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EPIDEMIOLOGY AND PREVENTION OF
NON-INTENTIONAL INJURIES

by Dr PHUA Kai Lit
School of Medicine and Health Sciences
Monash University Sunway Campus
Bandar Sunway, Malaysia


INJURIES

Injuries are a MAJOR cause of disability, morbidity (sickness) and mortality (death) in middle income developing countries and in rich countries. People aged between 15-35 are more likely to die of injuries than of disease! In the rich countries, they are the leading cause of death for babies and young children (besides congenital conditions)

According to the World Health Organization, about 1.2 million people are killed in road traffic crashes around the world each year. Furthermore, figures from the World Health Organization and the World Bank suggest another 50 million people may be left injured by crashes annually.

Information on injuries

Non-intentional injuries

Non-Intentional Injuries versus Intentional Injuries

Non-intentional injuries: injuries that are not purposely inflicted e.g. traffic injuries, falls, poisonings, drownings, suffocations, burns, electrocutions, radiation, iatrogenic injuries (injuries caused by doctors and other healthcare providers)

We can also classify injuries by place of occurrence (e.g. home injuries, workplace injuries) or by other criteria (e.g. sports/recreational injuries, occupational injuries)
Examples of dangerous sports include gymnastics, boxing and weight-lifting

Intentional injuries: caused on purpose e.g. physical assaults, sexual assaults, self-inflicted injuries such as suicide, mass violence (e.g. war), legal interventions (executions)

Note that if a car is used to run down another person, then the injury which results is an intentional injury!

Epidemiology and Prevention of Non-Intentional Injuries

(1) Identify risk factors (ethnicity, class, gender, age, region, education, occupation, marital status
(2) Identify time and place of occurrence i.e. occurence of injuries may "cluster" in time and place
(3) Design a prevention programme and an Emergency Medical Services (EMS) programme

Haj injuries and deaths from poor crowd control

Falls

Falls are the leading cause of injury-related morbidity for all age groups and of injury-related mortality for the "old old" (people over 75 years old).

Elderly: Fractures of vertebrae, hip and forearm most common. Hip fractures from falls can lead to person being bed-ridden (elderly with osteoporosis are at high risk of getting hip fractures from falls). Other sites of injury from falls - leg, ankle, upper arm and hand.
Elderly who suffer from Parkinson's Disease, who have a history of stroke or arthritis or who have cognitive or visual impairments are at higher risk

Young children: falls can lead to serious head injuries
Falls from high buildings
Falls from open windows (these can be prevented by the installation of windows that cannot be opened easily by kids or by installing metal grilles)
Falls from verandahs of kampung houses in rural areas
Falls down stairs (these can be prevented by the installation of simple gates at the top of stairs)
Tripping over objects within the home
The use of unstable baby walkers can also lead to fall-related injuries in young children
Falls can be reduced by removing slippery rugs, putting non-slip mats in bath tubs, installing grab bars and handrails, and by installing better lighting.

Poisonings

Young children are highly susceptible e.g. drinking cleaning liquids, kerosene (rural areas), eating parts of poisonous houseplants, ingesting medicines
---> Keep medicine in "childproof" containers in locked cabinets
---> House with babies and small children needs to be a "childproof" house
e.g. Tight containers, locked cabinets, keep things out of reach

Elderly: adverse drug interactions are possible because of "polypharmacy" (i.e. an elderly person taking many kinds of drugs for different health conditions

Drug abusers: drug overdose
Accidental poisoning can also occur when alcohol is consumed along with chemicals such as barbiturates.

Poisonings can also be job-related e.g. pesticide or herbicide poisoning in agricultural workers, Drownings

Young children are at high risk

Young children can drown in:
Small pails or buckets of water in places like the bathroom!
Bath tubs
Toilets
Swimming pools (unfenced)

Older children: mining pools

Rural kids: wells, drains, canals, rivers, etc. The risk increases during the monsoon season because kids are unable to tell which areas are deep and which areas are shallow under flood conditions.

Alcohol consumption increases the risk of drowning in adults

Suffocations

This is a major cause of injury-related mortality for children under 1 year old

Children can suffocate in plastic bags. Therefore, children should not be allowed to paly with plastic bags

Children can also choke on food, toys, and swallowed objects.
Thus, consumers need to be careful about what kinds of toys to buy for their children e.g. toy animals with eyes which detach easily are a choking hazard since small children may put these in their mouths.

Burns and Scalds

Boiling water and steam can result in scalds or serious injury
Other hot liquids e.g. hot soup, hot coffee, hot tea
Highly acidic or highly alkaline material can also cause injury

Fires
Squatter housing - fires can spread very quickly because houses are constructed of highly flammable material, they are located close together, and fire trucks may have difficulty reaching the houses because of narrow or blocked lanes. The use of candles and oil lamps rather than electricity increases the risk of fires
No fire alarm in the house
No sprinkler system
Flammable material piled up in the house
Flammable clothing, curtains, etc
Smoking in bed
Cooking or heating methods can also be fire hazards e.g. wood fires in the house.

