اپیدمیولوژی آسیب ها و سوانح

اپیدمیولوژی آسیب ها و سوانح
Mojtaba Sehat MD , Epidemiologist

خلاصه مباحث این جلسه تعاریف اصول کلی و تاریخچه
اپیدمیولوژی توصیفی آسیب ها مدل اپیدمیولوژیک، ماتریس هادون و مدل اکولوژیک نقش سلامت عمومی در پیشگیری و کنترل آسیب ها نظام مراقبت آسیب ها سیستم های کدگذاری آسیب ها برنامه های پیشگیری از آسیب معرفی منابع مفید

چرا سوانح و حوادث هنوز مشکل جامعه بشری است؟
سوانح و حوادثی که به صورت معمول اطرافتان می بینید و یا بعضا درگیر آن می شوید آیا یک واقعیت قابل پیش بینی هستند؟ قابل پیشگیری هستند؟ وضعیت سوانح و حوادث ایران چگونه است؟ حادثه با آسیب تفاوت دارند؟ به نظر شماعوامل موثر بر سوانح و حوادث در ایران چیست؟

آسیب در اثر انتقال انرژی بیش از یک حد آستانه تحمل به وجود می آید.
آسیب (injury) آسیب در اثر انتقال انرژی بیش از یک حد آستانه تحمل به وجود می آید.

تعریف آسیب مواجهه حاد با عوامل فیزیکی مانند انرژی مکانیکی، گرمایی، الکتریکی، شیمیائی و اشعه یونیزان به میزانی بیش از حد تحمل بدن انسان. در برخی از موارد آسیب ها به علت فقدان ناگهانی مواد ضروری مانند اکسیژن یا حرارت اتفاق می افتند. (Source: Gibson, 1961; Haddon, 1963)

تعریف خشونت (violence)
استفاده عمدی از نیرو یا توان فیزیکی (به صورت واقعی یا تهدید به استفاده) علیه خود یا فرد دیگر یا علیه یک گروه یا جامعه که منجر به آسیب، مرگ، اختلال روانی، اختلال رشد یا محرومیت شود (یا احتمال وقوع این موارد وجود داشته باشد) (Source: WHO 1996)

Exposure Event injury disability death
اصول کلی آسيب ها قابل پیشگیری و قابل پیش بینی اند آسیب با حادثه مترادف نیست عمدی یا غیر عمدی ایمنی عینی با ایمنی ذهنی متفاوت است. پیشگیری از آسیب (injury prevention)، کنترل آسیب (injury control) طیف مصدومیت؟ Injury, Event, ,Death , Exposure , disability Exposure Event injury disability death

تاریخچه اولین رویکرد های علمی به مسئله آسیب ها قرن 20، مطالعات منظم تر
قرن 19، آسیب های مربوط به اسب ها قرن 20، مطالعات منظم تر de Haven, Gordon, Gibson, Haddon, Abad

اپیدمیولوژی آسیب ها در جهان
روزانه مورد مرگ 9% كل مرگها و 12% بار بيماري ها در دنيا بيش از 90% اين مرگ ها : در كشورهاي با درامد كم و متوسط سالهاي از دست رفته بر اثر مرگ زودرس يا ناتواني (DALYs): 180 ميليون سال ِDALYs در آسيب هاي ترافيكي: 38 ميليون سال هزينه هاي اقتصادي ناشي از حوادث ترافيكي: 518 ميليارد دلار در سال 1 درصد توليد ناخالص ملي (GNP) در كشورهاي كم درآمد، 5/1 درصد با درآمد متوسط و 2 درصد در پردرآمدها به علت حوادث ترافيكي به هدر مي رود

بیش از 5 میلیون مورد مرگ در سال

Population, road traffic death, and registered motorized vehicles, by income group

Trends in road traffic fatality rates in selected high-income countries

by WHO region and income group
Modelled road traffic injury fatality rates (per population), by WHO region and income group ؟ ؟ ؟

Over 1.2 million people die each year on the world’s roads, and between 20 and 50 million suffer non-fatal injuries. Low-income and middle-income countries have higher road traffic fatality rates (21.5 and 19.5 per population, respectively) than high-income countries (10.3 per ). Over 90% of the world’s fatalities on the roads occur in low-income and middle-income countries, which have only 48% of the world’s registered vehicles.

Unsafe public transportation

بيش از 90% مرگ هاي ناشي از آسيب هاي ترافيكي در كشورهاي با درامد كم و متوسط اتفاق مي افتد

اپیدمیولوژی آسیب ها در ايران
علت اول مرگ و مير در سنين زير 50 سال سالانه بيش از50000 مورد مرگ ناشي از انواع آسیب ها 21000 مورد مرگ بر اثر حوادث ترافيكي در سال 1390 4000 ميلياردتومان هزينه اقتصادي تحميل شده به جامعه بر اثر حوادث ترافيكي در سال با ۰.۱۳ درصد از کل خودروهای جهان و ۱.۱ درصد جمعیت جهان ۱.۹ درصد مرگ های ترافیکی دنیا را داراست.

