bengaluru injury / road traffic injury surveillance programme

National Institute of Mental Health & Neuro SciencesBengaluru – 560 029, India

Bengaluru

Surveillance Programme:Injury / Road Traffic InjuryInjury / Road Traffic Injury

A feasibility studyA feasibility study

Bengaluru

Surveillance Programme:

BengaluruBaptist Hospital

BhagwanMahaveer

Jain Hospital

Bowring & LadyCurzon Hospital

Bengaluru Metropolitan

Transport Corporation

D.G. Hospital

District Hospital,Tumkur

HOSMATHospital

JayanagarGeneralHospital

K.R. Hospital

KempegowdaInstitute of

Medical Sciences &Research Centre

M. S. RamaiahMemorial Medical

Hospital

Mallige MedicalCentre

Mallya Hospital

Manipal Hospital

Bengaluru CityPolice

Victoria Hospital

St. Philomena'sHospital

St. Martha'sHospital

Ravi KirloskarMemorial Hospital

National Instituteof Mental Health

& Neuro Sciences

In Collaboration with

St. John'sHospital

Sri. SiddharthaMedical College,

Tumkur

Sparsh Hospital

Sanjay GandhiAccident Hospital

& ResearchInstitute

Sagar Hospitals

BengaluruBengaluru

Surveillance ProgrammeSurveillance ProgrammeInjury / Road Traffic InjuryInjury / Road Traffic Injury

World Health Organization,New Delhi

Ministry of Health &Family Welfare, New Delhi

Indian Council of Medical Research, New Delhi

iNIMHANS

Bengaluru Injury /Road Traffic Injury

SurveillanceProgramme:

A feasibility study

NATIONAL INSTITUTE OF MENTAL HEALTH &NEURO SCIENCES

Department of EpidemiologyWHO Collaborating Centre for Injury Prevention and Safety Promotion

Bengaluru – 560 029, India

ii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Title: Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Copyright: NIMHANS

ISBN no: 81-86423-00-X

Suggested citation:

Bengaluru Injury surveillance collaborators group. Gururaj et al.: National Institute of Mental Healthand Neuro Sciences, Publication No. 68, Bengaluru, 2008Bengaluru Injury surveillance collaborators (Nodal Officers) group: Gururaj, Sateesh V L, AjithBenedict Rayan, Alfred C Roy, Amarnath, Ashok J, Ashwath Narayan, Birje N.D, Chidananda, Devaraj,Harsha J.N, Kantaraj J, Kirankumar, Krishna Raj, Mabel Vasnaik, Mali Manjunath, Mallikarjun VAbdulpur, Manjunath, Manjunath A.V, Mohan Kumar, Narayanaswamy, Prabhakar, Prakash P.N,Rajeev Mathew, Ramaprasad, Ramesh E Raju, Ramesh K.V, Ramireddy, Ranganath, Rizwan AliKhan, Sunil Bhat, Suryanarayan S.P, Velu C.V

Year of publication: 2008

Key words:

Injury; surveillance; Data; Road Traffic Injury; Suicide; Burns; Poisoning; Mortality; Morbidity;Disability; policy and Programme

For further details about the programme, contact any of the programme nodal officers or –

Dr. G. GururajProfessor & HeadDepartment of EpidemiologyWHO Collaborating Centre for Injury Prevention and Safety PromotionNIMHANS, Bengaluru – 29Email: [email protected]

[email protected]

iiiNIMHANS

Safety and security of people has occupied centre stage of

human growth and development in recent years. Every year,

thousands of people lose their lives, millions get hospitalized,

and several become disabled due to an injury in India.

This tragedy need not and will not happen if safety and

security of people is given importance in all places and at

all stages of our growth and development. It is time

adhocism, knee jerk reactions, crisis reactions are replaced

with evidence based scientific approaches. People have a

right to safety at home, workplace, roads and in all public

places. It is the collective responsibility of governments,

policy makers, product-vehicle manufacturers (industry),

media and people to develop products and environments

that are safe to every one in the society.

Bengaluru Injury / Road Traffic Injury Surveillance Programme is a

collaborative programme between National Institute of Mental Health

& Neuro Sciences, 25 hospitals, Bengaluru City Police, Bengaluru

Metropolitan Transport Corporation and Bruhat Bengaluru Mahanagara

Palike and, facilitated by Indian Council of Medical Research and WHO,

India office. The programme aims at reducing / preventing injuries,

improving trauma care and strengthening rehabilitation services.

iv Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Partners in Programme

Bengaluru City Police

Sri. Shankar Bidari, IPS, Commissioner of Police, Bengaluru City

Sri. Neelam Achutha Rao, IPS, Fmr. Commissioner of Police, Bengaluru City

Sri. Pravin Sood, IPS, Additional Commissioner of Police, Traffic and Security

Sri. K. C. Ramamurthy, IPS, Fmr. Additional Commissioner of Police, Traffic and Security

Sri. M. N. Reddi, IPS, Fmr. Additional Commissioner of Police, Traffic and Security

Sri. M. R. Pujar, IPS, Additional Commissioner of Police, Law and Order

Sri. Bipin Gopalakrishna, IPS, Fmr. Additional Commissioner of Police, Law and Order

Dr. Parashivamurthy, IPS, Fmr. Commissioner for Road Safety, Karnataka

Sri. K. Srinivasa, IPS, Deputy Commissioner of Police (East)

Sri. M. A. Saleem, IPS, Fmr. Deputy Commissioner of Police (East)

Sri. Rama Subba, IPS, Fmr. Deputy Commissioner of Police (West)

Sri. N. Shivaprasad, IPS, Deputy Commissioner of Police (Admin)

Sri. N. D. Birje, Assistant Commissioner (Traffic & Planning) and Nodal Officer

Sri. Narasimaiah, Assistant Commissioner (Traffic & Planning) and Fmr. Nodal Officer

Sri. M. D. Mulla, Fmr. Public Relations Officer and Nodal Officer, Crime

Sri. V. Ramaiah, Deputy Commissioner of Police, Public Relations Officer and Nodal Officer, Crime

Sri. Raghuveer (Control room)

Smt. Girija, Inspector of Police, City Crime Record Bureau, and Mr. Prasanna

All staff from Traffic and Law and Order stations of Bengaluru

Dr. Harsha, IPS, Superintendent of Police, Tumkur

Sri. Harishekaran, IPS, Fmr. Superintendent of Police, Tumkur

Sri. Anantha Ramaiah, Additional Superintendent of Police, Nodal Officer, Tumkur, and

All the staff from Police Department in Bengaluru and Tumkur

National Institute of Mental Health and Neuro Sciences

Director - Dr. Nagaraja D

Nodal Officer - Dr. Sateesh V. L (Resident Medical Officer)

Department of EpidemiologyDr. G. Gururaj, Dr. Girish N. Rao, Dr. Kavita Rajesh, Dr. Umesh Shetty, Dr. Ranganath, Mr. Vijendra S. Kargudri,Mr. Girish B. G., Mr. Manjunath D. P., Mr. Srinivasamurthy, Mr. Basavaraj B, Mr. Lokesh M, Mr. ChandrashekarC, Mr. Raghu R and Mrs. Savitha B. G.

Department of Neuro SurgeryDr. Indira Devi, Dr. Chandramouli, Dr. Sampath, Dr. Shibu Pillai, and all unit heads

Casualty Medical OfficersDr. Chandrashekharan, Dr. Muralidhara K, Dr. Neetha Nagaraj, Dr. Renukadevi, Dr. Asgaribanu, Dr. LakshmiRajamma, Dr. Sridhara, Dr. Jayaprakash, Dr. Keshavamurthy and Dr. Yashoda

Medical Records DepartmentMr. Marie Joseph, Ms. Maria Alphonsa, Mr. Pulla Reddy, Mr. Vivekappa and Mr. Nanjappachar

Bengaluru Metropolitan Transport Corporation

Sri. Syed Zameer Pasha, IAS, Managing DirectorSri. Upendra Tripathi, IAS, Fmr. Managing DirectorSri. Dastagir Shariff (CTO)Sri. Narayanaswamy (DTO Accident) - Nodal Officer

vNIMHANS

Sri. Shankara Bharathi (Assistant Traffic Superintendent)Sri. Vijay B Chandapur (DTO TEe)Mrs. Dakshaini Devi and Mrs. Madhavi

Bruhat Bengaluru Mahanagara Palike

Dr. S. Subramanya, CommissionerNarayanaswamy, Jt. Director (Statistics) and Staff

Bangalore Baptist Hospital

Medical Superintendent – Dr. Alex Thomas;Dr. Santhosh Benjamin (Fmr. Superintendent);Nodal Officer – Dr. Alfred C Roy;Casualty Staff – Dr. Niranjan and Sr. Mary

Bhagavan Mahaveer Jain Hospital

Medical Director – Dr. Mohan Reddy;Nodal Officer – Dr. Prakash P. N;Casualty Staff – Dr. Jamuna, Dr. Suchetha, Dr. Bindu, Dr. Vinayaka andMr. Arun Arthur Kumar and Mr. Patil

Bowring & Lady Curzon Hospital

Medical Superintndent – Dr. Rajeev Shetty;Resident Medical Officer – Dr. Rajanna;Nodal Officers – Dr. Amarnath, Dr. K. Sreedhara Murthy, (Fmr.);Casualty Staff – Dr. Venkata Rajamma, Dr. Prasanna Kumar, Dr. Sreedhar, Dr. Banumurthy, Dr. Sudha, Dr.Vasanthakumar, Dr. Suresh, Dr. Harish, Dr. Banu; Mr. Raju, Mr. Nagaraja, Mr. Siraj and Mr. Nagaraj

D.G. Hospital

Chairman – Dr. Ramesh H. D;Nodal Officer – Dr. Rizwan Ali Khan;Casualty Staff – Dr. Ashok Shroff and Dr. Vishvas

HOSMAT Hospital

Medical Director – Dr. Thomas Chandy;Nodal Officer – Dr. Ajith Benidict Rayan;Casualty Medical Officer – Dr. Bhavani Shankar, Dr. Chetan Ray and Mrs. Valsala and Mr. Sugirth Raj

Jayanagar General Hospital

Medical Superintendent – Dr. Nagaraj K;Nodal Officer – Dr. Manjunath;Casualty Staff – Dr. Vasudeva Rao, Dr. Sreedhar Murthy, Dr. Srinivas, Dr. Kiran Kumar, Dr. Pushparaj,Dr. Pappu Vitalachar, Dr. Prameela, Dr. Sandya, Dr. Geetha, Dr. Revanna, Dr. Raghunandan, Dr. Thimmappa;Mrs. Geetha and Mrs. Pattar

KR Hospital

Director –Dr. Hariprasad;Medical Superintndent – Dr. Sriranga Prasad;ICU Director – Dr. Chandrashekhar;Nodal Officer – Dr. Harsha J. N;Medical Administrator – Mr. Mahesh Kumar

vi Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Kempegowda Institute of Medical Sciences and Research Centre

Director – Dr. K M Srinivasa Gowda;Medical Superintendent – Dr. Anjanappa T. H;Administrative Medical Officer – Dr. Ramachandra J;Nodal Officers – Dr. Devaraj, Dr. Ashwath Narayan and Dr. Gopal B. K, (Fmr.);Casualty Staff – Dr. Ramesh, Dr. Shankar and Dr. Prasanna;Medical Records Department – Mr. E. Selwyn Jebasingh and Mr. Lingappa;

M. S. Ramaiah Hospitals

Medical Directors – Dr. Sundaresh and Dr.Naresh Shetty;Joint Medical Director – Dr. Narendranath;Nodal Officers – Dr. Mali Manjunath and Dr. Suryanarayana S. P;Casualty Staff – Dr. Satish Varma, Dr. Gopalappa, Dr. Thyagaraj, Dr. Anand Kumar. C, Dr. Pruthvish,Dr. Aruna Ramesh; Mrs. Wilbert Mary, Mrs. Padma, Mrs. Margaret Rosy and Mrs. Shyamala

Mallige Medical Centre

Director – Dr. Sriram;Medical Superintendent – Dr. Sudarshini and Dr. Ravishankar Nair, (Fmr.);Nodal Officer – Dr. Ramireddy

Mallya Hospital

President – Comm. Indruwadwani;Nodal Officer – Dr. Pradeep Naik, Dr. Kirankumar;Casualty Staff – Dr. Prameela, Mr. Desican and Mrs. Usha

Manipal Hospital

Medical Director and Chief - Dr. D. P. Saraswath, Dr. Nagendra Swamy, (Fmr.);Nodal Officers - Dr. Ramesh E. Raju; Mr. T. Pradeep, Mr. P. Kumaran, Mr. Muthanna, Sr. Vimalamma

