prévention

World report on child

injury preventio

n

World report on child injury prevention

IMPLEMENTING PROVEN CHILD INJURY

prevention interventions could save more

than a thousand children’s lives a day.

— Dr Margaret Chan,

Director-General, WHO

and Mrs Ann Veneman,

Executive Director, UNICEF

IMPLEMENTING PROVEN CHILD INJURY

prevention interventions could save more

than a thousand children’s lives a day.

— Dr Margaret Chan,

Director-General, WHO

and Mrs Ann Veneman,

Executive Director, UNICEF

ISBN 978 92 4 156357 4

spine 1.62

World report on

child injury prevention

Edited by

Margie Peden, Kayode Oyegbite,

Joan Ozanne-Smith, Adnan A Hyder,

Christine Branche, AKM Fazlur Rahman,

Frederick Rivara and Kidist Bartolomeos

WHO Library Cataloguing-in-Publication Data:

World report on child injury prevention/ edited by Margie Peden … [et al]. 1.Wounds and injures - prevention and control. 2.Accident prevention. 3.Child welfare. I.World Health Organization.

ISBN 978 92 4 156357 4 (NLM classifi cation: WA 250)

© World Health Organization 2008

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Th e designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization or UNICEF concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

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All reasonable precautions have been taken by the World Health Organization or UNICEF to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. Th e responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or UNICEF be liable for damages arising from its use.

Cover design by INIS.Graphics by minimum graphics and L’IV Com Sàrl.Printed in Switzerland.

WORLD REPORT ON CHILD INJURY PREVENTION III

CONTENTS

Foreword vii Contributors ix Acknowledgements xiii Introduction xv

Chapter 1. Child injuries in context 1

Background 1 What is an injury? 1 Who is a child? 1 Why is child injury important? 1 How does child injury relate to other child health concerns? 2 Children’s injuries and the changing world 3 Th e characteristics of child injury 5 Th e child-injury pyramid 5 Fatal child injuries 5 Non-fatal child injuries 7 Child injury and age 8 Child injury and gender 9 Child injury and socioeconomic factors 9 Th e preventability of child injury 12 Th e principles of injury prevention 12 Learning from places with good safety records 16 Which approaches work? 16 Universal and targeted interventions 18 Cost and cost-eff ectiveness 20 Overcoming the obstacles 20 Conclusion 22 References 22

Chapter 2. Road traffi c injuries 31

Introduction 31 Epidemiology of road traffi c injuries 31 Mortality 31 Morbidity 33 Types of road user 34 Economic impact of road traffi c injuries 36 Limitations of data 36 Risk factors 36 Child-related factors 36 Vehicle-related factors 41 Environmental factors 41 Lack of prompt treatment 41 Interventions 42 Engineering measures 42 Vehicle design 43 Safety equipment 43

Contents

IV WORLD REPORT ON CHILD INJURY PREVENTION

Legislation and standards 46 Developing education and skills 47 Emergency and trauma care 48 Potentially harmful interventions 49 Evaluating interventions 49 Conclusion and recommendations 49 Recommendations 49 References 51

Chapter 3. Drowning 59

Introduction 59 Epidemiology of drowning 59 Mortality 59 Morbidity 62 Economic impact of drowning 62 Limitations of data 63 Risk factors 63 Child-related factors 63 Agent factors 65 Environmental factors 66 Access to treatment and rehabilitation 66 Interventions 66 Engineering measures 67 Environmental measures 67 Legislation and standards 68 Developing education and skills 69 Managing drowning 71 Adapting interventions 72 Further research on interventions 72 Conclusions and recommendations 72 Recommendations 72 References 73

Chapter 4. Burns 79

Introduction 79 Epidemiology of burns 80 Mortality 80 Morbidity 81 Limitations of data 84 Risk factors 84 Child-related factors 85 Agent factors 86 Environmental factors 86 Protective factors 86 Interventions 87 Engineering measures 87 Environmental measures 88 Laws and regulations 88 Educational approaches 89 Combined strategies 89 Managing burns 90 Adapting interventions 93 Evaluating interventions 93

WORLD REPORT ON CHILD INJURY PREVENTION V

Conclusions and recommendations 93 Recommendations 93 References 94

Chapter 5. Falls 101

Introduction 101 Epidemiology of falls 101 Mortality 102 Morbidity 102 Cost of fall-related injury 105 Limitations of data 106 Risk factors 106 Child-related factors 106 Agent factors 107 Environmental factors 109 Lack of treatment and rehabilitation 110 Interventions 110 Engineering measures 110 Environmental measures 110 Laws and regulations 111 Educational approaches 111 Combining strategies 112 Adapting interventions 113 Involving a range of sectors 114 Conclusions and recommendations 114 Recommendations 114 References 115 Chapter 6. Poisonings 123

