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Prevention of death and disability from injuries to children
Frederick P. Rivara, MD, MPHThe Harborview Injury Prevention and Research
CenterUniversity of Washington
Seattle, USA
Context for the talk
How can we move the field of child injury control forward - given the competing demands of the child survival world in low and middle income countries, and of the chronic disease world in high income countries?
Child survival: “the most pressing moral dilemma of the new millennium”
• 12 million children < 5 years dying annually in 1990, most in LIC
• Half occurred in six countries: India, Nigeria, Congo, Ethiopia, Pakistan and China
• Most deaths were from: measles, malnutrition, malaria, diarrhea, pneumonia, neonatal disorders, AIDS
• Interventions to reduce these deaths by two-thirds were available or developed
Jones et al, Lancet 2003
Number of deaths to children <5 years: 1970-2010
Rajaratnam et al, Lancet 2010
Van Cleave, J. et al. JAMA 2010;303:623-630.
Prevalence of Any Chronic Condition and Subgroups of Conditions in children, 1988-2006
1988-94 1994-2000 2000-06
Proportion of children 8-18 years with one or more chronic conditions, 2003
0
5
10
15
20
25
30
35
40
45
%
CZ UK DE FR PL ES HU AT NL CH GR
Berra et al, Medical Care 2009
Pediatric Obesity in the US
02
468
10
121416
1820
1963-5 1966-70
1971-4 1976-80
1988-94
1999-2000
2001-2 2003-4
%
2-5 yrs6-11 yrs12-19 yrs
Rates of overweight and obesity at 2-4 years of age
-60 -40 -20 0 20 40 60
Female 1-2 SD Female 2-3 SD Female >3 SD Male 1-2 SD Male 2-3 SD Male >3 SD
MALE FEMALESpain
Greece
Poland
England
Scotland
Italy
Netherlands
Romania
Czech
Cyprus
`
Kelishadi, R. Epidemiol Rev 2007
Prevalence of overweight/obesity in boys and girls aged 6-18 years in LMIC
Five themes
• Epidemiologic transition• Injury control not just prevention
• Evolution of the idea of adolescence
• Improving the quality of research
• Change priority setting
Epidemiologic transition in HIC
• Chronic illness in adults
• Chronic illness in children
• Low mortality from child trauma
• Increased disability from child trauma:– TBI and SCI– Burns– Amputations– Psychic injuries
\
U.S. death rates for infectious diseases and injuries, ages 1-19
Injuries
Mortality after pediatric trauma admission in North America
0
0.5
1
1.5
2
2.5
3
3.5
4
<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age
%
NTDB Pediatric Annual Report, 2009
Functional outcomes from trauma
Children
• 10-25% with severe injuries have functional limitations
• 30% of LE fracture and 15% of UE fracture have physical limitations at 12 mos.
• 2% of mild TBI, 50% of moderate TBI and >90% of severe TBI have disability
• 20% of children and 40% of adolescents have signs of PTSD
ADULTS
• 50% are not back to work at 1 year
• 35% report health as fair-poor at 1 year
• 40% of elderly have difficulty walking
• No effect of TC care on functional outcomes in TBI or elderly
• 40% of adults have PTSD sxs at one year
Epidemiologic transition in LMIC
Epidemiologic transition in LMIC: Drowning deaths in 1-4 year olds in Matlab, Bangladesh 1983-2000
Causes of death for children 5-9 years, Bangladesh
0
5
10
15
20
25
30
Ra
te p
er
100,0
00
Causes of death for children 15-17 years, Bangladesh
0
5
10
15
20
25
Ra
te p
er
100,0
00
The future for both HIC and LMIC
• Shift from acute to chronic illness• Shift from injury mortality to injury
morbidity• Anticipated burden of MV injuries:
pedestrian, occupant, motorcycle, bicycle• Burden from suicide: will be the 10 leading
cause of death in 2020• Burden from guns: will be the 12th leading
cause of DALYS by 2020
Five themes
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence
• Improving the quality of research
• Change priority setting
Injury ControlPrevention
Acute Care
Rehabilitation
Some facts on care of trauma patients
• Where injured patients get care makes a difference in outcomes
• Improving the quality of care makes a difference in outcomes
• Interventions are available to improve trauma care in HIC, MIC and LIC
Trauma Center care in HIC • US: 45% lower mortality for <55 year olds
in TC• Netherlands: 40% lower mortality in TC• UK: 48% lower mortality in TC• Mortality with an Injury Severity Score ≥ 9:
35% in US, 55% in Mexico, 63% in Ghana.• Trauma systems less developed in
Europe: UK trauma system launched in April 2010
Mackenzie, 2007; Davenport 2010; Spijkers 2010; Mock, 1998; Hettiaratchy 2010
Operative mortality in resource-limited settings: Médecins Sans
Frontières in 13 countries
• Trauma accounted for 14% of operations in 2000-2008
• Operative mortality for trauma:0.2%
• Operative mortality for non-intentional injury: 0.1%
Chu, 2010
--Maintain airways and assist breathing--Recognize and treat pneumothorax--Stop bleeding promptly--Shock is recognized and treated--Decompress ICH--Intestinal/abdominal injuries are recognized and promptly treated--Treat potentially disabling extremity injuries--Manage unstable spinal injuries --Supply appropriate rehab services--Medications to treat trauma and pain are available
Effect of surgical checklist in Toronto, New Delhi, Amman, Auckland, Manila, Ifakara, London, Seattle
0
2
4
6
8
10
12
Wound Infection
Return to OR
Pneumonia
Death
Any complication
Before
After
Haynes et al, NEJM 2009
Disability vs. death after trauma
0
2
4
6
8
10
12
14
16
18
Mill
ion
s o
f ye
ars
0-4 years 5-14 years
YLD
YLL
GBD, 2000
Incidence of injury mortality and morbidity to children
0
5
10
15
20
25
30
35
Burns,B'desh
Burns, US TBI, US* PTSD, US
FatalityDisability*
*Based on 5% disability
Rahman; Koepsell; Davydow
Rehabilitation
• Children account for one-third of the world’s disabled population
• Injuries from war and accidents are the 2nd leading cause in Africa
• In Germany, only 5% pts with TBI received inpatient neuro-rehabilitation
