Current trends and update on injury prevention

Abstract

Injuries are a major and growing public health problem, a leading cause of death and disabilities among people aged 1-44 years around the world. Each year, 5.8 million people die from injuries, accounting for 10% of the world's deaths. Road traffic injuries (RTIs), self-inflicted injuries and violence are the top three leading causes of all injury deaths, while RTIs, falls and drowning are the top three leading causes of unintentional injury death. In many high-income countries, trends of injury death have been decreasing as a result of prevention measures. In contrast, trends in low- and middle-income countries have been rising. In this article, we review the prevention strategies for RTIs, violence, falls and drowning developed over decades to disseminate the knowledge and inform health care providers, especially acute care physicians, about the importance of injury prevention.

Full text

International Journal of Critical Illness and Injury Science | Vol. 1 | Issue 1 | Jan-Jun 2011 57
Symposium on Trends in Trauma
Current trends and update on
injury prevention
Parichat Curry, Ramesh Ramaiah, Monica S. Vavilala
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Website: www.ijciis.org
DOI:
DOI: 10.4103/2229-5151.79283
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Department of Anesthesiology and Pain
Medicine, Harborview Medical Center,
University of Washington, Seattle, WA,
USA
Address for correspondence:
Dr. Monica S Vavilala, Department of
Anesthesiology and Pain Medicine,
Harborview Medical Center, University
of Washington, 325 9th Avenue, Box
359724, Seattle, WA 98104, USA.
E-mail: vavilala@uw.edu
ABSTRACT
Injuries are a major and growing public health problem, a leading cause of death and
disabilities among people aged 1–44 years around the world. Each year, 5.8 million people
die from injuries, accounting for 10% of the world’s deaths. Road traffic injuries (RTIs),
self-inflicted injuries and violence are the top three leading causes of all injury deaths,
while RTIs, falls and drowning are the top three leading causes of unintentional injury
death. In many high-income countries, trends of injury death have been decreasing as a
result of prevention measures. In contrast, trends in low- and middle-income countries
have been rising. In this article, we review the prevention strategies for RTIs, violence,
falls and drowning developed over decades to disseminate the knowledge and inform
health care providers, especially acute care physicians, about the importance of injury
prevention.
Key Words: Injury prevention, mortality, road traffic injury, violence
INTRODUCTION
Injuries are the leading cause of death and disability
among children and young adults around the world.[1]
Injury is a physical damage to the body, resulting from
various kinds of energy (mechanical, thermal, electrical,
chemical or radiant) in amounts that exceed the threshold
of physiological tolerance, or from the absence of essentials
(such as heat or oxygen). Injury can be categorized
into unintentional [i.e. road traffic injuries (RTIs) and
drowning] and intentional (i.e. suicide, homicide).[2] In
this article, we review the current prevention strategies
to encourage and inform health care providers about
the importance of this area. Approximately 5.8 million
people die from injuries each year, accounting for 10% of
the world’s deaths. Globally, the three leading causes of
death from injuries are RTIs (23%), self-infl icted injuries
(15%) and violence (11%) [Figure 1]. For unintentional
injuries, RTIs are the leading cause of death, followed by
falls and drowning[1,3] [Table 1].