ایران در ایران بروز مرگ ناشی از تروما5 تا 49 در صدهزار نفر گزارش شده است. در تهران 27در صدهزار(40 درصدهزار در مردان و 12 درصدهزار در زنان) پزشکی قانونی تهران مرگ از ترومای ترافیکی را 15/8در صد هزار گزارش نموده است. 14.9% موارد مرگ در ایران و 26.9 درصد از سالهای ازدست رفته عمر بعلت تروما می باشد. فراوانی مرگ ناشی از سوانح ترافیکی در ایران با 30 در صد هزار نفر بالاترین میزان در جهان می باشد. عدم وجود مطالعه مبتنی بر جامعه و عدم بررسی تاثیر متغیرهای اقتصادی اجتماعی بر تروما

مقایسه میزان بروز ترومای ترافیکی در گروه های سنی مختلف بر حسب جنس

چرا در ایران تروما و خصوصا ترومای ترافیکی اولین علت مرگ جوانان است؟

رویکرد مقابله با بروز اسیب ها
رویکرد سنتی مسئول اصلی تک تک افراد هستند و کانون تمرکز خطاهای انسانی است تمرکز بر حادثه است و آسیب نقش کمرنگ تری دارد برای رفع خطاهای انسانی تمرکز بر آموزش و مهارت و قانون است کمتر بر اصلاح محیط انرژي و مدیریت ان کمتر مورد توجه است رویکرد سیستمیک حادثه و آسیب از تعامل انسان با شرایط تکنیکی و اجتماعی و اکولوژی ایجاد می شود برای پیشگیری از آسیب باید انرژی و تعامل ان با محیط و شخص را باید مدیریت نمود هادون ماتریس

Epidemiological approach
Epidemiological approach Host Agent Environment Lucie Laflamme 27 Lucie Laflamme ♦ Department of Public Health Sciences ♦ 27

Epidemiological approach
Epidemiological approach ??? Injuries happen for several reasons agent host ??? environment Lucie Laflamme ♦ Department of Public Health Sciences ♦

Haddon Matrix

Agent (vehicle or product)
ماتریس هادون Host (person) Agent (vehicle or product) Physical environment Socio-economic environment Pre-event Is the person pre-disposed or overexposed to risk? Is the agent hazardous? Is the environment hazardous? Possibility to reduce hazards? Does the environment encourage or discourage risk-taking and hazard? Event Is the person able to tolerate force or energy transfer? Does the agent provide protection? Does the environment contribute to injury during event? Post-event How severe is the trauma or harm? Does the agent contribute to the trauma? Does the environment add to the trauma after the event? Does the environment contribute to recovery? Injuries result as a culmination of a set of circumstances and pre-existing conditions which can be best understood as a chain of events. One important model to understand the causal chain of events involved in injuries is that proposed by William Haddon, commonly known as the Haddon Matrix. This model extends the epidemiological approach, to produce a matrix where the causal factors involved in injury can be better understood through the interaction of multiple factors over time. It consists of temporal notions of pre-event, event and post-event phases plotted against the host or person, agent (product) and environmental factors (physical and social) of the epidemiological model. When these two axes (time and other factors) are combined they produce the Haddon Matrix. This is generally a twelve-cell matrix although it can be a none-cell matrix if the physical and social environment columns are combined into one. Haddon’s model effectively separates out the factors which predispose an injury causing event to occur (pre-event phase) from the actual event itself (event phase) in which energy is transferred to the host in an amount to cause damage. Haddon also added a post-event phase, encompassing transport, emergency care and rehabilitation, which affect survival and ultimate outcome once the energy transfer has occurred (17). Combining these phases of injury with the epidemiological model, creates a matrix for the study of both injury causation and prevention. The temporal phases are generally associated with primary (pre-event), secondary (event) and tertiary (post-event) prevention. The value of this model is that it points out different areas in which interventions can be mounted to prevent or reduce the severity of injuries. The point of intervention is not necessarily early in the chain of events. It should be where the intervention is possible, or ideally, where it is most effective.