Introduction 123 Epidemiology of poisoning 123 Mortality 123 Morbidity 125 Types of poison 125 Cost of poisoning-related injury 127 Limitations of data 127 Risk factors 129 Child-related factors 129 Agent factors 130 Environmental factors 131 Lack of prompt treatment 132 Interventions 132 Engineering measures 132 Environmental measures 134 Laws and regulations 134 Educational approaches 135 Managing poisoning 135 Involving a range of sectors 137 Evaluating interventions 137 Conclusions and recommendations 137 Recommendations 138 References 138

VI WORLD REPORT ON CHILD INJURY PREVENTION

Chapter 7. Conclusions and recommendations 145

Introduction 145 Main messages from the report 145 Child injuries are a major public health issue 145 Injuries directly aff ect child survival 145 Children are more susceptible to injuries 145 Child injuries can be prevented 146 Th e cost of doing nothing is unacceptable 147 Few countries have good data on child injuries 148 Research on child injuries is too limited 148 Th ere are too few practitioners in child injury prevention 149 Child injuries is the responsibility of many sectors 150 Child injury prevention is underfunded 150 Awareness needs to be created and maintained 150 Recommended actions 151 Translating recommendations into reality 153 Conclusion 154 References 155

Statistical annex 157 Index 203

WORLD REPORT ON CHILD INJURY PREVENTION VII

FOREWORD

Foreword

Every day around the world the lives of more than 2000 families are torn apart by the loss of a child to an unintentional injury or so-called “accident” that could have been prevented. Th e grief that these families suff er – mothers, fathers, siblings, grandparents and friends – is immeasurable and oft en impacts entire communities. Such tragedy can change lives irrevocably.

Once children reach the age of fi ve years, unintentional injuries are the biggest threat to their survival. Unintentional injuries are also a major cause of disabilities, which can have a long-lasting impact on all facets of children’s lives: relationships, learning and play. Among those children who live in poverty, the burden of injury is highest, as these children are less likely to benefi t from the protective measures others may receive.

Child injuries have been neglected for many years, and are largely absent from child survival initiatives presently on the global agenda. Th rough this World report on child injury prevention, the World Health Organization, the United Nations Children’s Fund and many partners have set out to elevate child injury to a priority for the global public health and development communities. Th e knowledge and experience of nearly two hundred experts from all continents and various sectors were invaluable in grounding the report in the realities faced in many countries.

Children’s maturity and their interests and needs diff er from adults. Th erefore, simply reproducing injury prevention strategies that are relevant to adults does not adequately protect children. Th ere are proven interventions such as child car seats, cycling helmets, child-resistant packaging for medications, fencing around swimming pools, hot water tap temperature regulation and window guards, to name a few.

Ministries of Health can play a central role in prevention, advocacy and research and in the care and rehabilitation of children with disabilities. Other key sectors include education, transportation, environment and law enforcement.

Th is World report on child injury prevention should be seen as a complement to the UN Secretary-General’s study on violence against children released in late 2006. Th at report addressed violence-related or intentional injuries. Both reports suggest that child injury and violence prevention programmes need to be integrated into child survival and other broad strategies focused on improving the lives of children.

Evidence demonstrates the dramatic successes in child injury prevention in countries which have made a concerted eff ort. Th ese results make a case for increasing investments in human resources and institutional capacities. Th is would permit the development, implementation and evaluation of programmes to stem the tide of child injury and enhance the health and well-being of children and their families the world over. Implementing proven interventions could save more than a thousand children’s lives a day.

Margaret Chan Ann M VenemanDirector-General Executive DirectorWorld Health Organization United Nations Children’s Fund

VIII WORLD REPORT ON CHILD INJURY PREVENTION

WORLD REPORT ON CHILD INJURY PREVENTION IX

CONTRIBUTORS

Contributors

Editorial guidance

Editorial Committee

Margie Peden, Kayode Oyegbite, Joan Ozanne-Smith, Adnan A Hyder, Christine Branche, AKM Fazlur Rahman, Frederick Rivara, Kidist Bartolomeos.

Executive Editor

Margie Peden.

Advisory Committee

Chair of Advisory Committee: Ala Din Abdul Sahib Alwan.Advisory Committee: Ileana Arias, Sebastian van As, Martin Eichelberger, Mehmet Haberal, Saad Houry, Etienne Krug, Douglas “Pete” Peterson, Joy Phumaphi, Wim Rogmans, Fernando Stein, Alan Whelpton, Fan Wu.

Contributors to individual chapters

Introduction

Writer: Alison Harvey.Box: Alison Harvey, Amaya Gillespie.