The consequence of injuries is not only death. Millions
of people die from injuries and substantial numbers
of people are le with either temporary or permanent
disabilities. An estimated 16% of all disabilities globally
are caused by injuries.[1,3] The eff ects of injuries are both
emotional and fi nancial, impacting individual, family and
friends along with the entire nation. The costs derive from
the cost of treatment, non-medical expenditure and loss of
productivity of the individual and family members who
need to take time off from work to care for patients. For
example, RTIs have been estimated to cost US$ 518 billion
globally, of which US$ 65 billion is accounted for by
low-income countries (LICs). Approximately 1% of gross
national product (GNP) in LICs, 1.5% in middle-income
countries (MICs) and 2% in high-income countries (HICs)
are a ributed to costs of RTIs.[3,4]
Road traffic
injuries
23%
Others
unintentional
injuries
21%
Self-inflict ed
injuries
15%
Violence
11%
Falls
8%
Drownings
7%
Poisonings
6%
Fires
6%
Wars
3%
Figure 1: Causes of injury deaths (source: Global Burden of Disease, 2004)
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International Journal of Critical Illness and Injury Science | Vol. 1 | Issue 1 | Jan-Jun 2011
58
Table 1: Leading causes of death by age group, both sexes
Rank Age group (years)
0–4 5–14 15–29 30–44 80+ All ages
1 Perinatal causes
3,180,174
Lower respiratory tract
infections
224,308
Road traffi c injuries
335,805
HIV/AIDS
958,851
Ischemic heart disease
2,072,949
Ischemic heart disease
7,198,257
2 Lower respiratory tract
infections
1,755,385
Road traffi c injuries
109,905
HIV/AIDS
333,953
Tuberculosis 367,837 Cerebrovascular disease
1,864,012
Cerebrovascular disease
5,712,241
3 Diarrheal diseases
1,716,410
Malaria
103,905
Tuberculosis
249,023
Road traffi c injuries
329,837
Chronic obstructive
pulmonary disease
960,598
Lower respiratory tract
infections
4,109,354
4 Malaria
828,666
Drowning
77,117
Violence
238,003
Ischemic heart disease
255,842
Lower respiratory tract
infections
674,079
Perinatal causes
3,180,421
5 Measles
396,072
Meningitis
63,755
Self-infl icted injuries
230,979
Self-infl icted injuries
19,557
Alzheimer and other
318,868
Chronic obstructive
pulmonary disease
3,024,912
6 Congenital anomalies
370,785
Diarrheal diseases
57,716
Lower respiratory tract
infections
122,707
Violence
179,916
Hypertensive heart disease
311,973
Diarrheal diseases
2,127,154
7 HIV/AIDS
258,861
HIV/AIDS
43,118
Drowning
89,434
Lower respiratory tract
infections
154,950
Diabetes mellitus
246,218
HIV/AIDS
2,039,727
8 Whooping cough
254,314
Tuberculosis
38,074
Fire-related burns
84,983
Cerebrovascular disease
147,224
Trachea, bronchus, lung
cancers
185,916
Tuberculosis
1,463,792
9 Meningitis
156,304
Protein-energy malnutrition
36,232
War-related injuries
66,319
Cirrhosis of the liver
101,593
Nephritis and nephrosis
172,709
Trachea, bronchus, lung
cancers
1,323,218
10 Tetanus
144,325
Fire-related burns
26,703
Maternal hemorrhage
65,077
Poisoning
87,576
Colon and rectum cancers
162,987
Road traffi c injuries
1,274,845
11 Protein-energy malnutrition
135,517
Measles
24,202
Ischemic heart disease
59,102
Maternal hemorrhage
71,774
Stomach cancer
148,299
Diabetes mellitus
1,140,881
12 Syphilis
63,857
Leukemia
20,861
Poisoning
55,139
Fire-related burns
67,338
Infl ammatory heart disease
122,263
Malaria
1,021,028
13 Drowning
58,467
Congenital anomalies
19,942
Abortion
46,335
Nephritis and nephrosis
66,154
Prostate cancer 109,217 Hypertensive heart disease
986,560
14 Road traffi c injuries
56,778
Trypanosomiasis 18,583 Leukemia
44,388
Drowning
62,683
Falls
100,954
Self-infl icted injuries
844,460
15 Fire-related burns
46,656
Falls
17,862
Cerebrovascular disease
40,827
Breast cancer
57,370
Breast cancer
80,322
Stomach cancer
803,095
Source: Injury and Violence: The Facts, 2010
Curry, et al.: Current Trends and Update on Injury Prevention
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International Journal of Critical Illness and Injury Science | Vol. 1 | Issue 1 | Jan-Jun 2011 59
Injuries have been traditionally thought of as accidents or
random events. This has resulted in a global neglect of this
area of public health. However, injuries are preventable
by changing the environment, individual behavior,
product, social norms, legislation and governmental and
institutional policies to reduce or eliminate risks and
increase protective factors.[5]
ROAD TRAFFIC INJURIES
An RTI is any injury secondary to crashes originating,
terminating or involving a vehicle partially or fully
on a public highway.[2] RTIs are a huge and growing
public health problem. In 2004, reported RTIs killed
1.3 million people worldwide, accounted for 2.2% of
global deaths and ranked as the ninth leading cause of
death. It is predicted to rise in rank to become the fi  h
leading cause of death by 2030 [Table 2]. More than
50% of road traffi c deaths occur among young adults
aged between 15 and 44 years and the mortality rate
for males is almost three times greater than that for
females.[1,3,4,6] Ninety percent of RTIs occur in low- and
middle-income countries (LMICs) which have only
half of the world’s registered vehicles. Almost half
of the global RTI deaths are vulnerable road users
(cyclists, pedestrians and motorcycle riders) and 48%
are car occupants.[1,3,4,6] In 2005, the United Nations
adopted third Sunday of November as the “World Day
of Remembrance of Road Traffi c Victims” in order to
acknowledge the road traffi c victims and their families.