Ravi Kirloskar Memorial Hospital

Project Director – Dr. Marker;Nodal Officers - Dr. A.V. Manjunath; Mr. Shekarappa

Sagar Hospital

Chairman – Dr. Hemachandra Sagar;Nodal Officers – Dr. Sunil Bhat; Dr. Rajeev Mathew, Mr. Stephen and Sis. Mangala

Sanjay Gandhi Institute of Trauma Care and Orthopaedics

Director – Dr. Govindaraju. V;Nodal Officers – Dr. Prabhakar, Dr. Ravikumar V (Fmr.); Mr. Agilasithan;Casualty Staff – Mr. Yashvanth, Ms. Meera and Mr. Dhananjaya

Sparsh Hospital

Medical Director – Dr. Sharan Patil;Nodal Officer – Dr Chidananda;Staff – Dr Yohannan John and Ms. Mathilda

St. John’s Medical College & Hospital

Associate Director – FR. M. A. Sebastian;Medical Superintendent – Dr. Mary Ollapally,Department of Community Medicine – Dr. Domnic Misquith, (Professor and Head); Dr. Shanthi;Nodal Officers – Dr. Mabel Vasnaik, Dr. Babu Palatti, Dr. Vargeese;Medical Records Department – Mrs. Irine Jacob, Sr. Reeta

viiNIMHANS

St. Martha’s Hospital

Superintendent – Sr. Dr. Theresita;Nodal Officer – Dr. Mallikarjun V. Abdulpur;Casualty Staff – Dr. Shashikanth, Dr. Pai A. G, Dr. Farid, Dr. Gopalaiah, Dr. Lucy Nora, Dr. Vidya andMr. Anthony

St. Philomena Hospital

Medical Superintendent – Dr. Shankar Prasad;Nodal Officer – Dr. C. V. Velu;Casualty Staff – Dr. Jayanand, Dr. Ramesh, Dr. Toby, Dr. Deepanjali; Mr. George

Victoria Hospital

Director – Dr. Subhash G. T; Dr. Rajeshwari (Fmr.);Medical Superintendent – Dr. Tilak B. G; Dr. Nanjundappa, (Fmr. Medical Superintendent),Dr. Ashok Kumar (Fmr.)Nodal Officer – Dr. Kantaraj J;Casualty Medical Officers – Dr. Vishwanath A, Mr. Sudeendra, and Dr. Sreedhar S. T, Dr. Gangadhara H. C,Dr. Sathyanarayana B. N, Dr. Shivakumar H. V, Dr. Yalugurudappa, Hanamappa Sankanal, Dr. CheluvanarayanaH. C, Dr. Tyagaraja B. N, Dr. Datta R. K, Dr. Muralidhar C. M, Dr. Ramesh R, Dr. Vishwanath B, Dr. Jayachandra,Dr. Kusuma B. K, Dr. Vijayashree M. S, Dr. Rajareddy, Dr. Prakash M. D, Dr. Srinivas G. A and Dr. VaralakshmiK. A., Dr. Ramesh B and Dr. Siddeshwar;Department of Medicine – Dr. Vasantha Kamat, Professor and Head;Department of Surgery – Dr. Shivaswamy, Professor and Head;Department of Plastic Surgery – Dr. Shankarappa, Professor;Administrative Officer – Dr. Shathrunjayan, Asst. Professor;Department of Community Medicine – Dr. Riyaz Pasha, Asst. Professor;Medical Records Department – Mr. Sudeendra and Mrs. Laxmi Devi

RURAL HOSPITALS

Siddartha Academy of Higher Education (Deemed to be University)

Director & Chancellor – Dr. Shivaprasad;Vice-Chancellor – Dr. Prabhakaran;Registrar – Dr. Srinivasa Gowda K. M;Principal – Dr. Sreenivasamurthy;Medical Superintendent – Dr. Ramesh Rao, Dr. Jena B. K (Fmr.);Nodal Officer - Dr. Ashok J, Dr. P. Venkatesh;Department of Community Medicine – Dr. Rajanna M. S, Professor & Head

District Hospital, Tumkur

District Surgeon – Dr. Pratap Surya and Dr. Siddaiah, (Fmr.);Resident Medical Officer – Dr. Rangaswamy;Nodal Officer – Dr. Ramaprasad;Casualty Staff – All Specialists in District Hospital

District Health and Family Welfare Office, Tumkur

DHO – Dr. Aravindappa;Nodal Officers – Dr. Ranganath, (Kallambella PHC); Dr. Krishna Raj (Nittur, PHC), Dr. Ramesh K. V(Sira, CHC), Dr. Mohan Kumar (Kunigal, CHC).

And all other staff working in emergency rooms - medical record divisions of hospitals, Bengaluru MetropolitanTransport Corporation and in all police stations of Bengaluru city.

and

World Health Organisation, India Country office, New DelhiIndian Council of Medical Research, New Delhi

viii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Table of Contents

Foreword — Dr. D. Nagaraja, Director, NIMHANS................................................................................. ix

Foreword — Sri. Srikumar, Director General and Inspector General of Police,Government of Karnataka ....................................................................................................................... x

Foreword — Dr. Bela Shah, Senior Deputy Director General and Chief of NCD Division,Indian Council of Medical Research ....................................................................................................... xi

Preface .......................................................................................................................................... xii

Acknowledgements .............................................................................................................................. xiii

Abbreviations ....................................................................................................................................... xiv

List of Tables ......................................................................................................................................... xv

List of Figures ....................................................................................................................................... xvi

Executive summary ............................................................................................................................ xviii

1. Introduction .................................................................................................................................. 1

2. What is an injury? ......................................................................................................................... 3

3. Injury: the scale of the problem ..................................................................................................... 5

4. Injury surveillance ......................................................................................................................... 7

5. Building Bengaluru Injury Surveillance Programme ....................................................................... 9

6. Planning Surveillance Activities ..................................................................................................... 9

7. Information sources and existing scenario ................................................................................... 11

8. Preparatory phase (Jan – March 2007) ........................................................................................ 16

9. Information gathering phase ....................................................................................................... 18

10. Results ......................................................................................................................................... 20

11. Burden, pattern and profile of fatal and non-fatal injuries ........................................................... 23

12. Road traffic injuries ..................................................................................................................... 27

13. Suicides ....................................................................................................................................... 34

14. Burns .......................................................................................................................................... 38

15. Poisoning .................................................................................................................................... 39

16. Falls .......................................................................................................................................... 41

17. Drowning .................................................................................................................................... 42

18. Animal bites ................................................................................................................................ 43

19. Assault / Violence ....................................................................................................................... 44

20. Prehospital care .......................................................................................................................... 44

21. Nature of injuries ......................................................................................................................... 48

22. Management and outcome........................................................................................................... 49

23. Injury: the hidden and unanswered epidemic ............................................................................... 50

24. Injury / RTI surveillance: strengths, opportunities and limitations ................................................ 54

25. Inputs to policies and programmes .............................................................................................. 58

26. Sustainability issues .................................................................................................................... 59

Recommendations ................................................................................................................................ 60

References: .......................................................................................................................................... 65

ixNIMHANS

Foreword

With the growth of the city of Bengaluru and its recent transformation to an

internationally acclaimed Centre for knowledge and technology, health, safety

and security have become important issues for planners and policymakers.

Every day, hundreds of people are injured on the roads, at homes and in

workplaces of Bengaluru. Behind every death and injury there is a human

face and a family. The pain and agony of the suffering families goes beyond

words.

With travel becoming an essential need for today’s life, road deaths and injuries are increasing significantly

and young people die at the formative and productive years of their life. Current efforts in addressing road

safety and prevention of other injuries are very minimal, especially in comparison to the increasing human

suffering. The psychosocial and mental health impact of injuries is huge and phenomenal, and stays with

affected individuals and families for the rest of their life.

Data from the report reveal that nearly 5,000 persons die and more than 100,000 hospitalized every year in

Bengaluru alone. This man-made carnage has to be stopped or at least reduced. Evidence and information

from Western countries indicate that majority of the injuries, including road traffic injuries are predictable

and preventable. Even with existing knowledge, there are several interventions, which, if properly implemented

can save “lives and limbs”. With much of focus on communicable disease control and a major perceived role

of hospitals being providing trauma care, systematic injury prevention efforts are totally lacking.

To develop scientific programmes for road safety and injury prevention, there is need for good-quality

information. Meaningful programmes can only be developed based on a good understanding of the current

situation and identifying areas where interventions can be effective. In addition, programmes that are

implemented need to be monitored and evaluated to see how far they have made a change in reducing

deaths and injuries. It is likely that decisions made in the absence of reliable data can only be adhoc and

crisis oriented. Since injury data is often lacking, many of the programmes that are developed are not

evaluated and hence does not sustain over a period of time.

NIMHANS with support from ICMR, WHO and leading organisations in the city of Bengaluru has developed

the methodology of Road Traffic Injury/injury surveillance programme and taken a lead role in its

implementation. The programme has shown that it is possible to develop a good foundation for present and

future programmes based on reliable and good-quality data. Political - administrative support and participation

of institutions is crucial to develop these programmes further. I hope this initiative by NIMHANS will be

seriously considered by policymakers to develop meaningful road safety, home safety and work safety

programmes in the coming years, along with expansion of this initiative across other centres in the country.

Prof. D. Nagaraja,Director / Vice-chancellor,

NIMHANS, Bengaluru.

x Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Foreword

Recent years have witnessed significant concerns on safety and security of

people all over the country especially in economically progressive States like

Karnataka. With increasing motorization, industrialization, and urbanization

in such states, Road Traffic Injuries are showing an upward head Injuries like

burns, falls, poisoning etc have also become equally important issues affecting

the safety of people on road, at home or at the work place. Today injuries are

a major public health and societal problem in Karnataka and its capital Bengaluru. In 2007, an estimated

30,000 deaths and 7,50,000 hospitalizations occurred in the State due to injuries affecting a large number

of people with disabilities and severe socioeconomic hardships. The effect of the traumatic experience of an

individual or a family with a patient in hospital is indeed phenomenal.

Increase in number of vehicles, infrastructure development and expansion and the necessity for travel have

made Road Traffic Injuries a leading cause of death in the young and productive sections of our society.

India and its states are facing a unique challenge of different type-size-velocity vehicles on its roads in a

heterogeneous traffic environment. Even though there are a few time tested and cost effective solutions

handed down by research and road safety programmes in the last 3-4 decades, more efforts are required in

the coming years.

This scenario calls for formulating and implementing scientifically developed road safety and injury prevention

policies and programmes in Karnataka and Bengaluru. To formulate these programmes and strategies,

there is a need for good quality, reliable, and scientific information on injury occurrence and related causes.

Unfortunately, the scientific analysis of injuries, particularly road traffic injuries has lagged behind due to

less importance being given to this aspect. The present initiative by NIMHANS in collaboration with State

and city police, Transport department, World Health Organization and Indian Council of Medical Research

is indeed a laudable effort. The methodology and the programme developed at NIMHANS would help policy

makers and professionals to strengthen safety on roads. Needless to say, quality information should be

utilized and applied for development of programmes to save lives in the region. I strongly hope this would

be given greater importance in the coming years by Government of Karnataka and city of Bengaluru to

strengthen this area.

R. Sri Kumar, Director General and Inspector General of Police,

Karnataka State, Bangalore

xiNIMHANS

Foreword

I am pleased to share with you The Injury Surveillance Report 2007-2008brought out by National Institute for Mental Health and Neurological Sciences,Bangalore. The Department of Epidemiology is a WHO collaborating Centrefor Injury Prevention and Safety Promotion and has conducted extensiveepidemiological studies on road traffic related injuries.

Worldwide injuries are recognized as a major public health problem thatplaces a significant strain on the government and communities. Road traffic injuries cause over 1 milliondeaths and 50 million injuries world over in a year. Official figures in India estimate that in 2007, 4,20,000road crashes were recorded which is 6% more than the number of crashes in 2006. It has resulted in over 1.1lakhs deaths and 4.6 lakhs injuries in the country. These figures are still underestimates as many of theaccidents go unreported. The problem is being recognized by the Government of India and efforts are beingtaken at various levels for their prevention. The Ministries of Transport, Health and Urban planning alongwith other related sectors are working together to identify various strategies at different levels. Steps arebeing taken to improve the data collection system, provide better emergency care for survivors and victims',strengthen advocacy programs for road safety and intensify the enforcement system.