Chapter 1. Child injuries in context

Writers: Elizabeth Towner, Ian Scott.Boxes: Margie Peden, Tony Kahane (Juan’s story), Margie Peden (1.1), Anuradha Bose (1.2), David Sleet, Barbara Morrongiello (1.3), Charles Mock (1.4), Karen Ashby, Ken Winkel, Julie Gilchrist (1.5).

Chapter 2. Road traffi c injuries

Writers: Kate McMahon, Gururaj Gopalakrishna, Mark Stevenson.Working group members: Nicola Christie, Wilson Odero, Krishnan Rajam, Junaid Razzak, Eugênia Maria Silveira Rodrigues, Chamaiparn Santikarn, Isabelle Sévédé-Bardem, Jean van Wetter. Boxes: David Blanchard (Deana’s story), AKM Fazlur Rahman (2.1), Flaura Winston (2.2), Mirjam Sidik (2.3).

Chapter 3. Drowning

Writers: Gitanjali Taneja, Ed van Beeck, Ruth Brenner.Working group members: Alfredo Celis, Steve Beerman, Julie Gilchrist, Olive Kobusingye, Jonathon Passmore, Linda Quan, Aminur Rahman, Carolyn Staines, Biruté Strukcinskiene, Li Yang.Boxes: Safekids New Zealand (Ruby’s story), Alfredo Celis, Frederick Rivara (3.1), Erin Cassell (3.2), Ruth Brenner, Gitanjali Taneja (3.3), Joan Ozanne-Smith (3.4), Frederick Rivara (3.5).

Chapter 4. Burns

Writers: Samuel Forjuoh, Andrea Gielen.Working group members: Carlos Arreola-Rissa, Mohamoud El-Oteify, Alison Macpherson, Ashley van Niekerk, Michael Peck, Andrés Villaveces.Boxes: Children of Fire (Vusi’s story), Samuel Forjuoh (4.1), Reza Mohammadi, Homayoun Sadeghi-Bazargani, Mohammad Mehdi Gouya (4.2), Wijaya Godakumbura (4.3), Pam Albany (4.4), Junaid Razzak (4.5), Rene Albertyn, Sebastian van As, Heinz Rode (4.6).

X WORLD REPORT ON CHILD INJURY PREVENTION

Chapter 5. Falls

Writers: Shanthi Ameratunga, Huan Linnan, Shaheen Sultana.Working group members: Francis Abantanga, Abdulbari Bener, Rieneke Dekker, Adisak Plitapolkarnpim, Shauna Sherker, Wendy Watson.Boxes: Aminur Rahman (Sohel’s story), Kidist Bartolomeos, Baltazar Chilundo, Orvalho Joaquim (5.1), Caroline Finch (5.2), Joan Ozanne-Smith (5.3), Margie Peden (5.4).

Chapter 6. Poisons

Writers: Yvette Holder, Richard Matzopoulos, Nerida Smith.Working group members: Mick Ballesteros, Anuradha Bose, Jenny Pronczuk de Garbino, Marisa Ricardo, Dinesh Sethi, Nelmarie du Toit. Boxes: Debbie Scott (Harrison’s story), Ken Winkel, Karen Ashby, Julie Gilchrist (6.1), Richard Matzopoulos (6.2), Yvette Holder (6.3), Fernando Ravindra (6.4).

Chapter 7. Conclusions and Recommendations

Writers: Margie Peden, Adnan A Hyder.Boxes: Anupama Kumar (Anupama’s story), Lucie Lafl amme (7.1), Adnan A Hyder, Nhan Tran, Abdulgafoor Bachani, David Bishai (7.2), Susan McKenzie (7.3), David Meddings (7.4), Veronika Benešová (7.5), Margie Peden (7.6).

Statistical Annex

Kidist Bartolomeos, Colin Douglas Mathers, Karen Oldenziel, Mike Linnan, Adnan A Hyder.

Peer reviewers

Pam Albany, Rene Albertyn, Ruth Barker, Chris Brewster, Mariana Brussoni, Marie Noël Brune, Erin Cassel, Kerry Chausmer, Chrissy Cianfl one, Ann Dillenger, Moira Donahue, Jacquie Dukehart, Martin Eichelberger, Robert Flanagan, Lucie Lafl amme, Abdul Ghaff ar, Rosa Gofi n, Robin Ikeda, Denise Kendrick, Shyan Lall, Jacques Latarjet, Edilberto Loaiza, Morag Mackay, Alison Macpherson, Candida Moshiro, Milton Mutto, Anthony Oliver, Luciana O’Reilly, David Parker, Eleni Petridou, Dragoslav Popovic, Aminur Rahman, Shumona Shafi naz, David Silcock, David Sleet, Hamid Soori, Joanna Tempowski, Maria Vegega, Andrés Villaveces, Joanne Vincenten, Diane Wigle.