Motorcyclists
Motorcycles are an important, but also a dangerous
means of transportation in LMICs. Motorcyclists have
the highest risk for injury and death in a motor vehicle
crash among all vehicle users. Motorcyclists are found
to be 37 times more likely to die in a motor vehicle crash
than passenger car occupants and 9 times more likely
to be injured.[7] In most countries in Southeast Asia,
motorized two- and three-wheelers account for more
than 60% of registered vehicles. In Vietnam, motorcycle
injuries account for 59% of road traffi c injuries.[8] The most
common site of all motorcycle related injuries is lower
extremity (30–70%), while head injuries are the leading
cause of death in motorcycle crashes.[9] Alcohol is a major
risk factor for fatal motorcycle crashes. The effects of
alcohol on motorcycle riding skills can be observed at
blood alcohol concentration (BAC) as low as 0.05 g/dl.
Not only does alcohol impair the riding performance
but also intoxicated motorcyclists are less likely to wear
a helmet.[7,10]
Prevention: Motorcycle helmets were found to reduce
the risk of death by 42% and the risk of head injury by
69%.[11] However, motorcycle helmets are underused.
In China, 72.6% of drivers and 34.1% of passengers are
reported using helmets.[12] In Vietnam, the prevalence of
helmet use ranges from 23.3 to 30%.[13] One study from
Pakistan reports that approximately 56% of motorcyclists
wear helmets.[14] It has been suggested that legislation
might increase helmet use among people. One study
from Vietnam showed that helmet use increased from
27 to 99% and the risk of road traffi c head injuries and
death decreased by 16 and 18%, respectively, as a result
of motorcycle helmet legislation.[15] Motorcyclists of age
25 years or more, having a higher education and higher
income are more likely to wear a helmet.[12-14] Asia Injury
Prevention (AIP) foundation is a non-profi t organization
that works to reduce the rate of RTIs and fatalities in
LMICs by creating public–private partnerships, as well
as developing and implementing traffi c safety education
programs. In 2009, the AIP foundation together with
the World Bank Global Road Safety Facility introduced
an international campaign, the Global Helmet Vaccine
Initiative, to promote motorcycle helmet wearing in
LMICs in Africa, Asia and Latin America (AIP).[16]
Bicyclists
The bicycle is a recreational vehicle in HICs, especially
for children and young adults; but in LMICs, bicycles
are used for necessary modes of transportation. In HICs,
the United States for instance, there were 716 deaths and
almost 500,000 injuries treated due to bicycle crashes in
2008. Children aged 5–14 years have the highest bicycle-
related injury rate.[17] In LMICs such as China, bicycle-
Table 2: Leading causes of death: Comparison of causes in
2004 and predicted causes in 2030
Rank 2004 Disease or injury Rank 2030 Disease or injury
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
22
Ischemic heart disease
Cerebrovascular disease
Lower respiratory tract
infections
Chronic obstructive
pulmonary disease
Diarrheal diseases
HIV/AIDS
Tuberculosis
Trachea, bronchus, lung
cancers
Road traffi c accidents
Prematurity and low birth
weight
Neonatal infections and
others
Diabetes mellitus
Malaria
Hypertensive heart disease
Birth asphyxia and birth
trauma
Self-infl icted injuries
Stomach cancer
Cirrhosis of the liver
Nephritis and nephrosis
Colon and rectum cancer
Violence
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Ischemic heart disease
Cerebrovascular disease
Chronic obstructive pulmo-
nary disease
Lower respiratory tract
infections
Road traffi c accidents
Trachea, bronchus, lung
cancers
Diabetes mellitus
Hypertensive heart disease
Stomach cancer
HIV/AIDS
Nephritis and nephrosis
Self-infl icted injuries
Liver cancer
Colon and rectum cancer
Esophagus cancer
Violence
Source: Injury and Violence: The Facts, 2010
Curry, et al.: Current Trends and Update on Injury Prevention
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International Journal of Critical Illness and Injury Science | Vol. 1 | Issue 1 | Jan-Jun 2011
60
related deaths account for 30% of all road traffi c deaths.