این اقدامات مربوط به کدام بخش ماتریکس هادون است؟
حذف راکتورهای هسته ای کاهش سرعت خودروها در مناطق مسکونی کاهش دمای اب جوش در مصارف خانگی استفاده از داربست د رمعادن ترمز ABS پل زیر گذر یا عابر پیاده فاصله زمانی بین پرواز و نشستن هواپیماها گاردریل استفاده از درب دارویی که بچه ها نتوانند باز کنند حضور عملیات کارکنان امداد و نجات متعاقب یک حادثه فیزیوتراپی حل مشکلات روانی بعد از یک سانحه ترافیکی

Levels of health intervention
Camara Phyllis Jones, MD, MPH, PhD

Camara Phyllis Jones, MD, MPH, PhD

Safety net programs and secondary prevention
Primary prevention Safety net programs and secondary prevention Medical care and tertiary prevention Camara Phyllis Jones, MD, MPH, PhD

social determinants of health Primary prevention
Addressing the social determinants of health Primary prevention Safety net programs and secondary prevention Medical care and tertiary prevention Camara Phyllis Jones, MD, MPH, PhD

Differences in exposures and opportunities
Differences in access to care Differences in quality of care (ambulance slow or goes the wrong way) Camara Phyllis Jones, MD, MPH, PhD

social determinants of equity: Why are there differences in resources
Addressing the social determinants of equity: Why are there differences in resources along the cliff face? in who is found at different parts of the cliff? Camara Phyllis Jones, MD, MPH, PhD

مدل اکولوژیک Society Community Relationship Individual
There are several ways of understanding injuries. Haddon’s model refers to the transfer of energy and the occurrence of events in time and place. Another model for understanding how injuries occur is known as the ecological model. This model has been particularly useful for understanding the causes of violence and will be explored in greater detail in Core Lesson 11: Introduction to intentional injuries. No single factor explains why some individuals behave violently towards others or why violence is more prevalent in some communities than in others. Violence is the result of the complex interplay of individual, relationship, social, cultural and environmental factors. Understanding how these factors are related to violence is one of the important steps in the public health approach to preventing violence (5). First introduced in the 1970s, the ecological model was initially applied to child abuse, then youth violence and more recently, it been used to understand intimate partner violence and abuse of the elderly. The model explores the relationship between individual and contextual factors and considers violence as the product of multiple levels of influence on behaviour (5). Complex Linkages Source: Krug E et al., eds., 2002.

پیشگیری براساس مدل اکولوژیک
عوامل خطر فردی سن ،‌جنس ، مصرف الکل و مواد مخدر، وضعیت اقتصادی،‌رانندگی با سرعت، عدم استفاده از کمربندی و کلاه ایمنی، اختلالات خواب و خستگی ، تلفن همراه، بیماریهای جسمی و روانی ارتباط های نزدیک (محیط های خانوادگی سالم) مکان های عمومی (ایمنی در مدارس، محل های کار) نابرابری جنسی (باور ها و نگرش های فرهنگی) عوامل اجتماعی، فرهنگی و اقتصادی عمده (فقر، برابری در دسترسی به کالاها، خدمات و فرصت ها) Because violence is a multifaceted problem with biological, psychological, social and environmental roots, it needs to be confronted on several different levels at once. The ecological model serves a dual purpose in this regard; each level in the model represents a level of risk and each level in the model can also be thought of as a key point for intervention. Dealing with violence on a range of levels involves addressing all of the following (5): addressing individual risk factors and taking steps to modify individual risk factors; influencing close personal relationships and working to create healthy family environments, as well as providing professional help and support for dysfunctional families; monitoring public places such as schools, workplaces and neighbourhoods and taking steps to address problems that might lead to violence; addressing gender inequality, and adverse cultural attitudes and practices; addressing the larger cultural, social and economic factors that contribute to violence and taking steps to change them, including measures to close the gap between rich and poor and to ensure equitable access to goods, services and opportunities. This model can also be used to understand the individual behavioural and wider socio-cultural risk factors associated with unintentional injury and to develop appropriate preventive strategies.

The systems approach to road safety

استراتژی های هادون در پیشگیری
Ban Hazardous Vehicles & Designs Reduce Aggregated Energy (Speed) Reduce Road and Vehicle Complexity Reduce Hazardous Environmental Features Incorporate Safety Features (Seatbelts)

استراتژی های هادون Soften Contact Areas (Soften Dash-Boards)
Separate Road User by Type (via Barriers) Strengthen Human Responses (Calcium for Older Users) Efficient Emergency Response Management & Treatment Long Term Rehabilitation

