Richard Matzopoulos

The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013

Background The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country. Methods Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures. Results In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries. Conclusions Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.

Interpersonal violence: an important risk factor for disease and injury in South Africa

BackgroundBurden of disease estimates for South Africa have highlighted the particularly high rates of injuries related to interpersonal violence compared with other regions of the world, but these figures tell only part of the story. In addition to direct physical injury, violence survivors are at an increased risk of a wide range of psychological and behavioral problems. This study aimed to comprehensively quantify the excess disease burden attributable to exposure to interpersonal violence as a risk factor for disease and injury in South Africa.MethodsThe World Health Organization framework of interpersonal violence was adapted. Physical injury mortality and disability were categorically attributed to interpersonal violence. In addition, exposure to child sexual abuse and intimate partner violence, subcategories of interpersonal violence, were treated as risk factors for disease and injury using counterfactual estimation and comparative risk assessment methods. Adjustments were made to account for the combined exposure state of having experienced both child sexual abuse and intimate partner violence.ResultsOf the 17 risk factors included in the South African Comparative Risk Assessment study, interpersonal violence was the second leading cause of healthy years of life lost, after unsafe sex, accounting for 1.7 million disability-adjusted life years (DALYs) or 10.5% of all DALYs (95% uncertainty interval: 8.5%-12.5%) in 2000. In women, intimate partner violence accounted for 50% and child sexual abuse for 32% of the total attributable DALYs.ConclusionsThe implications of our findings are that estimates that include only the direct injury burden seriously underrepresent the full health impact of interpersonal violence. Violence is an important direct and indirect cause of health loss and should be recognized as a priority health problem as well as a human rights and social issue. This study highlights the difficulties in measuring the disease burden from interpersonal violence as a risk factor and the need to improve the epidemiological data on the prevalence and risks for the different forms of interpersonal violence to complete the picture. Given the extent of the burden, it is essential that innovative research be supported to identify social policy and other interventions that address both the individual and societal aspects of violence.

MEETING THE CHALLENGE OF RAILWAY INJURY IN A SOUTH AFRICAN CITY

BACKGROUND Efficient and safe transport infrastructure is vital for economic growth in developing countries. The city of Cape Town, South Africa, has an extensive rail network with high levels of injury and violence. We investigated the reporting and frequency of railway injuries and examined their reduction through a range of interventions. METHODS We analysed railway injury and death reporting by Cape Towns rail utility, state mortuaries, and a regional trauma survey. The data were obtained over 2.5 years, and the use of more than one data source was necessary to increase the size of the data pool and to determine under-reporting. FINDINGS There were 379 railway-related deaths and 505 serious injuries during the study period. Most death (190) were train-pedestrian collisions, and the fatality rate on the metropolitan lines was about 60 per 100 million passenger journeys. There was substantial under-reporting by the rail utility of both fatal (20% under-reported) and non-fatal injuries (at least 24%). Many injuries occurred during peak commuting times and alcohol played an important part, especially in pedestrian fatalities. INTERPRETATION Our results demonstrate the importance of a comprehensive, sustainable railway injury surveillance system to promote safety engineering and law enforcement in a metropolitan rail system.

Estimating the burden of disease attributable to interpersonal violence in South Africa in 2000

To the Editor: Violence, previously considered a social issue, is now an acknowledged public health problem. It is defined as the intentional use of physical force or power, threatened or actual, against another person, against oneself, or against a group or community, that results in injury, death or deprivation. 1 In this study we focus on exposure to the interpersonal type of violence, which includes acts of family violence and community violence. Family violence is further categorised by victim: child, intimate partner, or elder. Community violence occurs among unrelated individuals and includes sexual assault and rape by strangers as well as youth violence. In South Africa (SA) violence has become the normative and accepted strategy for resolving conflict. This is the result of many decades of social injustice and political violence including state-sponsored violence. The political transition has seen a decrease in political conflict but exceedingly high levels of interpersonal violence remain, fuelled by rapid urbanisation and ongoing economic disparities. Injuries directly related to interpersonal violence caused an estimated 27 563 deaths in South Africa in 2000. The age-standardised homicide rate (65 per 100 000) was more than seven times the global average, placing South Africa among the most violent countries in the world. 2 Homicide was the leading cause of fatal injury in males and rates peaked in the 15 - 29-year age group at 184 per 100 000, ninefold higher than the global rate. 2 High levels of gender-based violence are also evident with excessive rates of female homicides. A recent study has shown that 1 in every 2 women killed by a known perpetrator in South Africa is killed by an intimate partner, leading to the highest reported intimate femicide rate in the world: 9 per 100 000 women. 3