In India, 12–21% of road traffic deaths occur among
bicyclists.[4] Extremities and head/neck region are the
primary parts aff ected by bicycle-related injuries.[18,19]
Brain injuries are the most common cause of bicycle-
related death.[20,21] Risk factors of serious injuries are
collision with motor vehicle, self-reported speed of >15
mph, age of <6 and >39 years.[22]
Prevention: Studies from HICs suggest that bicycle
helmets can reduce the risk of head, and brain injury
by 63–88% in all ages. Injury to the upper and mid face
areas can also be reduced by 65%.[23] Even in the United
States, only half of the children (48%) always wear
helmets, whereas 29% are reported to never wear their
helmet.[24] Factors associated with helmet use are race,
ethnicity, child age, household income, household
education, and helmet law status.[25] A Canadian study
demonstrated that the bicycle-related mortality rate in
children, 1–15 years of age, signifi cantly decreased by 52%
a er helmet legislation.[26] There are no data from LMICs.
Pedestrians
In the United States, 2008 data show that 4378 pedestrians
were killed and 69,000 pedestrians were injured in road
traffi c crashes.[27] Globally, children aged 5–14 years are at
a maximum risk of pedestrian related injuries. In LMICs,
child pedestrians comprise 30–40% of all road traffic
deaths as the road is a shared space for driving, walking,
cycling and playing for children.[28] Risk factors for child
pedestrian injury are male, younger age, belonging to
low income family, high volume of traffi c, high vehicle
speed, high street vendor density and absent lane
demarcations.[29,30]
Prevention: One systematic review of 15 randomized
controlled trials (RCTs) of pedestrian safety education
showed that safety education can improve the children’s
knowledge and change the road crossing behavior, but
there is no evidence on pedestrian injury.[31] Speed is a
major risk factor for road crashes and severity of injuries
from crashes. The probability of pedestrian death from
road crashes increases signifi cantly when the speed is
over 30 km/h.[28] In The United Kingdom, 20 mph speed
zones, as part of traffi c calming, have been established
since 1986. It has been shown that road casualties reduce
by 40% and have the greatest eff ect in children aged 0–15
years.[32] Alcohol does not affect only drivers but also
impacts pedestrians. According to National Highway
Safety Traffi c Administration (NHSTA) data, in 2008, 48%
of pedestrian deaths in traffi c crashes in the United States
were alcohol related.[27] Mobile phone use is another
risk factor. Studies have shown that both drivers and
pedestrians who talk on mobile phone while driving or
crossing the road are at increased risk due to cognitive
distraction.[33-36]
Most pedestrian fatalities occur in low-light
conditions.[27] Hence, interventions that improve
pedestrian visibility to drivers may reduce road traffi c
accidents. A recent Cochrane Database of Systematic
review which investigated the effect of light on road
traffic crashes involved 17 controlled before–after
studies (not RCTs) from HICs, demonstrating that street
lighting can prevent road traffic crashes, injuries and
fatalities. The risk of crash, injury-crash and fatal-crash
reduced by 55, 22 and 66%, respectively.[37] One review
of 42 studies comparing driver detection of pedestrians
or cyclists with or without visibility aids revealed that
fl uorescent materials in yellow, red and orange improved
drivers detection of pedestrians and cyclists during the
daytime. For nigh ime visibility, fl ashing lights and retro-
refl ective materials in red or yellow, particularly those
with a “biomotion” confi guration increased pedestrian
detection.[38]
Occupants
Alcohol consumption impairs cognitive ability and
decision-making skills of the driver. In 2008, 11,773 people
died in alcohol-impaired driving crashes, accounting
for 32% of the total motor vehicle traffic fatalities in
the United States.[39] In LMICs, 33–69% of drivers who
were fatally injured were positive for blood alcohol and
alcohol was found in 8–29% of the injured drivers.[28]
Some driving skills are impaired in most of the drivers
at BAC as low as 0.02 g/dl. The risk of involvement in
any crash increases signifi cantly with BAC at 0.04 g/dl