پیشگیری از آسیب انواع پیشگیری از آسیب و خشونت:
بر حسب زمان – مقدماتی، اولیه، ثانویه و ثالثیه برحسب گروه هدف – همگانی، انتخابی، مشخص فعال ( (activeدر برابر غیر فعال (passive) Public health interventions are traditionally characterized in terms of three levels of prevention, which relate back to the temporal dimension of the Haddon Matrix. Primary prevention includes any strategies aimed at stopping injury events from taking place, and thus relates to the time before injuries actually occur (pre-event phase). Secondary prevention includes any strategies aimed at minimizing the harm that occurs during an injury event (e.g. car crash or event phase). Examples include the protection of motor vehicle occupants in crashes (e.g. seat-belts). Tertiary prevention includes all efforts aimed at treating and rehabilitating injured people or in some cases, the perpetrators of violence. It is concerned with the period after an injury event has occurred (post-event phase). Another way of defining prevention activities focuses on the target group of interest. This definition groups interventions on three levels. Universal interventions are aimed at groups or the general population without regard to individual risk (e.g. violence prevention curricula delivered to all students in a school or children of a particular age; community-wide media campaigns; seat-belt laws; drinking and driving laws). Selective interventions are aimed at those considered at heightened risk of injury or violence – that is, have one or more risk factors (e.g. driver education for young or elderly drivers; training in parenting for low-income, single parents). Indicated interventions are aimed at those who have already demonstrated risk behaviours (e.g. interventions to curb alcohol consumption among alcohol abusers and avoid drinking and driving; treatment programmes for perpetrators of domestic violence). Passive versus active interventions Passive interventions are those aimed at preventing injuries where the individual is not required to take any action (e.g. an airbag deploys automatically on impact). They are interventions that are independent of human behaviour. Active interventions are those where an individual’s behaviour is involved (e.g. a seat-belt requires the individual to put the belt on). Such interventions require some human involvement for their success. In the field of unintentional injury prevention there is a strong consensus that passive interventions, aimed at creating a safer environment, are more likely to be successful than active interventions. This emphasis on passive countermeasures parallels the management of other public health problems. For example, the provision of a clean water supply is more successful in preventing disease, than asking people to boil their water before drinking, just as automatic sprinklers constitute a more effective fire protection than reliance on hand held extinguishers (19).

روش های پیشگیری از آسیب مهندسی Engineering
اصلاح محیط Environmental modification برخورد قانونی Enforcement آموزش/ توانمندسازی Education/empowerment There are a number of different strategies that have been proposed for controlling or preventing unintentional injuries. Engineering: includes making products safer for people. Environmental modifications: aimed at reducing the likelihood that individuals will have an injury by reducing risks in the environment. Enforcement: includes legal and police measures aimed at ensuring that certain behaviours and norms are maintained in the population. It also includes adequate rehabilitation of perpetrators who have caused injuries. It covers enforcement of laws directed at creating safe environments. Finally it also covers laws and norms that ensure the production and distribution of safe products. Education: includes programmes aimed at changing attitudes, beliefs and behaviours in the general population but also targeting individuals who are at higher risk of having an injury or producing an injury. Evaluation: refers to those actions aimed at determining which interventions, programmes and policies work best for injury prevention. It informs researchers and policy-makers as to what are the best course of action for prevention and control of injuries. A number of strategies may be employed concurrently or sequentially to achieve a particular objective. While education is a component of most intervention strategies, it is most effective when used to support a design measure or an enforced regulatory measure (e.g. advertising to support speed camera operations or random breath testing).

طبیعت بین بخشی پیشگیری از آسیب
Economics Injury prevention Law Social sciences Health sciences Education Public health Engineering The inter-disciplinary nature of injury studies Different disciplines that have provided major inputs to the field of injuries include the fields of education, engineering, law, health sciences, social sciences and economics. The knowledge derived from these disciplines is applied by various sectors in the development of policy and interventions designed to prevent or control injury.

نقش سلامت عمومی در کنترل آسیب ها
The role of public health While the health sector is only one of many fields involved in road safety – and usually not even the leading one – it nonetheless has important roles to play. These include: discovering, through injury surveillance and surveys, as much as possible about all aspects of road crash injury – by systematically collecting data on the magnitude, scope, characteristics and consequences of road traffic crashes; researching the causes of traffic crashes and injuries, and in doing so trying to determine: causes and correlates of road crash injury, factors that increase or decrease risk, factors that might be modifiable through interventions; exploring ways to prevent and reduce the severity of injuries in road crashes – by designing, implementing, monitoring and evaluating appropriate interventions; helping to implement, across a range of settings, interventions that appear promising, especially in the area of human behavior, disseminating information on the outcomes, and evaluating the cost-effectiveness of these programs; working to persuade policy-makers and decision-makers of the necessity to address injuries in general as a major issue, and of the importance of adopting improved approaches to road traffic safety; translating effective science-based information into policies and practices that protect pedestrians, cyclists and the occupants of vehicles; Promote capacity building in all areas of road safety and the management of survivors of road traffic crashes Include road safety in health promotion and disease prevention activities. Set goals for the elimination of unacceptable health losses arising from road traffic crashes. Strengthen pre-hospital and hospital care as well as rehabilitation services for all trauma victims. Develop trauma care skills of medical personnel at the primary, district and tertiary health care levels. Campaign for greater attention to road safety, based on the known health impact and costs. (Peden et al. 2004)

