the burden of injuries: a neglected public health · pdf filethe burden of injuries: a...

The Burden of Injuries: a Neglected

Public Health Priority

Abdulgafoor M. Bachani, PhD MHS

Assistant Professor

Associate Director, Johns Hopkins International Injury Research Unit

jhsph.edu/IIRU

Learning Objectives

By the end of this session, participants will be able to:

Define injuries and describe their typology

Highlight the burden of injuries

Describe approaches to addressing the burden of

injuries

Section A

Understanding Injuries

Defining Injuries

What Do We Mean by Injury?

“Body damage resulting from acute exposure to excessive amounts of thermal, mechanical (whether kinetic or potential), electrical, or chemical energy”

“Or from the absence of such essentials as heat or oxygen”

Epidemiology of Injuries

Injury model

Energy

Environment

Host

Vector or Vehicle

Microorganism

Environment

Vector

Infectious disease model

Host

Describing Injuries

Etiology: Inappropriate energy transfer

Vehicles or vectors: Motor vehicles, bullets, animals…

Pathology: Fractures, dislocations, sprains, strains, concussions…

Treatment: Outpatient, hospitalization…

Prognosis: Recovery, sequelae, death…

Injury Typology

Intentional Injuries

Homicide

Suicide

Self-harm

Unintentional Injuries

Road Traffic Injuries

Drowning

Burns

Falls

Poisoning

Section B

Why are injuries relevant to Public Health?

Death

(Acute) Hospitalization

Emergency Dept Visit

Injured But Not Treated

The Injury Pyramid

Disability

Why Are Injuries Relevant to Public Health?

Why Are Injuries Relevant to Public Health?

Mortality (death)

Morbidity (non-fatal injuries) E.D. visits

Hospitalization

Outpatients visits

Disability (short-term, mid-term, and long-term sequelae)

Cost

Let us review these 4 consequences…

Mortality

Injuries are among the main causes of death for the U.S. population (top 5)

Around 150-200,000 Americans die from injuries annually (60-70 per 100,000)

Injuries are the single greatest killer of Americans between the ages of 1-44 years

Injuries are responsible for 3-4 million years of life lost

Leading Causes of Global Mortality, 2010

12

Disease or injury Deaths in thousands

1. Ischemic heart disease 7,029

2. Stroke 5,874

3. COPD (pulmonary) 2,899

4. Lower respiratory infections 2,814

5. Lung cancer 1,527

6. Hiv/aids 1,465

7. Diarrheal diseases 1,445

8. Road injury 1,328

9. Diabetes 1,281

10. Tuberculosis 1,195

Source: (2010). Global Burden of Disease.

Leading Causes of Global Mortality, 2010

(cont.)

13

Disease or injury Deaths in thousands

11. Malaria 1,169

12. Cirrhosis 1,030

13. Self-harm 883

14. Hypertensive heart disease 873

15. Preterm birth complications 859

16. Liver cancer 752

17. Stomach cancer 754

18. Chronic kidney disease 735

19. Colorectal cancer 714

20. Other cardio and circulatory 685


Global Burden of Disease, 2010: Causes of

Death

14

Causes Deaths in thousands %

Group 1:

Communicable

(infectious), maternal,

perinatal, nutritional

conditions

13,156.4 25%

Group 2:

Non-communicable

(chronic) diseases

34,539.9 65%

Group 3:

Injuries (and violence)5,073.3 10%


Road Injury26%

Falls11%

Drowning7%

Burns7%

Poisonings3%

Other Unintentional

Injuries19%

Intentional Injuries (Self-harm, Assault,

Violence)27%

Global Mortality, All Injuries (2010)

A Central Question

Do injury patterns differ around the world?

16

17

Mortality Rates by Regions, 2010

Injury rates higher in developing countries

25.2 unintentional injury-related deaths per

100,000 in high-income North America

53.14 unintentional injury-related deaths per

100,000 in Central Sub-Saharan Africa


Injury-Related Deaths Worldwide by Sex,

2010

18

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

Females

Male


Global Burden of RTIs

Road Traffic Injuries (RTIs) take

approximately 1.33 million lives per year

- 3,600 deaths/day

- one death every 24 seconds

20-50 million people are seriously injured

each year.

