Levels and Trends in Injury Mortality and Morbidity in Sweden Since 1978

by Leif Svanstr6m, Ph.D., Lars Berg, M.D., Anders ~berg, and Lothar Schelp

Abstract

Sweden has after the Second World War established itself as a Welfare State, with a high life expectancy. However the reputation of a leading statistical system goes even further back. All citizens are covered in the national population register, since 1749. Death diagnoses are known since 1911, but there are reports on mortality pattern as early as in the late 18th century. The population is now 8,700,000, with 18 percent above 65 years of age.

Overall mortality has decreased substantially after the second world war. Injuries are the leading cause of death up to 45 years of age. However the rate of fatal injuries has decreased from above 100 per 100,000 mean population for men 1977 to 75 the year 1991. The corresponding figures for women are from 70 to 40. All types of injuries, intentional as well as non- intentional, have decreased about the same, for both genders.

Forty people per 100,000 cars in traffic (14 per 100,000 population) were killed in traffic injuries the year 1975. Corresponding figures 1992 were 19 (9 per 100,000 population). The number of work related fatal injuries were around 400 in 1955, and in 1992 it was less than 80.

About I0 percent of hospital care is due to injuries. About 1/3 of care days for males and more than 1/2 for females are caused by femoral fractures.

This means that there are new priorities above the traditional in injury prevention. A National Injury Prevention Programme has been established since 7-8 years ago.

Background

Sweden has after the Second World War established itself as a Welfare State, with a high life expectancy. However the reputation of a leading statistical system goes even further back. All citizens are covered in the national population register, since 1749.

Life expectancy at current rates in Western Europe, the United States, Canada, Australia, New Zealand and Japan exceeds 75 years; in Japan and the Scandinavian countries (and in some states of the United States such as Hawaii and Minnesota) life expectancy for women is around 80 years. The most reliable data on mortality rates up to the most advanced ages over a long period of time pertain to Sweden. Excellent data exists for Sweden since 1750; "superlative" data have been achieved since 1895 (Vaupel and Lundstr6m 1993). Death diagnoses are known since 1911, but there are reports on mortality pattern as early as in the late 18th century.

The Swedish population is now 8,700,000. Twenty-four and six-tenths percent (1990) are below 20 years of age, 17.8 percent 65 and above. The projection for the year 2025 is 23.2 percent and 21 percent respectively.

Injury Mortality Trends

After heart disease and cancer injury is the most common cause of mortality, while in the age groups -45 years injury is the number one cause of death. Looking at a long term perspective nonintentional injuries have been increasing as a cause of death since the beginning of this century but has constantly decreased since 1971 (figure 1). However that development is basically due to the traffic mortality, while drownings has constantly decreased and falls increased during this century.

5-1

Looking at a short term perspective there has been a decrease in the overall fatal injury rate from around 100 per 100,000 of mean population for males 1976 to 75 per 100,000 in 1991 (figure 2). Corresponding rates for females are 70 per 100,000 and 40 per 100,000. Looking at causes for males all show a decrease during this period with the exception of homicide, which however stays on a very low level (figure 3).

Suicide, falls and motor vehicle dominate as causes. For females there is a corresponding decrease of all causes, however falls are by far the dominating cause of mortality (figure 4).

In general the current picture of mortality is for intentional injuries dominated by suicide. The non-intentional injuries as a cause of death are dominated by falls, about 40 percent, motor vehicles and other traffic, about 30 percent, drownings, another 10 percent, while fire only causes 3 percent (figure 5).

Looking into some specific causes traffic injuries has decreased substantially both per population and per vehicles (table 1). In 1975 40 persons per 100,000 vehicles were killed, 1992 the rate had decreased to 19. The corresponding rates per 100,000 mean population were 14 and 9 respectively.

These rates places Sweden among the leading countries in the world together with Norway and Great Britain (table 2). There is a more intermediate group with Denmark, Italy and Finland, while countries like USA and France shows the double rate. The bicycle injury rate is high but is now slowly decreasing (figure 6).

There is a remarkable decrease of work related fatal injuries (figure 7).

Fatal drownings are to 1/3 related to boats activities, 29 out of 167 are related to activities on ice or with snowmobiles and only 18 of 167 are related to bathing (table 3). The figures have varied during the last decade from 145 to 203, with an average of 172.

In general there has been a remarkable decrease of childhood injuries in Sweden. A comparison made by Bergman and Rivara shows that USA and Sweden had the same injury mortality in the age group 5-14 years 1957-59 and Sweden had a higher rate for age 1-4 years, while 30 years later Sweden showed a rate of 1/4 to 1/3 of that of USA (figure 8).

Falls account to a major part of the mortal nonintentional injuries. Looking at trends (figure 9) for females as well as for males (figure 10) there is a remarkable decrease from 1980 to 1986. This is explained by changes in coding routines. However there seems to be a decrease for females from 1988 onwards, but an increase for males during the same period.

