Yuen Wai Hung

Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study

Background. Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low‐ and middle‐income countries where more than 90% of injury‐related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low‐ and middle‐income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital‐based trauma registries. Methods. From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes. Results. A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries. Conclusion. Hospital‐based trauma registries can be important sources of data to study the epidemiology of injuries in low‐ and middle‐income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality‐of‐care improvement programs.

Understanding patterns of injury in Kenya: analysis of a trauma registry data from a National Referral hospital.

Background. Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility‐based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes. Methods. An electronic, tablet‐based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in‐patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in‐patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes. Results. A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in‐hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity. Conclusion. The establishment of hospital‐based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.

Characteristics of Moderate and Severe Traumatic Brain Injury of Motorcycle Crashes in Bandung, Indonesia

BACKGROUND Traumatic brain injury (TBI) constitutes a critical public health and socioeconomic problem. As one of the leading causes of mortality and disability from road traffic crashes, the incidence of TBIs is increasing with increasing motor vehicle usage. Understanding the prevalence and describing the characteristics of TBI are crucial for successful implementation of prevention and treatment efforts to reduce the mortality and morbidity caused by TBIs. METHODS We studied cases of moderate and severe TBI resulting from motorcycle crashes from January 1, 2013 to June 30, 2014. Variables studied included sex, age, time interval (from crash to arrival at the emergency department), alcohol consumption, helmet use, severity of TBI, choice of treatment, and the outcome. RESULTS A total of 2108 head injury cases were seen at the emergency department during this period, 1324 (62.8%) of which resulted from motorcycle crashes. Of those cases, 30.7% (407 cases) were categorized as moderate or severe TBI with 29.2% mortality. Most of the patients were male (80.8%), <60 years old (96.1%), and did not wear a helmet (71.2%). More than half of the cases (56.7%) arrived at the emergency department within 6 hours, 14.0% of the cases were under alcohol intoxication, and 37.8% of the cases were operated on. CONCLUSIONS This preliminary analysis highlights the need to address road safety, especially with respect to helmet use and drink driving, to reduce the burden of TBIs in Bandung.

Exploring injury severity measures and in-hospital mortality: A multi-hospital study in Kenya

INTRODUCTION Low- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya. METHODS This study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations. RESULTS A total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866-0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852-0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736-0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures. CONCLUSIONS This multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya.

Prevalence, knowledge, attitude and practice of speeding in two districts in Kenya: Thika and Naivasha

INTRODUCTION In Kenya, RTIs had the second highest increase in disability-adjusted life years between 1990 and 2010, compared to other conditions. This study aims to determine the prevalence, knowledge, attitudes and practices for speeding in Thika and Naivasha districts in Kenya. METHODS Direct observations of vehicle speed were conducted at various times during the day and different days of the week on six roads selected based on a multi-stage sampling method in two districts to determine the prevalence of speeding. Roadside KAP interviews were administered to drivers, at motorcycle bays, petrol stations, and rest areas. RESULTS Eight rounds of speed observations and four rounds of KAP interviews were conducted between July 2010 and November 2012. Results from the speeding observational studies show an overall high proportion of vehicles speeding above posted limits in both districts, with an average of 46.8% in Thika and 40.2% in Naivasha. Trend analysis revealed a greater decline in this prevalence in Thika (OR: 0.804, 95% CI: 0.793-0.814) than in Naivasha (OR: 0.932, 95% CI: 0.919-0.945) over the study period. On average, 58.8% of speeding vehicles in Thika and 57.2% of speeding vehicles in Naivasha travelled at 10 km/h or higher above speed limit. While the majority of respondents agreed that speeding is a cause of road traffic crashes in both Thika (70.3%) and Naivasha (68.7%), knowledge of speed limits at the location of the interview was limited. Enforcement levels also remained low, but subsequent rounds of data collection showed improvement, especially in Thika. CONCLUSIONS This study demonstrates an improvement in the prevalence of speeding in two districts of Kenya over 2010-2012. It also highlights the need for further action to be taken to address the problem, and represents new data on speeding in Kenya and Africa.