- 14 Million years of life lost due to

Disability

Lozano, R. et al, 2012 ; VosT Fau - Flaxman, A. D. et al, 2012

Burden of RTIs

(WHO, 2013)

1.3 billion vehicles

Deaths vs Vehicle Ownership

Morbidity

In 2002, approximately 92.3 million Americans required medical attention due to sustained injuries

58.7 million visits to office based physicians

5.6 million hospital outpatient visits

28 million hospital emergency room visits

Every year, one in three persons suffers a non-fatal injury

One in every eight hospital beds is occupied by an injured patient

Severity of Injuries

What does the severity of injuries depend on?

Energy being dissipated (amount/time)

Shapes of the colliding objects

Rigidity of colliding objects

Tolerance (susceptibility) of host

Every year, more than 80,000 people in the U.S. suffer a brain or spinal cord injury that would lead them to a permanent disablement

Cost

In 2000 the estimated costs of motor vehicle crashes in the US was $230.6 billion

Some break-downs for 2000:

Alcohol-related crashes cost $51.1 billion

Medical expenses $32.6 billion

Lost market productivity $61 billion

US Incidence and Costs of Injury

(Finkelstein, et al 2006)

Fatal

Hospitalized

Non-

hospitalized

Total

Medical Costs Productivity

LossesTotal Costs

$1 Billion $142 Billion $143 Billion

$34 Billion $49 Billion $ 92 Billion



Cost Estimates Based on 2000 data

Injuries a public health issue

It is due to these health consequences that injuries need to be addressed

The economic implications make a further strong case for investment in prevention and control

There are moral and ethical concerns especially when injuries afflict the poor and vulnerable around the world

…So, what do we do about it?

Section C

A Neglected Priority

Multi-Sectoral Issue

Police

Enforcement

Policy

Legislation

HealthEngineering

Vehicle &

Road design

Consumer

protection

Product

Manufacturers

Urban

Transport

Planning

Safety

1. Themselves Nature of injury (e.g., fracture, laceration,

contusion)

Body region affected (e.g., head, chest, abdomen)

Severity (e.g., fatal, non-fatal)

2. Consequences Death, hospitalization, emergency department visit .

. .

Continued

Classification of Injuries

3. Mechanism of Injury

Mechanism

Penetrating—knife, bullet

Blunt—do not penetrate into the body

Burn—electrical, thermal, chemical

Continued


4. The Hazard that “Caused” Them

“Cause” (e.g., motor-vehicle, falls, drowning)

Type of activity (e.g., work, sport, recreational)

Product involved (e.g., firearm, snowmobile)

Location of activity (e.g., school, outdoors, home)

Intent (e.g., intentional, unintentional)


Cost-Effective Interventions

Myth: injury prevention interventions are too

expensive to implement and not cost-effective

Huge Health and Economic losses

Injury prevention interventions are among the most

cost-effective

Example: Traffic Enforcement

Source: Disease Control Priorities in Developing Countries | Chapter 39: Unintentional Injuries| Robyn

Norton, Adnan A. Hyder, David Bishai, and others

Example: Speed Bumps

Source: Disease Control Priorities in Developing Countries | Chapter 39: Unintentional Injuries| Robyn

Norton, Adnan A. Hyder, David Bishai, and others

Section D

Preventing Injuries

History of the Field

De Haven (1942): Survivability of events Stapp (1955): Energy tolerance

Gordon (1949): Application of epidemiological framework

Gibson (1961): Energy as source of injury

Haddon (1970): Preventability strategies—matrix and principles Nader (1965): Consumer protection Baker (since late 60s): Public health leadership in

measuring the burden of injury

Source: Waller, Am J Pub Health 1996; 84:664-670

Preventing Injuries: Lessons Learned

Severity of injuries depends on:

Energy being dissipated

Shapes of the colliding objects

Rigidity of colliding objects

Tolerance of host

Impact of injuries depends on:

Post-event care

rehabilitation

Continued

Preventing Injuries: Lessons Learned

Injuries are predictable

Epidemiology, risk factors

Accidents vs. injuries

“Accidents happen” vs. injuries are not accidents

Injuries are preventable

Strategies for Injury Prevention

Injury model

Energy

Environment

Host

Vector or Vehicle


Strategies for injury prevention

Primary, secondary, and tertiary prevention

Individual, vector, environment-level interventions

Environment

Host

(Person) Vector / Vehicle Physical

Socio-economic

The Haddon Matrix: 1st Axis

Continued

Environment Time Frame

Host (Person)

Vector / Vehicle Physical Socio-economic

Pre-event

Event

Post-event

The Haddon Matrix: 2nd Axis

Haddon Matrix (illustrative)

Pre-Crash Post-CrashCrash

Intervention can

prevent:

• death

• injury

• property damage

Intervention can

prevent:

• death

• injury

Intervention can reduce

the chances of:

• death

• injury

Haddon Matrix (illustrative)

• alcohol use

• driving speeds

• protective

equipment

• reflectors

• lights

• brakes

• street lighting

• paved roads

• road barriers

Person

Vector

Environment

What Can We Do? Prevention

Primary prevention or “prevention”

Avoid something that might happen

Prevent, reduce, or modify hazards or events that cause injury


Secondary prevention or acute care Minimize the damage if it happens

Counter the damage already done by the hazard

Stabilize and repair the damage


Tertiary prevention or rehabilitation Reduce the sequelae once it has happened

Restore the functioning of injured patients to pre-injury levels

What Do We Need to Know to Prevent Injuries?

Scope of the problem

Trends over time

Risk factors

Design of interventions

Effectiveness and efficiency of strategies


Strategies for injury prevention

Primary, secondary, and tertiary prevention

Individual, vector, environment-level interventions

Systems approach to injury prevention

Systems Approach to Road Safety

INFRASTRUCTURE

HUMAN

RESOURCES

TECHNOLOGY

/SCIENCE

Systems Approach

PRODUCTION

OF SAFETY

INFRASTRUCTURE

HUMAN

RESOURCES

TECHNOLOGY

/SCIENCE

Interventions for Road Traffic Injuries: Haddon Matrix

Person Vector (Motorcycle)

Environment

Pre-Event

Event

Post-Event

Systems to prevent

road traffic crashes

Interventions for Road Traffic Injuries: Haddon Matrix

Person Vector (Motorcycle)

Environment

Pre-Event

Event

Post-Event

Systems to ensure

road traffic crashes

do not cause death

or injury and limit

impact of disability

on quality of life and

productivity

Examples of Effective Interventions: Road

Safety

Speed

• Set/enforce limits

• Road design

• Cameras

Drinking & Driving:

• Set/enforce limits

• Random breath testing

• Swift and tough penalties

Motorcycle Helmets:

• Set/enforce laws

• Helmet standards

• Penalties for non-use

Seatbelts/Child restraints:

• Set/enforce laws

• Audible reminders in cars

• Loan programs?

Visibility:

• Daytime running lights

• Reflectors

• Bright helmets

• Street lighting

Source: Global Status Report on Road Safety, 2009

Legislation

48% of countries have some types of

laws on all 5 risk factors.

15% have COMPREHENSIVE laws on

all assessed risk factors.

Inadequate enforcement

Source: Global Status Report on Road Safety, 2009

Section E

CASE STUDY OF HELMET LEGISLATION IN VIET NAM

Acknowledgments

Publications from which data/graphs are taken:

Passmore JW, Nguyen LH, Nguyen NP, Olive JM.

“The formulation and implementation of a national helmet law:

a case study from Viet Nam.” Bull World Health Organ 2010;

88: 783-87.

Pervin A, Passmore J, Sidik M, et al. “Viet Nam’s mandatory

motorcycle helmet law and its impact on children.” Bull World

Health Organ 2009; 87: 369-73.

