Surveillance and Intervention

Adolescent and young adult mortality from road traffic accidents in Greece

Young people aged 10-24 years are over-represented in mortality rates because of their risk-taking behavior. Several important public health and social problems related to reckless behavior, e.g. motor vehicle crashes, either peak or start during this age range.We studied road traffic accident mortality among young people aged 10-24 years in all geographical regions in Greece, over the decade 2000-2009. Data were derived electronically from the database of the Hellenic Statistical Authority for three age groups: younger adolescents (10-14 years), older adolescents (15-19 years) and young adults (20-24 years). Road traffic accidents were the leading external cause of death for young people and dominated the pattern in every single region of the country. During the period 2000-2009, a total of 3,844 individuals aged 10-24 died from road traffic accidents (mean annual mortality rate of 17.9 per 100,000) in Greece. The majority (59.9%) of deaths due to road traffic accidents occurred amongst young adults (2,301/3,844 cases), whereas 174 (4.5%) and 1,369 (35.6%) deaths were recorded in younger and older adolescents, respectively. The mean annual mortality rates for the whole of Greece were 3.0/100,000 for younger adolescents, 18.9/100,000 for older adolescents and 27.5/100,000 for young adults. Surprisingly, among the geographical regions, the area of Attica recorded the lowest mortality rates (14.6/100,000 per year) for road traffic accidents, while the highest rates were seen in Sterea Ellada (23.7/100,000 per year), excluding Attica. Overall, the total age-adjusted male to female ratio was 4.4, but it varied between 3.8 in central/west Macedonia to 5.4 in the islands. The male predominance in deaths increased with age, from 69% in the younger age group to 85% in the 20-24 age group. Greece showed a decline in road traffic accident deaths rates over time. The mortality rate (deaths per 100,000) of young people aged 10-24 decreased significantly by 33%, from 21.3 in 2000 to 14.3 in 2009 (p=0.001), mainly due to the significant decrease in mortality, by 41%, in for older adolescents (p<0.0001). The death rates for the younger adolescents remained practically unchanged throughout the study period (p=0.22) and for the young adults the decline of 30% was of borderline significance (p=0.04).The patterns of young people’s death in Greece followed the global patterns of youth mortality: in 2004, traffic accidents were the largest cause of death world-wide and accounted for14% and 5% of male and female deaths, respectively. The decrease in mortality could be the combined result of the implementation of a number of interventions throughout Greece during these consecutive years of economic growth, the country’s commitment to the Olympic Games, and an increase in public awareness.The significant decrease in road fatalities could be attributed primarily to the intensified enforcement of a set of priority measures within the first (2001‐2005) and second (2006‐2010) national road safety strategic plans. These focused on the following areas. (a) An intensification of road safety enforcement along with a more modern and stricter highway code. Over the decade, state control became more intense and effective in enforcing the mandatory seat belt and helmet laws, as well as traffic-calming measures, i.e. speed and alcohol control measures. One of the most important policy measures introduced in the late 1990s was the implementation of breath analyzer tests by the traffic police. Another alcohol control regulation has been the enforcement of penalties for drunk drivers according to their blood alcohol concentrations, i.e. fines, driving license suspension and prison penalties. (b) An improvement in environmental factors that contribute to road safety, i.e. road infrastructure with the construction of the Attica Tollway in the Attica region, the Egnatia Motorway, which crosses Greece from its westernmost edge to its easternmost borders, the Aegean Motorway, and the increase in public transport with the construction of metro lines 2 and 3, tramways, the suburban railway, the reintroduction of the urban rail in Attica and the construction of suburban railway in Central Macedonia. (c) Finally, there have been frequent and targeted road safety education and information campaigns carried out by non-governmental organizations.

Invited articles

http://www.keelpno.gr info@keelpno.gr

10

The capital region of Attica recorded the lowest death rates due to road traffic accidents. This can be explained by the fact that this was the most economically important region of the country, where most of the infrastructure projects were carried out during the decade and health-care effectiveness was highest. Furthermore, most roads in Attica are heavy traffic/low speed, thus preventing speeding, which is a major risk factor in motor vehicle accidents (a 5% increase in average speed leads to a 20% increase in mortality).During the last decade, Greece has shown one of the lowest levels of road safety (highest fatality rate) among the 27 European Union (EU) countries. Despite improvement, Greece in 2009 still had one of the higher rates of road traffic accidents in Europe and the Balkans. Studies show that car crashes are weakly related to the level of traffic, road and weather conditions and improvements due to road maintenance. In fact, the factors that contribute to injuries are frequently behavioral and poorly defined, with risk-taking behavior factor being the major cause of crashes. Young people are particularly vulnerable to road traffic accidents because of a combination of physical and psychological characteristics: limited experience, a tendency to engage in risky behaviors (non-compliance with regulations, likely to drive or agree to be driven recklessly or while intoxicated, not being afraid of death, etc.) and a greater vulnerability to the effects of alcohol, especially among young males. Despite some positive developments towards a preventive alcohol policy in recent years, Greece still lacks a comprehensive alcohol control system, possibly because alcohol production and consumption have been interwoven between the Greek economy and social life for a very long time. The significant decrease in fatalities from road traffic accidents among young people between 2000 and 2009 indicates that there is great potential for further improvement by increasing focus on this vulnerable group. The unprecedented economic crisis in Greece could mean that the aforementioned services are curtailed due to a lack of resources, but could also mean that more serious efforts to provide positive developmental interventions and comprehensive behavioral strategies for young people throughout the country are needed.

The authors are responsible for the choice and presentation of views contained in this article and for the opinions expressed therein, which are not necessarily those of UNESCO and do not commit the organization.

REFERENCES

1. Patton GC, Coffey C, Sawyer SM, et al. 2009.Global patterns of mortality in young people: a systematic analysis of population health data. Lancet 374:881-892. DOI:10.1016/S0140-6736(09)60741-8.

2. International Transport Forum. 2010. Irtad Annual Report. Available at: http://www.internationaltransportforum.org/irtadpublic/pdf/10IrtadReport.pdf [Accessed 20 September 2012].

3. World Health Organization. 2009. Mortality from Road Traffic Injuries in Children and Young People. Factsheet 2.1 Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/96976/2.1.-Mortality-from-road-trafficinjuriesEDITED_layouted_V2.pdf [Accessed 18 May 2012].

4. World Health Organization. Alcohol Consumption and Harm. Available at http://data.euro.who.int/alcohol/Default.aspx?TabID=4936 [Accessed 20 November 2012].

5. Guria J. 1999. An economic evaluation of incremental resources to road safety programmes in New Zealand. Accid Anal Prev 31:91-99.