ICMR has been a partner to the Ministry of Health and Family Welfare in research activities related to roadtraffic injuries. In 2006-2007 it conducted multi-stakeholder workshops and coordinated a feasibility studyon injury surveillance with NIMHANS, Bangalore and BJ Medical College, Pune. This project was undertakenwith the support of many hospitals, medical colleges, police, and other related agencies. The study highlightedvarious operational and logistic issues related to the conduct of injury surveillance in the hospitals. Roadtraffic injuries has also been identified as a key area under the ICMR's INDO-US Joint Collaboration onEnvironment and Occupational Health. Two workshops and a Joint meeting of the team from US andofficials from the Ministries of Health and Family Welfare, Transport, Urban planning, industry, insurance,licensing, and enforcement agencies were held during 2007-2008. These activities highlighted the need forsurveillance and improvement of prehospital and emergency care services in the country.

The present report highlights the findings of the Bengaluru Injury Surveillance Program that was launchedby NIMHANS in 2006. ICMR has strongly supported this activity that addresses issues related to themethodology, strengths, and limitations of Road Injury Surveillance. The findings will surely help the policymakers to develop better strategies for prevention of road traffic injuries.

While progress has been made, much more is still to be done. Unless additional steps are taken, projectionsshow that Road Traffic injuries will be the third leading contributor for disease burden in the world. Let usmake collective efforts to prove it wrong.

Dr. Bela Shah,Senior Deputy Director General and Chief of NCD Division,

Indian Council of Medical Research

xii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Preface

In recent times, injuries have become a day-to-day event in our lives. Recently,injuries are being recognized as an emerging public health problem by policymakers and professionals. While there is enormous concern at all levelsincluding media about the day-to-day tragic events, efforts towards preventionand control are few and yet to begin. Road traffic injuries, suicides, burns,occupational injuries and others contribute significantly to deaths,hospitalizations, disabilities and socioeconomic losses.

Reliable and good quality data is the foundation to build injury prevention and control programmes.Information is required on - the magnitude and characteristics of injuries, nature of the affected people,situation - context - circumstances of injury occurrence, characteristics of products and vehicles contributingfor injuries, prehospital and trauma care practices and others to formulate effective policies and programmes,proper implementation of which can result in significant reduction of injuries. The current informationsystems systems in India and its districts and cities only provide information on numbers and very littlebeyond that. Even these numbers are under reported, and hence the real burden, profile and pattern of theproblem are not clearly known.

The present feasibility study on Injury/Road Traffic Injury Surveillance was undertaken in Bengaluru incollaboration with City Police, transport department and 25 hospitals. Instead of building entirely newsystems, the approach was to strengthen the existing systems to obtain "small amounts of good qualityinformation" for developing injury prevention and control programmes. More than 300 professionals frompolice department and emergency rooms of hospitals participated in information gathering activities.

The present report outlines the methodology of surveillance programme and also the type of data that canbe generated through such programmes. At the same time, the strengths - opportunities - limitations andbarriers have been identified to know the scope of injury surveillance. Surveillance data can provide meaningfulinputs for developing policies and programmes, capacity strengthening, prioritization of problems, resourceallocation and can provide directions for interventions. Whether the implementation of interventions resultedin a meaningful change will once again be shown by surveillance data. The development of specific andtargeted intervention require more research from health, safety agencies, product/vehicle manufacturersand others on different dimensions. Using the findings of the study, a set of 10 simple fact sheets have beendeveloped to highlight individual type of injuries. In addition, the five public health alerts reiterate the needfor systematic interventions, that have been proven to be effective all over the world.

In this approach, one has to be cautious to keep the surveillance simple and cost effective withoutoverburdening the systems. The nature - contents - amount of data to be collected should be decided "apriori"and quality should be ensured. Most importantly, there is need for building mechanisms to ensure that thedata collected is used meaningfully and not a waste of time and resources. Further, the type and nature ofinstitutions to be involved along with quality control mechanisms should be put in place. The efforts of thiscollaborative group will be amply rewarded, if, Parliamentarians, Policy makers and Professionals recognizethe seriousness of the emerging injury epidemic and facilitate multisectoral institutional based activities forprevention and control of injuries.

Dr. G. GururajProfessor & Head

Dept. of Edidemiology and WHO Collaborating Centre for Injury Prevention and Safety Promotion,NIMHANS, Bengaluru.

xiiiNIMHANS

Acknowledgements

The Bengaluru Road traffic injury/injury surveillance programme is a collaborative effort between NIMHANS,

Bengaluru city police, Bengaluru transport development Corporation, 25 hospitals and NGO's. Nearly 300

professionals have participated in the programme from various organisations. Listing individual names

will run into several pages, but sincere thanks to all of them for taking interest in developing this programme.

Specially, thanks to all nodal officers for taking leadership role in their respective organisations.

Thanks to Dr. D. Nagaraja, Director / Vice Chancellor for being a constant source of support and guidance

along with taking keen interest in the programme.

Sincere thanks to Indian Council of Medical Research and World Health Organisation, India country office

for facilitating the study and providing financial support. Especially, we are thankful to Dr. Bela Shah,

Dr. Geetha Menon, Dr. Cherian Varghese and Dr. Kavita Venkataraman for all help and support in developing

the programme.

Specially, my colleagues Dr. Girish N Rao and Dr. Kavita Rajesh participated and supported the programme

at all levels from planning to finalization of report. Their immense contribution was beneficial in completing

this feasibility study and moving to the next phase of programme. My sincere thanks to both of them for

all contributions towards this programme. Thanks to Sri. Vijendra S Kargudri and Sri. Girish BG for

co-ordinating data editing and efficient data management.

We are grateful to Sri N. Gopalkrishna, Assistant Editor, NIMHANS and Ms. Manasi Paresh Kumar for help

in editing the manuscript. Thanks to M/s. Aditi Enterprises for design and printing of the report, factsheets

and public health alerts.

xiv Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

List of Abbreviations

CMO : Casualty Medical Officer

CBHI : Central Bureau of Health Intelligence

CC : Co-ordinating Centre

CCRB : City Crime Records Bureau

CDs : Communicable Diseases

ER : Emergency Room

ETCR : Emergency Trauma Care Record

FIR : First Information Report

HICs : High Income Countries

ICD : International Classification of Diseases

ICECI : International Classification of External Causes of Injuries

ICMR : Indian Council of Medical Research

IPC : Injury Prevention and Control

LMICs : Low and Middle Income Countries

MCCD : Medical Certification of Cause of Death

MLC : Medico-Legal Case

NCRB : National Crime Records Bureau

NIMHANS : National Institute of Mental Health & Neuro Sciences

NCDs : Non-Communicable Diseases

NGO : Non-Governmental Organization

OTC : Over The Counter

RMO : Resident Medical Officer

RTI : Road Traffic Injury

SRS : Sample Registration Scheme

WHO : World Health Organization

xvNIMHANS

List of Tables

Table 1:Example of Haddon's matrix as applied to two wheeler road traffic injury .................................... 4

Table 2:Strengths and limitations of different strategies ........................................................................... 13

Table 3:Inventory results of the staffing pattern at casualty depts. of various hospitals ............................. 14

Table 4:Inventory details on the approximate patient load in the casualty department ofvarious hospitals ......................................................................................................................... 15

Table 5:Bengaluru city - A socio-demographic profile .............................................................................. 21

Table 6:Motorization index for Bengaluru ................................................................................................ 21

Table 7:Distribution of fatal and non-fatal injuries ................................................................................... 23

Table 8:Number of fatal injuries registered with police, Jan - Dec 2007 ................................................... 24

Table 9:Non-fatal injury registrations in Emergency rooms of select hospitals, April-March 2007 ............. 25

Table 10:Education & occupation of persons in RTIs .................................................................................. 30

Table 11:Environmental factors .................................................................................................................. 33

Table 12:Education & occupation levels among completed & attempted suicides ........................................ 35

Table 13:Major causes of suicide for different age groups .......................................................................... 37

Table 14:Education and occupation distribution of non-fatal fall injuries ................................................... 41

Table 15:Place of first aid for injured persons ............................................................................................ 45

Table 16:Place of first aid for non-fatal injured persons ............................................................................. 46

Table 17:Severity of injuries in ER facilities ................................................................................................ 49

Table 18:Injury pattern with reported and estimated figures ....................................................................... 51

xvi Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

List of Figures

Figure 1: Epidemiological model of an injury caused by a motorcycle collision ................................. 4

Figure 2: The injury spectrum ............................................................................................................ 4

Figure 3: India injury pyramid ........................................................................................................... 5

Figure 4: Road accident deaths in India, 1980-2006 .......................................................................... 6

Figure 5: State wise distribution of RTIs in India, 2006 ..................................................................... 6

Figure 6: State wise distribution of suicides in India, 2006 ................................................................ 6

Figure 7: Designing and building a surveillance system ..................................................................... 9

Figure 8: Sources of information for injury ...................................................................................... 11

Figure 9: Map of Bengaluru showing the location of various partner hospitals ................................ 14

Figure 10: Vehicular growth in Bengaluru ......................................................................................... 20

Figure 11: Distribution of deaths in Bengaluru, 2005 ........................................................................ 22

Figure 12: External causes of injuries ................................................................................................ 23

Figure 13: Age - sex distribution of injury deaths ............................................................................... 23

Figure 14: Bengaluru injury pyramid ................................................................................................. 24

Figure 15: Traffic deaths in Bengaluru (2000 - 2007) ........................................................................ 24

Figure 16: Suicides in Bengaluru (2000 - 2007) ................................................................................. 25

Figure 17: Age-sex distribution of fatal & non-fatal injuries ............................................................... 26

Figure 18: Place of injury occurrence ................................................................................................ 26

Figure 19a: Injury causes .................................................................................................................... 27

Figure 19b: Injury causes for rural non-fatal injuries ........................................................................... 27

Figure 20: Place of occurrence of RTIs .............................................................................................. 28

Figure 21: Distribution of RTI deaths based on place of death ........................................................... 28

Figure 22: RTIs in Bengaluru ............................................................................................................ 29

Figure 23: Age-sex distribution of RTI deaths .................................................................................... 29

Figure 24: Time of crash in fatal and non-fatal injuries ..................................................................... 30

Figure 25a: Road user categories in urban fatal and non-fatal injuries ................................................ 31

Figure 25b: Road user categories in rural non-fatal injuries ................................................................ 31

Figure 26a: Injury collision pattern amongst pedestrians ..................................................................... 31

Figure 26b: Pedestrian activity at time of injury ................................................................................... 31

Figure 27a: Collision pattern of two-wheeler rider/pillion ................................................................... 32

Figure 27b: Crash pattern and type of collision among two-wheeler rider/pillion ................................ 32

Figure 27c: Use of helmets among two-wheeler riders ......................................................................... 32

Figure 28a: Bicyclist hit by ................................................................................................................. 32

Figure 28b: Crash pattern and type of collision among bicyclist .......................................................... 32

xviiNIMHANS

Figure 29a: Car occupant hit by .......................................................................................................... 33

Figure 29b: Crash pattern and type of collision among car occupants ................................................. 33

Figure 29c: Usage of seat belts among car drivers ............................................................................... 33

Figure 30: Month of occurrence, suicides .......................................................................................... 34

Figure 31: Age-sex distribution of completed & attempted suicides .................................................... 35

Figure 32: Place of occurrence of completed and attempted suicides ................................................. 35

Figure 33: Methods of suicide ............................................................................................................ 36

Figure 34: Suicide situation ............................................................................................................... 36

Figure 35: Time of completing and attempting suicides .................................................................... 36

Figure 36: Age-sex distribution of burn injuries ................................................................................. 38

Figure 37: Place of occurrence of burns ............................................................................................. 39

Figure 38: Distribution of burn injuries as per time ........................................................................... 39

Figure 39: Fatal & non-fatal poisoning - age-sex distribution ............................................................. 40

Figure 40: Place of poisoning ............................................................................................................ 40

Figure 41: Age-sex distribution, falls ................................................................................................. 41

Figure 42: Place of occurrence, falls ................................................................................................. 42

Figure 43: Age-sex distribution, drowning ......................................................................................... 43

Figure 44a: Age-sex distribution of assault / violence injuries .............................................................. 44

Figure 44b: Place of assault / violence ................................................................................................ 44

Figure 45: First aid care for persons with fatal and non-fatal injuries ................................................ 45

Figure 46: Personnel delivering first aid for fatal and non-fatal injuries ............................................. 46

Figure 47a: Mode of transportation in urban Bengaluru ...................................................................... 46

Figure 47b: Mode of transportation in rural Bengaluru ....................................................................... 46

Figure 48: Time interval between time of injury and registration, fatal & non-fatal, all injuries ........ 47

Figure 49: Time interval between time of injury and registration, fatal & non-fatal, RTIs .................. 47

Figure 50a: Body parts injured in RTIs ................................................................................................ 48

Figure 50b: Body parts injured in assault/violence .............................................................................. 48

Figure 50c: Body Parts injured in Falls ................................................................................................ 48

Figure 51: Extent of burns among fatal & non-fatal burn injuries ....................................................... 48

Figure 52: Status of injured persons at hospital entry......................................................................... 49

Figure 53: Mode of management ....................................................................................................... 50

Figure 54: Pathways of research ........................................................................................................ 55

Figure 55: Inputs for RTI prevention and control ............................................................................... 55

Figure 56: Need for an intersectoral approach ................................................................................... 58

xviii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Executive Summary

The city of Bengaluru has grown by leaps and bounds during the last decade. A "cosy & comfortable

Bengaluru" has changed to a "Bruhat Bengaluru", embracing a population of 8 million in its day to day

activities. As a senior citizen remarked "the city is a living testimony to what socioeconomic changes can

make for a one time peaceful city". As city planners and administrators take pride in many positive

developments of education, information technology, raising living standards, vibrancy and hope for millions,

etc. safety and health have also become matters of great concern.

