Ronald Lett

Injury patterns in rural and urban Uganda

Objectives—To describe and contrast injury patterns in rural and urban Uganda. Settings—One rural and one urban community in Uganda. Methods—Community health workers interviewed adult respondents in households selected by multistage sampling, using a standardized questionnaire. Results—In the rural setting, 1673 households, with 7427 persons, were surveyed. Injuries had an annual mortality rate of 92/100 000 persons, and disabilities a prevalence proportion of 0.7%. In the urban setting 2322 households, with 10 982 people, were surveyed. Injuries had an annual mortality rate of 217/100 000, and injury disabilities a prevalence proportion of 2.8%. The total incidence of fatal, disabling, and recovered injuries was 116/1000/year. Leading causes of death were drowning in the rural setting, and road traffic in the city. Conclusion—Injuries are a substantial burden in Uganda, with much higher rates than those in most Western countries. The urban population is at a higher risk than the rural population, and the patterns of injury differ. Interventions to control injuries should be a priority in Uganda.

Hospital-based trauma registries in Uganda.

OBJECTIVES Toward the establishment of an injury surveillance system in Uganda, the first step was to initiate hospital-based trauma registries that generate relevant and timely data on the causes, severity, morbidity, mortality, and outcomes of injuries at Mulago and Kawolo hospitals. This would help establish injury patterns and priorities in these hospital populations. The registries are based on a minimal data set and a new injury severity instrument, the Kampala Trauma Score (KTS). The usefulness of the registry and the qualities of the KTS are presented. METHODS The Accident and Emergency Department of Mulago, an urban 1,500-bed, tertiary hospital, and the Casualty Unit of Kawolo, a 100-bed district-level hospital. Trained staff in the hospitals used a one-page, 19-item registry form to collect data on demographic, injury incident, and outcome data. The registry describes injuries based on cause, frequency, and severity. The inter-rater reliability and the predictive validity of the KTS were evaluated. Registry subjects include all injured persons that come to the above hospitals. RESULTS Results are based on the first 5,210 records. Gender distribution was 27.7% female and 71.3% male. The younger than 5 years old category was 7.4%, whereas 3.9% were older than 55 years old. Admitted patients composed 37.3% of cases, and three of four injuries were unintentional. The KTS is highly predictive of need for admission or death (adults, Az = 0.95 +/- 0.01; children, Az = 0.89 +/- 0.01). CONCLUSION A trauma registry and injury severity measurement are both possible and useful in sub-Saharan Africa. This minimal data set and the KTS are recommended for investigators with similar resource constraints.

Citywide trauma experience in Kampala, Uganda: a call for intervention

Objectives: To describe injuries and their emergency care at five city hospitals. Setting: Data were collected between January and December 1998 from casualty departments of the five largest hospitals of Kampala city, Uganda, with bed capacity ranging from 60 to 1200. Methods: Registry forms were completed on trauma patients. All patients with injuries were eligible. Outcome at two weeks was determined for admitted patients. Results: Of the 4359 injury patients, 73% were males. Their mean age was 24.2 years, range 0.1–89, and a 5–95 centile of 5–50 years. Patients with injuries were 7% of all patients seen. Traffic crashes caused 50% of injuries, and were the leading cause for patients ≥10 years. Fifty eight per cent of injuries occurred on the road, 29% at home, and 4% in a public building. Falls, assaults, and burns were the main causes in homes. Fourteen per cent of injuries were intentional. Injuries were severe in 24% as determined with the Kampala trauma score. One third of patients were admitted; two thirds arrived at the hospital within 30 minutes of injury, and 92% were attended within 20 minutes of arrival. Conclusions: Injuries in Kampala are an important public health problem, predominantly in young adult males, mostly due to traffic. The majority of injuries are unintentional. Hospital response is rapid, but the majority of injuries are minor. Without pre-hospital care, it is likely that patients with serious injuries die before they access care. Preventive measures and a pre-hospital emergency service are urgently needed.

Assessing the impact of the trauma team training program in Tanzania.

BACKGROUND In sub-Saharan Africa, injury is responsible for more deaths and disability-adjusted life years than AIDS and malaria combined. The trauma team training (TTT) program is a low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation. The purpose of this study was to assess the impact of TTT on trauma knowledge and performance of Tanzanian physicians and nurses; and to demonstrate the validity of a questionnaire assessing trauma knowledge. METHODS This is a prospective study of physicians and nurses from Dar es Salaam undergoing TTT (n = 20). Subjects received a precourse test and, after the course, an alternate postcourse test. The equivalence and construct validity of these 15-item multiple-choice questionnaires was previously demonstrated. After the course, subjects were divided into four teams and underwent a multiple injuries simulation, which was scored with a trauma resuscitation simulation assessment checklist. A satisfaction questionnaire was then administered. Test data are expressed as median score (interquartile ratio) and were analyzed with the Wilcoxons signed rank test. RESULTS After the TTT course, subjects improved their scores from 9 (5-12) to 13 (9-13), p = 0.0004. Team performance scores for the simulation were all >80%. Seventy-five percent of subjects were very satisfied with TTT and 90% would strongly recommend it to others and would agree to teach future courses. CONCLUSIONS After completion of TTT, there was a significant improvement in trauma resuscitation knowledge, based on results from a validated questionnaire. Trauma team performance was excellent when assessed with a novel trauma simulation assessment tool. Participants were very supportive of the course.