6. Petridou E. 2000. Childhood injuries in the European Union: can epidemiology contribute to their control? Acta Paediatr 89:1244-1249.DOI: 10.1111/j.1651-2227.2000.tb00743.x.

7. Eurostat. Regional Gross Domestic Product (million EUR), by NUTS 2 regions. Available at: http://epp.eurostat.ec.europa.eu/tgm/graph.do?tab=graph&plugin=1&pcode=tgs00003&language=en&toolbox=sort [Accessed 20 April 2012].

8. World Health Organization. 2009. Mortality from Road Traffic Injuries in Children and Young People. Factsheet 2.1. Available at: http://www.euro.who.int/__data/assets/pdf_file/0010/96976/2.1.-Mortality-from-road-trafficinjuriesEDITED_layouted_V2.pdf [Accessed 18 May 2012].

Flora Bacopoulou, Eleni Petridou, Terpsichori N. Korpa, Efthimios Deligeoroglou, George P. Chrousos,

Center for Adolescent Medicine, UNESCO Chair in Adolescent Medicine and Health Care, First Department of Pediatrics, University of Athens

Medical School, Aghia Sophia Children’s Hospital

Invited articles

http://www.keelpno.gr info@keelpno.gr

12

Prevention of fall injuries in primary health care: an urgent issue for Greece

The prevention of physical injuries from accidents and violence in primary health care (PHC) has recently received much attention in the literature. Nevertheless, the Greek experience within PHC is minimal, even though it is a field where intervention by the health professionals is possible, effective and beneficial. This paper focuses on a brief literature review of the prevention of injuries from falls, and the efforts that have been made in general practice as there is no relevant information for health professionals working in primary care, even though such intervention is feasible since it can be made at the health center, the rural practice or generally in any office of the national organization providing health services (Greek acronym: EOPYY).Falls account for about 1:5 injuries amongst patients who seek care in emergency departments, and patients in this category are more likely to be female, elderly (79 years and older) and living alone [1]. Indeed, older patients require a comprehensive assessment of risk factors and their physical condition, and should be educated regarding the prevention of falls and consequent injuries. The strategy for prevention of physical injury from falls has two main foci: the control of risk factors that predispose falling, including intrinsic (physical weakness, polypharmacy, etc.) and extrinsic (house, carpets, etc.) factors, and prevention of the consequences of a fall (osteoporotic fractures).Programs for the prevention of falls in general practice have been initiated many years ago in other countries, and relative meta-analyses on cost-efficient interventions for the prevention of fall injuries among elderly people, as well as evidence-based clinical models, have already been published, describing the development of electronic information systems to assess the risk of falling and manage such situations (a falls risk assessment and management system) and how enthusiastically they were accepted by patients [2]. Management strategies include changes in prescriptions, patient education, recommendations for changes in physical activity, nutrition, control of environmental safety, reducing the consequences of falling, etc.The importance of education of elderly patients regarding issues of maintaining balance and empowerment has been reported in several randomized controlled studies examining the potential of lifestyle programs with integrated functional exercise, involving a series of exercises incorporated into everyday activities aimed at improving functionality and empowering individuals aged 70 years and older. Such initiatives involving education of elderly patients in techniques for functional exercises in daily life seems to be the key factor that is missing today in PHC in Greece.Specific needs in the training of general practitioners (GPs) and nurses, as key members of the health-care team in the community, have also received special attention in order to enable them to develop programs and preventive measures aimed at preventing disability. To this end, specific steps have been proposed: screening, assessment, analysis, preliminary design, agreeing an action plan, implementation of the program and evaluation/monitoring [4]. These steps do not differ from those followed in any other intervention aimed at behavioral change, but as rule they are not taught during the training of primary care staff. The first two steps are typically followed in primary care, i.e. screening for those at risk and assessing the potential for physical injury after a fall [3].The contribution of physical exercise is essential in the prevention of fractures from falling. A recent guide published in Australia targets GPs and other professionals in primary care and includes instructions for physical exercises that strengthen the muscles [6]. As well as high-intensity exercises with progressive resistance, there is also progressive equilibrium training with moderate to severe aerobic exercise. These selected exercises are aimed at several of the determinants of osteoporotic fracture, including ‘osteopenia, muscular weakness, falls, poor balance, depression, use of antidepressants and anxiolytics in [the] sedentary, kinetic impairment and disability’. The role of GPs and other health professionals in assessing the physical conditions and health status of elderly patients, but also in locating the factors that increase the risk of osteoporosis

and fracture from a fall, is of paramount importance. Smoking cessation, reducing alcohol consumption, avoiding malnutrition, minimizing the use of steroids, fall prevention, detection and control of malabsorption and chronic inflammation, avoidance of a sedentary lifestyle and supplementation with vitamin D and calcium and appropriate medication are among the recommendations to reduce the likelihood of osteoporotic fractures [5]. In conclusion, prevention of falls among elderly patients is an important public health issue that should involve the services provided by the PHC practitioners in our country, particularly during this period of financial crisis. Regional planning and training health professionals (GPs and nurses) in the development of programs for the prevention of accidents from falls, as well as awareness raising and education of the elderly population at risk, in particularly elderly women living alone, are of prime importance in the public health agenda.

REFERENCES

1. Petridou ET, Manti EG, Ntinapogias AG, et al. 2009. What works better for community-dwelling older people at risk to fall? A meta-analysis of multifactorial versus physical exercise-alone interventions. J Aging Health 21:713-729.

2. Liaw ST, Sulaiman N, Pearce C, et al. 2003. Falls prevention within the Australian general practice data model: methodology, information model, and terminology issues. J Am Med Inform Assoc 10:425-432.

3. Clemson L, Fiatarone Singh MA, Bundy A, et al. 2012. Integration of balance and strength training into daily life activity to reduce rate of falls in older people (the LiFE study): randomised parallel trial. BMJ 345:e4547. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23084513 [Accessed 14/1/2013].

4. Daniels R, van Rossum E, Metzelthin S, et al. 2011. A disability prevention programme for community-dwelling frail older persons. Clin Rehab 25:963-974. Available at: http://www.sagepublications.com [Accessed 14/1/2013].

5. Ewald D. 2012. Osteoporosis: prevention and detection in general practice. Bones 41:104-108. Available at: http://www.racgp.org.au/afp/2012/march/osteoporosis-prevention-and-detection/ [Accessed 14/1/2013].

