The Global Burden of Injury Rochelle A. Dicker, MD, FACS Assistant Professor of Surgery University of California, San Francisco

INJURY claims over 5 million lives worldwide every year

Calculating Burden Cause of Death Patterns by age and gender Cause of Death Patterns by age and gender Worldwide this is known only 35% of the timeWorldwide this is known only 35% of the time Disability Impact Disability 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 durationAverage age of disability onset and its duration Severity of disabilitySeverity of disability

Disability Adjusted Life Years Major Factors Duration of time lost due to a death Duration of time lost due to a death Disability weights/Degrees of incapacity: 0-1 Disability weights/Degrees of incapacity: 0-1 Age weights=Importance of healthy life at a given age Age weights=Importance of healthy life at a given age

DALY Disability Weights BKA.281 BKA.281 Paraplegia.671 Paraplegia.671 Quadriplegia.895 Quadriplegia.895

DALYs 2005

Bottom Line INJURY is the lead cause of death and disability worldwide in people under 60 years of age

Impact of Injury by Region: Leading Causes of Injury Mortality Low and Middle Income Countries: Low and Middle Income Countries: Western Pacific-Interpersonal Violence and Road Traffic CrashesWestern Pacific-Interpersonal Violence and Road Traffic Crashes Europe-Suicide and PoisoningsEurope-Suicide and Poisonings Americas-Interpersonal ViolenceAmericas-Interpersonal Violence 88% of road traffic crashes-$65 billion 95% of homicides

Injury in Africa The third leading cause of death The third leading cause of death 7 of 15 and 5 of 15 leading causes of death in men and women, respectively; years old 7 of 15 and 5 of 15 leading causes of death in men and women, respectively; years old

Studying the Burden of Disease Studying 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 screening Recognition of risk factors Development of prevention and intervention strategies Progressive evaluation of effects to target population Policy Implementation and targeted resource allocation for health carePolicy Implementation and targeted resource allocation for health care

Getting Started: Surveillance Measuring Injury in Uganda 88% of population live in rural areas 88% of population live in rural areas 220% increase in motor vehicles % increase in motor vehicles Households in rural and urban areas were randomly selected for survey Households in rural and urban areas were randomly selected for survey Survey was qualitative and quantitative Survey was qualitative and quantitative

Injury Mortality Urban: 217/100,000 Urban: 217/100,000 Traffic crashes and violenceTraffic crashes and violence Rural: 92/100,000 Rural: 92/100,000 Drownings are a tremendous issue in the lake regions (rural)Drownings are a tremendous issue in the lake regions (rural) Burns and falls affect childrenBurns and falls affect children Kobusingye O, Guwatudde D, Lett R, “Injury Patterns in urban and rural Uganda” Injury Prevention 2001; 7:46-50

Infrastructure in Uganda No prehospital system No prehospital system The injured are brought in by bystanders, police, or relativesThe injured are brought in by bystanders, police, or relatives One 24 hour casualty ward: Mulago Hospital; 1200 beds One 24 hour casualty ward: Mulago Hospital; 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 Kampala Trauma registry data Trauma registry data 4359 injured patients from 5 hospitals4359 injured patients from 5 hospitals 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- studentsLargest occupation of the injured- students Kobusingye OC, Guwatudde D, Owor G, Lett RR; “Citywide trauma experience in Kampala, Uganda: A call for intervention” Injury Prevention 2002:8;

A Call for a System and Prevention The unaccounted injuries The unaccounted injuries People who never make it to the hospitalPeople who never make it to the hospital 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% of severely injured arrive >1hour after injury36% of severely injured arrive >1hour after injury

Steps towards Policy and Prevention WHO’s Department of Injuries and Violence Prevention-2000 WHO’s Department of Injuries and Violence Prevention-2000 Review of 28 existing Nation Policies regarding injuryReview of 28 existing Nation Policies regarding injury Many provide a framework for Prevention strategiesMany provide a framework for Prevention strategies NO Violence Prevention policy was found in Asia, Africa, Eastern Europe or Middle EastNO Violence Prevention policy was found in Asia, Africa, Eastern Europe or Middle East

Examples of National Goals Examples of National Goals “An injury free Sri Lanka”. Integrating injury prevention into everyday life “An injury free Sri Lanka”. Integrating injury prevention into everyday life Brazil: Contribute to the quality of life of people; reduce morbimortality Brazil: Contribute to the quality of life of people; reduce morbimortality

How to Develop National Policy? Tunisia: National strategy for Emergency Medical Services Tunisia: National strategy for Emergency Medical Services Medical practitioners working groupMedical practitioners working group Presentation to policymakersPresentation to policymakers Lessons learned Lessons learned The 5 E’s The 5 E’s EducationEducation EnforcementEnforcement EngineeringEngineering EmergencyEmergency EvaluationEvaluation

Key Steps for Policy Situation analysis of epidemiology; geared towards solutions Situation analysis of epidemiology; geared towards solutions Identify a lead agency Identify a lead agency Prepare a strategy and plan of action Prepare a strategy and plan of action Raise awareness Raise awareness Create task forces amongst the key stakeholders and community Create task forces amongst the key stakeholders and community Seek LONG-TERM commitments Seek LONG-TERM commitments Allocation of personnel and $$$$$ Allocation of personnel and $$$$$

Who are the Leaders? Ministries of Health Health Catalyst Catalyst Facilitator Facilitator Advocate Advocate Coordination Coordination Supportive Supportive Ministries of Transport, Justice, Education, Sport, Housing, Interior

Choosing Interventions Evidence Evidence Cost effectiveness Cost effectiveness Acceptability Acceptability Feasibility Feasibility Time frame Time frame Measurability Measurability

International agreements can help societies demand change

UCSF/Mulago Research