The Burden of Injuries: a Neglected Public Health Priority Abdulgafoor M. Bachani, PhD MHS Assistant Professor Associate Director, Johns Hopkins International

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?

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 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.

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.

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.

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 Source: (2010). Global Burden of Disease.

Injury-Related Deaths Worldwide by Sex, 2010 18 Source: (2010). Global Burden of Disease.

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

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 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

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 Health Engineering 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 Penetratingknife, bullet Bluntdo not penetrate into the body Burnelectrical, thermal, chemical Continued Classification of Injuries

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

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 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

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 Strategies for injury prevention Primary, secondary, and tertiary prevention Individual, vector, environment-level interventions

The Haddon Matrix: 1 st Axis Continued

The Haddon Matrix: 2 nd Axis

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

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

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

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

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 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 PersonVector (Motorcycle) Environment Pre-Event Event Post-Event Systems to prevent road traffic crashes

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

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 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.

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 15 th ) 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 (

Documents

The Burden of Injuries: a Neglected Public Health Priority Abdulgafoor M. Bachani, PhD MHS Assistant Professor Associate Director, Johns Hopkins International