PW 0706 Using injury severity measures in trauma research – a review from low- and middle- income countries

Injury remains a major public health problem globally, but 90% of all trauma deaths occur in Low-and-Middle-Income-Countries (LMICs), where resources to deal with this crisis are inadequate. Characterization of injury severity is an important pillar of scientific research to measure and compare the outcomes, in order to improve the quality of care. Although no single injury measure is considered the best or the most comprehensive, many have been formulated over time with a wide range of methodologies and are being used in both high-income-countries and LMICs. We conducted the following study to summarize the evidence on performance of injury severity measures based on empirical validation analysis and their applicability in LMIC settings. A systematic search of PubMed, Global Health, and EMBASE on literature published in LMICs from January 2006 through June 2016 was undertaken. We conducted a detailed literature review to assess the application and performance of injury severity measures to predict in-hospital mortality. Studies that applied one or more global injury severity measure(s) on all types of injuries were included, except for those that focused only on war injuries, poisoning, drowning, and ocular trauma. Out of 3862 non-duplicate citations, 597 studies from fifty-four LMICs were listed as eligible studies. Full text review revealed 37 studies describing performance of injury severity measures for outcome prediction. Twenty-five articles from thirteen LMICs assessed the validity of at least one injury severity measure for in-hospital mortality. ISS was the most commonly validated measure in LMICs, with a wide range of performance (AUROC between 0.9–0.65). TRISS validation studies reported AUROC between 0.80 and 0.98. Empirical studies from LMICs frequently utilize injury severity measures, however, no single injury severity measure has shown a consistent result in all settings or populations and thus warrants further validation studies.

Helmet wearing in Kenya: prevalence, knowledge, attitude, practice and implications☆

OBJECTIVES In light of the increasing prevalence of motorcycles on Kenyan roads, there is a need to address the safety of individuals using this mode of transport. Helmet use has been proven to be effective in preventing head injuries and fatalities in the event of a crash. This study aims to understand the prevalence of helmet use as well as knowledge, attitudes, and practices in two districts in Kenya over a 5-year period (2010-2014). STUDY DESIGN Observational studies on helmet use at randomly selected locations throughout each district were done every quarter to estimate the prevalence of helmet use. Roadside knowledge, attitude, and practice (KAP) surveys were done two times a year in each district. METHODS Helmet use among motorcycle drivers and passengers in Thika and Naivasha was assessed through systematic observations at randomly selected locations in the two districts between August 2010 and December 2014. Roadside KAP surveys were administered in both sites to motorcyclists in areas where they stopped, including motorcycle bays, petrol stations and rest areas near the helmet observation sites. Secondary analysis of trauma registries was also used. Negative binomial regressions were used to assess trends of helmet wearing among motorcyclists over time, and logistic regressions were used to analyze associated risk factors as well as association with health outcomes among those admitted to the four hospitals. RESULTS A total of 256,851 motorcycles were observed in the two target districts during the study period. Overall, prevalence of helmet use among motorcycle drivers in Thika and Naivasha across all periods was 35.12% (95% confidence interval [CI]: 34.87%-35.38%) and 37.42% (95% CI: 37.15%-37.69%) respectively. Prevalence of helmet wearing remained similar after the passage of a traffic amendment bill. These results were not statistically significant in either Thika or in Naivasha. Data from the KAP survey showed that respondents recognized the life-saving effect of wearing a helmet, but many did not always wear a helmet because they found it inconvenient/uncomfortable. Analysis of trauma registry data showed that helmet wearing was associated with a significant reduction in head injuries among motorcyclists (adjusted odds ratio: 0.472, 95% CI: 0.327-0.684). CONCLUSIONS This study highlights the low prevalence of helmet use and documents the potential reduction in the risk of head injuries to motorcyclists if this risk factor was addressed. The passage of a traffic amendment bill showed negligible impact on helmet use. This highlights the need for a multi-faceted strategy that includes media campaigns and widespread enforcement in addition to legislative change for improving helmet use.

