The Global Burden of Injury

The Global Burden of The Global Burden of InjuryInjury

Rochelle A. Dicker, MD, FACSRochelle A. Dicker, MD, FACSAssistant Professor of Surgery Assistant Professor of Surgery

University of California, University of California, San FranciscoSan Francisco

INJURYINJURY claims over claims over

5 million lives worldwide 5 million lives worldwide every yearevery year

Calculating BurdenCalculating Burden

Cause of Death Patterns by age and Cause of Death Patterns by age and gendergender• Worldwide this is known only Worldwide this is known only 35%35% of the of the

timetime Disability ImpactDisability Impact

• Incidence of disease or injuryIncidence of disease or injury• Proportion leading to disabling outcomeProportion leading to disabling outcome• Average age of disability onset and its Average age of disability onset and its

durationduration• Severity of disabilitySeverity of disability

Disability Adjusted Life YearsDisability Adjusted Life Years

Major FactorsMajor Factors Duration of time lost due to a deathDuration of time lost due to a death Disability weights/Degrees of Disability weights/Degrees of

incapacity: 0-1incapacity: 0-1 Age weights=Importance of healthy Age weights=Importance of healthy

life at a given agelife at a given age

DALY Disability WeightsDALY Disability Weights

BKA BKA .281.281 Paraplegia Paraplegia .671.671 Quadriplegia .895Quadriplegia .895

DALYs 2005DALYs 2005

Bottom LineBottom Line

INJURYINJURY

is the lead cause of is the lead cause of death and death and disability disability

worldwide in worldwide in people under 60 people under 60

years of ageyears of age

Impact of Injury by Region: Leading Impact of Injury by Region: Leading Causes of Injury MortalityCauses of Injury Mortality

Low and Middle Income Countries:Low and Middle Income Countries:• Western Pacific-Interpersonal Violence and Western Pacific-Interpersonal Violence and

Road Traffic CrashesRoad Traffic Crashes• Europe-Suicide and PoisoningsEurope-Suicide and Poisonings• Americas-Interpersonal ViolenceAmericas-Interpersonal Violence

88% of road traffic crashes-$65 billion88% of road traffic crashes-$65 billion

95% of homicides95% of homicides

Injury in Africa Injury in Africa

The third leading cause of deathThe third leading cause of death

7 of 15 and 5 of 15 leading causes of 7 of 15 and 5 of 15 leading causes of death in men and women, death in men and women,

respectively; 15-44 years oldrespectively; 15-44 years old

Studying the Burden of DiseaseStudying the Burden of Disease

Recognition of its implications:Recognition of its implications:• Development of prevention strategiesDevelopment of prevention strategies

The Public Health Model:The Public Health Model:Surveillance and screeningSurveillance and screeningRecognition of risk factorsRecognition of risk factorsDevelopment of prevention and intervention Development of prevention and intervention

strategiesstrategiesProgressive evaluation of effects to target Progressive evaluation of effects to target

populationpopulation

• Policy Implementation and targeted Policy Implementation and targeted resource allocation for health careresource allocation for health care

Getting Started: SurveillanceGetting Started: Surveillance

Measuring Injury in UgandaMeasuring Injury in Uganda 88% of population live in rural areas88% of population live in rural areas 220% increase in motor vehicles 220% increase in motor vehicles

1985-19951985-1995

Households in rural and urban areas Households in rural and urban areas were randomly selected for surveywere randomly selected for survey

Survey was qualitative and Survey was qualitative and quantitativequantitative

Injury MortalityInjury Mortality

Urban: 217/100,000Urban: 217/100,000• Traffic crashes and violenceTraffic crashes and violence

Rural: 92/100,000Rural: 92/100,000• Drownings are a tremendous issue in Drownings are a tremendous issue in

the lake regions (rural)the lake regions (rural)• Burns and falls affect childrenBurns and falls affect children

Kobusingye O, Guwatudde D, Lett R, “Kobusingye O, Guwatudde D, Lett R, “Injury Patterns in urban and rural Injury Patterns in urban and rural Uganda” Uganda” Injury Prevention 2001; 7:46-50Injury Prevention 2001; 7:46-50