Injuries, hitherto referred as accidents, have emerged as an important public health problem in the city. It

has become common to read, listen, witness or even experience an injury in our day-to-day lives. Many

times these are considered as accidents, events due to bad times, or simply an act of fate. Till a few years,

many High Income Countries (HICs) of the world had similar understanding of injuries and were doing,

what we are doing today. This changed with information - knowledge - data - evidence and evaluation and

resulted in significant changes in the way we use roads, live at home or work in different places.

This knowledge and information came from years of research that resulted in a better understanding of

injury phenomenon in terms of burden, characteristics, causes, risk factors, determinants, impact and

outcome. Surveillance is one such activity that will help in recognizing the burden of injuries, identifying

broad risk factors and causes, prioritizing activities, monitoring and evaluating interventions, capacity

development, and stimulating further research. Even though India has considerable experience in

Communicable Disease (CD) surveillance, Injury and Road Traffic Injury surveillance is new and its importance

is recently gaining recognition.

In India, during 2007, there were 315,641 injury related deaths and 493,515 persons sustained injuries as

per NCRB report. The report also provides detailed information as per states, cities and on major socio-

demographic variables (age, sex, time, categories and an overview of causes). This information though

extremely useful, needs to be strengthened with data on causes, risk factors and specific attributes of each

injury by further systematic studies. Further, local data in states, cities and rural areas are required to

develop locally relevant programmes.

To develop systematic and scientific injury prevention - Road traffic injury prevention, trauma care and

rehabilitation programmes, comprehensive information on epidemiological characteristics of injuries are

required. Reliable and good-quality information is the basic foundation and one of the requirements for

injury prevention and safety promotion programmes. Till date, all over India, police sources of data have

been the only ones available for understanding injuries and health sector information has been lacking and

research studies have been limited. The police collect large amount of information for medico legal and

administrative requirements. Despite this and even though health, transport sectors collect data on deaths

and injuries, the data has several limitations in terms of completeness, coverage, quality, utility and integration.

xixNIMHANS

Data is often not available in some vital areas that are essential to develop prevention, management and

rehabilitation programmes. Surveillance has been recognised as an important activity to develop good-

quality information which can act as the basis for larger programmes. Contrary to popular belief, surveillance

can be built on existing systems with appropriate strengthening at different levels.

Injury surveillance defined as systematic collection, analysis, interpretation, dissemination of data along with

feedback and action is an essential component of injury prevention and road traffic injury prevention programmes.

Injury/RTI surveillance is the foundation on which other data components can be established. If implemented

well, it can provide information on the burden and magnitude of the problem, injury patterns and profiles,

major characteristics of injured and killed persons, risk factors, pattern of care and outcome. The amount of

data that is made available depends on the amount of information collected from different sources in varied

sittings. Using surveillance as the first level of activity, additional activities such as trauma registries, risk

factors studies, focused research activities, product / vehicle related research, behavioural studies and

multidisciplinary crash and injury investigations can be added to develop comprehensive understanding of

injury / RTU phenomenon. Injury/RTI surveillance data will be useful in recognising the public health impact

of the problem, prioritisation process, resource allocation, capacity development, monitoring the impact of

interventions and stimulating further research.

The present injury/RTI surveillance activity was started as a feasibility study to understand the process and

issues, develop methodology, and implement a programme with necessary tools. The study was undertaken in

Bengaluru, Pune and New Delhi during 2007-08. The initiative in Bengaluru was coordinated and initiated by

department of Epidemiology and the WHO collaborating Centre for injury prevention and safety promotion at

NIMHANS. The programme was developed in a collaborative manner between NIMHANS, Bengaluru city

police, Bengaluru Metropolitan Transport Corporation, 25 major hospitals from rural and urban areas and

NGO's. Attempts are being made to develop this feasibility work into a long-term activity, so that continuous

data is available on a regular basis.

The programme beginning with consultation of stakeholders, undertook the preliminary activities of situation

analysis, review and utility of available data, need for good-quality data, mechanisms required for information

collection along with dissemination and feedback activities. Data collection formats were developed and

implemented along with training of personnel in police and hospitals. During a one year period, information

was collected from 3,427 (total 4334 - 79% coverage) injury deaths, 53,448 (total 68,498 - 78% coverage)

hospitalised patients and 113 fatal bus crashes. The present report summarises the situation and lays a

roadmap for the future.

Information gathered in this one year reveals that - nearly 5,000 individuals have lost their lives and more

than 100,000 were hospitalised due to an injury in 2007. In the hospitals, injuries accounted for 21% of ER

registrations, 10% admissions and 30% of total deaths. Majority of those killed and injured were in younger

age groups of 16 to 45 years and were predominantly men. Road traffic injuries and suicides were two

major injury problems in the city of Bengaluru. Pedestrians, two wheeler riders and pillions, and pedal

cyclists were involved in greater numbers. Crashes between these vulnerable road users and heavy vehicles

resulted in higher deaths and serious injuries. Suicides were commonly due to consumption of

organophosphorus compounds and drugs, occurring at a time when the person was alone and at home.

Burns, poisoning, falls were other major injuries responsible for deaths and hospitalisations. Trauma care

xx Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

was found to be inadequate and poor, requiring immediate strengthening. Nearly half of the injured reaching

the hospitals were in moderate to severe levels of severity requiring further management.

Implementation of the programme during the last one year and its continuation during the last few months

reveals that road traffic injury and injury surveillance is possible, feasible and can be developed within the

existing systems. While data on deaths could be collected from police after improving their data collection

capacity, hospitals can collect injury data using the uniform emergency trauma care record. Opportunities

exist for integrating both police and hospital information, more so with technology tools. Administrative

support, training of personnel, monitoring and regular feedback are highly essential for sustainability of

programme. Apart from collecting data, it is crucial to build capacity within the existing systems for careful

analysis and interpretation of data. Discussions with policymakers and professionals indicated that the data

developed will be useful to develop new activities as well as to monitor existing programmes. Surveillance

data can be extremely useful to identify new and emerging problems with the passage of time.

Despite the usefulness of data and the programme, several limitations need to be addressed and activities

initiated for long-term continuation of programme. These include cooperation from police and hospital

staff, administrative approvals, continuous training programmes, mechanisms for analysis - dissemination

- applications, systematic feedback, resource allocation, leadership roles and others. Most importantly, the

data developed must be utilised for developing intervention programmes on a continuous basis. If the data

collected is not utilized for the benefit of the common man to reduce injuries, it will only have limited utility.

At this juncture, injury (RTI) prevention and control is a shared activity among several sectors and there is

no dedicated -lead agency to address prevention and control issues. Mechanisms to guide-direct-co-ordinate-

implement-monitor- and evaluate need to developed in the coming days. Surveillance should be developed

in a phased manner with a focus on select injury causes in select institutions. There are several opportunities

and mechanisms to use data as strong evidence to develop scientific programmes for injury prevention and

control. It is hoped that this experience and learning will help professionals across the country to initiate

activities for injury prevention and control on a scientific basis using evidence based approaches.

1NIMHANS

Injury and violence is one of the leading causes fordeath and disability worldwide, more so in Low andMiddle Income Countries (LMICs). Recent years havewitnessed a rapid increase in motorization,industrialization, migration, urbanization, changinglife styles, habits and value systems of people. Theinfluence of print and visual media is also muchlarger today. While this ongoing epidemiologic,demographic and socio-economic transition has seena decline of some communicable diseases, it has alsoseen the emergence of injuries as a leading healthproblem (1). India and Bengaluru are no exceptionto this change.

India has made substantial progress in communicabledisease control, expansion of Non-CommunicableDisease prevention and control programmes anddevelopment of trauma care services in managingthe unfolding triple epidemics of today. Undoubtedly,the best of trained health professionals and state ofart health facilities are rapidly emerging. The countryhas not lagged behind in offering high quality healthcare services and medical tourism is emerging in abig way. Augmentation of facilities and improvementin the quality of services is receiving greater attentionof policy makers and administrators. Increasingparticipation and contribution of the largelyunregulated private health sector (large chain ofspecialty hospitals, teaching hospitals, nursinghomes, family practitioners and local doctors ofIndian systems of medicine), increasing costs ofhealth care, greater burden on individuals andfamilies are some accompanying changes in thisscenario. Most of the health care at individual andfamily level are still met by out of pocket expenditure.Injuries affect the most economically productivesections of our society, thereby depleting precioushuman resources along with huge socio economiclosses to the individual, family and national economy.

No single day passes in our lives without injuriesmaking a direct or indirect appearance. Injuries arecommon and affect all people, more so theproductive sections of our society. Road trafficinjuries, falls, burns, poisoning, occupational / workrelated injuries, suicides, violence / assault and

1. Introduction

animal bites are some common injuries. Individualsin the age-group of 5-44 years and also men are themost affected. People in middle and lower incomestrata of society are more vulnerable, thus makingthem poor due to economic impact of injuries. Healthsector bears the maximum brunt by providing carefor affected individuals and families. At the sametime, policies and programmes to address thisproblem are emerging few and limited. Recently,there is a growing recognition that injuries are amajor killer in our society. Research and experienceof High Income Countries (HICs) in the world revealthat majority of injuries are predictable andpreventable.

In India, systematic and scientific efforts in injuryprevention and control are yet to begin. While injurieshave declined in many developed parts of the world,it has been steadily rising in India. The need to adoptand suitably modify lessons from HICs is crucial forinjury prevention and control in India to avoidrepetition of mistakes and to make appropriatedecisions by recognition of principles. The last fourdecades of research and policy developments acrossthe world have shown that injuries are predictable,preventable, but needs a systems approach. In theabsence of coordinated, integrated and intersectoralapproaches, injury prevention and control is at crossroads and without direction in India.

Injury prevention and control should be evidencebased and data driven. Good quality, reliable andrepresentative information is very vital to formulateinjury prevention programmes. However, in India,comprehensive information is often lacking or, atbest, patchy. Though police data on injuries areavailable to a limited extent, health sectorinformation has been totally missing. Further, eventhe collected information is not systematically andscientifically analysed to develop a betterunderstanding of injury pattern, profile anddeterminants. Even the available data are not aptlyutilized in policy and programme development.Nevertheless, the scenario has begun to change andtime is appropriate to give a major push anddirection for this area.

2 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

Several initiatives at international and national levelsin recent times have paved the way for this change.The World report on Road Traffic Injury Prevention(2), World report on Violence & Health (3) and fewnational reports (4, 5, 6) have recommended injurysurveillance and good data as an important tool toreduce the growing burden of injuries in all countries.Efforts to improve police, transport and health datahas been on the anvil for past few years. Road Trafficinjury surveillance initiative in select cities on a pilotbasis by the Indian Council of Medical Research hasjust been completed in 2007 / 08 (7). Injury surveillanceacross trauma care centres is under the considerationof the Ministry of Health, Government of India.Research in the areas of suicide and violence prevention,though limited, has recommended good data as aprimary need to develop National Suicide Preventionpolicy and Programmes (8). The report of the NationalCommission on Farmers (http://krishakayog.gov.in/)and Prevention of Domestic Violence Act (http://ncw.nic.in/DomesticViolenceBill2005.pdf) includemeasures for reduction of suicides by strengthening theevidence base. Violence prevention is gainingimportance with an active judiciary and NGO networkalong with recognizing the importance of information.Work related injuries, though on the increase, has notreceived much attention as majority are employed inthe unorganised sectors. The media has been spreadingsafety messages and have contributed significantly tobuilding a safety movement in the country and availablestatistics are quoted many times. Most importantly,people, at least in urban areas, are thinking of safetyas an important component. What is most crucial isthe fact that all these initiatives should be driven bydata based decision making.

