Prevention of death and disability from injuries to children Frederick P. Rivara, MD, MPH The...

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




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



• Evolution of the idea of adolescence• Improving the quality of research


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




• 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






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:






“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)

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