Infrastructure in UgandaInfrastructure in Uganda

No prehospital systemNo prehospital system• The injured are brought in by The injured are brought in by

bystanders, police, or relativesbystanders, police, or relatives One 24 hour casualty ward: Mulago One 24 hour casualty ward: Mulago

Hospital; 1200 bedsHospital; 1200 beds Other hospitals:Other hospitals:

• Daytime injuries-seen in clinicDaytime injuries-seen in clinic• Nighttime-direct admit to wardNighttime-direct admit to ward

The City of KampalaThe City of Kampala

Trauma registry dataTrauma registry data• 4359 injured patients from 5 4359 injured patients from 5

hospitalshospitals• 75% went to Mulago75% went to Mulago• Mean age 24.2 yearsMean age 24.2 years• Traffic crashes=50% of all injuriesTraffic crashes=50% of all injuries• Largest occupation of the injured-Largest occupation of the injured-

studentsstudents

Kobusingye OC, Guwatudde D, Owor G, Lett RR; Kobusingye OC, Guwatudde D, Owor G, Lett RR; “Citywide trauma “Citywide trauma experience in Kampala, Uganda: A call for intervention” experience in Kampala, Uganda: A call for intervention” Injury Injury Prevention 2002:8;133-136Prevention 2002:8;133-136

A Call for a System and PreventionA Call for a System and Prevention

The unaccounted injuriesThe unaccounted injuries• People who never make it to the People who never make it to the

hospitalhospital• 2.2/1000 per year die of injuries2.2/1000 per year die of injuries• Minor injuries are crowding hospitalsMinor injuries are crowding hospitals• Poor triage systemPoor triage system• 36%36% of severely injured arrive >1hour of severely injured arrive >1hour

after injuryafter injury

Steps towards Policy and Steps towards Policy and PreventionPrevention

WHO’s Department of Injuries and WHO’s Department of Injuries and Violence Prevention-2000Violence Prevention-2000• Review of 28 existing Nation Policies Review of 28 existing Nation Policies

regarding injuryregarding injury• Many provide a framework for Many provide a framework for

Prevention strategiesPrevention strategies• NONO Violence Prevention policy was Violence Prevention policy was

found in Asia, Africa, Eastern Europe or found in Asia, Africa, Eastern Europe or Middle EastMiddle East

Examples of National GoalsExamples of National Goals

““An injury free Sri An injury free Sri Lanka”. Integrating Lanka”. Integrating injury prevention injury prevention into everyday lifeinto everyday life

Brazil: Contribute Brazil: Contribute to the quality of life to the quality of life of people; reduce of people; reduce morbimortalitymorbimortality

How to Develop National Policy?How to Develop National Policy?

Tunisia: National strategy for Tunisia: National strategy for Emergency Medical ServicesEmergency Medical Services• Medical practitioners working groupMedical practitioners working group• Presentation to policymakers Presentation to policymakers

Lessons learnedLessons learned The 5 E’sThe 5 E’s

• EducationEducation• EnforcementEnforcement• Engineering Engineering • EmergencyEmergency• EvaluationEvaluation

Key Steps for PolicyKey Steps for Policy

Situation analysis of epidemiology; Situation analysis of epidemiology; geared towards solutionsgeared towards solutions

Identify a lead agencyIdentify a lead agency Prepare a strategy and plan of actionPrepare a strategy and plan of action Raise awarenessRaise awareness Create task forces amongst the key Create task forces amongst the key

stakeholders and communitystakeholders and community Seek LONG-TERM commitmentsSeek LONG-TERM commitments Allocation of personnel and $$$$$Allocation of personnel and $$$$$

Who are the Leaders?Who are the Leaders?

Ministries ofMinistries of HealthHealth

CatalystCatalyst FacilitatorFacilitator AdvocateAdvocate CoordinationCoordination SupportiveSupportive

Ministries of Transport, Ministries of Transport, Justice, Education, Justice, Education, Sport, Housing, InteriorSport, Housing, Interior

Choosing InterventionsChoosing Interventions

EvidenceEvidence Cost effectivenessCost effectiveness AcceptabilityAcceptability FeasibilityFeasibility Time frameTime frame MeasurabilityMeasurability

International agreements can help International agreements can help societies demand changesocieties demand change

UCSF/Mulago ResearchUCSF/Mulago Research