1. Prevention of death and disability from injuries to children Frederick P. Rivara, MD, MPH The Harborview Injury Prevention and Research Center University of Washington Seattle, USA

2. 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?

3. 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

4. Number of deaths to children <5 years: 1970-2010 Rajaratnam et al, Lancet 2010

5. Van Cleave, J. et al. JAMA 2010;303:623-630. Prevalence of Any Chronic Condition and Subgroups of Conditions in children, 1988-2006 1988-941994-20002000-06

6. Proportion of children 8-18 years with one or more chronic conditions, 2003 Berra et al, Medical Care 2009

7. Pediatric Obesity in the US

8. Rates of overweight and obesity at 2-4 years of age MALEFEMALE Spain Greece Poland England Scotland Italy Netherlands Romania Czech Cyprus `

9. Kelishadi, R. Epidemiol Rev 2007 Prevalence of overweight/obesity in boys and girls aged 6-18 years in LMIC

10. Five themes Epidemiologic transition Injury control not just prevention Evolution of the idea of adolescence Improving the quality of research Change priority setting

11. 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

12. \ U.S. death rates for infectious diseases and injuries, ages 1-19 Injuries

13. Mortality after pediatric trauma admission in North America NTDB Pediatric Annual Report, 2009

14. 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

15. Epidemiologic transition in LMIC

16. Epidemiologic transition in LMIC: Drowning deaths in 1-4 year olds in Matlab, Bangladesh 1983-2000

17. Causes of death for children 5-9 years, Bangladesh

18. Causes of death for children 15- 17 years, Bangladesh

19. 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 12 th leading cause of DALYS by 2020

20. Five themes Epidemiologic transition Injury control not just prevention Evolution of the idea of adolescence Improving the quality of research Change priority setting

21. Injury Control Prevention Acute Care Rehabilitation

22. 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

23. 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

24. 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

25. --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

26. Effect of surgical checklist in Toronto, New Delhi, Amman, Auckland, Manila, Ifakara, London, Seattle Haynes et al, NEJM 2009

27. Disability vs. death after trauma GBD, 2000

28. Incidence of injury mortality and morbidity to children * *Based on 5% disability Rahman; Koepsell; Davydow

29. Rehabilitation Children account for one-third of the worlds disabled population Injuries from war and accidents are the 2 nd 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

30. Priorities for Comparative Effectiveness Research in US Institute of Medicine, 2009

31. Five themes Epidemiologic transition Injury control not just prevention Evolution of the idea of adolescence Improving the quality of research Change priority setting

32. Adolescence Ages 10-19 years One-sixth of the worlds population; 90% in LMIC Concept of adolescence did not exist prior to 20 th century Views have shifted over time and place: Members of family economic assets valued members of society with future contributions

33. Injuries to adolescents

34. Deaths per 100,000 from injuries MaleFemaleMale FemaleMale Female 10- 15- 20- 10- 15- 20- 10- 15- 20- Patton et al, 2009

35. Risk of injury among in-school adolescents 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

36. Five themes Epidemiologic transition Injury control not just prevention Evolution of the idea of adolescence Improving the quality of research Change priority setting

37. 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 ???

38. 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

39. Case Fatality Rate per Facility for Level I Facilities NTDB Annual Report, 2009

40. 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

41. 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

42. 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

43. Five themes Epidemiologic transition Injury control not just prevention Evolution of the idea of adolescence Improving the quality of research Change priority setting

44. 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

45. Resources for injury control are woefully inadequate YLLDALYs WHO reg. $ WHO extra $ Communicable disease & maternal, perinatal and nutritional conditions 54%41%68%91% Non-communicable dis.33%47%31%8% Injuries13%12%<1% Lopez, The Lancet Nov 2008

46. 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

47. Criteria for setting priorities among different research options

48. 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 individuals opinion Focus has been on injury prevention and not on injury control

49. 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, 2 nd edition

50. In sum: Epidemiologic transition Injury control not just prevention Evolution of the idea of adolescence Improving the quality of research Change priority setting

51. 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)