Many of the Indian states and cities are movingtowards road safety, though home safety and worksafety have lagged behind. The national road safetypolicy for India is in final stages of approval. Nationalpolicies on transport development, urbanimprovement and infrastructure expansion haveincluded an element of road safety. Many Indianstates have evolved independent road safety policiesand plans. Ministries of transport, home affairs,social welfare and urban development have begunsupporting safety programmes. Highway expansionand improvements, Golden Quadrilateral Project,new plans and investments in infrastructure expansionare gathering pace. Multilateral projects of World

Bank, Asian Development Bank and others aremoving rapidly. Infrastructure development projectsin Karnataka, like B–TRAC 2010 of Government ofKarnataka for Bengaluru city have identified roadsafety information system as one of the 10 maincomponents. Helmet legislation & enforcement,programmes on reducing drinking and driving, speedcontrol measures through road engineering and useof speed cameras, pedestrian safety are all inchingforward. Awareness programmes are conducted,though not systematic and co-ordinated. Ministry ofHealth & Family Welfare has been focusing onstrengthening trauma care across the country andseveral states have taken up this as a priority area.While new initiatives need to be formulated andimplemented, ongoing activities should be monitoredand evaluated for their effectiveness and efficacy. Thisis possible with surveillance, combined with goodresearch and evaluation studies.

Given the magnitude and burden of the problem, theefforts for prevention, management and rehabilitationare pitiably low. The obvious questions are - Why shouldyoung people lose their lives or become disabled onroad, at work or at home?, why should families suffer?,why should the country be losing precious humanresources?, why should people end up with lifelongdisabilities?, why are injuries on the increase despitethe availability of enormous knowledge towardsprevention and control?,. These questions are becomingtopics of debate as injury and violence related issueshave moved on to the front page of the newspapersand prime time issues on television channels.Consequently, people today have begun to debate,discuss and demand safety on roads, at home and inwork places. In response, in recent years, there hasbeen a greater concern across several ministries on theneed for prevention. To transform this concern to action,quality information forms the first step in making injuryprevention and control a reality as mere concern aloneis not enough, but calls for action.

The current information available primarily frompolice (9) and to a limited extent from health istotally inadequate to formulate injury and road safetyprogrammes in the country. In recent years, theGovernment of India, World Health Organization,Indian Council of Medical Research and severalprofessionals from health, transport, police, urbanand rural development and NGOs have identified

3NIMHANS

information strengthening as the basis for injuryprevention and road safety programmes. Goodinformation, undoubtedly, provides a foundationand direction for development of sustainableprogrammes.

With this in view, the present programme on injury

and Road traffic injury surveillance in Bengaluruhas an important place to understand the currentscenario, examine the feasibility and develop amethodology to generate information andfacilitate its greater application in road safetyand injury prevention programmes across thecountry.

2. What is an injury?Commonly, injuries are considered as accidents,‘Accident’ simply means that it just happens andnothing can be done about it. The term “injury” bydefinition means that there is a body lesion due to anexternal cause, either intentional or unintentional,resulting from a sudden exposure to energy(mechanical, electrical, thermal, chemical or radiant)generated by agent - host interaction (10). Thisgeneration & transfer of energy in an injury event (orcrash) lead to tissue damage when it exceeds thephysiological tolerance of the individual. On thecontrary, injury can also occur due to suddenwithdrawal of a vital requirement of the body, forexample, withdrawal of air in drowning. Thus, aninjury is damage to a body organ, which occurs rapidly,with sudden energy transfer being the reality andreason. In injuries, there is a definite interactionbetween agent, host and environment, is an acute event,occurs in varying severities and with chances ofrepeated occurrence. Global understanding of injurycausation and mechanism has revealed that injuriesare not just accidents, as exemplified by the 2004 WorldHealth Day slogan “Road safety is no accident”.

2.1. Types of injuryInjuries are classified in number of ways. Acommonly used method is to classify injuries asintentional, unintentional and undetermined injuries,based on intent of injury occurrence. Unintentionalinjuries are also referred to as accidental injuries,while intentional injuries are self-inflicted or causedby others. The latter include suicides, homicides,injuries due to violence against women, children andelderly, those due to wars, riots and conflicts, etc.,A second common method of classifying injuries isaccording to the mechanism which caused the injury,like road traffic crashes, poisoning, falls, fires/

burns, drowning, fall of external objects and others.A third method of classifying injuries is accordingto place of occurrence like road injuries, homeinjuries, sports injuries and work related injuriesbased on place of occurrence of injury. The fourthmethod is based on anatomical types and locationof injuries depending on body organs injured likehead injuries, facial injuries, injury to long bonesetc. A continuation of this is seen as fractures,contusions, haemorrhage, etc. InternationalClassification of Diseases (11) and InternationalClassification of External Causes of Injuries (12) arecommonly used for systematic and scientificclassification of injuries all over the world. Aparticular classification chosen is primarilydetermined by the purpose of a (or more)programme(s) and availability of resources.Commonly, the first three methods (viz., intent,mechanism, place) are preferred, as changes canbe made in products and environment, to preventinjuries occuring in future.

2.2. Understanding injuriesHistorically, in 1970, William Haddon Jr., proposeda matrix for consideration of all factors involved ininjury causation at different time periods and atvarious levels (13). This involved identifying whatcan be done for people, products and the environmentbefore injury, during an injury and after its occurrence(Table 1). This concept has revolutionized injuryprevention since 1970s all over the world, and canbe used to analyze any type of injury, identifyinterventions that might prevent such an event fromhappening again or reducing the harm done.

Injuries occur due to a combination of agent, host,vector and environment factors. The epidemiological


triad of agent, host and environment has been usedin our understanding of communicable diseasesearlier and injuries too have similar dimensions likeany other public health problem. There is a clearneed to understand injury mechanisms to developintervention programmes.

Some appropriate interventions that might preventsuch collisions from happening in future are givenbelow and several more can be added to this list.• Implementing helmet & drink drive laws• Reducing speeds with safety in focus• Increasing visibility of two-wheelers and/or riders• Strengthening brake & light systems• Improving pre hospital & emergency care• Overall safety improvement of roads and others

Use of injury spectrum is another useful method tounderstand injuries. This method (figure 2) mapsan injury over time, starting with its exposure,followed by the event, through the occurrence ofinjury time finally resulting in disability or death.Understanding this time spectrum can help indeveloping interventions that can either prevent injuryor lessen the impact of injury.

The case of an injury to a motorcycle rider involvedin a motorcycle collision is shown in Figure 1. Here,the host is the rider, vector is a motorcycle, agent isthe mechanical force or energy and environment isthe road. Similarly, in an act of interpersonaldomestic violence in which a husband causes injuryto his wife, the host is the injured person, the agentis the energy (physical assault), the vector is theperson inflicting injury and the environment includedomestic situation and societal norms and valuesthat allow for such behaviours to occur.

Using a model of this type helps in identifying factorsinvolved in an injury. This would help policymakers,professionals, product manufacturers and others toidentify situations and target interventions to preventsuch injuries from happening in the future or reducethe harm done when they happen. For instance, inthe first example, there may be factors about therider, the motorcycle or the road that contributed tothe crash. One or more of these can be changed inorder to prevent such incidents in the future.Interventions that might be done by anyone thinkingabout these elements is given in Table 1.

Based on this understanding, injury prevention andcontrol is broadly classified as primary prevention,secondary prevention and tertiary prevention.Primary prevention involves preventing the eventfrom occurring or preventing it from leading toinjuries. This involves taking all necessary steps tosee that injuries do not happen and includes allactivities that are done to make people, productsand their environment safer. Secondary preventioninvolves early diagnosis and appropriatemanagement of an injury. Most of the times healthprofessionals are involved in providing care andservices for injured people. This includes allactivities right from application of basic first aidat the place of injury to stopping an injury fromhaving serious consequences. Tertiary preventionaims at improving the final outcome and involvespreventing further complications throughrehabilitation programmes.

Source: (19)

Figure 1: Epidemiological model of an injury caused by amotorcycle collision

ENVIRONMENTSlippery roadway

HOSTRider

AGENTCollision

(mechanical)force or energy)

VECTORMotorcycle

Table 1: Example of Haddon’s matrix as applied to two wheeler road traffic injury

Human Vehicle Environment

Pre-event Increase awareness about safe Increase visibility of vehicle Implement safety features ondriving, helmet wearing, drink roadsdriving etc.

Event Early transfer to hospital and Better braking systems of Crash protective road siderequired care two wheelers stationary objects

Post-event Rehabilitate and improve health Improve safety technologies Facilities for early rescue ofcare services and components injured persons

EXPOSURE EVENT INJURY DISABILITY DEATH

Source: (19)

Figure 2: The injury spectrum

5NIMHANS

3. Injury: the scale of the problem

The precise number of deaths and injuries due tospecific causes are not clearly available in India.The National Crime Records Bureau (NCRB) atnational (9), state and city levels are the primarysources of information in the country. The nationalagency collects, compiles and publishes annualreports based on data received from state and cityagencies. An overview of current scenario is providedin Annexure 1.

• Nearly 4, 59,709 injury deaths and 2.5 millioninjuries were reported in India in 2007. RTIsand suicides, being 2 major injuries, accountedfor 1, 14, 590 and 1, 2, 637 deaths, respectively.A recent national review (1) has estimated thata million injury deaths and 30 millionhospitalizations occur every year. SouthernIndian states reported higher number of deaths,reasons for which can be several and notclearly defined.

• In Karnataka, 12304 suicides and 8762 RTIdeaths were reported followed by 1593 homicidaldeaths for the year 2007. In the same year, 1, 82,321 persons were injured as per police reportswith a ratio of nearly 1:5. Combining bothaccidental and suicidal causes it was observedthat there were 19, 390 accidental and 12, 304suicidal deaths during 2007.

••••• Bengaluru city reported 5,660 injury deaths withsuicides (2429) and RTIs (961) topping the list;burns were the 3rd leading cause with 371deaths. Road traffic injury alone claimed nearly1,000 lives while injuring 6,591 people as perofficial reports.

Studies, both in India and outside, indicate thatinjuries are underreported in all parts of the world(14, 15, 16). In India, while official statistics areable to capture large majority of deaths, non-fatalinjuries of various severities are highlyunderreported. Data from HICs & studies from Indiaindicate that for every person killed by injury,approximately 30 persons are hospitalized androughly 100 times are treated in hospital emergency

rooms and then released (1, 2). For each death frominjury, there are many more injuries that result inhospitalization, treatment in emergency departmentsor treatment by practitioners in formal and/orinformal health sectors. Studies in Bengaluru andHaryana have shown that injury problems are muchhigher in the community than officially reportedfigures (17, 18). Recent studies (14, 15, 16) usingverbal autopsy methods have shown that injurydeaths contribute for 13–18% of total deaths varyingfrom place to place. The recent national review oninjuries estimated that in 2005, 8,50,000 (nearly amillion) persons were killed and 17,000,000hospitalized (1) (Figure 3). If unchecked, numberswill increase to 1,100,000 deaths and 22,000,000hospitalizations of serious injuries by 2010. Roadtraffic Injuries, suicides, burns, poisoning, violenceare all major causes of deaths and disabilities andfigures 4, 5 & 6 show trend of RTIs deaths and statewise distribution of RTIs and suicides, respectively,for the year 2006.

To formulate effective injury prevention and control(IPC) programmes, information is required on whattypes of injuries occur? Who are the affected people?What are their characteristics? Where and howinjuries occur? What are the causes?, what are theagent – host – environment factors that can bemodified? and what needs to be done towardsprevention, improving trauma care andrehabilitation?, etc. The currently available datafrom police reveal the number of deaths due todifferent causes of injuries in India and Bengaluru.The data also provide broad characteristics of injurieslike age, gender, some socio-demographiccorrelates, while risk factors and causes are notdelineated clearly. However, information on numberof deaths alone is not enough to formulate injuryprevention programmes. Even though state-level and

Deaths (1)

Serious Injuries (20)

Minor Injuries (50)

8,50,000 (upto 10,00,000)

17,000,000 (upto 20,00,000)

42,500,000 (upto 50,00,000)

Source: (1)

Figure 3: India Injury Pyramid


city level information is available, it once againindicates the broad characteristics of injuries butdoes not specifically inform as to what can be doneto reduce these injuries. Numbers are also collectedby different agencies like transport department, CityCorporation and others for their own use. Thecollected information is not used for prevention andcontrol, but more for administrative and legalpurposes. In addition, total information is notavailable in the public domain for researchers andpolicy analysts. Thus, information is piecemeal,fragmented and not integrated.