Injury "Morbidity" Trends

Hospital discharge registers is the main source of information on injuries besides the mortality register. By far the most dominating cause of hospital in-patient care due to non-intentional injuries is falls, 57 percent in 1988, thereafter transport, 13 percent (figure 11). Actually about 1/3 of the hospital care days for males and more than 1/2 for females in Sweden were caused by femoral fractures (table 4).

There has since long been an increase iu the rate of non-intentional injuries leading to hospital care for females, dominated by falls (figure 12). However there is now a levelling of, even a decrease. There is also a corresponding development for males (figure 13).

Looking at hospital care due to intentional injuries shows that almost 60 percent are caused by suicide attempts and 20 percent by assaults (figure 14).

During the last 15-20 years there is a growing source of information on injuries through local surveillance systems based on all kinds of doctor's and hospital visits. In table 5 are reported percent distribution of registered injuries

5-2

in two counties and one municipality. About 1/3 of injuries occur at home, 1/6 at transport, production/cormnerce and sports environment respectively.

Looking at a similar surveillance in FalkOping 1978 (Schelp and SvanstrOm 1986) indicates an injury incidence in total of 113 per 1,000 inhabitants and year out of which 27 per 1,000 are home injuries, 22 per 1,000 are work related injuries and 9 per 1,000 are transport injuries. The surveillance system from Motala municipality shows for 1983-84 that 38 percent of traffic-related injuries are caused by cyclists and another 29 percent by pedestrians (figure 15). A similar study from LidkOping municipality 1984 shows that the dominating age group is 15-24 followed by 0-14 (table 6).

The study from the Motala surveillance system also shows that 40 percent of sports injuries are caused by soccer, 10 percent by basket/volleyball/handball and 10 percent by bandy and ice-hockey.

Summary and Conclusion

The rate of fatal injuries has do'teased from above 100 per 100,000 mean population for men 1977 to 75 the year 1991. The corresponding figures for women are from 70 to 40. All types of injuries, intentional as well as non- intentional, have decreased about the same, for both genders.

Forty people per 100,000 cars in traffic (14 per 100,000 population) were killed in traffic injuries the year 1975. Corresponding figures 1992 were 19 (9 per 100,000 population). The number of work related fatal injuries were around 400 in 1955, in 1992 it was less than 80. Actually more people are now killed in bicycle injuries yearly than at work!

About 10 percent of hospital care is due to injuries. About I/3 of care days for males and more than 1/2 for females are caused by femoral fractures.

This means that there are new priorities than the traditional in injury prevention. A National Injury Prevention Programme has been established since 7-8 years ago in order to formulate national targets and strategies as well as to support regional and local preventive activities. There is also a priority to improve the quality of national, regional and local registers and surveillance systems.

References

I .

2.

3.

4.

5.

6.

.

Bergman AB and Rivara FP. Sweden's Experience in Reducing Childhood Injuries. Pediatrics 1991:88(1).

Causes of Death 1987. Stockholm:

Causes of Death 1988. Stockholm:

Causes of Death 1991. Stockholm:

Statistics Sweden, 1989.

Statistics Sweden, 1991.

Statistics Sweden, 1993.

Drowning statistics 1993. Stockholm: Press Information, Swedish IMe Saving Society, 1994.

Hospital Discharge Registry. Stockholm: National Board of Health and Welfare, Centre for Epidemiology, 1994.

Lindqvist K. Towards Community-Based Injury Prevention. The Motala Model. Link~6ping: Link0ping University, Dept. of Community Medicine, 1993. Thesis.

5-3

.

.

10.

11.

12.

Schelp L and Svanstr6m L. One-Year Incidence of tlome Accidents in a Rural Swedish Municipality. Scand J Soc Med 1986;14:75-82.

Strategies for a Safe Sweden. Stockholm: National Board of llealth and Welfare, 1991.

Traffic Injuries 1991. Stockholm: Statistics Sweden, 1992.

Vaupel J W and LundstrOm H. Longer Life Expectancy?: Evidence from Sweden of Reductions in Mortality Rates at Advanced Ages. Odense University, Denmark and Duke University, USA and Statistics Sweden. Manuscript. 1993.

Work- related Injuries. Stockholm: Statistics Sweden, 1992.

5-4

Table 1. Fatal traffic injuries in Sweden 1975-1992, by 100 000 vehicles in traffic, 100 000 mean population and year. Source: Traffic Injuries 1991. Stockholm: Statistics Sweden 1992.

Year 1975 1980 1985 1990 1992

Killed/100 000 veh 40 28 24 20 19

Kil led/lO0 000 pop 14 10 10 9 9

Table 2. No. of killed in traffic injuries per 100 000 inhabitants in some selected countdes, by year. Source: Traffic Injuries 1991. Stockholm: Statistics Sweden 1992.