Additional contributors

Regional Consultants

WHO African Region / Eastern Mediterranean Region

Francis Abantanga, Hala Aboutaleb, Wahid Al-Kharusi, Jamela Al Raiby, Sebastian van As, Abdulbari Bener, Hesham El-Sayed, Mahmoud El-Oteify, Mouloud Haddak, Lara Hussein, Syed Jaff ar Hussain, Olive Kobusingye, Richard Matzopoulos, Candida Moshiro, Junaid Razzak, Jamil Salim, Babatunde Solagberu, Hamid Soori, Dehran Swart.

WHO Region of the Americas

Carlos Arreola-Rissa, Simone Gonçalves de Assis, Yadira Carrer, Alfredo Celis, Sara Diaz, Ann Dellinger, Samuel Forjuoh, Andrea Gielen, Maria Isabel Gutierrez, Yvette Holder, Debra Houry, Sylvain Leduc, Luciana O’Reilly, Michael Peck, Maria Fernanda Tourinho Peres, Eugênia Maria Silveira Rodrigues, Maria Ines Romero, Gitanjali Taneja, Andrés Villaveces, Billie Weiss, Elizabeth Ward.

WHO South-East Asia Region / Western Pacifi c Region

Pamela Albany, Shanthi Ameratunga, Nguyen Trong An, Anuradha Bose, Rafael Consunji, Yoshikazu Fujisawa, Wijaya Godakumbura, Gopalakrishna Gururaj, Huan Linnan, Michael Linnan, Hisashi Ogawa, Joan Ozanne-Smith, Jonathon Passmore, Adisak Plitponkarnpim, AKM Fazlur Rahman, Aminur Rahman, Krishnan Rajam, Marisa Ricardo, Siriwan Santijiarakul, Chamaiparn Santikarn, Ian Scott, Isabelle Sévédé-Bardem, Richard Tan, Tetsuro Tanaka.

WORLD REPORT ON CHILD INJURY PREVENTION XI

WHO European Region

Ed van Beeck, Veronika Benešová, Christine Branche, Gudula Brandmayr, Murat Derbent, Olivier Duperrex, Rosa Gofi n, Loek Hesemans, Rupert Kisser, Lucie Lafl amme, Jacques Latarjet, Morag Mackay, Alison Macpherson, Kate McMahon, Eleni Petridou, Dragoslav Popovic, Olga Poyiadji-Kalakouta, Francesca Racioppi, Ian Roberts, Wim Rogmans, Maria Segui Gomez, Dinesh Sethi, Biruté Strukcinskiene, Elizabeth Towner, Iva Truellova, Joanne Vincenten, Michael Watson.

None of the experts involved in the development of this report declared any confl ict of interest.

XII WORLD REPORT ON CHILD INJURY PREVENTION

WORLD REPORT ON CHILD INJURY PREVENTION XIII

Th e World Health Organization and UNICEF would like to thank the more than 180 contributors (editors, lead authors, working group members, regional consultation participants and peer reviewers) to this report from 56 countries around the world. In addition, the support and guidance off ered by the report advisors, WHO regional advisors and UNICEF staff are acknowledged. Without their dedication, support and expertise this report would not have been possible.

Th e report also benefi ted from the contribution of a number of other people, in particular, Tony Kahane who edited the fi nal text of the main report and Angela Burton who edited the summary version. Joanne Vincenten and Morag Mackay prepared the fi nal text for the summary and fact sheets. Th anks are also due to the following: Kidist Bartolomeos and Ian Scott for the day-to-day coordination of the project; Mike Linnan for the UNICEF/TASC data analysis; Kidist Bartolomeos, Colin Mathers and Karen Oldenziel for analysis and interpretation of WHO data; Adnan Hyder and Prasanthi Puvanachandra for data analysis from the multicountry study; Laura Sminkey and Steven Lauwers for communication and advocacy; Susan Kaplan for proofreading and Liza Furnival for indexing; Susan Hobbs, L’IV Com Sàrl and Aaron Andrade for graphic design; Pascale Broisin and Frederique Robin-Wahlin for coordinating the printing; and fi nally, Pascale Lanvers-Casasola for her administrative support and for coordinating the translation of the diff erent versions of this report.

Th e World Health Organization and UNICEF also wish to thank the following for their generous fi nancial support for the development, translation and publication of the report: the Arab Gulf Programme for United Nations Development Organizations (AGFUND); the Public Health Agency of Canada, the Governments of Belgium, Mexico, the Netherlands, Norway, Sweden, and the United Kingdom; the Global Forum for Health Research; the United States Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

ACKNOWLEDGEMENTS

Acknowledgements