6. Osteoporosis Australia. Available at: www.racgp.org.au/afp/2012/march/osteoporosis-prevention-and-detection

Christos Lionis Professor of General Practice and Primary Health Care

Faculty of Medicine, University of Crete

Invited articles

http://www.keelpno.gr info@keelpno.gr

14

Accidents among health professionals and viral hepatitis

Health professionals, because of the nature of their work, come into contact with infectious diseases, with the inherent dangers of contagion and transmission of illness to other people. Specifically, accidental inoculation with contaminated blood or other body fluids can lead to serious infection of hepatitis B and C.From the enquiries made to the Office of Viral Hepatitis of the Hellenic Center for Disease Control and Prevention (HCDCP), for advice in the case of puncture by sharp objects or exposure to biological fluids, it seems that such accidents happen frequently. It is noteworthy that, despite their daily exposure, a significant number of health professionals are not vaccinated against hepatitis B.Important measures for the prevention of transmission of viral hepatitis in health professionals comprise the following.• The use of protective equipment (gloves, goggles, protective shirts) when contact with

blood or other body fluids is likely.• Hand washing and using alcoholic solutions, and avoiding dangerous procedures and risky

practices (e.g. repositioning of needles, transportation of bodily fluids between tubes or ampoules, failing to organize waste collection safely).

Specifically for hepatitis B, the transmission of infection can be avoided if all health professionals are vaccinated.The vaccine is safe and effective and is provided free of chargeIf there is professional exposure, to reduce the danger of transmission certain actions should become effective immediately.The actions required are described in detail in the ‘Protocol for managing professional exposure to HBV, HCV’, which is posted on the HCDCP’s website: www.keelpno.gr

The Office of Viral Hepatitis is available daily for health professionals to help resolve any problem or query.Telephone numbers 210 5212183 – 210 5212178 from 8.00 to 15.00.

Georgia Nikolopoulou, Head of the Office of Viral Hepatitis, HCDCP

Accidents at work in Greece

An accident at work is a discrete occurrence during the course of a job that leads to physical or mental health issues. Accident statistics are very useful for risk assessment of various areas of activity and for the implementation of relevant health and safety policies.

Origin of dataThe data for work accidents in Greece are provided by institutions where work accidents are declared by law. The Social Insurance Foundation (IKA) set up a registry in 1938, with the most recent data examined being from 2007. Accidents in the merchant navy and in mines are also registered by the relevant organizations. The Ministry of Labor keeps another registry through the Labor Inspection.

Data reliability The IKA data also includes accidents occurring during transportation from home to work and vice versa, therefore occupational risk is overestimated. Accidents of non-insured employees are not declared, except in the case of fatal or severe injuries. Accident victims are reimbursed from the first day of their absence from the work, which encourages absenteeism for minor injuries. In contrast, some employers do not declare accidents in concordance with victims, to avoid further Labor Inspection controls. Even though it is mandatory to declare accidents from all activities to the Labor Inspection, the number declared in the Labor Inspection is about 60% less than that reported to IKA. There are two reasons for this. One is that the IKA registry also contains accidents occurring during transportation from home to work, and the second is that employees only declare severe accidents to the Labor Inspection. Fatal accident statistics are more reliable. Although the data do not allow accurate estimates of the number of incidences, they do provide valuable information on the trends in incidences and the differences between different activities.

Conclusions from the existing dataThe annual incidence of work accidents increased from 1938 to 1964. It then remained constant until 1972, and thereafter followed a continuous reduction. From 1997 to 2007 the annual incidence for 100 employees has dropped from 3.81 to 0.56. The annual average reduction was approximately 5.6%. Progressive de-industrialization, the development of the tertiary sector, implementation of safer technologies, improvements in the health and safety legal framework, and promotion of a safety culture among management and employees may explain this trend, although it is not easy to estimate the attributable contribution of the different determinants. The reduction of accidents in observed high-risk sectors, such as construction and industry, indicates a real improvement in health and safety conditions. The Labor Inspection registry has shown an increase in accidents from 2000 to 2004, throughout Greece. According to the Labor Inspection report, this is due to the very high construction rates related to the Athens Olympic Games 2004. In contrast, the IKA statistics show a reduction in accidents for the same period. The fact that the Labor Inspection registers more severe accidents cannot explain this difference alone. The reform and development of the Labor Inspection during the same period could have resulted in an overestimation of the rates. Table 1 shows the total number of fatal accidents for the years 2003-2011. Although the IKA statistics stop at 2007, it is obvious from the Labor Inspection data that there has been a considerable fall during the last few years of the economic recession. The diachronic analysis of accidents shows a reduction in the total number of lost work days for accidents. In contrast, the average number of days lost per accident increased until 1985 and appeared constant thereafter. Social security direct costs have been increasing diachronically, reaching 6 million Euro at 2007. This is only the cost for reimbursement of the days lost and invalidity pensions. The cost of health care, productivity costs for the businesses and the social costs are the hidden side of the iceberg. There is a need for more complete registries of work accidents and for the implementation of policies to reduce their incidence and cost further.

Recent publications

info@keelpno.grhttp://www.keelpno.gr

16

REFERENCES

1. “ΙΚΑ-ΕΤΑΜ. Διεύθυνση Αναλογιστικών μελετών. Δελτίο εργατικών ατυχημάτων 1999-2007”

2. “ΣΕΠΕ Έκθεση Πεπραγμένων Υπουργείο Εργασίας και Κοινωνικής Ασφάλισης Αθήνα 2011”

3. “Κωνσταντινίδη Θ.Κ. “Περιγραφική επιδημιολογία των εργατικών ατυχημάτων στον ελληνικό πληθυσμό κατά την περίοδο 1956-1994”. - Αθήνα ΕΛΙΝΥΑΕ, 2001. - 79 σ.”

4. “Παπαδόπουλος Στυλιανός “Το οικονομικό κόστος των εργατικών ατυχημάτων στην Ελλάδα” / Ιατρική της εργασίας : υγιεινή και ασφάλεια στην εργασία, 1989, 1(1), σ. 27-30.”

5. “Κουκουλάκη Θ. “Καταγραφή εργατικών ατυχημάτων στην Ελλάδα - αδυναμίες και προοπτικές Εισήγηση στην ευρωπαϊκή διάσκεψη με θέμα “Υγιεινή και ασφάλεια στους χώρους εργασίας Συνομοσπονδία Ευρωπαϊκών Συνδικάτων και τη Γενική Συνομοσπονδία Εργατών Ελλάδας, 3-5 Απριλίου 2003”.