or higher.[40] Therefore, the WHO recommendation for a
blood alcohol concentration limit for driving is 0.05 g/dl
or less for the general population and 0.02 g/dl for young
drivers (20 years and younger).[7]
Prevention: Protective devices include seat belts and
airbags. Seat belts prevent ejection and reduce the
frequency and severity of occupant’s contact with the
vehicle’s interior during crashes, while airbags only
reduce the frequency and severity of occupant’s contact.
Lap-shoulder belts, when used correctly, can reduce
fatalities by 72% in frontal collision.[41] Airbags alone can
reduce mortality by 63%.[41] Airbags are most eff ective
when used together with seat belts, which can reduce the
mortality by more than 80% in frontal collision.[41] The use
of child restraints can reduce the risk of deaths during
traffi c collision by 71% in infants and 54% in children
aged 1–4 years.[42]
In the United States, the observed seat belt use rate in
2008 was 83%, and among fatally injured passenger
vehicle occupants, 55% of those killed were not
restrained.[42] In China, the prevalence of seat belt use
for drivers varies from 30 to 66%, while less than 10% of
front seat passengers wore seat belts.[43] The prevalence
of seat belt use in China increased by 12% due to the
interventions adopted from HICs which included
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International Journal of Critical Illness and Injury Science | Vol. 1 | Issue 1 | Jan-Jun 2011 61
enhanced police training and enforcement, social
marketing, and health education.[44] There are no other
data from LMICs.
Guidelines developed by the American Academy of
Pediatrics[45] and the National Highway Traffic Safety
Administration[46] for child passenger safety suggest
that infants should ride rear-facing in an infant seat
or convertible seat in the backseat as long as possible
until they have reached the height or weight limit for
the particular seat or at least 1 year of age and weigh 20
pounds. The safest position for children seats is in the
center rear. The risk of injury is 43% lower compared to
the right outbound position, whereas the front seat is
the least safe.[47]
When children have outgrown the rear-facing seats, they
should sit facing forward in children seats in the backseat
until they reach the upper weight or height limit. Then,
children should change to a booster seat secured to the
backseat when around 4 years of age or weigh around
40 pounds, until he or she is 4′9″ in height, i.e. when they
are around 8–12 years old. Children in belt positioning
booster (BPB) seats are 45% less likely to sustain injuries
compared to those in seat belts.[48] In China, the BPB use
increased from 15.5 to 85.5% as a result of knowledge-
plus-motivation video, designed for US audience,
translated into Mandarin.[49]
Violence
WHO defi nes violence as “The intentional use of physical
force or power, threatened or actual, against oneself,
another person, or against a group or community, that
either results in or has a high likelihood of resulting in
injury, death, psychological harm, maldevelopment or
deprivation”.[50] In 2004, around 1.6 million people died
due to violence worldwide, with a signifi cant proportion
(1.5 million) reported from LMICs.[1]
Intimate partner violence
Intimate partner violence (IPV) refers to behavior
within an intimate relationship that causes physical,
sexual or psychological harm, including acts of physical
aggression, sexual coercion, psychological abuse and
controlling behaviors.[50] The prevalence of IPV ranges
between 15 and 71%, and LICs tend to have higher
rates.[51] Risk factors of IPV can be categorized into four
levels: individual, relationship, community and societal
factors.[50,52] Risk factors for perpetrators are young age,
alcohol use, depression, personality disorders, hostility,
low income, low education and having experienced
violence as a child. Relationship factors are marital
conflict or instability, poor family functioning, and
male dominance. Community factors are poverty, weak
community sanction against IPV. Societal factors include
traditional gender norms and social norms supportive of
violence. Risk factors for victims are the same as and/or
associated with those for perpetrators: young age, low
income, low education, depression and alcohol use.