مشخصات رویکرد سلامت عمومی به مشکل آسیب ها
مبتنی بر جمعیت است چند بخشی است مبتنی بر شواهد است بر اقدام مشترک و جمعی تاکید دارد تمرکز بر پیشگیری است Defining characteristics of the public health approach (5). It is population-based. By definition, public health is not about individual patients but rather is concerned to prevent health problems and extend better care and safety to whole populations. It is multidisciplinary. It draws on knowledge from many disciplines including medicine, epidemiology, engineering, sociology, psychology, criminology, education and economics. It is evidence-based. The public health approach is based on the scientific method. It emphasizes collective action. It has been proved over and over again that cooperative efforts from such diverse sectors as health, education, social services, justice and policy are necessary to solve what are often assumed to be purely “medical” problems. It emphasizes prevention. Above all, public health is characterized by its emphasis on prevention. Rather than simply accepting that injuries happen, its starting point is that injury events and violent behaviour, and their consequences, can be prevented.

evaluate interventions
رویکرد سلامت عمومی (1) Surveillance What is the problem? (2) Risk factor identification What are the causes? The public health approach to injury and violence prevention is based on the rigorous requirements of the scientific method. In moving from problem to solution, there are four key steps (5). Uncovering as much basic knowledge as possible on all aspects of injury or violence. Through systematically collecting data on the magnitude, scope, characteristics and consequences of injury and/or violence at the local national and international levels. This involves the collection of data, or the gathering of information, through the use of surveillance, surveys or other techniques. Investigating why injuries and violence occur: the causes and correlates of injuries and violence; the factors that increase or decrease the risk of injury or violence; the factors that might be modifiable though interventions. Through the information-gathering process, and through epidemiological research, multiple risk and protective factors can be identified and associated with specific injury outcomes. Exploring ways to prevent injury and violence, using the information derived in the research process by designing, implementing, monitoring and evaluating interventions. The modification of risk factors is a crucial element that determines the design of interventions aimed at reducing injuries. Once the identification of effective preventive measures has occurred, these measures should be implemented through policy measures. These interventions should always be evaluated. Implementing, in a range of settings, interventions that appear promising, widely disseminating information and determining the cost-effectiveness of programmes. The implementation of these measures should change the nature of the problem which, when re-assessed, leads to a re-evaluation of the situation and so on. (4) Implementation How is it done? (3) Develop and evaluate interventions What works?

نظام مراقبت آسیب ها اساس پیشگیری و کنترل آسیب است

نقش نظام مراقبت آسیب ها (What is the intended Public Health Action?)
مشکل تشریح و ارزیابی شود اولویت ها مشخص شود منابع تخصیص یابد فرضیات تست شود برنامه های مداخله ای طراحی و اجرا شود استراتژیهای مختلف مانیتور و ارزشیابی شود A surveillance program can be designed to produce a variety of output data depending on the program. Data from an injury surveillance system can be used to evaluate the extent of the injury problem in a given population where the information can be used by decision makers for allocation of resources and setting priorities for interventions. Surveillance can also be used to confirm a hypothesis or indicate the need for further study and/or additional data. Analysis of surveillance data can lead to the development and/or institution of an intervention, development of policies, implementation of program and monitoring of the results and assessing the impact of intervention strategies. Injury surveillance can also be used to generate research hypotheses and to identify and recruit cases for epidemiological research, such as cohort studies or case-control studies. The value of injury surveillance data is further enhanced where the data is collected for a whole population, enabling the expression of the data as rates per 100,000 population. Rate data facilitates reliable comparisons over time or between geographic areas.

شروع کنید و یک نظام مراقبت طراحی کنید
در سوانح و حوادث کشور نظام مراقبت داریم؟ شما اگر قرار باشد نظام مراقبت سوانح را طراحی کنید از کجا اطلاعات می گیرید؟ چه اطلاعاتی لازم دارید؟ چقدر آسیب دیدن برای شما اهمیت دارد؟