• Few RCTs and lack of standard interventions for TBI
Von Wild 2008; Cameron 2005
Priorities for Comparative Effectiveness Research in US
Institute of Medicine, 2009
Five themes
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence• Improving the quality of research
• Change priority setting
Adolescence
• Ages 10-19 years
• One-sixth of the world’s population; 90% in LMIC
• Concept of ‘adolescence” did not exist prior to 20th century
• Views have shifted over time and place: Members of family economic assets valued
members of society with future contributions
Injuries to adolescents
0
10
20
30
40
50
60
1-4 5-9 10-14 15-19
Unintentional, LMICUnintentional, HICRTI, HICRTI, LMICHomicide, LICHomicide, HICSuicide,HICSuicide, LMIC
Deaths per 100,000 from injuries
Male Female Male Female Male Female
10- 15- 20- 10- 15- 20- 10- 15- 20- 10- 15- 20- 10- 15- 20- 10- 15- 20-
Patton et al, 2009
Risk of injury among in-school adolescents
0
10
20
30
40
50
60
70
80
% in
jure
d la
st y
ear
Kenya
Namib
ia
Sawzil
and
Uganda
Zambia
Zimbab
we
• Risk factors: smoking, drinking, drugs, truancy, condom non-use, depression
• RR of injury:– 1 risk factor: 1.4– 2 risk factors: 1.8– 3 risk factors: 3.1– 4 risk factors: 3.8– 5 risk factors: 4.1
Peltzer, Injury Prevention 2008
Five themes
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence
• Improving the quality of research• Change priority setting
Improving the quality of research: research networks
• Definition: Investigators from different institutions with ongoing commitment to the network and a structure that transcends research projects
• PEM: US, Canada, Australia, NZ, Europe and Middle East
• Primary care research networks: US, UK, Netherlands• Child Cancer: COG• Neonatology: NICHD, Vermont• HIV• European and Developing Countries Clinical Trials
Partnership• INJURY ???
Improving the quality of research: National Trauma Data Bank
• Operated by the American College of Surgeons
• Includes data from 765 hospitals in North America
• >3 million trauma patients, including 132,000 children and adolescents last year
• Uses: quality improvement, comparative effectiveness research
Case Fatality Rate per Facility for Level I Facilities
NTDB Annual Report, 2009
Improving the quality of research: International trauma registry
• What it could accomplish:– Quality improvement of trauma care
• Pre-hospital• Hospital• Post-discharge
– Patterns of injury prevention– Information on Deaths and Disability from
trauma Rehabilitation, GBD, magnitude of problem
Improving the quality of research: Research Training
• NIH: K awards, T-32
• NIH Fogarty International Collaborative Trauma and Injury Research Training Program – 12 US programs teamed with 12 non-US universities
• WHO Mentor-VIP
Improving the quality of research: Large scale intervention trials
• Kumar: Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. 104,000 people in 39 villages. 52-54% reduction in neonatal mortality.
• Rhee: Maternal and birth attendant hand washing and neonatal mortality in southern Nepal. 23,000 neonates; 41% lower mortality
• Diguiseppi: Incidence of fires and related injuries after giving out free smoke alarms: cluster randomised controlled trial 40 wards, 20,000 smoke detectors distributed, but only 30% installed. No effect on injuries.
• Roberts: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. 10,000 pts with TBI in 239 countries in 49 hospitals. No protective effect
Five themes
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence
• Improving the quality of research
• Change priority setting
Why has there been success in other areas of child health?
• Increase in new knowledge and development of new technologies has been responsible for most of the advances and gains in life expectancies.
• Efforts to improve health systems and policies have been central to success in these other diseases
• Increases in life expectancies increased incomes and GDP
Resources for injury control are woefully inadequate
YLL DALYs WHO reg. $
WHO extra $
Communicable disease & maternal, perinatal and nutritional conditions
54% 41% 68% 91%
Non-communicable dis. 33% 47% 31% 8%
Injuries 13% 12% <1% <1%
Lopez, The Lancet Nov 2008
Change priority setting
• Need exceeds resources everywhere and require new approaches to priority setting
• Research needs fall into one of 3 domains: – Assess injury burden and its determinants– Improve performance of existing capacities to decrease
burden– Develop new capacities to decrease injury M&M
• Current research priority setting may be flawed and contribute to persistent injury M&M
• Consider the CH&NRI priority setting process to inform investors about possible gains and risks to their investment
Rudan et al, 2008
Criteria for setting priorities among different research options
Priority setting
• Has occurred but has not followed evidence-based format
• Most decisions seem to depend on which way the political wind is blowing or one individual’s opinion
• Focus has been on injury prevention and not on injury control
Priority setting• Invest more wisely in R&D
• Broaden to include injury control
• Shift the paradigm for priority setting - commonality of injuries in HIC and LMIC
• Maximize the potential of Information Technology
• Increase global research capacity
• Create a global health architecture
Disease control priorities in developing countries, 2nd edition
In sum:
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence
• Improving the quality of research
• Change priority setting
“Injury is a problem that can be diminished considerably if adequate attention and support are directed to it…. The alternative is the continued loss of health and life to predictable, preventable, and modifiable injuries.”
- William Foege, MD Injury in America (1985)