The impact of violence on health in low- to middle-income countries

More than 90% of violence-related deaths occur in low- to middle-income countries (LMICs), where the mortality rate due to violence is almost 2.5 times greater than in high-income countries. Over and above the substantial contribution of violence as a cause of death and physical injuries, victims of violence are also more vulnerable to a range of mental and physical health problems. Several studies describe the deleterious impact of different types of violence on a range of health outcomes, but no review has yet been undertaken that presents a composite overview of the current state of knowledge in LMICs. This paper reviews the scientific literature describing the nature, magnitude and impact of violence on health, describing the current state of violence-prevention policy developments within the global health agenda and highlighting the health consequences, disease burden and economic costs of violence. Although data are limited, the review indicates that costs relating to violence deplete health care budgets considerably and that scarce resources could be better used to address other health threats that hamper development.

The electronic Trauma Health Record: design and usability of a novel tablet-based tool for trauma care and injury surveillance in low resource settings.

BACKGROUND Ninety percent of global trauma deaths occur in under-resourced or remote environments, with little or no capacity for injury surveillance. We hypothesized that emerging electronic and web-based technologies could enable design of a tablet-based application, the electronic Trauma Health Record (eTHR), used by front-line clinicians to inform trauma care and acquire injury surveillance data for injury control and health policy development. STUDY DESIGN The study was conducted in 3 phases: 1. Design of an electronic application capable of supporting clinical care and injury surveillance; 2. Preliminary feasibility testing of eTHR in a low-resource, high-volume trauma center; and 3. Qualitative usability testing with 22 trauma clinicians from a spectrum of high- and low-resource and urban and remote settings including Vancouver General Hospital, Whitehorse General Hospital, British Columbia Mobile Medical Unit, and Groote Schuur Hospital in Cape Town, South Africa. RESULTS The eTHR was designed with 3 key sections (admission note, operative note, discharge summary), and 3 key capabilities (clinical checklist creation, injury severity scoring, wireless data transfer to electronic registries). Clinician-driven registry data collection proved to be feasible, with some limitations, in a busy South African trauma center. In pilot testing at a level I trauma center in Cape Town, use of eTHR as a clinical tool allowed for creation of a real-time, self-populating trauma database. Usability assessments with traumatologists in various settings revealed the need for unique eTHR adaptations according to environments of intended use. In all settings, eTHR was found to be user-friendly and have ready appeal for frontline clinicians. CONCLUSIONS The eTHR has potential to be used as an electronic medical record, guiding clinical care while providing data for injury surveillance, without significantly hindering hospital workflow in various health-care settings.

Collecting injury surveillance data in low- and middle-income countries: The Cape Town Trauma Registry pilot

Abstract Injury is a major public health issue, responsible for 5 million deaths each year, equivalent to the total mortality caused by HIV, malaria and tuberculosis combined. The World Health Organisation estimates that of the total worldwide deaths due to injury, more than 90% occur in low- and middle-income countries (LMIC). Despite the burden of injury sustained by LMIC, there are few continuing injury surveillance systems for collection and analysis of injury data. We describe a hospital-based trauma surveillance instrument for collection of a minimum data-set for calculating common injury scoring metrics including the Abbreviated Injury Scale and the Injury Severity Score. The Cape Town Trauma Registry (CTTR) is designed for injury surveillance in low-resource settings. A pilot at Groote Schuur Hospital in Cape Town was conducted for one month to demonstrate the feasibility of systematic data collection and analysis, and to explore challenges of implementing a trauma registry in a LMIC. Key characteristics of the CTTR include: ability to calculate injury severity, key minimal data elements, expansion to include quality indicators and minimal drain on human resources based on few fields. The CTTR provides a strategy to describe the distribution and consequences of injury in a high trauma volume, low-resource environment.

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.

Violence, violence prevention, and safety: A research agenda for South Africa

Violence is a serious problem in South Africa with many effects on health services; it presents complex research problems and requires interdisciplinary collaboration. Two key meta-questions emerge: (i) violence must be understood better to develop effective interventions; and (ii) intervention research (evaluating interventions, assessing efficacy and effectiveness, how best to scale up interventions in resource-poor settings) is necessary. A research agenda to address violence is proposed.

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.