The Burden of Injuries: a Neglected Public Health Priority Abdulgafoor M. Bachani, PhD MHS Assistant...
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- Slide 1
- 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
- Slide 2
- 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
- Slide 3
- Section A Understanding Injuries
- Slide 4
- 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
- Slide 5
- Epidemiology of Injuries Injury model Energy Environment Host
Vector or Vehicle Microorganism Environment Vector Infectious
disease model Host
- Slide 6
- 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
- Slide 7
- Injury Typology Intentional Injuries Homicide Suicide Self-harm
Unintentional Injuries Road Traffic Injuries Drowning Burns Falls
Poisoning
- Slide 8
- Section B Why are injuries relevant to Public Health?
- Slide 9
- Death (Acute) Hospitalization Emergency Dept Visit Injured But
Not Treated The Injury Pyramid Disability Why Are Injuries Relevant
to Public Health?
- Slide 10
- 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
- Slide 11
- 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
- Slide 12
- Leading Causes of Global Mortality, 2010 12 Disease or
injuryDeaths in thousands 1. Ischemic heart disease7,029 2.
Stroke5,874 3. COPD (pulmonary)2,899 4. Lower respiratory
infections2,814 5. Lung cancer1,527 6. Hiv/aids1,465 7. Diarrheal
diseases1,445 8. Road injury1,328 9. Diabetes1,281 10.
Tuberculosis1,195 Source: (2010). Global Burden of Disease.
- Slide 13
- Leading Causes of Global Mortality, 2010 (cont.) 13 Disease or
injuryDeaths in thousands 11. Malaria1,169 12. Cirrhosis1,030 13.
Self-harm883 14. Hypertensive heart disease873 15. Preterm birth
complications859 16. Liver cancer752 17. Stomach cancer754 18.
Chronic kidney disease735 19. Colorectal cancer714 20. Other cardio
and circulatory685 Source: (2010). Global Burden of Disease.
- Slide 14
- Global Burden of Disease, 2010: Causes of Death 14 CausesDeaths
in thousands% Group 1: Communicable (infectious), maternal,
perinatal, nutritional conditions 13,156.425% Group 2:
Non-communicable (chronic) diseases 34,539.965% Group 3: Injuries
(and violence) 5,073.310% Source: (2010). Global Burden of
Disease.
- Slide 15
- Global Mortality, All Injuries (2010)
- Slide 16
- A Central Question Do injury patterns differ around the world?
16
- Slide 17
- 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
Source: (2010). Global Burden of Disease.
- Slide 18
- Injury-Related Deaths Worldwide by Sex, 2010 18 Source: (2010).
Global Burden of Disease.
- Slide 19
- 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 ; Vos T Fau - Flaxman, A. D. et al,
2012
- Slide 20
- Burden of RTIs (WHO, 2013)
- Slide 21
- 1.3 billion vehicles Deaths vs Vehicle Ownership
- Slide 22
- 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
- Slide 23
- 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
- Slide 24
- 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
- Slide 25
- US Incidence and Costs of Injury (Finkelstein, et al 2006)
Fatal Hospitalized Non- hospitalized Total Medical Costs
Productivity Losses Total Costs $1 Billion$142 Billion$143 Billion
$34 Billion$49 Billion$ 92 Billion $45 Billion$125 Billion$ 171
Billion $80 Billion $326 Billion $ 406 Billion Cost Estimates Based
on 2000 data
- Slide 26
- 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?
