Citation

Krug EG. Lancet 2004; 364(9445): 1563-1566.

Affiliation

Department of Injuries and Violence Prevention, World Health Organization, CH-1211 OK Geneva, Switzerland. kruge@who.int

Copyright

(Copyright © 2004, Elsevier Publishing)

DOI

10.1016/S0140-6736(04)17328-5

PMID

15519616

Abstract

The US Centers for Disease Control and Prevention (CDC) recently published an important report describing in detail for the first time the patterns of fatal and non-fatal injuries in the USA for 2001. The report shows that, in that year, 157 000 people died from injuries in the USA, and that unintentional injury was the fifth leading cause of death. The main injury cause of death was traumatic brain injury. About one in every three people treated in an emergency department in the USA was treated for an injury. An estimated 29.7 million people, or one in ten US residents, were treated for non-fatal injuries in hospital emergency departments and 1.6 million were admitted. The leading cause of injury death was motor-vehicle traffic crashes, and the leading cause of non-fatal injuries treated in hospital emergency departments was unintentional falls. Injuries cost the USA an estimated $117 billion in medical care annually.

There are several reasons why this report is important but two stand out. First, the report confirms the important public-health impact of injuries. Second, it illustrates the detailed information that can become available when investment is made in the development of a surveillance system for injury. So far, few countries have produced such detailed accounts of injury patterns. This information is vital, however, for planning and evaluating prevention efforts and services for survivors, for targeting capacity-development programmes, and for raising awareness.

The CDC report's focus is on immediate consequences--death and injury--and therefore, despite the staggering statistics, it still provides only a partial description of the true size of the injury problem. Research from around the world has shown that in addition there are often considerable longer term consequences, such as physical disability or mental health sequelae. Studies indicate, for example, that exposure to violence during childhood is associated with risk factors and risk-taking behaviours later in life, such as violent victimisation and perpetration, depression, smoking, obesity, high-risk sexual behaviours, unintended pregnancy, and alcohol and drug use. Such risk factors and behaviours then lead directly to some of the leading causes of death, disease, and disability, namely heart disease, cancer, suicide, and sexually transmitted diseases.

With more than 5 000 000 deaths every year, violence and injuries account for 9% of global mortality. Seven of the 15 leading causes of death for people between the ages of 15-29 years are injury-related. Children and young adolescents are also particularly vulnerable to injury. In addition to death, injuries cause tens of millions of disabilities each year. Injury death and disability rates vary greatly by sex: for most types of injuries, death rates are higher for boys and men, whereas women are at higher risk for non-fatal injuries resulting from sexual or intimate-partner violence and, in some regions, for burn injuries. Responding to injuries and their numerous consequences requires extensive health-system resources. The burden imposed by violence and injury is particularly heavy on low-income families and societies with high levels of economic inequality. Injury-related death and disability rates are generally higher in low-income and middle-income countries, in communities of migrants, ethnic minorities, marginal groups, or in areas with high rates of unemployment.

Data collection on the size of the problem is still in its infancy. In many low-income and middle-income countries, almost no data are available on the burden of injuries. In most high-income countries, only data on mortality have been assembled. Few countries have comprehensive surveillance systems for non-fatal injuries. In low-income and middle-income countries, population-based data on injury mortality and morbidity are rare. Global and regional estimates are therefore based on relatively complete statistics from a minority of countries. For the other countries, complex models are used to estimate the global and regional burden.

The lack of data on the size of the injury problem and on prevention has contributed to the traditional view of injuries as 'accidents', suggesting that they are random unavoidable events and has resulted in their historical neglect, both as a subject of research and as a preventable outcome. Expenditure on injury-related research lags behind other health outcomes when considering global research expenditure per disability-adjusted life-year. Research has provided clear evidence, however, that a range of interventions can prevent injuries. In Thailand, there was a 41.4% reduction in head injuries and a 20.8% reduction in deaths in the year after the enforcement of a motorcycle-helmet law. Several other interventions have been shown to have benefits, such as seat belts, helmets, and blood-alcohol limits for traffic injury prevention, child-resistant containers for prevention of poisonings, home hazard-modification to prevent falls in the elderly, pool fencing to reduce the risk of drowning, or home-visit programmes for reducing child maltreatment.

Decreasing the burden of injuries is among the main challenges for public health in the next century. Injuries are preventable but the first step of a scientific approach to address them is to understand their magnitude and the distribution of causes. In the past 2 years, the World Health Assembly has passed two important resolutions related to the field of injury prevention and safety promotion: WHA 56.24--Implementing the recommendations of the World report on violence and health and WHA 57.10--Road safety and health. Both resolutions call for the strengthening of data-collection systems.

To assist with the development of such data-collection efforts, WHO recently published guidelines for community surveys on injuries and violence and on injury surveillance (published in collaboration with CDC). With these and other guiding documents, systems for injury surveillance are emerging around the world to capture information on non-fatal injuries. Countries as diverse as China, Jamaica, Nicaragua, South Africa, Thailand, and Uganda have all started the development of injury-surveillance systems during the past years. The recent report from CDC is the perfect illustration of the potential of these emerging injury-surveillance systems. The data they will provide in the future will no doubt lead to more and better targeted injury-prevention programmes.