Megan Prinsloo

Estimating the South African trauma caseload

A survey of medical superintendents revealed that an estimated 1.5 million trauma cases presented to South Africas 356 secondary and tertiary level hospitals in 1999. Injury rates for traffic, violence and other injuries showed considerable inter-provincial variation, with violence accounting for more than half of the trauma caseload. This type of survey is a simple low cost alternative for monitoring injury patterns and supplementing burden of disease and injury costing studies.

Mortality trends and differentials in South Africa from 1997 to 2012: second National Burden of Disease Study

BACKGROUND The poor health of South Africans is known to be associated with a quadruple disease burden. In the second National Burden of Disease (NBD) study, we aimed to analyse cause of death data for 1997-2012 and develop national, population group, and provincial estimates of the levels and causes of mortality. METHOD We used underlying cause of death data from death notifications for 1997-2012 obtained from Statistics South Africa. These data were adjusted for completeness using indirect demographic techniques for adults and comparison with survey and census estimates for child mortality. A regression approach was used to estimate misclassified HIV/AIDS deaths and so-called garbage codes were proportionally redistributed by age, sex, and population group population group (black African, Indian or Asian descent, white [European descent], and coloured [of mixed ancestry according to the preceding categories]). Injury deaths were estimated from additional data sources. Age-standardised death rates were calculated with mid-year population estimates and the WHO age standard. Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) estimates for South Africa were obtained from the IHME GHDx website for comparison. FINDINGS All-cause age-standardised death rates increased rapidly since 1997, peaked in 2006 and then declined, driven by changes in HIV/AIDS. Mortality from tuberculosis, non-communicable diseases, and injuries decreased slightly. In 2012, HIV/AIDS caused the most deaths (29·1%) followed by cerebrovascular disease (7·5%) and lower respiratory infections (4·9%). All-cause age-standardised death rates were 1·7 times higher in the province with the highest death rate compared to the province with the lowest death rate, 2·2 times higher in black Africans compared to whites, and 1·4 times higher in males compared with females. Comparison with the IHME GBD estimates for South Africa revealed substantial differences for estimated deaths from all causes, particularly HIV/AIDS and interpersonal violence. INTERPRETATION This study shows the reversal of HIV/AIDS, non-communicable disease, and injury mortality trends in South Africa during the study period. Mortality differentials show the importance of social determinants, raise concerns about the quality of health services, and provide relevant information to policy makers for addressing inequalities. Differences between GBD estimates for South Africa and this study emphasise the need for more careful calibration of global models with local data. FUNDING South African Medical Research Councils Flagships Awards Project.

Second National Burden of Disease Study South Africa: national and subnational mortality trends, 1997–2009

Abstract Background Global Burden of Diseases, Injuries, and Risk Factors Study 2010 results show continued limitations of data quality and availability in most of the African region. Focused efforts in South Africa, however, have contributed to improved completeness and availability of mortality data, such that South Africa is currently undertaking a second National Burden of Disease Study. Mortality estimates have been developed nationally and for the nine provinces for 1997–2009. Methods Vital registration data obtained for 1997–2009 were adjusted for completeness using indirect demographic techniques. A regression approach was used to identify misclassified AIDS deaths, and garbage codes were proportionally redistributed by age, sex, and population group. Injury deaths were estimated from additional data sources. Age-standardised mortality rate (ASMR) trends for the nine provinces were calculated using ASSA 2008 population estimates and the WHO age standard. Findings All-cause mortality peaked in 2006 and thereafter started to decline. ASMRs showed a two-fold difference between the highest-affected and lowest-affected provinces for the 1997–2009 period. ASMR from HIV/AIDS increased threefold since 1997 with provincial variation, while mortality from non-HIV-related tuberculosis declined. Mortality rates from non-communicable diseases decreased over the period nationally but increased for some provinces and remained stable for others as a result of differing trends in hypertensive heart disease and respiratory diseases. Nationally, preliminary analyses for 2009 show that HIV/AIDS was responsible for the highest number of deaths (31·2%; n=194 322 of 622 300 deaths), followed by cerebrovascular disease (6·2%; n=38 666), tuberculosis (5·4%; n=33 375), lower respiratory infections (5·2%; n=32 568), and ischaemic heart disease (4·4%; n=27 688). However, tuberculosis and interpersonal violence ranked among the top five causes for males, while hypertensive heart disease and ischaemic heart disease featured for females. Interpretation The downward trend in HIV/AIDS mortality can be attributed to the extensive antiretroviral treatment rollout since 2005. Differential provincial mortality trends reflect the different stages of epidemiological transition and differential health services in the provinces, providing relevant information for policy makers to address inequalities. Funding South African Medical Research Council.

Injury-related mortality in South Africa: a retrospective descriptive study of postmortem investigations.