Studies from both HICs and LMICs show that 40–70% of
female murder victims are killed by their boyfriends or
husbands.[50,53] In 2007, 64% of female homicides in the
United States were commi ed by intimate partner or a
family member.[54]
The most common injuries are minor, such as scratches
and bruises, while more serious types of injuries such as
deep lacerations, broken bones or bullet wounds are less
common.[55] In the long term, IPV can result in chronic
health problems such as neurological defi cit, seizures,
chronic pain, gastrointestinal symptoms, sexually
transmi ed diseases, pregnancy, sexual dysfunction and
psychiatric problems including depression, pos raumatic
stress disorder, suicidal thoughts, and alcohol abuse.[56-58]
Prevention: Primary prevention aims to prevent IPV before
it occurs. Strategies include educational interventions
targeting young people to change individual a itudes,
risk-taking behaviors. The Safe Dates Program, an RCT
investigating the effects of school- and community-
based programs on the prevention of dating violence
among adolescents, has shown that physical and sexual
violence rates were reduced and mediating variables
were positively changed.[59] Secondary prevention aims
to detect or identify IPV in early stages. Reports from the
US Preventive Services Task Force and the Canadian Task
Force for preventive Health Prevention and Treatment
of Violence against women concluded that there was
insuffi cient evidence to recommend for or against routine
screening of adult women for IPV.[60,61]
Tertiary prevention focuses on long-term care such as
rehabilitation. A recent review of 10 RCTs found that
intensive advocacy interventions (12 hours or more
duration) were eff ective in reducing physical abuse, but
the eff ects on emotional abuse, depression, quality of life
and psychological distress were equivocal.[62] A meta-
analysis of 22 controlled ba erer intervention program
studies found that overall eff ects of ba erer intervention
program were in a small range.[63] There are explanations
why perpetrator’s programs have modest effects,
for instance, unidentified or untreated psychological
conditions, and substance use. Studies have shown that
alcoholism treatment, either individual or couples-based,
reduced intimate partner violence in both male-to-female
and female-to-male violence.[64]
Youth violence
Youth violence is violence involving people between the
ages of 10 and 29 years. In 2000, it was estimated that
199,000 youths died as a result of violence around the
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world. Africa and Latin America are the two regions of
the world that have the highest rates of youth homicide,
while western Europe and parts of Asia and the Pacifi c
have the lowest rates.[50] Risk factors for youth violence
are categorized into four types: individual, family, peer/
school and environmental/community.[50,65,66] Individual
risk factors are male gender, history of early aggression,
low IQ, substance use and exposure to media violence.