Emmanuel G. Velonakis , Professor of Prevention, Nursing Department, University of Athens

Recent publications

Sass AC, Stang A. Population-based incidences of non-fatal injuries: results of the German-wide telephone survey 2004. BMC Public Health 2013;13:376. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3641992/

This paper describes the methodology and results of a cross-sectional telephone survey of the resident adult population of Germany regarding unintentional injuries caused by accidents in the 12 months preceding the subjects’ interview, conducted between September 2003 and March 2004. One-year cumulative incidences of injuries by gender, age and educational level were estimated by the researchers. Further data were collected regarding the location, type of body part injured and consequences of the accident. Overall, 10.3% of the subjects reported an unintentional injury in the previous 12 months. The age-standardized incidence of injuries was higher among men than women. Generally, accidents at home were the most frequently reported. Men and women aged 18 to 29 years suffered accident-related injuries the most often. Although the overall incidence of injuries caused by accidents did not differ by educational level, the incidences of accidents at different places differed by educational level (the incidence of work-related injuries was higher among people with a low educational level). The researchers mention the restrictions of the study because of the non-inclusion of fatal injuries (i.e. the interviews were by definition of accident survivors), as well as the under-representation of severe injuries that may have resulted in brain damage (an exclusion criterion). Furthermore, they refer to the possible errors related to the fact that they relied completely on self-reports: nο validation study was performed. Finally, the response rate (32.6-39.4%) was deemed low, and there was considerable under-representation of immigrants. However, there is no nationwide comprehensive recording of injuries caused by accidents in the country, thus the present study is an important complement to other sources of relevant information (e.g. police documentation, statistics by statutory accident insurance carriers and statistics related to causes of death).

Galéra C, Orriols L, M’Bailara K, et al. Mind wandering and driving: responsibility case-control study. BMJ 2012;345:e8105. Published online 2012 December 13. Available at:http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3521876/

This case-control study aimed to assess the association between mind wandering and the risk of being responsible for a motor vehicle crash. The study sample was 955 drivers admitted to the emergency department of a French hospital for injury sustained in a road traffic crash, between April 2010 and August 2011. Drivers’ responsibility levels in the crash were determined using a standardized methodology. Four hundred and fifty-three participants were classified as responsible for the crash (representing the ‘cases’ of the study) and 502 as not responsible (representing the ‘controls’). The researchers used univariable and multivariable analyses to quantify the association between responsibility for the crash and a number of factors (mind wandering, external distraction, negative affect, use of alcohol, use of psychotropic drugs, sleep deprivation). All of the factors examined were statistically significantly associated with responsibility for the crash. The association between intense mind wandering and responsibility for the crash remained significant after adjustment for a range of potential confounders (adjusted odds ratio 2.12, 95% confidence interval 1.37-3.28). This is the first study to use an observational approach to assess the relation between internal distraction and road traffic crashes in the real world. The possible mechanism of mind wandering being implicated in accident occurrence is via the decoupling of attention from visual and auditory perceptions, thus diminishing the driver’s ability to incorporate information from the environment.

Conferences and meetings

info@keelpno.grhttp://www.keelpno.gr

18

Kendrick D, Young B, Mason-Jones AJ, et al. Home safety education and provision of safety equipment for injury prevention (Review). Evid Based Child Health 2013;8:761-939.

In this review article, the authors attempt to evaluate the effectiveness of home safety education, with or without the provision of low cost, discounted or free equipment, in reducing child injury rates or increasing home safety practices, as well as evaluating whether the effect varies by social group. The authors describe the methodology of the data collection and evaluation and conclude that home safety interventions, especially the provision of safety equipment, are effective in increasing a range of safety practices. There is some evidence that such interventions may reduce injury rates, particularly where interventions are provided at home. Further studies are still required to confirm these findings with respect to injury rates. Finally, there was no consistent evidence that home safety education, with or without the provision of safety equipment, was less effective for those participants at greater risk of injury.

Head of the Office for the Co-ordination of Surveillance Systems, HCDCP

Conferences and meetingsSeptember 2013

12-13 September 2013

Title: 4th annual meeting of the European Legionnaires’ Disease Surveillance Network (ELDSNet)

Country: GreeceCity: AthensVenue: National School of Public HealthWebsite: http://www.ecdc.europa.eu/en/press/events/Lists/Events/ECDC_DispForm.aspx?List=43564830-6b8a-442f-84e7-2495fa49489b&ID=253&RootFolder=%2Fen%2Fpress%2Fevents%2FLists%2FEvents

21-24 September 2013

Title: American College of Epidemiology Annual Meeting

Country: United States of AmericaCity: LouisvilleVenue: Galt House HotelContact Number (fax): 919-861-5573Website: http://www.acepidemiology.org/content/2013-annual-meeting

27 September 2013

Title: 1st Pan-Hellenic Meeting of Aids & Hepatitis

Country: GreeceCity: Athens Venue: Royal Olympic Hotel Contact Number (fax): +30 210 6827405Website: http://www.tmg.gr/content/aids-registrations

Office for Public and International relations, HCDCP

Interview

http://www.keelpno.gr info@keelpno.gr

20

Eleni Petridou, Professor of Preventive Medicine and Epidemiology, Athens University Medical School

Physical injuries and accidents, at all ages, are a public health problem recognized internationally. How important is it in our country?The national picture of recorded mortality from unintentional and intentional injuries reflects the economic growth and consequent changes in family and social cohesion that have been observed in our country over the last century. For example, the introduction of motor vehicles was followed by a sharp increase in traffic accidents, the industrial revolution caused an increase in occupational accidents, and swimming during summer vacations has caused an increase in drowning. But over the last three decades, with the rise in living standards and public awareness, the Center for Research and Prevention of Injuries (CEFR) has seen a significant (60%) reduction in pre-published mortality rates from unintentional injuries. However, for many types of accidents, such as traffic accidents and drowning, Greece is one of the worst in comparison with other European Union (EU) countries, without any evidence of improvement over time. Road traffic accidents are the most lethal type of accident; home and leisure accidents are frequent; while a significant reduction has been seen after co-ordinated preventative actions regarding occupational accidents, which are now less than 5% of the total.In contrast, mortality rates for intentional injuries (suicide and violence) are still very low in most countries of southern Europe, despite the increase that has occurred in our country because of the financial crisis.

2. What is the scale of the problem? It is true that it is particularly acute for children and elderly patients?Deaths from injury constitute 5% of the total number of injuries. According to the estimates of the CEFR, each year more than 1 million Greek citizens are injured severely enough to seek help in outpatient clinics for some kind of physical injury, and accidents are one of the main causes of lifelong disability. Specifically, unintentional injuries are the leading cause of death in the first few decades of life, which consistently account for the most expected cause of loss of life than any other disease entity.Due to the scarcity of other fatal causes after the first year of life, during childhood and adolescence physical injuries are the leading cause of death, with a clear predominance amongst boys, mostly teenagers, versus girls, reaching 9:1. Traffic accidents are over-represented compared with other types of accidents, and young people lose their lives most often as pedestrians. The elderly population, in absolute numbers, is responsible for a much greater burden on the health service, from physical injuries, especially falls, traffic accidents

and drowning, than any other age group. The prevention of unintended injuries among elderly people ranks high in prevention programs, as injuries to the body in elderly patients also has an extremely high mortality, with an up to 2.6 times greater risk of death compared with the total of other age groups. Our country is one of the worst in the EU regarding drowning of elderly people, probably because of climatic and social conditions and/or co-morbidity in older people who tend to swim. The optimistic message, however, is that southern European countries, because of good climatic and environmental factors, enjoy the most favorable mortality rates from falls amongst elderly patients and, at least until 2010, have seen a significantly reduced mortality from this type of injury, greater than the average in the EU 27.