Passmore J, Nguyen THT, Luong MA, et al. “Impact of

Mandatory Motorcycle Helmet Wearing Legislation on Head

Injuries in Viet Nam: Results of a Preliminary Analysis.”Traffic Injury Prevention 2010; 11: 202-6.

Description of Fleet in Viet Nam

January 2009: 27 million registered vehicles

95% motorcycles

Number of motorcycles increased by 7,680 per

day in 2008

Represents ~3 fold increase in fleet size over the

past decade

Increase largely due to number of motorcycles

~8,000 new motorcycles registered per day in 2008

Burden of Road Traffic Injuries

2007: 12,800 road traffic deaths

15 deaths per 100,000

population

Potential of 30%

underestimate of deaths and

90% underestimate of

injuries*

1995 to 2002: 135% increase in road traffic deaths

60% of road traffic fatalities occur in motorcycle occupants*

*Pervin et al., 2009

Evidence of Helmet Efficacy

Cochrane Review:

Reduce risk of death by 42% (OR 0.58, 95% CI:

0.50, 0.68)

Reduce risk of head injury by 69% (OR 0.31, 95%

CI: 0.25, 0.38)

WHO recommends laws/implementation

Wide range of “helmets” in use

80% of helmets in use did not

meet standards

(April 08 Viet Nam Standard &

Consumer Association survey)

Helmet Legislation

1998-2006: Confusing legislation

Helmets mandated on certain roads

Unclear if passengers needed to wear them

No coverage of children

2007: Resolution 32 (December 15th)

Mandatory helmets: locally appropriate

All occupants, all roads, all times

Helmet Standards

ECE 22:

Approved worldwide

Safe, effective

Is it practical?

QCVN 2:

“Tropical helmet”

Approved for motorcycle heavy roads

Implementation Details

Political Support Buy-in from high levels

Prime minister, all parties

Full government approach

Demonstrated effectiveness Used data to convince public of benefits

Enforcement Penalties increased by 10 fold

High perception of being caught

Social marketing/education Eliminated confusion in messaging

Enforcement

Increased penalties

From 20-40,000 VND to 100-200,000 VND (US $6-12)

per offense

Traffic Tickets in 2008:

Total: 5,431,191

682,789 (13%) for helmets

No reliable prior data

Ongoing challenges

Human resources for enforcement

Maintaining perception of “getting caught”

Helmet Infractions over Time

Social Marketing

Campaigns commenced prior to the law

Targeted

TV

Cinema

Posters

Billboards

Bus stops

Focused on the law, benefits and penalties

Social Marketing: Focused and

Graphic

Indicators

Intermediate:

Helmet wearing prevalence

Tickets issued for inappropriate/lack of wearing

Outcome:

Decrease in motorcycle-associated road traffic

mortality

Decrease in motor-cycle associated road traffic

injuries

All injuries

Severe injuries

Head injuries

Immediate Visible and Reported Impact

MoH Surveillance, 3 months

16% Reduction in Head Injuries

(RR 0.84, 95% CI: 0.81, 0.87)

18% Reduction in Traffic Deaths

(RR 0.82, 95% CI: 0.73, 0.93)

Police Data

2008 vs 07: 1,557 less deaths,

2,495 less injuries

2009 vs 08: 149 less deaths, 212

less injuries

Sustained Success:

Helmet Wearing in Yen Bai Province

Is It Working in Everyone?

Helmet Wearing in Urban vs Rural

Drivers

Vulnerable Group: Helmet Wearing in

Primary School Children

Loophole: Children

Perceptions:

Thought to be

dangerous for kids

Enforcement

No way to punish a

parent

Wearing Rate (<16)

39% in 2008

Loophole: Incorrect Use

Low Quality Helmets

Is something better

than nothing?

Incorrect wearing

Lack of fastening

straps

Legal Modifications: 2009

Must be fastened!

Defined un-fastened as equivalent to un-worn

Parent penalties

Able to penalize parents if children not wearing a

helmet

Thank You

Email: [email protected]

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