Given these limitations of existing data, the BISP inthe city of Bengaluru aimed at collecting small and

relevant information from large number ofparticipating organizations in a uniform way tounderstand injury profiles and characteristics withthe major goal of improving injury informationsystems for future activities.

Figure 5: State wise distribution of RTIs in India, 2007 (Rate / 100,000 population; National average 10.1)

State RateGoa 21.3Haryana 18.6Tamil Nadu 18.2Andhra Pradesh 16.9Karnataka 15.4Himalchal Pradesh 15.3Chandigarh 14.4Rajasthan 12.7Delhi 12.7Maharashtra 11.9Gujarat 11.3Kerala 11.2Uttaranchal 10.4Madhya Pradesh 9.3Arunachal Pradesh 9.1

State RateSikkim 8.8Punjab 8.2Jammu & Kashmir 7.9Orissa 7.7Uttar Pradesh 6.7Tripura 6.4Jharkhand 5.9West Bengal 5.6Assam 5.4Meghalaya 5.3Manipur 4.4Nagaland 4.2Mizoram 3.6Bihar 3Chattisgarh 1.3

Figure 6: State wise distribution of Suicides in India, 2007 (Rate / 100,000 population; National average 10.8)

State Rate/100,000Kerala 26.3Karnataka 21.6Tamil Nadu 20.9Chattisgarh 20.7Sikkim 20.7Tripura 20.3Andhra Pradesh 18.2West Bengal 17.0Goa 16.9Maharashtra 14.3Orissa 10.9Arunachal Pradesh 10.8Assam 10.3Haryana 10.3Gujarat 10.0

State Rate/100,000Madhya Pradesh 9.2Delhi 8.9Chandigarh 7.8Rajasthan 6.9Himachal Pradesh 6.2Jharkhand 4.3Meghalaya 3.5Punjab 3.2Mizoram 2.9Uttarakhand 2.6Uttar Pradesh 2.1Jammu & Kashmir 1.9Manipur 1.5Nagaland 1.1Bihar 1.0

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Figure 4: Road Accident Deaths in India, 1980-2007

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7NIMHANS

4. Injury surveillance

The term “surveillance” as used in public healthfield refers to ongoing, continuous and systematiccollection, analysis, interpretation anddissemination of health information (19). Itincludes collecting information on individual casesor assembling information from records, analyzingand interpreting information, reporting andproviding feedback into programmes.Surveillance is a continuous activity with aninbuilt feedback mechanism and an actioncomponent. It is also the best way of monitoringchanging trends, identifying new/ emergingproblems, selecting interventions and measuringthe impact of interventions in a timely manner.Surveillance data can be a meaningful input toseveral programmes and activities of variousministries, government departments, healthprofessionals, transport, police, NGOs and allothers interested in injury prevention.

In India, few surveys have been undertaken in recentyears by individual researchers. A summary ofIndian studies is available in the recent reportentitled “Injuries in India: A National Perspective”(1). In Bengaluru, few studies have been undertakenby NIMHANS on epidemiological, preventive andpublic health aspects of road traffic injuries,brain injuries, suicides and violence(www.nimhans.kar.nic.in/epidem/WHO). In NewDelhi, TRIPP at IIT has made significantcontributions in road safety and transportmanagement (http://web.iitd.ac.in/~tripp/). Fewmedical colleges and engineering and transportdepartments have also undertaken studies in theirrespective areas of interest. Studies and reportsavailable from independent agencies like WHO,World Bank, IndiaClen, NGO’s and other agencieshave added substantial information. However, thesehave been stand alone - one time studies andprovided useful information for interventions andpolicymaking process. A surveillance programmehas not been in place and this collaborative activityis the first of its kind being undertaken in Bengaluruand also in Pune, India. Details of the programmeare available in the recently published report fromIndian Council of Medical Research (7).

4.1. Why do injury surveillance ?Without reliable information on the burden,pattern, trends and causes of injuries, it is difficultto develop any systematic interventions. Hence,in India, lack of reliable information on injuryburden and impact has been one of the majorbarriers for absence of systematic programmes forinjury prevention and control. Consequently, manyof the measures are ad hoc, at times unscientific,and have not made any significant change. In theabsence of systematic information, the injuryproblem is poorly recognised even though evidenceexists that the burden is huge and systematicinterventions can be put in place. Nearly 15% ofdeaths are due to injuries (14–16). Many of theefforts required like allocation of resources,human resource and capacity development,systematic efforts for care and management, injuryprevention interventions, and others have notreceived much importance. Hence, injuries havebeen a clearly neglected problem and a hiddenepidemic for many decades in India.

While reporting systems generally present totalnumbers, Injury surveillance is the first step inunderstanding the burden and characteristics ofinjuries. This needs to be supplemented with focussedand systematic research (e.g., trauma registries) andmultidisciplinary crash and injury investigations byexperienced teams. By bringing data in a continuousmanner, new insights into programmes can bedeveloped in focussed areas.

Surveillance generates data that helps inunderstanding the:

• Magnitude of the problem and itscharacteristics

• Changing trends• Populations at risk• General and select risk factors, and• Impact of interventions

By identifying what interventions are likely to work(time tested solutions should be implementedwithout further delay while waiting for surveillance


systems to develop) with such information, it ispossible to design and apply appropriate scientificinterventions and monitor the results along withassessing the impact of interventions. Local, regionaland national injury surveillance systems will providedata required for planning and delivering effectiveinjury prevention programmes to communities andto the country at large. It will help planners andadministrators to take appropriate action on acontinuous and regular basis. Further, it helpssocieties to advocate for positive changes that arerequired for safety of everyone.

4.2. How is injury surveillance differentfrom surveillance of CDs and NCDs

Public health problems confronting societies arebroadly classified as Communicable Diseases (CDs),Non-Communicable Diseases (NCDs) and injuries.The epidemiology of various conditions has focussedon identifying agent – host and environmentcharacteristics, thus being able to target specificinterventions to reduce deaths, morbidity anddisability. Surveillance of CDs has been in place fora long time and health sector has been the primemover in this area. NCD surveillance is a new entrantand efforts to identify risk factors (e.g., tobacco use,alcohol intake, unhealthy diet, physical inactivity,and others) and targeted diseases (cancer and stroke)have been developed. In injuries, as highlighted inthe previous sections of this report, the agent – host– environment concerns are different even thoughthe primary foundation and principles of diseaseoccurrence remain the same. The mechanism,context, situation, risk groups are different for injuriesand vary within different injury groups, despitecommonalities. Consequently, informationrequirements for surveillance differ for different typesof injuries, even though some will be general andcommon. Hence, injury surveillance focuses oncharacteristics of injured and killed, major injurycauses and selected risk factors along with outcomeof injuries depending on the place, type and extentof information gathering. There are major differencesin surveillance of CDs, NCDs and injuries and hence,type, source and extent of information gathering –analysis – interpretation and utilization vary acrossdifferent groups.

It is once again crucial to highlight that injurysurveillance provides broad and specific information

(depending on the extent and depth of surveillance)and should be supplemented with data from focussed,targeted and specific studies to obtain furtherinsights. Injury surveillance, thus is often the firststep in the larger information networks.

Most importantly, action based on surveillance datais different for 3 major groups mentioned earlier.A quick reaction from concerned public healthagencies (epidemic outbreaks) is possible and helpsin further transmission of disease. Surveillance forNCDs and their risk factor requires broader inputsfrom several ministries. Injury surveillance will beuseful, sustainable and cost effective, if policies-programmes-action plans- and interventions cancome up based on data. The data recipients shouldbe able to act and see whether their actions madeany difference to deaths and injuries throughsurveillance. This needs to be addressed fromearly stages by creating mechanism to share,disseminate, apply and implement injuryprevention and control programmes.

RTI / Injury surveillance also does not necessarilymean building new systems for data collection. Theexisting systems and methods can be improved,strengthened and utilized to develop information thatcan be applied for injury prevention and controlprogrammes.

4.3. Characteristics of SurveillanceProgramme

For any surveillance programme to be operationaland sustainable, it should be

• Simple• Acceptable• Sensitive• Reliable• Representative• Sustainable• Timely• Cost effective and, most importantly,• Useful

The essence of surveillance is to collect smallquantities of good, reliable and useful information(by well defined methods) and apply it to developpolicies, programmes and interventions, therebyreducing the occurrence or harm from injuries.

9NIMHANS

5. Building Bengaluru Injury Surveillance

Programme

As surveillance is a systematic activity, it involvescontinuous and systematic collection of informationfrom designated sources to develop injury preventionprogrammes. The steps of developing andimplementing a surveillance programme are givenin figure 8, as proposed by WHO. These steps mightoverlap in different stages depending on resourcesand ongoing activities. The present report onfeasibility of establishing RTI / injury surveillanceprogramme in Bengaluru identifies the steps,processes, data availability, limitations and barriersalong with opportunities for improvement. Thereport should be seen as a process input to the largerprogramme and reveals the type of data that can begenerated in a continuous surveillance programme.

6. Planning Surveillance Activities

6.1. Stake holder's involvementIt is important to involve all stakeholders in injuryprevention and control including ministries of health,police, transport, urban and rural development,social welfare, education, industries and commerce,media, NGOs and others. Recognising the role andcontributions of all stake holders is crucial as it isan inter-sectoral and coordinated activity.

In Bengaluru, stakeholders from - Police (Traffic,Crime and Law and Order), Health (Directorate ofHealth Services, Directorate of Medical Education,officials from Integrated Disease SurveillanceProgramme and all hospital administrators), Heads(Directors, Chief Executive Officers, Senioradministrators) of major hospitals, Transport(transport department and Bengaluru MetropolitanTransport Corporation), Bruhat BengaluruMahanagara Palike, social welfare, urbandevelopment, National Highway Authority and Non-Governmental Organizations working with injury

issues were contacted, sensitised and involved in theprogramme. The first formal meeting of stakeholderswas held on February 3, 2007 at NIMHANS.

The interactions started with a situation analysisbased on available data, and recognized theimportance and utility of good quality informationalong with identification of injuries as a healthproblem. Even though the roles and responsibilitiesof participating members were different, the needfor joint collaborative programmes was recognizedas a felt need. The interactions focussed on who iscollecting information?, what information isalready gathered?, what information needs to becollected?, how it will be collected and utilized?Following this, all stakeholders have met in seriesof review meetings and training programmes.Individual discussions were also held withstakeholders on several occasions. The identifiedroles and responsibilities for selected major partnerswere as follows:

Figure 7: Designing and building a surveillance system

1. Identifystakeholders

2. Define systemobjectives

3. Define“a case”

4. Identifydata sources

5. Access availableresources

6. Inform and involvestakeholders

7. Define data needs

8. Collect data

9. Establish a dataprocessing system

10. Design anddistribute reports

11. Train staffand

activate system

12. Monitor and evaluate

Source: (19)


Roles & Responsibilities of Partnering Hospitals• Nominating nodal officer• Facilitating training of CMO's/ Medical records

personnel/others• Printing of forms as per individual requirements• Participating in information collection• Using data for hospital and community

programmes• Participating to identify, promote, implement

and evaluate joint activities

Roles and responsibilities of nodal officers inhospitals• Sensitising and sharing information with all

persons in casualty• Organizing training as and when required• Ensuring information collection• Establishing quality control• Designating a place and person to keep data

sheets• Examining data as and when required• Development of joint programmes and• Coordinating in strengthening logistics support-

forms /printing etc.