Abstract Objective To investigate injury-related mortality in South Africa using a nationally representative sample and compare the results with previous estimates. Methods We conducted a retrospective descriptive study of medico-legal postmortem investigation data from mortuaries using a multistage random sample, stratified by urban and non-urban areas and mortuary size. We calculated age-specific and age-standardized mortality rates for external causes of death. Findings Postmortem reports revealed 52 493 injury-related deaths in 2009 (95% confidence interval, CI: 46 930–58 057). Almost half (25 499) were intentionally inflicted. Age-standardized mortality rates per 100 000 population were as follows: all injuries: 109.0 (95% CI: 97.1–121.0); homicide 38.4 (95% CI: 33.8–43.0; suicide 13.4 (95% CI: 11.6–15.2) and road-traffic injury 36.1 (95% CI: 30.9–41.3). Using postmortem reports, we found more than three times as many deaths from homicide and road-traffic injury than had been recorded by vital registration for this period. The homicide rate was similar to the estimate for South Africa from a global analysis, but road-traffic and suicide rates were almost fourfold higher. Conclusion This is the first nationally representative sample of injury-related mortality in South Africa. It provides more accurate estimates and cause-specific profiles that are not available from other sources.

A retrospective time trend study of firearm and non-firearm homicide in Cape Town from 1994 to 2013

BACKGROUND Gunshot injuries from interpersonal violence are a major cause of mortality. In South Africa (SA), the Firearms Control Act of 2000 sought to address firearm violence by removing illegally owned firearms from circulation, stricter regulation of legally owned firearms, and stricter licensing requirements. Over the last few years, varied implementation of the Act and police corruption have increased firearm availability. OBJECTIVES To investigate whether changes in firearm availability in SA were associated with changes in firearm homicide rates. METHODS This was a retrospective time trend study (1994 - 2013) using postmortem data. Time trends of firearm and non-firearm homicide rates were analysed with generalised linear models. Distinct time periods for temporal trends were assigned based on a priori assumptions regarding changes in the availability of firearms. RESULTS Firearm and non-firearm homicide rates adjusted for age, sex and race exhibited different temporal trends. Non-firearm homicide rates either decreased or remained stable over the entire period. Firearm homicide increased at 13% annually from 1994 through 2000, and decreased by 15% from 2003 through 2006, corresponding with changes in firearm availability in 2001, 2003, 2007 and 2011. A 21% annual increase in firearm homicide after 2010 coincided with police fast-tracking new firearm licence applications. Cape Towns coloured population experienced a significantly greater increase than other population groups following additional exposure to illegal firearms from 2007. CONCLUSIONS The strong association between firearm availability and homicide, and the reversal of a decreasing firearm homicide trend during a period of lax enforcement, provide further support for the association between reduced firearm homicide and stricter regulation.

ASSESSING FIELDWORKER RELIABILITY IN A NATIONAL STUDY OF INJURY MORTALITY IN SOUTH AFRICA

Background Vital registration data indicate that injury deaths have decreased since the first National Burden of Disease (NBD) study in South Africa for 2000 but it is not clear which injury types may have been affected as a high proportion have undetermined intent. In order to quantity injury types, as part of the second NBD study, we conducted a national survey of non-natural deaths presenting to South African mortuaries in 2009. Aims/Objectives/Purpose To test inter-observer reliability between fieldworkers. Methods Lay interviewers were trained to identify the external cause of injury and mobile telephones were used for data capture. The main study sampled 22 000 records from 45 mortuaries. Reliability was tested by two field-workers independently collecting data from the same folder on the same day for 5% of the sample. The proportion of potential agreement beyond chance between two data collectors extracting the same data was determined using the Kappa score, with a value of 0.6 denoting substantial and a value of greater than 0.8 denoting near perfect agreement. Results/Outcome Based on data from 1025 cases, the agreement on the manner of death showed high agreement with a Kappa of 0.861 (95% CI 0.837 to 0.884). There was 88.8% agreement on the detailed information about the external cause of the injury death. Significance/Contribution to the Field Fieldworker coding errors are a potential source of bias in injury surveys, particularly when information is interpreted from secondary sources. The current study provides a simple and cost-effective method with which to measure the reliability of information.

Historical trends of homicide and road traffic fatalities in South Africa: 1968–1989

Introduction South Africa has a high injury burden, with homicide and road traffic injuries (RTI) being the leading causes of injury death. There is little information about long-term trends. Good quality vital statistics are available for 1968–1989 for selected population groups and will be analysed towards understanding the historical pattern of violence and road deaths within South Africa. Method Unidentified unit record cause of death data with ICD-9 coding were obtained from the national statistical office for 1968–1989, including population groups assigned during the Apartheid-era, age and sex. Trends in injury proportions due to homicide and RTI and the ratio of homicide to suicide were examined by population group. Age standardised rates will be calculated for whites, coloureds and Indians since data for Blacks are incomplete. Results RTI as a proportion of total injuries were highest for whites and Indians at approximately 42% and 35% respectively. At 6–10 homicides for every suicide, the ratio for coloureds was fairly constant until 1980, after which it increased sharply for coloureds and Blacks. For whites the ratio was <1 over the period, while for Indians the ratio ranged between <1 and 2.5. Age standardised rates will also be presented. Conclusion Preliminary results indicate that homicides were considerably higher for coloureds and Blacks than for whites and Indians, with increases during the last stages of Apartheid. While fatal RTIs appear to have remained fairly constant, decreases which may have been associated with petrol restrictions during the global oil crisis were noticed.