3. What do you think are appropriate methods for preventing such a heterogeneous set of risks?

Most types of injuries share common etiologic factors, such as risky behavior, and are governed by common principles of prevention, including legislation with subsequent monitoring of implementation of the legislation, training at various levels, mainly on techniques to reduce increased risk behaviors, other active safety practices, but also widespread use of new technologies within the framework of effective implementation of passive safety measures. These principles can be applied to all preventive interventions aimed at avoiding injuries or promoting the best possible outcome in the event of an accident. The individual interventions require implementation of a framework for the political health of the population, which includes four stages: fixing the problem; identifying the risk factors; prevention strategies; and the implementation and evaluation of the prevention programs. For example, in Singapore, where they found a comparatively higher death rate for young children due to falls from heights, they immediately halted the ‘epidemic’ by mounting rails in the windows of higher buildings.It is necessary that the principles of prevention are individualized and adjusted according to the range of causal factors of accidents in each country, without simply transferring the experience of one country to another. Successful prevention programs also take into account aspects of the psyche and stereotypical behavior of the citizens of the relevant country, because they are closely related to the adherence to preventive measures.The main obstacle in making and implementing prevention programs is indeed the heterogeneity of the various types of accidents, making it difficult to initiate any social pressure. A second major obstacle is the difficulty in recognizing personal responsibility for the cause of an accident combined with the illusion of immortality, because an accident, for most people, is an event that happens to someone else. A further obstacle in our country is a difficulty in co-operation between the various ‘partners’ in addressing a problem that requires an eminently interdisciplinary co-operation and multifaceted actions. The national network for accident prevention and violence (EDIPAV) was a first attempt at combining actions and reconciling views; however its progress so far is not optimistic.Road safety is the most ‘popular’ safety sector and brings together a wide range of national, regional and local interventions aimed at both passive and collective prevention measures, such as improving the safety of vehicles and more recently the development of road systems that can compensate for careless driving behavior, and active prevention via demonstrably effective measures, such as seat belt/helmet wearing and compliant ride. It is spectacular that 500-2,500 annual deaths from road traffic accidents in our country could be avoided if we could persuade all road users to use helmets and belts. There are many examples of active safety measures with excellent effectiveness for other types of accidents, such as the reduction of poisoning in children after the introduction of secure lids to drug/cleaning chemical containers, and the installation of smoke detectors in homes preventing accidents from fire. These simple practices have been codified at the initiative of the CEFR in the European Code Against Injuries, which is the main working tool for those who want to tackle the whole issue of the prevention of injury from various types of accidents.But no measure can be effective unless you apply it consistently on a massive scale, taking into account those conditions that would make it acceptable and accessible to the general public, such as tax reductions on consumer products intended to enhance active and passive safety.

Interview

http://www.keelpno.gr info@keelpno.gr

22

4. Could these prevention strategies be integrated in a broader public health policy?

Most EU countries have developed and follow with some degree of consistency 5-year national strategic plans and programs for the prevention of various types of injury, depending on their priorities. Similarly, in European programs such as TACTICS, there are benchmarks for measuring European countries with good practices in place for the safety of children and adolescents, derived by calibrating the actions of public and private actors. A practice scorecard has proven to be effective at a collective level. Recording the activities of several praiseworthy individual action plans that are growing spontaneously in our country, and even better an immediate evaluation by a central policy-making body for public health, would be especially important in our country, as it would help not only in the design of public health policies, but also, in view of their work, the potential to attract private funds during the financial crisis.

5. How do you think the HCDCP and other public health organs could help reduce the phenomenon?The Hellenic Center for Disease Control and Prevention (HCDCP) has made remarkable achievements in the field of epidemiological surveillance of infectious diseases, and in the evaluation of data in collaboration with ECDC. In a similar way, it is essential to proceed with the registration of chronic diseases, such as cardiovascular disease and cancer, and also physical injuries through joint registration programs with other European countries. The CEFR has expertise and experience in the outpatient accident recording system (Emergency Department Injury Surveillance System, EDISS) that operated during 1996-2004, and other systems with less data. These databases have allowed the extent and an understanding of conditions that cause physical injuries in our country to be mapped. Having a central strategic role, HCDCP will be able to connect individual health data-recording sources with other services that have record bases for specific types of accidents, such as traffic accidents, burns, drownings and poisonings, and move towards a definition of priorities, the recording of organizations implementing prevention programs and minimum criteria for self-assessment of the work of public and private sectors involved in the prevention of injury. The ideal would be to develop an integrated recording system across sectors, which apart from the central database co-ordinated data would provide serif typeface recording units reliable information usability data locally and personal identification of residents with prevention activities. A concrete example is Cyprus, where a society sensitive to preventing road traffic accidents attended a weekly traffic bulletin and considered whether the number of victims had decreased and how the residents themselves could contribute to reduce them further.

6. In this era that we are experiencing of reducing economic resources, what is the importance of epidemiology and preventive medicine in maintaining and improving the health of the population?A friend in England, who is an orthopedic pediatrician, during the daily briefing of new clinical presentations, persistently sought the exact cause of the accident and tried to make a home visit for further investigation. The obvious logic was that, to reduce the frequency and cost of new cases every possible effort should be made at a preventive level to avoid a recurrence of the event for the same person and others. Simple reasoning is needed to guide our thoughts and efforts in a crisis in order to implement the secondary units that are already operating with reduced staff and resources. It is easy to invoke other experiences, and difficult to act on them, but our health system will find a point of balance thanks largely to the efforts of the dedicated health care professionals in our country.