117 Long-term health, economic, and social impact of injury in four low- and middle-income countries

Background With 90% of the burden of injuries concentrated in low- and middle-income countries (LMICs), the impact on individuals, families, and society, especially in the case of non-fatal injuries, is exacerbated by the absence of insurance or social support mechanisms. There is a dearth of information in the literature on the occurrence of non-fatal injuries, and their long-term consequences. This study aims to understand the health (disability), social and economic impact of injuries in LMICs. Methods This is a prospective cohort study of 4200 moderate to severely injured patients at seven government hospitals in four LMICs (Cambodia, Kenya, Malaysia, and Vietnam). We administer a baseline and four follow-up surveys at home (at 1, 2, 4, and 12 months after discharge) to participants about their injury, functioning and disability, medical costs, employment, household composition and roles, as well as support systems (social & economic). Results The on-going study has enrolled 2293 individuals at the seven hospitals (Cambodia: 595, Kenya: 320, Malaysia: 284, and Vietnam: 1094). Participants are 72–84% male, with an average age of 30–42 years. The top cause of injury across all countries is road traffic injury (47–72%). The second leading cause is falls (17–20%), except for Kenya, where assaults rank second (20%) and falls rank third (16%). Changes in levels of disability, health care costs, productivity, household economic status, and roles of family members, as well as the respective influencing factors will be examined using marginal models with Generalised Estimating Equations (GEE) approach. Conclusions Injury predominantly affects young males at their prime, having a significant impact not only on themselves, but their family as well as the society. This study will lead to a better understanding of the far reaching health, social, and economic impact of injuries. Data collected could be used to guide policy and programs in each of the implementing countries.

869 Road traffic injuries in kenya: a hospital-based surveillance study

Background Road Traffic Injuries (RTIs) are a leading cause of disability and mortality worldwide with a disproportionate burden in Low-and Middle-Income Countries (LMICs). RTIs account for 3.6 percent of the global mortality burden [1]. Additionally, the risk of death from injuries in LMICs is six times more likely than in High Income Countries (HICs)[2]. RTIs are estimated to be the fifth leading cause of disability-adjusted life-years (DALYs) lost by 2030 worldwide[3]. Data defining the burden of injury, risk factors and outcomes of RTIs in LMICs are limited. Our study analyses RTIs seen in the casualty departments at four regional referral hospitals in Kenya. Methods Electronic-based trauma registries were developed at four regional hospitals in Kenya: Kenyatta National, Thika, Meru and Machakos. Information on mechanism of injury, injury severity, patient outcomes, and patterns of care (pre-hospital and hospital-based) was collected prospectively between January 2014 to September 2015. Results A total of 6429 patients were enrolled. Patients were predominantly male (78.5%), young (median age 27.6 years) and arrived mainly by car/taxi (49.4%), mini bus (18.9%) or an ambulance (16.2%). Injuries were common amongst pedestrians (40.8%) and passengers (36.7%). Seatbelts were used by 7.2% of passengers. Body regions most commonly injured were the extremities (54%) and head (22.7%). The overall mortality rate was 2.2%. Predictors of RTI deaths were moderate head injury [GCS 9–12] (OR 6.4, 95% CI: 4.0–10.1), severe head injury [GCS ≤ 8] (OR 71.5, 95% CI: 49.7–102.8), moderate ISS [ISS 9–15] (OR 3.6, 95% CI: 2.5–5.1) and severe ISS [ISS > 15] (OR 9.4,95% CI: 5.7–15.2). Conclusions RTIs contribute significantly to the burden of disease in Kenya. A renewed focus on addressing this burden through the development of a trauma care system is necessary. Trauma registries can be used as a plausible tool to identify priority areas for quality improvement and injury prevention.

1034 Level of disability among adult injury patients in Kenya

Background Low- and middle-income countries have a disproportionally high burden of injuries. However, the short and long-term consequences of injuries on individuals remain largely unknown. While studies have found injuries among the top three causes of death among the urban poor in Kenya, little is known about the aftermath of injury among survivors in this largely young population. Methods The Health, Economic and Long-term Social Impact of Injuries (HEALS) Study is currently being conducted in Kenya. Adult patients at least 18 years old who are hospitalised due to injury for one day or more in Kenyatta National Hospital are recruited to the longitudinal study. Baseline interview is conducted in the hospital, and follow-up interviews, at 1, 2, 4, and 12 month after hospital discharge, are completed via phone. Baseline interview includes questions about the injury that resulted in hospitalisation, associated costs and support received. Disability is measured using WHO Disability Assessment Schedule-II (WHODAS-II) at baseline and each subsequent follow-up interview. Results Preliminary findings of the 320 respondents who completed the baseline interview show that majority (92.8%) reported having no difficulty on all 6 domains of functioning prior to their injury (mean: 0.23, SD: 1.19). At 1 month after hospital discharge, only 4.9% respondents (n = 247) reported having no difficulty in all domains of functioning (mean: 14.39, SD: 15.97). Exploratory factor analysis will be conducted to determine if the disability measure correlate with latent general disability in this population. Distribution of the disability score will be examined by severity of injury and types of injury. Conclusions Preliminary findings suggest high level of disability at one month after hospital discharge. Data on subsequent follow-ups will strengthen the findings on short- and long-term burden of injuries in Kenya.