هرم (کوه یخ) آسیب ها Deaths Injuries resulting in hospitalization
Injuries resulting in ambulatory and emergency treatment Injuries resulting in treatment in Primary care settings Injuries treated by paramedics only (school nurse, physiotherapist, first aid) Untreated injuries or injuries which were not reported The injury experience of a population is often presented as a pyramid based on the level of medical treatment, which is a broad surrogate for injury severity (20). The apex represents the relatively small number of fatal injury cases, and the broader, lower parts of the pyramid represent the more numerous injuries of lesser severity. In descending order of severity, but increasing level of magnitude, one can identify injuries that require hospitalization, ambulatory treatment, injuries that are not emergencies, mild forms of injuries treated by paramedics and the most common which are injuries that are go unreported. Two points need to be emphasized. First, the availability of injury data is in direct proportion to case severity and in inverse proportion to case frequency. In countries with well-developed vital statistics systems, quite a lot is known about the relatively small number of injury deaths, less about hospital inpatient cases, and still less about cases requiring less medical treatment. While the priorities implied by this hierarchy of information availability may be correct, the importance, in human and economic terms, of ‘less severe’ injuries should not be under-rated. Second, constructing the pyramid highlights the crudeness of injury case categorization used. For want of more direct measures, hospital admission or attendance at a hospital emergency department tends to be used as a proxy for case severity. This is done despite the fact that: clinical criteria for admission may vary considerably; economic and other factors may determine which cases go to which service and these factors vary with time and place; level of medical treatment is often dependent on the services available. Improving the ability to measure injury severity (particularly injury that is not life-threatening), rigorously and practicably is a challenge for injury researchers and important for international comparability of injury data (21).

منابع بالقوه داده ها کجا می توانند باشند؟
There are many potential sources of data that are useful for injury prevention purposes. Some of the more commonly used sources of data for injuries are; Health clinic records, Family doctors’ records, Emergency Room records, ward admission, Intensive care unit (ICU) admission records and death certificates. Based on the level of severity of the injury, different sources of data can be used. Each potential source of data has its own set of advantages and disadvantages. For instance, whereas one particular data source may provide relatively complete information, this information may be less reliable than that obtained from other sources. Some data sources are likely to be more representative of the injured population than others. Even in places where data from the sources listed above exist, often data is not used as the basis for making decisions towards public health action. Specialized injury data collections, such as police reported road traffic injury data and workers’ compensation data, are fundamentally important to injury prevention in their respective sectors in many countries.

شما آسیب ها را چگونه طبقه بندی می کنید؟
نوع آسیب (شکستگی، سوختگی و غیره) شدت آسیب محل وقوع (منزل، مدرسه، محل کار، جاده و غیره) نوع فعالیت (ورزش، تفریح، کار و غیره) مکانیسم عمدی یا غیر عمدی There is no single comprehensive and mutually exclusive method for injury categorization. All classifications have merit, and often a combination is chosen. Some categorizations which have been used include: severity (level of medical treatment required) setting (e.g. home, school, workplace, road) activity (e.g. sport, recreation, work) mechanism (e.g. fall, burn, dog bite, motor vehicle crash, drowning) intent (intentional, unintentional) nature of injury (e.g. fracture, burn). Other categorisations are based on the demographics of injury victims and may include: age (child, adolescent, elderly) gender socioeconomic status ethnicity or aboriginality.

سیستم های طبقه بندی آسیب ها
International Classification of Disease (ICD): Most common classification worldwide Provides separate codes for nature of injury and mechanism (external cause) Other classification systems: Occupational Injury and Illness Classification System (OIICS) Nordic Medico-Statistical Committee (NOMESCO) The International Classification of External Causes of Injury (ICECI) The Abbreviated Injury Severity Scale (AIS) A disease classification system is a system of categories to which diseases and causes of death are assigned according to established criteria. It is used to organize information so as to permit easy storage, retrieval and analysis of data. According to Fingerhut & McLoughlin (22), an injury classification system should allow for the capture of information about the nature of injury, the body region affected, the external cause (mechanism), intentionality, and circumstances such as location, activities and products involved. Most countries in the world use a version of the International Classification of Disease (ICD), developed by WHO, for coding deaths and morbid conditions. It includes a code for classifying the nature of injury and another for the external cause of injury. External cause of injury codes (E-codes) in the ICD capture the circumstances of injury along two dimensions: intent (unintentional, self-inflicted, assault, legal intervention, undetermined) mechanism (e.g. fall, drowning, gunshot, fire, motor vehicle collision). Intent takes precedence over mechanism in the structure of the ICD in that the coder must first determine the intent (e.g. self-inflicted) before assigning the mechanism (e.g. fall/jump) (22). Other injury classification systems include the: Occupational Injury and Illness Classification System (OIICS) Used in the United States by the Bureau of Labour Statistics for classify information relating to occupational injury and illness. NOMESCO Used in some European countries, the NOMESCO (Nordic Medico-Statistical Committee) classification was developed to collect information on events resulting in injury treated in hospital emergency departments. The International Classification of External Causes of Injury (ICECI) The ICECI is being developed under the auspices of WHO by an international working group to remedy some of the shortcomings of the ICD for injury prevention. The Abbreviated Injury Severity Scale (AIS) Developed by the Association for the Advancement of Automotive Medicine (AAAM), the American Medical Association (AMA) and the Society of Engineers (SAE), to catalogue the anatomic injuries sustained in motor-vehicle crashes, the primary role of the AIS was to supplement crash investigations with detailed anatomical descriptions of occupant injury. The AIS90 incorporates a unique six-digit description code in addition to an AIS severity score (23).