7. What do you consider to be the challenges faced by health professionals and especially public health officials in times of crisis?Public health has always been the poor relation of clinical and laboratory medicine. Notably, reduced spending programs and the nosological load of those related to reducing risk factors pale in comparison with those implemented for diagnostic and therapeutic interventions, as the latter are inextricably linked with industrial production, with consequent pressure on overused services within the limits of medical indications. In some cases exceeded, may

include procedures for secondary prevention, for example, due to the number of ultrasound for monitoring even of normal pregnancy. In contrast, until recently, medical practices for primary prevention were not formally recognized in compensation for medical operations, while there are few examples where the same consumers of health services felt that there was an excess spent on prevention and public health protection.The reduction of resources and personnel has undeniably been borne by health service professionals at the front line, and the secondary and tertiary care, and the usual practice is to further reduce the already lean department of public primary care for the maintenance of hospital structures. Unique private initiatives have already appeared, and many private practitioners contribute by providing an informal freedom to offering medical care. These efforts, exemplified the basic obligation of the State coverage in persons who undertake to make voluntary workshops NGO community need to be coordinated, systematic, focusing on prominent public health problems and some form of supervision. An imponderable factor, even in roughly planning public health needs within the new health map, is the attitude of the same Greek population, with its particular temperament and reactions, which we hope to mobilize towards a positive protection of personal and public health.

8. Please allow us some more personal questions. Why and in what circumstances did you decide to focus your career in the fields of epidemiology and prevention?Luck, whatever that term stands for, often plays a catalytic role in the choices made by a person during his or her life. Personally, apart from the choice of pediatrics, a specialty with an important preventive role, I had the good fortune to be apprenticed to the great tutor of epidemiology, preventive medicine and public health, Professor Trichopoulos. At his urging, I did my postgraduate studies at the School of Public Health in Harvard, while my parents supported me by taking my own role in the care of my children. The experience was unique; it opened new scientific horizons for me, and I was taken by the beauty of work centered on human nosology, etiology and preventative research, and its applications at the population level. It was there that I realized the significant burden of the untimely death of children and adolescents due to body injuries and also the large preventative potential of co-ordinated action programs.

9. Do you feel, through this long and very successful scientific career, vindicated in dealing with public health?On my return to Greece I had the opportunity, as a faculty member of the Laboratory of Hygiene, Epidemiology and Medical Statistics and Operations Manager at CPC, to work with dedicated health professionals in a field that combined a pediatric specialty in public health and social medicine, and to experiment, with personal satisfaction, in the traditional ‘barren ground’ that can offer much after persistent effort. My persistence in dealing exclusively with public health and to renounce clinical medicine, and the pleasures of an immediate and tangible result and personalized supply appears to derive from my character and my personal needs. The survey was a demanding virgin field, with particular challenges. My colleagues in America, Europe, South Africa and Australia helped to set up and utilize databases, using horizontal learning, interdisciplinary collaboration and experience of different health systems in order to recommend policies and implement programs in the field and to realize how necessary collaboration with younger colleagues is and conveying knowledge within both the formal and especially the informal curriculum.My personal satisfaction is that there are now multiple sectors involved partially or exclusively in reducing body injuries in our country and the mortality during this period has shown a decrease of more than 50%. I hope the seeds of hope for improvement do not dry out because of the crisis.

Myths and truths

info@keelpno.grhttp://www.keelpno.gr

24

Injury mortality during the last three decades (1980-2009) in Greece

Myths TruthsAccidents are acts of fate; they will happen anyway. We simply need to improve the rapid response of our health care system to those who sustain injuries

Injuries are both foreseeable and preventable events, as documented by the experience of other countries that have devoted efforts to active and passive preventionPeople tend to blame their injuries on ‘accidents’ and nominally perceive them to be acts of fate. In fact, they are largely (90%) preventable and predictable, but once they occur the risk of lifelong disability or post-traumatic stress disorder is high. The Center for Research and Prevention of Injuries (CEREPRI) has conducted a series of studies on the preventable proportion of injuries: more than 73,000 lives could have been saved in the European Union (EU)-25 in a single year, notably nearly half the unintentional injury deaths in children, over half in adults and ~40% in elderly patients, if established preventive strategies and projects were implemented in all member states [1]. The respective avoidable proportion of unintentional childhood injury deaths using existing means and resources in the USA reached about one-third. Despite the wide recognition of the importance of injury prevention, investment in prevention and health promotion pales in comparison with the expenditure dedicated to diagnostic and treatment services. The multitude of injury types and the lack of personal identification with the problem of injury, despite the commonality of the causes, prevents the formation of strong interest groups that would influence policy makers.

10. What advice would you give to young professionals who decide to engage in epidemiology and disease prevention?Public health and personal financial prosperity are not compatible. In everyday practice, research and services are governed by a shortage of resources, without the possibility of competing with professional advertising promoting industrial and other products (e.g. tobacco), which often compete with our own goals in relation to the defense and protection of public health.However, preventive medicine has made profound developments, including expansion of the medical industry into areas of interest in pharmaceuticals and diagnostics technology aimed at prevention and early application of nosology. Moreover, several new colleagues might be care physicians acting as consultants in the field of new products, where it is essential that the security value of the new product is incorporated. We also need to work with industry to improve the safety of the consumer products already in circulation, as has happened, for example, with baby walkers, when the accident prevention foundation found that they were responsible for some serious childhood accidents. Finally, it is the duty of the medical body, according to a recent circular issued by the Ministry of Health, to control and remove unsafe materials used in daily medical practice, and it is extremely interesting to investigate the safety of medical procedures. For example, there is an intense research interest, and our team is participating effectively, in investigating the impact of in vitro pregnancy on the health of the mother and child. The research question in this case is whether one can give the same effect on infertility for which also refer the couple in vitro or in the process itself and the substances used to achieve and maintain pregnancy. This is just one example that highlights the mental challenges of research in this field and the boundaries that have to be met: who decides whether someone should exceed the limits of nature in order to satisfy the desire of an individual to perpetuate him or herself, and what our role as adviser should be. A number of similar challenges arise from other preventive practices, the value of which we thought were clearly documented, such as mammography, but which are being re-evaluated today, especially under the pressure of an economic crisis, and others that are under investigation beyond the boundaries of our country but the evaluation of which, by Greeks researchers with imagination, curiosity and dedication, can play an essential role.

Thank you very much.