Year 1975 1980 1985 1990

Norway 13 9 10 8 Sweden 14 10 10 9 GB 12 11 9 9 Denmark 16 13 15 12 Italy 18 16 13 12 Finland 19 12 11 13 USA 21 22 18 18 France 27 25 21 20

5-5

Table 3. Number of fatal drownings in Sweden 1992, by cause and age. Source: Drowning statistics 1993. Stockholm: Press Information, Swedish Life Saving Society, 1994.

Cause Children Adults Total 0-4 5-9 10-14

Ice/ snowmobile 1 2 1 25 29 Bathing 0 2 0 16 18 Sport boats 0 0 2 52 54 Vessels 0 0 0 2 2 Other 6 0 1 57 64

Total 7 4 4 152 167

Table 4. Number of hospital discharges and care days caused by injuries in Sweden 1989, by diagnosis and gender. Source: Hospital Discharge Registry. Stockholm: National Board of Health and Well, Centre for Epidemiology, 1994.

Diagnosis Gender No. discharges No. care days %

Scull fractures M F

Femoral fractures M F

Other fractures M F

All other injuries M F

2 846 19 558 1 080 8 400 6 599 196 069 18 117 693 081 18 234 181 319 21 292 366 627 38 796 243 653 28 850 209 285

31 54

Total M F

66 475 640 599 69 339 1 277 393

100 100

5-6

Table 5. Injuries by environment in two Swedish counties and one municipality. %- distribution. Source: Strategies for a Safe Sweden. Stockholm: National Board of Health and Welfare, 1991.

Environment Geographical area Bohus county Lidk6ping municip

Transport 12 16 15 Home 37 33 29 Production/ Commerce 14 20 16 School 7 7 11 Sport 15 16 18 Entertainment 3 2 4 Nature 6 3 3 Sea,lake etc 3 1 1 Other 2 1 3

Total 100 100 100

Viistmanland county

Table 6. Traffic injuries in Lidk6ping, Sweden, 1984, by age group and gender. In numbers, % and per 1 000 mean population/year. Source: Lindqvist K. Towards Community- Based Injury Prevention. The Motala Model. Link6ping: Link6ping University, Dept. of Community Medicine, 1993. Thesis.

Age Gender Total % M F

Per 1 000 pop/year

0-14 25 27 52 29 8 15-24 34 23 57 31 11 25-34 8 3 11 6 2 35-44 5 9 14 8 3 45-54 8 7 15 8 4 55-64 3 10 13 7 3 65-74 6 9 15 8 4 75- 3 2 5 3 2

Total 92 90 182 100 5

5-?

4000

3500

3000

2500

2000

1500

1000

500

0

o

Total

I

I i i I I

911 -21 -31 -41 -51 -61

L

I i - - I

-71 -81 -85

Drowning

' ~ ~- , Traffic

I I Fall

-86 -87

SOURCE: Causes of Death 1987. Stockholm: Statistics Sweden, 1989.

Figure 1. Number of non-intentional injuries in Sweden 1911-87, by cause and year

110

100

90

80

70

60

50

40

~ ' ~ Men

\ . . . , , ~ - . ~ ,,,,,,,,.~ , ' '1 , - - ~ , W o m o n

76 77 78 79 80 81 82. 83 84 85 86 87 88 89 90 91

SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

Figure 2. Fatal injuries in Sweden 1976-91, by gender and year. Rate year 100,000 of mean population.

5-8

Motor vehicle "-"!1- Alcohol poisoning

- -O-- Other non-intentional ' - - 0 - Suicide

~ Homicide

32

28

24

20

16

12

" ~ - Falls

- '-'0- - Other intentional

76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91

8

4

0

SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

Figure 3. Fatal injuries in Sweden 1976-91, by cause and year. Rates per 100,000 of mean population. Males.

Motor vehicle " - - I I - Alcohol poisoning " i l ' - Falls

Other non-intentional ~ Suicide - " -e I'-- Other - - X - - Homicide intentional

40

35

30

25

2O

15

10

5

0 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91

SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

Figure 4. Fatal injuries in Sweden 1976-91, by cause and year. Rates per 100,000 of mean population. Females.

5-9

P o i s o n i r . . . . 1 %

Other 10%

Drownir etc. 9% pen fire 3%

.~r traffic 5%

Mot . . . . . . . . . . . . . .

SOURCE Causes of Death 1988. Stockholm: Statistics Sweden, 1991.

Figure 5. Fatal non-intentional in Sweden 1988, by cause. Number (n=1804) and percent.