- Slide 27
- Section C A Neglected Priority
- Slide 28
- Multi-Sectoral Issue Police Enforcement Policy Legislation
Health Engineering Vehicle & Road design Consumer protection
Product Manufacturers Urban Transport Planning Safety
- Slide 29
- 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
- Slide 30
- 3. Mechanism of Injury Mechanism Penetratingknife, bullet
Bluntdo not penetrate into the body Burnelectrical, thermal,
chemical Continued Classification of Injuries
- Slide 31
- 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) Classification of Injuries
- Slide 32
- 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
- Slide 33
- Example: Traffic Enforcement Source: Disease Control Priorities
in Developing Countries | Chapter 39: Unintentional Injuries| Robyn
Norton, Adnan A. Hyder, David Bishai, and others
- Slide 34
- Example: Speed Bumps Source: Disease Control Priorities in
Developing Countries | Chapter 39: Unintentional Injuries| Robyn
Norton, Adnan A. Hyder, David Bishai, and others
- Slide 35
- Section D Preventing Injuries
- Slide 36
- 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 strategiesmatrix 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
- Slide 37
- 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
- Slide 38
- Preventing Injuries: Lessons Learned Injuries are predictable
Epidemiology, risk factors Accidents vs. injuries Accidents happen
vs. injuries are not accidents Injuries are preventable
- Slide 39
- Strategies for Injury Prevention Injury model Energy
Environment Host Vector or Vehicle
- Slide 40
- Strategies for Injury Prevention Strategies for injury
prevention Primary, secondary, and tertiary prevention Individual,
vector, environment-level interventions
- Slide 41
- The Haddon Matrix: 1 st Axis Continued
- Slide 42
- The Haddon Matrix: 2 nd Axis
- Slide 43
- Haddon Matrix (illustrative) Pre-CrashPost-Crash Crash
Intervention can prevent: death injury property damage Intervention
can prevent: death injury Intervention can reduce the chances of:
death injury
- Slide 44
- Haddon Matrix (illustrative) alcohol use driving speeds
protective equipment reflectors lights brakes street lighting paved
roads road barriers Person Vector Environment
- Slide 45
- What Can We Do? Prevention Primary prevention or prevention
Avoid something that might happen Prevent, reduce, or modify
hazards or events that cause injury
- Slide 46
- What Can We Do? Prevention Secondary prevention or acute care
Minimize the damage if it happens Counter the damage already done
by the hazard Stabilize and repair the damage
- Slide 47
- What Can We Do? Prevention Tertiary prevention or
rehabilitation Reduce the sequelae once it has happened Restore the
functioning of injured patients to pre- injury levels
- Slide 48
- 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
- Slide 49
- Strategies for Injury Prevention Strategies for injury
prevention Primary, secondary, and tertiary prevention Individual,
vector, environment-level interventions Systems approach to injury
prevention
- Slide 50
- Systems Approach to Road Safety INFRASTRUCTURE HUMAN RESOURCES
TECHNOLOGY /SCIENCE
- Slide 51
- Systems Approach PRODUCTION OF SAFETY INFRASTRUCTURE HUMAN
RESOURCES TECHNOLOGY /SCIENCE
- Slide 52
- Interventions for Road Traffic Injuries: Haddon Matrix
PersonVector (Motorcycle) Environment Pre-Event Event Post-Event
Systems to prevent road traffic crashes
- Slide 53
- Interventions for Road Traffic Injuries: Haddon Matrix
PersonVector (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
- Slide 54
- 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
- Slide 55
- 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
- Slide 56
- Section E CASE STUDY OF HELMET LEGISLATION IN VIET NAM
- Slide 57
- 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 Nams 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.
- Slide 58
- 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
- Slide 59
- 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
- Slide 60
- 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
- Slide 61
- Wide range of helmets in use 80% of helmets in use did not meet
standards (April 08 Viet Nam Standard & Consumer Association
survey)
- Slide 62
- 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 15 th )
Mandatory helmets: locally appropriate All occupants, all roads,
all times
- Slide 63
- Helmet Standards ECE 22: Approved worldwide Safe, effective Is
it practical? QCVN 2: Tropical helmet Approved for motorcycle heavy
roads
- Slide 64
- 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
- Slide 65
- 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
- Slide 66
- Helmet Infractions over Time
- Slide 67
- Social Marketing Campaigns commenced prior to the law Targeted
TV Cinema Posters Billboards Bus stops Focused on the law, benefits
and penalties
- Slide 68
- Social Marketing: Focused and Graphic
- Slide 69
- Slide 70
- Slide 71
- 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
- Slide 72
- 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
- Slide 73
- Sustained Success: Helmet Wearing in Yen Bai Province
- Slide 74
- Is It Working in Everyone? Helmet Wearing in Urban vs Rural
Drivers
- Slide 75
- Vulnerable Group: Helmet Wearing in Primary School
Children
- Slide 76
- Loophole: Children Perceptions: Thought to be dangerous for
kids Enforcement No way to punish a parent Wearing Rate (