The kitchen and the bathroom are dangerous places!

Electrocutions and Radiation

Faulty wiring, frayed wiring increases the risk of electrocution (as well as fires)
Poor quality electrical equipment also increases the risk

Radiation
This can be ionizing radiation or non-ionizing radiation

Non-occupational exposure:
Exposure that is not related to work e.g.exposure to radon gas within the home

Occupational exposure:
Uranium miners
Lab workers
X-ray technicians
Traffic police using scanners in USA - testicular cancer
Iatrogenic Injuries

Recently, these have been recognised as among the top 10 leading casues of morbidity and mortality in countries like the USA
Caused by healthcare workers such as doctors, surgeons, nurses, pharmacists etc

---> surgical errors e.g. leaving surgical tools/material in the body after an operation
---> medical mistakes e.g. prescribing a patient with incorrect drugs for the medical condition which the patient is experiencing
---> drug overdoses for kids and elderly e.g. prescribing correct drugs in wrong dosages
---> adverse drug interactions
---> misprescription by the pharmacist e.g. cannot read the doctor's illegible handwriting and gives the wrong drug or in a wrong dose!
---> adverse events caused by medications
---> medical devices e.g. catheters infected with bacteria, equipment malfunction (such as X-ray machines that emit excessively high doses of electro-magnetic waves)

Workplace Injuries

Lower back injuries are the most common

Other injuries - chemical poisonings, falls, electrocutions, etc

Repetitive motion injuries e.g. carpal tunnel syndrome

Agriculture, mining, quarrying and construction are dangerous occupations

Road Traffic & Transportation Injuries

These are a major cause of disability, morbidity and mortality in nations all over the world. The interesting fact is that rates tend to be lower in rich nations as compared to middle income developing nations.

Car crashes
Motorcycle crashes
Bicyclists
Pedestrians
Other - plane crashes, train derailments, truck (lorries), boating injuries

* When we compare rates (and not absolute numbers), the motorcycle is the most dangerous mode of transportation (high injury and death rates in relation to other modes)!
Motorcycle crashes have been reduced by headlight regulation, special motorcycle lanes which separate them from cars
Severity reduced by wearing of helmets, protective clothing

Risk Factors for Motor Vehicle Crashes

Risk factors in humans (HOST)
Male
Young
Lack of driving experience
Alcohol consumption - this is a major risk factor
Dangerous driving - speeding, aggressive driving
Risk factors in the vehicle (AGENT)
Condition of the car - tyres, brakes, lights etc
Small car - offer less protection for passengers
SUVs (Sports Utility Vehicles) - some of these are more likely to "roll over" and cause serious injury
Risk factors in road conditions (ENVIRONMENT)
Bad weather e.g. wet roads, fog
Sharp curves in the road
Trunk roads in Malaysia - these are actually more dangerous than highways because they are only two lane and head on crashes are more likely to occur. Also, they are likely to have more curves than highways

Lowering Disability, Morbidity and Mortality from Car Crashes

WHO on road traffic injuries

Road Safety in UK

1. Passive and active strategies
Passive i.e. person does not need to do anything (take action)e.g. automatic airbags
Active i.e. person needs to take action e.g. seat belts that need to be fastened, car seats for kids

2. Four E's of Intervention

Engineering/Environmental Modification, Economic, Enforcement, Education

Engineering/Environmental Modification - building safer cars (special glass in windshields, collapsible steering column, stronger car frame, anti-skid devices, better tyres)

- modifying the driving environment (crash barriers, non-rigid lamp posts, special lanes for motorcycles, better lighting, bumps to discourage speeding etc)

Building safer cars

Economic - economic incentives (to encourage safer behaviour)and disincentives (to discourage high risk behaviour) e.g. high taxes on alcohol (since alcohol consumption is a major risk factor), heavy fines for dangerous driving, Govt tax deductions or subsidies for buying safety devices such as child seats, lower insurance charges for drivers with good driving records

Enforcement - laws, traffic police, courts, jail sentences for dangerous driving, punishment for driving under the influence of alcohol

Education - road safety campaigns, better driver education

3. Using the Haddon Matrix

You should know what the Haddon Matrix is, i.e., a 3 X 3 table with "pre-event", "during the event", and "post-event" on the left hand side and, across the top of the table, "human" (AGENT), "vehicle" (HOST), and "environment" (ENVIRONMENT).

Sometimes, the Haddon Matrix is expanded to a 3 X 4 table with "human", "vehicle", "physical environment" and "social environment" on the top.

The Haddon Matrix

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