Editing: Philip Koukouritakis

Myths and truths

http://www.keelpno.gr info@keelpno.gr

26

We know enough about the problem of injuries in our country. We should look immediately towards prevention without wasting scarce resources on injury registration

Injury registration is a prerequisite for injury prevention and the evaluation of injury prevention activities Incidence and mortality rates from injuries, notably accidents, suicide and homicide, vary widely because of the intrinsic and extrinsic characteristics of the underlying populations. Additionally, cultural beliefs/attitudes and social coherence patterns, as well as the safety ethos of the respective society, shape the major part of this variability, whereas the health care system and hospital procedures impact mainly on fatality and disability rates. Prevention of injuries requires a population health framework that consists of four steps: defining the problem; identifying risk and protective factors; developing prevention strategies; and then implementing and evaluating these strategies. Hence they cannot be prevented if a clear understanding of the circumstances under which the injury occurred is not available, including the place, the products and the agents involved. Mortality data, if coded in detail by the most recent ICD-10 classification or other more specific classification, provide substantial information on the causes of injury; however, they represent only the tip of the iceberg regarding injury prevention. For example, it has been estimated that in the EU-27 deaths from injury amount to roughly 255,000 cases, compared with some 7,200,000 who were admitted to hospital and some 34,800,000 who sought care in outpatient departments [2]. This means that detailed hospital statistics do not provide an adequate approximation of the burden of injuries imposed in the health-care system or the society at large, if the high disability probability of these events is not also taken into account.Hence the development of a comprehensive registration system functioning at an inter-sectoral level with a central co-ordinating database and remote registration units is beyond any doubt, if injury prevention is to be addressed seriously. Previous experience of CEREPRI, with the development of the Emergency Department Injury Surveillance System (EDISS), in line with similar EU registration systems, guarantees that such an endeavor is feasible and can function with reasonably low costs [3]. Central injury registration represents an important source of valid information for strategic planning, evaluation of injury prevention and control measures, and other research purposes, including the role of consumer products, while simultaneously encouraging and improving the quality of local registration. Bone fide scientific institutions can ensure real-time registration and calculation of statistics needed for policy makers as well as for organizations that undertake prevention efforts and in particular citizens who have lost loved ones because of injuries.

Prevention of motor vehicle injuries should spearhead injury-prevention efforts in Greece, taking into account the experience gained from other prevention measures and strategies

An alarming increase in accidental poisoning (the third cause of unintentional injury) has been noted, especially among teenagers and young adults, which may be attributed to overdoses. Moreover, Greece has one of the worst drowning rates (21st worst position) among the EU-27 countries, with no evidence of a decline over the last 30 years, in contrast to the significant decrease observed in EU average rates.During the last three decades, among the EU-27 countries, Lithuania and Spain have experienced the highest and the lowest age-standardized mortality rates due to unintentional injuries, respectively. Greece holds the intermediate, 14th position, showing a 60% decrease during this period. Indeed, we hold the non-enviable record in motor vehicle traffic crashes, ranking 1st worst among the 27 European countries, whereas Sweden holds the lowest; moreover, a noticeably slower decrease during the study period has been observed in relation to the mean decline rate in the EU-27 average rate. Falls represent the second leading cause of injury mortality in Greece, (6th best position), with Portugal and Slovenia having the best and worst rates, respectively. A welcome promising decrease in fall injury mortality for our country among the elderly population, which is even higher than the EU-27 average, should be noted, along with the worthy ranking of several Mediterranean countries in relation to age-standardized fall injury mortality rates among the elderly population.In contrast, poisoning rates were 4-fold higher during 2009 in Greece than in 1980 and became the third leading cause of injury mortality. With an absolute toll of 6,443 deaths during the 30-year period, Greece ranks 17th out of EU-27 countries, and the exact causes of this phenomenon need to be clarified. Regarding drowning, Greece also experiences one of the worst rates (21-worst ranking in the EU-27). Despite the significant decrease observed in the EU member states, no significant change over the time period has been noted in Greece.

We don’t know the exact reasons why males sustain more injuries compared with women

Risky behaviors leading to higher accidental risk are more evident among males. Importantly, there are significant differences in the uptake of injury prevention messages by gender that must be taken into consideration in the implementation of preventive programs The mortality rate among males in Greece for all types of injury is 4-fold higher than for females, almost 8-fold higher for poisoning and 3-fold higher for accidental falls; this gender difference is reduced to 2-fold in the group aged 75+ for accidental falls, which are sustained mainly by osteoporotic women. Indeed, this is the only type of injuries where the rates among women outnumber those even from motor vehicle traffic accidents, which are by far the leading cause of injury mortality for both sexes in all age groups. Examination of the time trends during the last 30 years shows a slower decrease among males, possibly pointing to the known reluctance of males to adopt preventive measures of known. Therefore injury prevention projects have to be targeted and explore barriers and facilitators carefully, taking into account human behavior stereotypes, if they want to maximize efficiency in the current phase of the financial crisis.

Myths and truths

http://www.keelpno.gr info@keelpno.gr

28

Injuries are most common among children and should therefore be prioritized in all injury prevention programs

Childhood injuries are the most common cause of death among the young due to the rarity of other competing conditions, and indeed are of prime importance given the years of life lost in comparison with those of the elderly population. Yet injuries in elderly patients impose a much higher burden on the health services due to their frequency and the extremely high fatality rates in this age group. Injuries are among the leading causes of death until 45 years of age, yet injury fatality rates and hospitalization rates are extremely high among people over the age of 75 due to the effects of age and co-morbidity, accounting for 2.6-fold higher rates than those observed in all age groups combined, with a range of 2-20 depending on the type of injury. In the EU population, people over 65 years of age constitute only ~15% of the population, but they account for ~40% of total hospital costs, because they consume a disproportionate share of hospital resources for trauma care, mainly caused by hip fractures and fractures of the knee/lower leg [4].Therefore, given the high contribution of young age groups in the potential years of life lost and disability and the high frequency of injuries and fragility of elderly patients, prevention efforts should be tailored differentially to meet the specific needs in different population groups. Examples of successful preventive measures are those for occupational accidents, which respond to legislation and are implemented with concerted and consistent efforts.

During the last few years, Greece has experienced the lowest record in road traffic fatalities, probably because of the financial crisis and the decreased circulation of motorized vehicles

Health-care resources have been similarly reduced during the same time period. Indeed, in comparison with the other EU-27 countries, Greece experiences the highest motor vehicle traffic accident mortality and the downward trend already noted during the last 30 years has never reached the magnitude of the mean decrease in EU. Injury prevention strategies are the only way to reduce the relatively high burden of injuries, especially from motor vehicle traffic accidents, in the health-care system. The national injury mortality picture underwent a substantial transformation from late 1990s to the 21st century. A global public health problem, motor vehicle traffic accidents has emerged as the leading cause of injury mortality in Greece, followed by falls, poisoning and drowning. Unique within the spectrum of injury prevention, motor vehicle traffic safety is the object of a wide array of national, state and local evidence-based interventions targeting both passive prevention, such as improvement of motor vehicle safety characteristics, and the building of road systems that can alleviate the effect of careless behavior of drivers. Moreover, active prevention measures such as car restraints and helmets have been shown to be extremely effective measures. It has been estimated that ~500 out of the 25,000 annual deaths could have been avoided in Greece if all passengers had used these protective devices [5]. Nonetheless, injury prevention is a moving target. Still greater progress in motor vehicle traffic safety is being impeded by newer challenges, such as driver and pedestrian misuse of cell phones and headphones, and persistent ones, such as intoxicated drivers. While the economic crisis may lead to a numerical reduction in injuries due to reduced exposure to road hazards, a corresponding decrease in the consumption of health-care services is not expected due to similar cuts in personnel and resources. Prevention strategies and programs are the only real hope for a successful system to minimize the human suffering that injuries cause, particularly deaths and disabilities in young age groups.