ICD Codes Diagnostic codes (N-Codes) E-Codes
- Record the clinical nature of the injury and the area of the body injured. E-Codes Record the external cause of the injury Often missing in the medical record Most injuries are identified at the point when an individual comes into contact with the health care system. Injuries are usually defined in medical records by one of the most widely used classification systems in the world; the International Classificat ion of Diseases (ICD) system and codes. Two types of ICD codes are of most interest; N-codes (nature of injury codes) which identify the anatomy involved in the injury, and E-codes (external cause of injury codes) which identify the events leading to the injury. One major issue of concern for injuries, is that monitoring systems based upon medical records do not always provide details of the cause for the injury (E-codes). Other types of classification schemes exist for injuries as well. These include systems to classify the severity of injury; such as the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS). Also, there is a rubric recently adopted to class ify the intent underlying the injury; i.e was it intentional or unintentional.

Anatomic scores Abbreviated Injury Scale (AIS)
AIS originally developed for impact injury assessment Revisions: AIS 76, AIS 80, AIS 85, AIS 90, AIS 98 Classifies individual injuries by body region on a 6-point scale ranging from AIS 1 (minor injury) to AIS 6 (non-survivable) The score represents the 'threat to life' associated with an injury and is not meant to represent a comprehensive measure of severity AIS 98 scores are based on ICD9 nature of injury (diagnosis) codes.

Anatomic scores Type of anatomic structure = whole area, vessels, nerves, organs, skeletal, head Specific anatomic structure = nature of the injury (10=amputation) Level = level of injury within the specific body regions and anatomic structure (e.g. 02 closed fracture) . Body region Type of anatomic structure Specific anatomic structure Level AIS  1 Abdomen Liver Contusion or laceration Sbucapsular Moderate 5 4 8 2 The AIS code describes: 1. the body region that is injured 2. the type of anatomic structure that has been injured 3. the nature of the injury 4. the level within the structure that the injury occurred 5. the AIS which is a scale from 1 to 6 that rates the overall severity of the injury (1=minor, 6=unsurvivable) AIS coding is based on a coding manual and a short AIS training course should be undertaken to gain the required skills for coding.

Anatomic scores Injury Severity Score (ISS)
Foundation for ISS is the AIS Summary score for multiple traumatic injuries Takes values from 1 to 75 ISS is calculated by summing the squares of the 3 highest AIS scores for injuries to different body regions If an injury is assigned an AIS of 6 (non- survivable injury), the ISS score is automatically assigned to 75 Limitations of the ISS include the lack of scores for non-anatomic injuries e.g. asphyxiation, and under-estimation of the combined severity of injuries when multiple injuries are localized to one or two body regions.

Example of ISS calculation
Anatomic scores Example of ISS calculation Region Injury Description AIS Square Top Three Head & Neck Cerebral contusion 3 9 Face No injury Chest Flail chest 4 16 Abdomen Minor contusion of liver; Complex rupture spleen 2 5 25 Extremity Fractured femur External Injury Severity Score: 50 An ISS of 16 is generally taken to be the cut-off point for major trauma. ISS=16 is one of the entry criteria for trauma registries. ISS is most frequently used summary measure of severity of anatomic injuries and in large studies has been shown to correlate with survival rate.

نظام مراقبت با سیستم گزاش دهی مناسب را طراحی نمودید ، از کم و کیف سوانح اطلاع یافته اید . اکنون اقدام بعدی شما چیست؟

evaluate interventions
رویکرد سلامت عمومی (1) Surveillance What is the problem? (2) Risk factor identification What are the causes? The public health approach to injury and violence prevention is based on the rigorous requirements of the scientific method. In moving from problem to solution, there are four key steps (5). Uncovering as much basic knowledge as possible on all aspects of injury or violence. Through systematically collecting data on the magnitude, scope, characteristics and consequences of injury and/or violence at the local national and international levels. This involves the collection of data, or the gathering of information, through the use of surveillance, surveys or other techniques. Investigating why injuries and violence occur: the causes and correlates of injuries and violence; the factors that increase or decrease the risk of injury or violence; the factors that might be modifiable though interventions. Through the information-gathering process, and through epidemiological research, multiple risk and protective factors can be identified and associated with specific injury outcomes. Exploring ways to prevent injury and violence, using the information derived in the research process by designing, implementing, monitoring and evaluating interventions. The modification of risk factors is a crucial element that determines the design of interventions aimed at reducing injuries. Once the identification of effective preventive measures has occurred, these measures should be implemented through policy measures. These interventions should always be evaluated. Implementing, in a range of settings, interventions that appear promising, widely disseminating information and determining the cost-effectiveness of programmes. The implementation of these measures should change the nature of the problem which, when re-assessed, leads to a re-evaluation of the situation and so on. (4) Implementation How is it done? (3) Develop and evaluate interventions What works?