A unified framework for injury control: the public health approach and Haddon's Matrix combined

Injury specialists have not successfully convinced policy makers and the public that injuries can be controlled. That failure may be due in part to the lack of a unified understanding of injury control. The two most important models utilized in injury control are Haddons Matrix1 and the Public Health Approach (PHA). This paper argues that the PHA should be combined with the two axes of Haddons Matrix to result in a model that is coherent and comprehensive. Thus it is better than either one of the original models on their own. Haddons Matrix has two axes. The first includes elements of the epidemiological triad, host, vector, and environment and likens injury to disease. The second axis includes three time intervals, pre-event, event, and post-event. The importance of including time was that injury was conceptualized as predictable and preventable. The weakness of Haddons matrix is that it lacks a systematic plan of action. The Public Health Approach is a methodology for addressing injury, which consists of a hierarchy of four levels; surveillance, risk factor identification, intervention evaluation and program implementation. The use of the PHA with no specific orientation or means of application is its weakness. The PHA lacks a systematic point of application. Haddons Matrix lacks a systematic action plan. Therefore we propose the PHA as the systematic strategy for the more theoretical framework of Haddons matrix. By combining these concepts a coherent and comprehensive three-dimensional framework is defined. The unified model closes the potential gaps in the two original models and includes a systematic approach not previously achieved. This unified model is practical in defining individual studies and groups of studies. It can be used as an inventory, for a complete understanding of a particular injury. Diagrams of the model are presented to help teach the concepts of injury described in this unitary model. In conclusion, we can say that the inclusion of three injury concepts in one framework provides a rigorous and coherent construct for the understanding of injury and implementation of control activities. It can therefore be used to design more comprehensive programs for injury control and promote policies and funding commensurate with the magnitude of the injury problem.

Intentional injuries among Ugandan youth: a trauma registry analysis

Purpose To determine intentional injury burden, incident characteristics, and outcomes among Ugandan youth. Methods A cross sectional analysis of trauma registry data from accident and emergency units of five regional referral hospitals was conducted. Data had been prospectively collected from all patients accessing injury care at the five sites between July 2004 and June 2005: youth records were analysed. Results Intentional injuries among youth victims, especially school-age males, are common in all five regions, constituting 7.3% of their injury burden with a male dominance. Intentional youth victimisation mainly occurred at home, on roads, and in public places; incidents were largely due to blunt force, stabs/cuts, and gunshots in general, although variations in causes were evident depending on age. Intentional injuries among the youth victims often manifested as head, neck, and face injuries: 2% were severe and there were 4%case fatalities at 2 weeks. Conclusions and recommendations Intentional injuries among youth victims, especially school-age males, are important contributors of injury burden in all five sites. Homes, roads, and public places are unsafe for Ugandan youth. Although guns were used in all five sites, less lethal mechanisms (blunt force, stabs/cuts, and burns) are the most common with variations between locations. Incidents involving teenage housewives could reflect underlying problem of domestic violence. Community based studies could be highly informative. Youth should be prioritised for prevention of injuries both in and out of school.

Occupational injuries and fatalities in a tanzanite mine: Need to improve workers safety in Tanzania.

Introduction Work related injuries are common, and the mining industry accounts for a significant proportion of these injuries. Tanzania is among the countries with high rates of mining injuries, nevertheless pre-hospital care is almost non existant and health care service deliveries are poor. This study sought to identify factors associated with injuries and fatalities among miners in Mererani, Tanzania. Methods A Cross - Sectional study of miners who sustained injuries and seen at Mererani health centre between January 2009 and May 2012. Results In the selected period 248 injury patients were seen. All were males, and 54% were between 18 - 30 years age-group. Almost all (98.7%) didn’t use protective gears at work, and worked for more than 12 hours daily. Falling rocks were the leading cause of injury (18.2%), and majority sustained multiple injuries (33%). Of the patients seen, 41.3% died. The following were more likely to die than others; Primary education (p = 0.04), Less than 5 years work experience (p = 0.000), unintentional injuries (p = 0.000), fall injuries (p = 0.000) and sustaining multiple injuries (p = 0.000). Conclusion The burden of injuries and fatalities demonstrated in this study, point to the need for implementation and monitoring of the use of safety equipment and operating procedures of the mines by government and other regulatory authorities. Initiation of pre hospital care at the mines and improved emergency medical service delivery at health centers in Tanzania.