REFERENCES

1. Petridou ET, Kyllekidis S, Jeffrey S, et al. 2007. Unintentional injury mortality in the European Union: how many more lives could be saved? Scand J Public Health 35:278-287.

2. World Health Organization. 2012. Workshop on building capacity for injury prevention through improved injury surveillance. World Health Organization Regional Office For Europe.

3. Gyllensvard H. 2010. Cost-effectiveness of injury prevention: a systematic review of municipality based interventions. Cost Eff Resour Alloc 2010;8:17.

4. Polinder S, Meerding WJ, van Baar ME, et al. 2005. Cost estimation of injury-related hospital admissions in 10 European countries. J Trauma 59:1283-1290;discussion 90-91.

5. Petridou E, Skalkidou A, Ioannou N, Trichopoulos D. 1998. Fatalities from non-use of seat belts and helmets in Greece: a nationwide appraisal. Hellenic Road Traffic Police. Accid Anal Prev 30:87-91.

*The Center for Research and Prevention of Injuries (CEREPRI) was established by the Ministry of Health and Welfare in the premises of the Athens University Medical School in 1991, aimed at the prevention and control of injuries through evidenced-based research and services. Based on two decades of experience, we herein present myths and truths regarding injury prevention and control.

C. Papadopoulou, N. Dessypris, E. Petridou*Center for Research and Prevention of Injuries (CEREPRI), Department

of Hygiene, Epidemiology and Medical Statistics, Athens University Medical School

info@keelpno.gr

31

http://www.keelpno.gr

30

Outbreak news, August 2013

Middle East respiratory syndrome coronavirus (MERS-CoV) [1]Globally, from September 2012 to the end of August 2013, the World Health Organization (WHO) has been informed of a total of 108 laboratory-confirmed cases of infection with MERS-CoV, including 50 deaths. To date laboratory-confirmed cases have originated in the following countries in the Middle East: Jordan, Qatar, Saudi Arabia and the United Arab Emirates (UAE). France, Germany, Italy, Tunisia and the United Kingdom have also reported laboratory-confirmed cases; the patients were either transferred there for care of the disease or had returned from the Middle East and subsequently became ill. In France, Italy, Tunisia and the United Kingdom, there has been limited local transmission among patients who had not been to the Middle East but had been in close contact with laboratory-confirmed or probable cases. WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.

Human infection with influenza A (H7N9) virus [1]As of 11 August 2013, the global total of laboratory-confirmed cases is 135, including 44 deaths. At the present time there is no evidence of sustained human-to-human transmission. WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.

Rubella (German Measles) [2]As of 15 August 2013, 36,087 rubella cases have been reported in Poland during 2013. Numbers of rubella cases have been highest in the western region (Malopolskie and Wielkopolskie provinces). Other provinces with high numbers of cases include Lublin, Lubusz, Kuyavian-Pomeranian, Podkarpackie, Pomeranian, and Zachodniopomorskie (West Pomeranian).

Polio [2]As of 20 August 2013, 108 cases of polio have been reported from Somalia since April 2013. These are the first wild poliovirus cases reported in Somalia since 2007.Twelve polio cases have also been reported from Kenya. These are the first wild poliovirus cases confirmed in Kenya since July 2011. One case from July has been reported from the Somali Region of Ethiopia. This is the first wild poliovirus case reported in Ethiopia since 2008.

REFERENCES

1. World Health Organization (WHO). Available at: http://www.who.int/csr/don/ [Accessed 2 September 2013]

2. Centers for Disease Control and Prevention (CDC). Available at: http://wwwnc.cdc.gov/travel/ notices/outbreak-notices/ [Accessed 2 September 2013]

Travel Medicine Office, Department for Interventions in Healthcare Facilities

Quiz of the month, August 2013

Mortality from childhood accidents in Greece (for the years from 1990 to 2010) is higher in which age group?

A) 0-4B) 5-9C) 10-14

Send your answer to the following e-mail: info-quiz@keelpno.gr

The answer to July’s quiz was: Sir Ronald Ross. In 1897, he was the first person to discover that Plasmodium malaria can be transmitted from patients to mosquitoes, and in 1902 he won the Nobel Prize.

For further information see:http://www.cdc.gov/malaria/about/history/ross.html

2 people answered correctly.

Quiz of the month

World day

http://www.keelpno.gr

Chief Editor:Ch. Hadjichristodoulou

Associate Editors:P. Koukouritakis

Μ. Fotinea

Scientific Board:Ν. Vakalis

Ε. VogiatzakisP. Gargalianos- Kakoliris

Μ. Daimonakou- VatopoulouΙ. LekakisC. Lionis

Α. PantazopoulouV. Papaevagelou

G. SaroglouΑ. Tsakris

Editorial Board:R. Vorou

E. KaratampaniP. Koukouritakis

Κ. MellouD. PapaventsisΤ. PatoucheasV. Roumelioti

V. SmetiCh. TsiaraΜ. Fotinea

Ε. Hadjipashali

Editors:Τ. Kourea- Kremastinou

HCDCP President

T. PapadimitriouHCDCP Director

Graphic Design:Ε. Lazana

Copy Editor:P. Koukouritakis

http://www.keelpno.gr info@keelpno.gr

MINISTRY OF HEALTH

HCDCP

HELLENIC CENTER FORDISEASE CONTROL & PREVENTION

MINISTRY OF HEALTH

September 28th World Rabies Day

The 28th of September is the official global initiative day to increase rabies awareness, prevention and reduction of mortality from this fatal disease.The World Rabies Day was established on 7 September 2007, organized by the Center for Disease Control and Prevention of the United States (CDC) and the Alliance to fight rabies (ARC), headquartered in United Kingdom. Other organizations that supported this effort are the World Health Organization (WHO ), the Pan - American Health Organization (PAHO), the World Organization for Animal Health [The World Organization for Animal Health (OIE)] and Public Health Centers collaborating with WHO (WHO collaborating centers).The site for this initiative is www.worldrabiesday.org.During the first meeting, 54 million people were approached, 400,000 people from 74 different countries participated in various activities to raise awareness and increase financial support for this effort, while about 600,000 animals were vaccinated in the first attempt . World Rabies Day goal is the constant update, the increased professional awareness and the vaccination of stray and domestic animals, aiming to eliminate the disease.For more information please visit the HCDCP web page (www.keelpno.gr) in rabies section.

Make Rabies History is the slogan of the day.