4,5

4,0

3,5

3,0

2,5

2,0

1,5

1,0

0,5

0

. . . . . 0-14 - - - 1 5 - 2 4 - - - - 2 5 - 6 4 . . . . .

m

I ' ,

I %

65 and over

• d % j

B

I I I i I I I ~ " " I I I I 78 79 80 81 82 83 84 85 86 87 88 89 90

SOURCE: Traffic injuries 1991. Stockholm: Statistics Sweden, 1992.

Total

Figure 6. Fatal bicycle injuries in Sweden 1978-90, by age group and year• Rates per 100,000 of mean population

5-10

450

400

350

300

250

200

150

100

50

B

D

B

B

m

B

l l l [ l l l l l l l l l l l l l l l l l l l l l l l l l l l l [ l l l l l

54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92

SOURCE: Work-related Injuries. Stockholm: Statistics Sweden, 1992.

Figure 7. Number of work related fatal injuries in Sweden 1955-92, by year

50

40

30

20

10

0 m

:. i:: :::~.:~ :~i~ i ::;i:~i::

USA 57/59

: : :~i Age

E] 1-4 • < : < i i i

: / 7 1 ~C ;:~!:!

~i!iii;~i!:i,i<~ ~ii!~ii!i

Sweden 57/59 USA 86

I I 5-14

Sweden 86

SOURCE: Bergman AB and Rivara FP. Sweden's Experience-in Reducing Childhood Injuries. Pediatrics 1991:88(1 ).

Figure 8. Fatal child injuries in USA and Sweden 1957-59 and 1986, by age group and year. Rates per 100,000 of mean population

,5-11

, . .4-85-89 95 over • --~-65-69 -N--75-79 * and 400 - o - 7 0 - 7 4 . -a-80-84 .-.t~-90-94

ooo

60o

2o0

8oo 7

4OO

o 78 79 80 81 82 83 84 85 86 87 88 89 90 91

SOURCE:Causes of Death1991.Stockholm:Statistics Sweden, 1993.

Figure 9. Fatal injuries in Sweden due to falls 1978-91, by age group and year. Rates per 100,000 of mean population

- i - 6 5 - 6 9

24002800~ - -o -70-74

16oo

1200

800

.~ 75-79 ,-a.- 80-84

85-90 ,..o... 90-94

95 and over

400

• o . - - __ . " - ' . , ; o

78 79 80 8~1 82 83 84 85 86 87 88 89 90 91 • , - - - __ - - , ; o

SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

Figure 10. Fatal injuries in Sweden due to falls 1978-91, by age group and year. Rates per 100,000 of mean population

5-12

5 7 %

Open fire 1%

Machine etc 9%

Other traffic 3 c

"vehicle 10% Othe l . . . . . . . . . . . . . . ~ 2%

SQURCE: Hospital Discharge Registry. Stockholm: National Board of Health and Welfare, Centre for Epidemiology, 1994.

Figure 11. Hosp i ta l d i s c h a r g e s in S w e d e n due to non - i n ten t i ona l in jur ies 1988, by cause , n u m b e r ( n = 1 4 3 , 5 8 9 ) and p e r c e n t

1400-- 1200-- 1 0 0 0 ~ . ~ 4 ~ " ~ 8OO

600

400

200

0

- I - Transport @ Poisoning ~ Falls

m n i I iN m i j i I m

m i l i -- I | m m m -- |

ep-.,i-e,-.~-~ a ~ ~ = L ~ I ~ ~ L ~--m--~. ~ ~ ~ , , ~ , , 3 78 79 80 81 82 83 84 85 86 87 88 89 90 91

SOURCE: Hospital Discharge Registry. Stockholm: National Board of Health and Welfare, Centre for Epidemiology, 1994

Figure 12. Hospital discharges in Sweden due to non-intentional injuries 1978-91, by cause and year. Rates per 100,000 of mean population

5-13

900

800

700

600

500

400

300

200

100

0

--I1"- Transport ~ Poisoning ~ Falls

m m I m J i m

m m i i w

I I I | I I i I I I I I I

78 79 80 81 82 83 84 85 86 87 88 89 90 91

SOURCE: Hospital Discharge Registry. Stockholm: National Board of Health and Welfare, Centre for Epidemiology, 1994

Figure 1 3. Hospital discharges in Sweden due to non-intentional injuries 1978-91, by cause and year. Rates per 100,000 of mean population

Assault 20% 58%

Unknown 14%

SOURCE: Hospital Discharge Registry. Stockholm:National Board of Health and Welfare, Centre for Epidemiology, 1994.

Figure 14. Hospital discharges in Sweden due to intentional injuries 1991, by cause, number (n=14,069 and percent)

5-14

(38%)

ssengers =(2%)

Pedestrians (29%)

SOURCE: Lindqvist K. Towards Community-Based Injury Prevention. The Motala Model. Link~ping: Link6ping University, Dept. of Community Medicine, 1993. Thesis.

Figure 15. Traffic injuries in Motala, Sweden 1983-84, by category and percent (n=632)

5-15