Family risk factors are low socioeconomic status, poor
parent–child relations, poor family functioning. Peer/
school risk factors are academic failure, and gang
membership. Environment or community risk factors are
crime, neighborhood drugs, community disorganization
and access to fi rearm. Protective factors are safeguards
which help prevent or reduce the chance of young people
from becoming violent. For this instance, individual/
family protective factors are high IQ, higher grades,
connectedness with parents and other adults.[67,68]
Prevention: Primary prevention aims to prevent the
onset of violence by reducing or changing risk of youth
violence. Secondary and tertiary prevention aims to
reduce violence in young people at risk or who already
have demonstrated violence. Prevention strategies should
target all levels: individual, relationship, community and
societal level. Strategies at individual level aim to increase
protective factors associated with individual skills,
a itudes and beliefs. Strategies targeted at relationship
level a empt to aff ect relationships of young people with
others. Strategies targeting community level are those that
a empt to modify community risk factors. Interventions
that change the social and cultural environment to
reduce violence are societal approaches.[50] Blueprints
for violence and prevention are a US violence prevention
initiative to identify the violence prevention programs
that are effective. The Blueprints has evaluated over
800 programs and reported 11 model programs and 19
promising programs.[69] The examples of model programs
are Life Skills Training (LST), the Midwestern Prevention
Project, the Olweus Bullying Prevention Program and the
Multi-System Therapy (MST).[69]
Strategies such as individual counseling, peer counseling/
peer mediation and gang prevention programs have not
been shown to be eff ective in reducing youth violence or
risk factors for youth violence.[50]
FALLS
A fall is an event which results in a person coming to
rest inadvertently on the ground or fl oor or other lower
level. Unintentional falls and fall-related injury are major
public health problems among older people. Each year,
approximately 424,000 people die from falls worldwide.
Over 80% of fall-related deaths occur in LMICs.[70] The
incidence of falls varies among countries. The prevalence
of falls in community-living Chinese Hong Kong is
26.4%.[71] Approximately 30% of people aged 65 years
or more fall each year and it increases up to 40% for
people aged over 75 years.[70,72] Approximately 40–60%
of falls lead to injuries, 10% result in serious injuries
and 5% being fracture.[70] Most common fractures are
hip fractures and fractures of upper extremities.[73] Falls
also have psychological impacts. People who have fallen
may develop a fear of falling which leads to a restriction
in physical and mental performance and increase the
risk of falling.[74] Risk factors for falls can be classifi ed
as intrinsic and extrinsic. Intrinsic factors are increasing
age, history of falls, female sex, use of medications such
as sedatives/hypnotics, benzodiazepines, psychotropic,
or diuretics, arthritis, impaired mobility and altered gait,
cognitive impairment, or visual impairment. Extrinsic
or environmental factors are environmental hazard,
footwear and inappropriate walking aids.[73-78]
Prevention: Many studies and reviews reported that
exercise, vitamin D supplement, expedited first eye
cataract surgery, multifactorial interventions and gradual
withdrawal of psychotropic medication are eff ective in
falls reduction. Exercise reduces the rate of falling by
17%. Diff erent types of exercise that target two or more
of the components such as strength, balance, fl exibility or
endurance are eff ective in reducing both the rate of falling
and the risk of fall. Eff ective exercise includes exercise
in supervised group, individually prescribed exercise
at home or Tai Chi.[79,80] Vitamin D at a dose of 700–1000
IU/day also has been found to reduce the risk of falling
by 19%.[81] Expedited fi rst eye cataract surgery has been
reported to reduce the rate of falling by 34% compared to
routine cataract surgery.[82] Multifactorial interventions are
found to be eff ective in reducing the rate of falls but not
the risk of falling.[79] A prescribing modifi cation program
for primary care physicians reduced the risk of falling,
and gradual withdrawal of psychotropic medication
reduces the rate of falls.[79] However, studies have failed
to demonstrate the eff ectiveness of some interventions
such as cardiac pacing[83] and home safety interventions.[79]
DROWNING
Drowning is defined as the process of experiencing
respiratory impairment from submersion/immersion
in liquid. Drowning outcomes are classified as death,
morbidity and no morbidity by the World Congress on
Drowning and World Health Organization in 2002.[84] Each
year, more than 175,000 children and teenagers die from
drowning, which makes drowning the second leading
cause of unintentional injury death for children under the
age of 18 years.[28] Ninety-seven percent of unintentional
drowning deaths occur in LMICs.[84] Children under 5
years of age have the highest drowning mortality rate
worldwide.[28,85,86] Drowning of most of the children,
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International Journal of Critical Illness and Injury Science | Vol. 1 | Issue 1 | Jan-Jun 2011 63
younger than 1 year of age, occurs in bathtubs or buckets.