Role and Responsibilities of Police• Providing consent and designating a Nodal

Officer• Facilitating data collection from individual

stations• Facilitating training of staff from individual

stations• Developing joint mechanisms for data pooling• Supporting development of joint reports• Identifying mechanisms for sharing of data• Leading interventions in all possible areas, and• Participating in evaluation activities

Roles and Responsibilities of transport sector• Participating and designating Nodal Officer• Developing mechanisms for data collection and

pooling• Facilitating training of staff• Facilitating data collection on bus related

crashes• Development of joint reports• Identifying mechanisms for sharing of data• Leading interventions in transport department,

and• Participating in evaluation activities

Roles and Responsibilities of Co-ordinatingCentre - NIMHANS (with all partners)• Initiating the programme• Developing operational guidelines• Providing training to police and hospital staff• Facilitating data collection in hospitals• Undertaking data collection at NIMHANS• Developing quality control mechanisms• Developing computer data entry/analysis

formats• Undertaking joint analysis and interpretation• Providing individual and collective data to

police and all hospitals• Preparing joint reports in consultation and

agreement with all partners• Organizing meetings with all stakeholders once

in 3 months (on rotation)• Identifying and supporting development of

prioritised interventions to be implemented bypolice, transport, health and others

• Expanding programme to districts and state• Organizing annual meetings, and• Providing leadership for the programme

6.2. Focus of surveillanceThe types of injuries included in surveillance needto be clearly defined in the beginning. Problemdefinition determines the structure and content ofthe surveillance system including potential sourcesof information and how this will be collected. Itclearly outlines what injuries would be placed undersurveillance?, what information needs to becollected?, and how it should be utilized?. Underthe proposed surveillance programme, it was decidedto include• Road traffic injuries• Falls• Burns• Poisoning• Suicides and• Assault/violence

While the focus was on all injury causes, the majorfocus was on road traffic injuries as identified bystakeholders. It was decided to include occupationalinjuries in later stages of the programme.

6.3. Goals, purpose and objectivesThe overall goal of the programme is to achieve areduction in injury (RTI and others) deaths,

11NIMHANS

hospitalisations and disabilities in Bengaluru. Thepurpose and objectives of Bengaluru Injury/Roadtraffic Injury Surveillance Programme were to:

• Identify various stakeholders and delineate theprocess of information collection along withstrengths and limitations of existing datacapture systems.

• Collect and analyse data from selectedparticipating health care institutions, policesources and transport sector on specific aspectsof RTIs and other injuries.

• Examine the merits and demerits of data

collected and identify mechanisms forimproving quality of data.

• Facilitate application and utilization of datafor planning and implementing interventionprogrammes through various policies andprogrammes.

The scope of the present feasibility study (2007 - 08)was to develop a mechanism of information collection- pooling - analysis - application - dissemination andto examine the possibility of developing a long term/ continuous activity in Bengaluru.

7. Information sources and existing scenario

7.1. Sources of informationThe different agencies collecting injury relatedinformation in the city of Bengaluru are police,hospitals, transport, city corporation vital registrydivision, insurance and NGOs. The sources of datawithin these agencies include information frompolice reports, hospital records, death registers, anddata from Transport Department. The latter speciallycollects data on crashes where city publictransportation vehicles are involved and compilesthem on a regular basis. Summary information isalso forwarded in prespecified formats to the CityCrime Records Bureau and to the Police Department.

7.1.1. Police reportsIt was decided to collect data on injury mortalityfrom police sources as previous studies have shown

that majority of deaths are reported to police.Bengaluru City Police collect information on variousaspects of RTIs and other injuries (any unnaturaldeath) under the “medico-legal” rubric. All deathsdue to road crashes, suicides, homicides and otherunnatural (suspicious) deaths are considered medico-legal and police are entrusted with the primaryresponsibility of documenting information.Information is based on the formats provided byNCRB. A review of the road crash death and otherinjury death records revealed that large body ofinformation is collected on every case and processedas per administrative and legal requirements. Amajor limitation of this approach has been thatinformation on preventive aspects that can be helpfulfor planners and policymakers are not clearlyavailable. Secondly, the collected data is notcompiled and analyzed systematically at the city orstate level. Thirdly, information is distributed acrossthe 35 traffic and 103 law and order police stationsof the city and is not available in any systematicformat in a central place for examination. Fourthly,information is not brought to the attention of allstakeholders and is not applied for programmes andhence decisions made are not evidence based. Theflow of information for RTIs is given in Annexure 2.

It is to be noted that for all deaths due to injuries, aFirst Information Report (FIR) is completed which

PoliceDeaths

Vital DeathRegistration

Transportinjuries

involvingBuses

RuralHospitals

UrbanHospitals

BISP

Figure 8: Sources of information for injury


contains informant details, enquiry details, mahajar(accident enquiry) and medical reports. Recently, citypolice have introduced a system wherein for everyroad death, possible remedial measures of how itcould have been prevented (based on what causedthe crash) has to be filed and report sent to DeputyCommissioner of Police. The Information containedin FIR focus on:• Administrative details• Identification details• Police station limits• Section of Indian Penal Code• Date / Time / Day• Location• Vehicle involved / Property damaged,• Brief details of injury• Name of hospital• Outcome, and• Action taken

Since there is no online computerization facility inall police stations, mostly the data is handledmanually. FIR and summary sheets are the finalinformation available for each case. Initiallyinformation for surveillance has to be extracted fromFIR and summary sheet.

A review of the existing police information systemrevealed that:• Lack of a uniform reporting format for injuries• Information systems are piecemeal and

fragmentary• Different types of records received from casualty

rooms of hospitals for reporting injuries topolice (along with duplication of work)

• Manual handling of data• Frequent transfer of officials and personnel• Lack of analysis of data• Absence of linkage of records between police

and health• Absence of a centralized agency to process,

analyse and utilize data• Absence of systematic reporting to concerned

stakeholders, society at large and others, and• Medico legal problems of a continuous nature.

7.1.2. Hospital recordsHospitals and health professionals (doctors, nurses,specialists, technicians, medical record staff, etc.)provide care for injured persons across the city and

round-the-clock. Information is collected in medicalrecords as per the practices followed by individualhospitals. An inventory of few hospitals prior to thebeginning of the surveillance programme revealedthat the methods, practices and procedures variedfrom hospital to hospital. Information on road trafficinjuries (especially deaths), suicides, homicides andother unnatural deaths are commonly reported tothe police in different formats (as followed byindividual hospitals). A review of the systemindicated that information is not collected on injurynature, causes, situation, circumstances, use ofprotective equipments or pre-hospital care details,except the source of referral. The diagnostic andmanagement details are written in detail to documentcare for patients. There is no central agency ororganization within the health sector that collectsinformation from all the hospitals, analyses andprocesses data and brings it on a common format todevelop intervention programmes.

Limitations of Health Sector Information• No uniform data formats in the hospitals• The death certificate does not mention injury

as associate or antecedent condition, evenwhen injury has been cause of death; injurydeaths are reported to police separately

• Information on injury patterns, profile andcauses not available

• Data on pre-hospital care factors not elicited• Data on injury care and disability details are

not available, analyzed or reported• Hospitals do not use ICD-10 classification or

the ICECI classificatory systems• Overburdened and overstretched emergency

staff in hospitals (more so in public sectorhospitals)

• Injury surveillance system is absent in thecountry

• No information system with in the healthsector

• Lack of resources (money, manpower, timeand other facilities)

• Rudimentary information systems on RTIsand other injuries

• Very few hospital based studies

A summary of merits and demerits of extracting datafrom existing and proposed systems are given intable 2. It can be seen that there are many

13NIMHANS

Table 2: Strengths and limitations of different strategies

Strategies Strengths Limitations

Extracting data from MLC recordsand other hospital records

Information already documented byCasualty Medical Officers (CMOs)

Registers readily available.

Each hospital maintains records indifferent ways and there is no uniformity.

Information is piecemeal and depends oninterest of the CMO.

Vital information on preventive andemergency care aspects not available.

Focuses mainly on medico legal aspects.

Difficult to read through at times.

Prospective documentation ofinformation

Uniform information collected from allhospitals in a uniform way.

Possible to collect information relevantfor prevention, management andrehabilitation.

Can be integrated with police records.

Facilitates application of data, if thereis timely analysis.

Requires direction from national or localministries and administrative approvals.

Success depends on participation andcooperation of hospital staff.

Needs initial investment for 1 - 2 years forcapacity strengthening of staff andstreamlining of procedures at all levels.

Without feedback and use of data,exercise would be useless, as staff wouldnot be keen on completing forms.

From Injury registry to injurysurveillance

Gives initial window period forpreparations and capacity strengthening.

Can sensitise staff for various activities.

Administrative approvals will be the firststep.

Continuity between and shift from registryto surveillance is crucial.

disadvantages in the current methods of documentinginformation in ERs. Coupled with lack of centraldata collection agency for any city of India, the endresult is working in a vacuum. As there was nouniformity, it was decided in the stakeholders meetingthat all hospitals will adopt a system of documentinginformation in a uniform manner using a commonprotocol supplemented by training and sensitisationprogrammes.

7.1.3. Selection of centers for surveillanceIn the stakeholders review meeting it was decidedthat injury death information will be extracted from35 traffic and 103 law and order police stations asall deaths are reported to police authorities on aregular basis soon after the occurrence of an event.For selection of hospitals a list of all hospitals wasdrawn up in the beginning. For phase 1, 21 urbanand 4 rural hospitals based on the criteria of -• Geographical coverage• Availability of round the clock trauma care• Location of the hospitals and,• Willingness to participate

were identified. It was estimated that these hospitalswould cover nearly 60-70% of injury registrationsand hospitalisations.

In order to test the feasibility in district & ruralareas, the neighbouring district of Tumkur wasidentified. The reasons for choosing this districtwere – location, status of rapid industrialization &migration, presence of a highway and proximity toBengaluru. The district police were sensitised onthis programme. The Government district hospitaland Siddhartha Medical College Hospital alongwith 2 community health centres and 2 PrimaryHealth centres were invited to participate in phase1 of the programme.

7.1.4. Hospitals InventoryA scoping study was undertaken in the beginning toidentify the caseload in emergency rooms, type andnature of personnel available, type of documentsmaintained, information flow and other aspects(Table 3 and 4).


Table 3: Inventory results of the staffing pattern at casualty depts. of various hospitals

Sl No Hospital Nature ofHospital

DoctorsInterns/

ResidentsNursingStaffs

Nursingstudents

Medicalrecordofficials

State ofcomput-erisation

1 Bangalore Baptist Hospital Pvt. teaching 5 4 12 nil Present No

2 Bhagawan Mahaveer Jain Hospital Pvt. teaching 10 nil 16 5 Present Yes*

3 Bowring & Lady Curzon Hospital Govt 2 5 2 4 Present No

4 D.G. hospital Private 3 5 7 nil Present Yes

5 General hospital, Jayanagar Govt 2 nil 16 nil Present No

6 Hosmat Hospital Private 9 2 12 12 Present Yes

7 K.R. Hospital Private 2 4 3 3 Present Yes

8 KIMS Hospital Pvt. teaching 25 6 30 25 Present Yes

9 M. S. Ramaiah Hospital Pvt.teaching 10 5 22 nil Present Yes

10 Mallige Medical Centre Private 4 nil 6 nil Present Yes

11 Mallya Hospital Pvt. teaching 3 nil 12 nil Present Yes

12 Manipal Hospital Pvt. teaching 10 nil 15 5 Present Yes

13 NIMHANS Govt teaching 16 6-8 15 Yes Present Yes

14 Ravi kirlosker Hospital Private 7 nil 6 nil Present Yes

15 Sagar Hospital Private 7 nil 17 nil Present Yes

16 Sanjay Gandhi Institute ofTrauma & Orthopaedics Govt 4 1 4 6 Present No

17 Sparsh Hospital Private 3 4 10 nil Present Yes

18 St. John’s Medical College Pvt. teaching 15 3 12 6 Present Yes

19 St. Philomena’s Hospital Pvt. teaching 6 nil 10 nil Present Yes

20 St. Martha’s Hospital Pvt. teaching 3 nil 10 4 Present Yes

21 Victoria hospital Govt teaching 24 15 6 2 Present No

22 District hospital, Tumkur Govt teaching 12 8-10 6 nil Present No

23 Siddharatha Medical College,Tumkur Pvt. teaching 4 4 3 nil Present No

Figure 9: Map of Bengaluru showing the location of various partner hospitals

Code Hospital01 Bangalore Baptist Hospital02 Bhagwan Mahaveer Jain Hospital03 Bowring & Lady Curzon Hospital04 D G Hospital05 Hosmat Hospital06 Jayanagar General Hospital07 Kempegowda Institute of Medical Science & Research Centre08 K R Hospital09 M S Ramaiah Memorial Hospital10 M S Ramaiah Medical Teaching Hospital11 Mallige Medical Centre12 Mallya Hospital13 Manipal Hospital14 NIMHANS15 Ravi Kirloskar Memorial Hospital16 Sagar Apollo Hospital17 Sanjay Gandhi Accident Relief Centre18 Sparsh Hospital19 St. John’s Medical College & Hospital20 St. Martha’s Hospital21 St. Philomena’s Hospital22 Victoria Hospital

* yes indicate that only the admission counter and sections of hospitals are computerised.