Development and effective enforcement of legislation is critical in :
Traffic laws Reducing drink driving Excessive speed Increasing use of helmets Increasing use of seat belts Increasing use of child restraints

اپیدمیولوژی آسیب ها در ایران

سازمان ها و برنامه های کنترل آسیب مربوط به حوزه سلامت
کمیسیون ایمنی راه ها مرکز مدیریت بیماری ها – جامعه ایمن دبیرخانه تحقیقات کاربردی – شبکه آن لاین حوادث

The 'WHO Safe Communities' model for the prevention of injury in whole populations (Cochrane Review)
Background: The safe communities approach has been embraced around the world as a model for coordinating community efforts to enhance safety and reduce injury. Over 80 communities throughout the world have been formally designated as 'Safe Communities' by the World Health Organization. It is of public health interest to determine to what degree the model is successful, and whether its application does indeed reduce injury rates in communities to which it is introduced.

Objectives: To determine the effectiveness of the Safe Communities model to prevent injury in whole populations, or targeted sub-groups of populations. Search strategy: The search strategy was based on electronic searches, handsearches of selected journals, snowballing from reference lists of selected publications and contacting a key person from each WHO-designated Safe Community. Selection criteria: Studies were independently screened for inclusion by two reviewers. Included studies were those conducted within a WHO Safe Community that reported changes in population injury rates within the community compared to a control community.

Data collection and analysis: Data were independently extracted by two reviewers. Meta-analysis was not appropriate, due to the heterogeneity of the included studies. Main results: Only seven WHO Safe Communities, of more than 80 worldwide, have undertaken controlled evaluations using objective sources of injury data. These communities represent only four countries from two geographical regions in the world: the Scandinavian countries of Sweden and Norway and the Pacific nations of Australia and New Zealand. Safe Communities in Sweden and Norway have resulted in significant reductions in injury rates. The Australian and New Zealand communities have been unable to replicate the same level of success.

Authors' conclusions: Evidence suggests the WHO Safe Communities model is effective in reducing injuries in whole populations. However, important methodological limitations exist in all studies from which evidence can be obtained. A lack of reported detail makes it unclear which factors facilitate or hinder a programme's success, and makes uncertain, whether the success of any particular application of the model is necessarily replicable in other communities. In evaluated programmes that did not report significant decreases in injury rates, this lack of information makes it difficult to distinguish between evidence of no effect of the model, or no evidence of effect. The four countries that have evaluated their Safe Communities with a sufficiently rigorous study design have higher economic wealth and health standards and lower injury rates than much of the world.

No evaluations were available from other parts of the world, despite the designation of WHO Safe Communities in countries such as South Africa, Bangladesh, China, Vietnam, Canada, UK and USA. Generalisation of results of studies conducted in just four countries, to the international population needs to be done with caution. There is a need for more high-quality, methodologically strong evaluations of the model in a range of diverse communities and detailed reporting of implementation processes. Citation: Spinks A, Turner C, Nixon J, McClure R. The 'WHO Safe Communities' model for the prevention of injury in whole populations. The Cochrane Database of Systematic Reviews 2005, Issue 2.

Safe Communities Designations under preparation
Arsanjan………….. Iran Bardscan…………. Iran Kashmar………….. Iran

16th International Conference on Safe Communities June, 2007 Tehran, Iran Theme: Road Safety Pledge with National Resolution

Traffic injuries are Preventable
Seat belts : > lives saved/year (US) Speed : for 1 km/hr less, 2-3% less fatal collisions Reflectorization : 50% reduction night-time pedestrian collisions White helmets: 45% reduction in conspicuity- related bike injuries Alcohol: Designated driver, law enforcement Road design: traffic calming measures, over- bridges, etc

Death rates have been declinig over the last four to five decades in many high-income countries. Even in these countries, road traffic injuries remain an important cause of death ,injury and disability.

Violence is Preventable
Pre-school enrichment programmes Home visitation and parent training Incentives for high risk youth to complete schooling Reducing alcohol availability Reducing income inequality Strengthening police and criminal justice

با تشکر از توجه شما سئوال؟؟؟

اپیدمیولوژی آسیب ها و سوانح

Similar presentations

Presentation on theme: "اپیدمیولوژی آسیب ها و سوانح"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

اپیدمیولوژی آسیب ها و سوانح

Similar presentations

Presentation on theme: "اپیدمیولوژی آسیب ها و سوانح"— Presentation transcript:

Similar presentations

About project

Feedback