Transcript 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.

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
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 twothirds were available or developed
Jones et al, Lancet 2003
Number of deaths to children <5 years: 1970-2010
Rajaratnam et al, Lancet 2010
Prevalence of Any Chronic Condition and Subgroups of Conditions in children, 1988-2006
1988-94
Van Cleave, J. et al. JAMA 2010;303:623-630.
1994-2000
2000-06
Proportion of children 8-18 years with
one or more chronic conditions, 2003
45
40
35
30
%
25
20
15
10
5
0
CZ
UK
DE
FR
Berra et al, Medical Care 2009
PL
ES
HU
AT
NL
CH
GR
Pediatric Obesity in the US
20
18
16
14
12
% 10
8
6
4
2
0
2-5 yrs
6-11 yrs
12-19 yrs
1963-5 1966- 1971-4 197670
80
198894
1999- 2001-2 2003-4
2000
Rates of overweight and obesity at
2-4 years of age
MALE
FEMALE
Spain
Greece
Poland
England
Scotland
` Italy
Netherlands
Romania
Czech
Cyprus
-60
-40
Female 1-2 SD
-20
Female 2-3 SD
0
Female >3 SD
20
Male 1-2 SD
40
Male 2-3 SD
60
Male >3 SD
Prevalence of overweight/obesity in boys and girls aged 6-18 years in LMIC
Kelishadi, R. Epidemiol Rev 2007
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
4
3.5
3
2.5
%
2
1.5
1
0.5
0
<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 fairpoor 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
25
20
15
10
Rate per 100,000
Causes of death for children 5-9
years, Bangladesh
30
5
0
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20
15
10
5
Rate per 100,000
Causes of death for children 1517 years, Bangladesh
25
0
V
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ni
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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
Evolution of the idea of adolescence
Improving the quality of research
Change priority setting
Injury Control
Prevention
Rehabilitation
Acute Care
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 resourcelimited 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
12
Before
10
After
8
6
4
2
0
y
An
R
n
n
io
at
ic
pl
O
ia
on
to
io
ct
fe
In
m
co
h
at
De
m
eu
Pn
nd
ou
rn
tu
Re
W
Haynes et al, NEJM 2009
Disability vs. death after trauma
18
Millions of years
16
14
YLD
YLL
12
10
8
6
4
2
0
0-4 years
GBD, 2000
5-14 years
Incidence of injury mortality and
morbidity to children
35
30
25
20
15
Fatality
Disability
*
10
5
0
Burns,
B'desh
Burns, US
*Based on 5% disability
Rahman; Koepsell; Davydow
TBI, US*
PTSD, US
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
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence
• Improving the quality of research
• Change priority setting
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
60
50
Unintentional, LMIC
Unintentional, HIC
RTI, HIC
RTI, LMIC
Homicide, LIC
Homicide, HIC
Suicide,HIC
Suicide, LMIC
40
30
20
10
0
1-4
5-9
10-14
15-19
Deaths per 100,000 from injuries
10- 15- 20- 10- 15- 20-
Male
Female
Patton et al, 2009
10- 15- 20- 10- 15- 20-
Male
Female
10- 15- 20- 10- 15- 20-
Male
Female
Risk of injury among in-school adolescents
% injured last year
80
70
60
50
40
30
20
10
0
a ia nd da bia we
y
n ib ila an m ab
e
K am wz Ug Za b
N a
m
S
Zi
Peltzer, Injury Prevention 2008
• 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
Five themes
• Epidemiologic transition
• Injury control not just prevention
• Evolution of the idea of adolescence
• 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
•
•
•
•
Epidemiologic transition
Injury control not just prevention
Evolution of the idea of adolescence
Improving the quality of research
• Change priority setting
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:
•
•
•
•
•
Epidemiologic transition
Injury control not just prevention
Evolution of the idea of adolescence
Improving the quality of research
Change priority setting
“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)