[87] More than 50% of drowning among children aged
1–4 years in HICs occurs in swimming pools,[87] whereas
most drowning occurs in natural bodies of water in rural
areas in LMICs.[27,86,88] Globally, males have higher rates of
drowning than females at all ages, except in infants where
females have a higher rate of drowning than males.[84,85]
Prevention: Drowning mostly occurs when the child is
inadequately supervised or unsupervised.[87-89] A study
from Bangladesh showed that child supervision can be
increased by using supervision tools such as a playpen
and a door barrier.[90] A pilot study from Bangladesh
demonstrated that a drowning prevention program can
be developed by using low-cost local resources involving
the community. The prevention measures included
three facets: i) increased child supervision by creating
drowning-safe homes and establishing community
crèches, ii) heightened water safety culture by formation
of village commi ees, conduction of courtyard and social
autopsy meetings with communities, and iii) providing
basic fi rst response skills to the community. This study
also showed that the program was well accepted,
feasible and sustainable to the community.[91] Lack of
pool barrier or inadequate fencing is another risk factor
for drowning. A meta-analysis in 2000 showed that pool
fencing significantly reduced the risk of drowning.[92]
A study from the European Association for Consumer
Representation in Standardization (ANEC) indicated
that the most eff ective barrier was 1.2 m high, inclining
at an angle toward the climbers.[93] A systematic review
in 2004 revealed that alcohol was detected in blood of
30–70% of persons who drowned while being involved in
recreational aquatic activities in HICs. Moreover, 10–30%
of drowning deaths could be a ributed to alcohol use.[94]
People with epilepsy also have a greater risk of drowning.
The risk is approximately 15–19 fold greater compared
to the general population. Bathtubs and pools are major
submersion sites for children with epilepsy.[95,96]
Currently, the American Academy of Pediatrics
recommends that swimming lessons should be given
to children of age 4 years or older.[97] However, recent
case–control studies from the United States and China
demonstrated that children under 4 years of age may
be benefited from the swimming lessons. The risk of
drowning was found to reduce by 88% among children
aged 1–4 years who had formal swimming lessons.[89,98]
The International Task Force on Prevention of Open Water
Drowning established the guidelines for individual and
families[99] [Table 3]. The International Drowning Research
Centre-Bangladesh (IDRC-B) is a child drowning research
center, working to enhance and improve drowning-
related research, as well as developing drowning
prevention strategies and aff ordable prevention packages
for application in LMICs.
For those interested in injury and violence prevention,
Centers for Disease Control and Prevention (CDC)’s
National Center for Injury Prevention and Control
(NCIPC or CDC’s injury center) and Society for the
Advancement of Violence and Injury Research (SAVIR)
are excellent resources for injury and violence prevention
information and research. The Bangladesh Center of
Injury Prevention and Research, Bangladesh (CIPRB)
provides information on injury prevention for LMICs.
SUMMARY
Injuries are a major and growing public health problem.
Injury deaths have been increasing in many LMICs
over the past 20 years. Without prevention efforts, by
the year 2030, injuries will be the fifth leading cause
of death worldwide. Injuries cause not only loss of life
but also long-term disabilities and other consequences
including economic burden for individuals, families
and communities. In HICs, prevention strategies are
be er established and proven to be eff ective, resulting
in a continuously decreasing number of deaths and
disabilities from injuries. However, in many LMICs,
people are not aware of injuries as a problem, there is
a paucity of injury data, and little to no information
on injury prevention measures has been disseminated.
Injuries can only be effectively prevented by active
collaboration between stakeholders from international,
national, and local communities, and individuals to
address the problems, create prevention strategies and
policies.
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Cite this article as: Curry P, Ramaiah R, Vavilala MS. Current trends
and update on injury prevention. Int J Crit Illn Inj Sci 2011;1:57-65.
Source of Support: The International Task Force on Prevention of
Open Water Drowning available at http://www.seattlechildrens.org/
classes-community/community-programs/drowning-prevention/open-
water-guidelines/, Confl ict of Interest: None declared.
Curry, et al.: Current Trends and Update on Injury Prevention
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