Bangalore Injury Surveillance Hospital Code List

15NIMHANS

The scoping study highlighted that variouscategories of personnel were available in institutionsdepending on the type of organization. Commonly,in medical college teaching hospitals - casualtymedical officers, nurses, residents, postgraduate

students, interns and medical records personnelwork round the clock to provide care for patients.In other hospitals, primarily of a private nature,casualty medical officers and nurses are the onlyroutine personnel.

Table 4: Inventory details on the approximate patient load in the Casualty department of various hospitals

Sl No HospitalNo. of patients attending

casualty/weekNo. of Injury Patients in

casualty /week

1 Bangalore Baptist Hospital 320 to 350 50 to 70

2 Bhagawan Mahaveer Jain Hospital 430-450 15 to 20

3 Bowring & Lady Curzon Hospital 180 to 200 150 to 160

4 D.G. Hospital 50 to 70 10 to 20

5 General Hospital, Jayanagar 130 to 150 40 to 60

6 Hosmat Hospital 100 to 120 40 to 60

7 K.R. Hospital 120 to 140 10 to 15

8 KIMS Hospital 130 to 150 50 to 60

9 M.S. Ramaiah hospital 450 to 470 40 to 50

10 Mallige Medical Centre 300 to 320 15 to 20

11 Mallya Hospital 230 to 250 35 to 50

12 Manipal Hospital 480 to 500 50 to 60

13 NIMHANS 550 to 570 180 to 200

14 Ravi Kirloskar Hospital 130 to 150 15 to 30

15 Sagar Hospital 280 to 300 40 to 50

16 Sanjay Gandhi Institute ofTrauma & Orthopaedics 30 to 50 30 to 50

17 Sparsh Hospital 70 to 90 40 to 60

18 St. John's Medical College 680 to 700 100 to 120

19 St. Martha's Hospital 340 to 360 40 to 50

20 St. Philomena's Hospital 500 to 520 40 to 50

21 Victoria Hospital 750 to 770 250 to 270

22 District Hospital 250 to 300 50 to 60

23 Sri Siddhartha Medical College 100 to 150 2 to 3

The review of the existing hospital information system revealed that:• Information is collected in detail on patient care and management• Information collection depends on attending physician• Different types of records maintained in casualty rooms with duplication of work(number of records

maintained for injuries varied from 1 – 15 across hospitals)• No central processing of data in hospitals• Absence of systematic reporting to any agency, as there is no designated agency• Lack of a uniform reporting format for injuries• Transfer and turnover of staff at regular and frequent intervals• Medico legal problems• Reluctance on the part of some hospitals to undertake shared responsibility• Information is piecemeal and fragmented• No information on preventive aspects


8.1. Administrative approvals• The State Director General of Police and City

Commissioner of Police provided permissionand passed necessary official orders for allpolice officers to extend support.

• The Sr. Deputy Director General of ICMRprovided a letter of appeal to all institutions.

• The State Director of Medical Education andDirector of Health services sent necessaryinstructions to medical colleges in Bengaluruand Tumkur, and also to district hospital inTumkur.

8.2. Point of Information collection oninjury and deaths

The police receive information on deaths occurringin different places and also on injuries from fewhospitals. Even though it is mandatory for hospitalsto report all injuries, only few of them report as pertheir individual practices. For injury deaths, the pointof information collection was the individual policestations (35 traffic and 103 law and order) and thefirst information report and summary sheet werechosen as the source of information. It was decidedto extract information from FIRs into a commonformat under the surveillance programme.Depending on the need, rest of the documents werereviewed at times of need (especially in situationswhere investigation was not completed).

In the hospitals, data was collected from casualtydepartments, as it is the first point of contact forinjury patients. It was also agreed that data wouldbe collected uniformly in a standard format alongwith training of all involved personnel. Informationwas collected as part of the history taking processor soon after treatment procedures were completed.

8.3. Defining Information requirementsAny injury surveillance programme should outlinecore data for the programme and include optionalitems depending on the need. A draft questionnaireoutlining the various elements of surveillance frompolice reports was developed by co-ordinating centreat NIMHANS based on information needs of stake

holders and experience of earlier studies. Thestakeholder’s consultation meetings reviewed thesedata elements and identified them as core dataelements for the programme.

The focus of information collection in the beginningwas on -• Basic identification and brief socio-

demographic details• Information on injury and death (place, type,

activity, intent)• Details of road traffic deaths (where, who, how

and selected risk factors)• Details of other types of injury and deaths

(intent, place, type),• Pre-hospital care (first aid, transport, referral)• Management and outcome

Two types of proforma were developed (one for RTIdeaths and another for other injury deaths), keyreason being that traffic and non-traffic deaths arehandled separately. A common format for reportinginjury events to police was also developed and agreedupon by all hospital authorities. Specific details onburns, suicides, assault and poisoning have beenincluded in the proforma. The contents of all formswere discussed between partners and consensus wasarrived at and agreed upon.

The methodology was discussed at length in thenodal officer’s training programme held on 3 March,2007 and members suggested changes and the samewere incorporated into the proforma. It was decidedto focus on core data elements with scope forexpansion in due course of time. The responsibilityof identifying personnel to complete the surveillanceform was left to individual hospitals to identify thenecessary personnel. However, majority were trainedto ensure uniformity in data collection. Anoperational-training manual (available on request)was developed for training of all involved personnelfrom police and health. The manual includeddescription of purpose of collecting information,various variables – brief description – codingpatterns - methods of filling up of the forms.

8. Preparatory phase (Jan - March 2007)

17NIMHANS

8.4. Pilot studyA pilot study was undertaken on 50 FIRs from policestations. The pilot study showed that it was possibleand feasible to transfer and collect data in a uniformformat. Trained staff from NIMHANS did datacollection during this phase. On an average, it took8-10 minutes to complete a form depending on theexperience of the person filling up the proforma.

A similar attempt was made in few of the hospitalsduring the pilot phase of the programme. A commonERTCR (Emergency Room Trauma Care Record) wasdeveloped. On an average, it took about 5–6 minutesto collect information by direct interviews withinjured patients or their attendants. However, therewere problems experienced with unknown patientsbrought by police.

Following the pilot phase, the findings were discussedwith stakeholders and nodal officers. The proformawas revised accordingly. The revised police andhospital format was accepted as the core data elementform with provision for addition of information atlater stages of the programme.

8.5. Training of Police and healthpersonnel

In the beginning, the field research officers fromNIMHANS were trained in data collection. Thesepeople had basic qualifications in sociology, socialwork, rural development, or in other areas and hadprior research experience in health.

In the police department, the writers of policestations were invited for training programmes. Sincecapacity development is a systematic activity, repeatprogrammes were done to improve contents andquality of data. The training focussed onunderstanding contents of proforma, definitions used,method of entering and coding, checking forcompleteness and other aspects. The details of thetraining programme held for the writers in the policedepartment are provided in annexure 4.

In the hospital, training of casualty staff (CasualtyMedical Officers, nursing personnel and medicalrecords staff) was crucial to ensure completeness,coverage and uniformity in data collection. It wasessential to do this in a phased manner, as therewere large numbers of people to be trained (due to

frequent change of personnel). The training focussedon purpose of the programme, persons responsiblefor data collection, nature of information beingcollected, coding patterns and ensuring safety ofcompleted forms to be collected. Training was alsooffered to different personnel depending on roles andresponsibilities of the personnel. Series of trainingprogrammes have been conducted under theprogramme as shown in annexure 4.

• In order to develop uniformity in data collectionprocedures, the first training program of allnodal officers (Bengaluru City Police and 25identified hospitals) was conducted atNIMHANS on 3 March, 2007. About 40 nodalofficers attended the programme. The variouscomponent discussed in the training were♦ Need for surveillance programme♦ The roles and responsibilities of individual

institutions♦ Roles and responsibilities of nodal officers♦ Need for training of staff in individual

institutions♦ Methods of data collection in emergency

rooms♦ Contents of the proposed questionnaire♦ Brief description of the individual items♦ Time of completion of forms♦ Responsibility of staff in ensuring

completeness and accuracy of data♦ Collection & storage of surveillance forms

in the emergency rooms♦ Transfer of forms to the coordinating

centre♦ Broad outline of data analysis♦ Reporting formats to stakeholders &

hospitals♦ Feedback to individual institutions and to

the nodal officers♦ Data pooling mechanisms♦ Methods of data utilization by individual

institutions

Following the nodal officers training, casualtypersonnel of various hospitals – nursing staff andmedical records personnel were invited for trainingprogrammes. Eighteen orientation and trainingprogrammes were conducted in different institutions.In this process, large number of people weresensitised on various aspects of data collection,


9. Information collection phase

9.1. Supply of formsAs agreed in the stakeholders and nodal officersmeeting, the CC took up the responsibility of printingand supply of forms to all institutions for the first3 months to start the process. Accordingly, the formswere first made available to all hospitals during15–20 March, 2007. The hospitals were requestedto print their own forms with their name and logoas per the requirements. After initial administrativedelays, by the 3rd or the 4th month, almost allhospitals (except 1) printed their own forms andcontinued to use them. With the evolution of theprogramme, it was proposed to shift from paper-based forms to online transmission depending uponthe availability of computer facilities. Discussionshave begun with local IT companies to develop asuitable software package.

9.2. Data collection mechanismsInformation capture has been in progress from April1, 2007 and two different mechanisms were evolvedfor data collection purposes.

From the police records and primarily from FIRs,information was transferred to the surveillance

questionnaire on a day-to-day basis. From April 2007,the station staff completed the forms soon afterinvestigations were completed or during the courseof investigation. The programme started in 4 policestations, expanded to 10 and then covered all policestations, both traffic and law and order. As of July2008, writers of 35 traffic stations and 103 law andorder stations were trained. These trained staffs sendthe completed forms to the nodal officer in policedepartment. Quality control mechanisms wereestablished through cross checks, samplingrecords for reliability and validity checks and forcompleteness.

In the hospitals, information was collected frominjury patients in emergency rooms with effect fromApril 2007 after initial training. It was agreed thatdata would be collected in casualty departments soonafter completing treatment procedures or as part ofhistory taking process. Different modalities ofoperations were evolved in different situations.

• In 5 of the major hospitals, CC staff incollaboration with local team of doctorsundertook data collection. As doctors were

utilization and application components with localdata and examples.

For the casualty department personnel, the trainingwas focused on

♦ Need for surveillance programme♦ Need for training of staff in individual

institutions♦ Contents of the proposed questionnaire♦ Brief description of the individual items♦ When to complete forms♦ Completion of forms as per coding♦ Responsibility of staff in ensuring

completeness and accuracy of data♦ Collection & storage of surveillance forms

in the emergency rooms

♦ Advantages to individual staff membersand institutions

♦ Methods of data utilization by individualinstitutions

A consensus was reached on many of the items andmethodology of data collection - pooling - transfer -analysis - reporting and feedback of the programme.

The training was held in the local language with simpleexamples and colloquial terms. Several questions thatcame up were answered and wherever needed in theproforma changes were incorporated. In the ruralareas, staff from district hospital and SiddharthaMedical College hospital was trained on the variousaspects of the programme in a similar manner.

19NIMHANS

busy with heavy casualty workloads, it was feltthat this was essential. Over a period of time,some doctors / nurses in these hospitals startedcompleting forms on their own. However, sincethere was only one CC staff working on datacapturing, there was difficulty in capturingnight time and week end cases and someinformation has been found missing.

• In few hospitals, CMO’s and nurses undertookthe responsibility of data collection, whilemedical records personnel undertook datacollection in 2 of the hospitals.

• In order to encourage hospital staff for localuse of data and also for administrativerequirements the surveillance forms wereprinted in duplicate (with a carbon copy). Onecopy of the form was retained within thehospitals as the ERTCR and the other one wasforwarded to the CC for data entry. The nodalofficer in each hospital supervised the datacollection process and also ensured properstorage of forms. The CC staff visited each ofthe hospitals on a fixed day at a fixed time tocollect all the completed forms.

9.3. Data management stepsThe writers of traffic and law and order policestations collected information from the police recordsand primarily from FIRs with effect from Jan 2007.The data forms were sent to the nodal officer underthe programme before 5th of the following month.All forms were transferred to the CC by 10th of themonth for computerization. The informationcollected was used for the subsequent trainingprogramme on a regular basis for continuedstrengthening of the programme. A uniform formatfor documenting transfer of completed data sheetswas maintained in the police department andhospitals to ensure completeness and transparencyof entire procedures.

9.4. Data pooling from other sourcesIn addition to information collected from police andhospital sources, data was also collected from thestatistics division of health dept of BBMP, transportdepartment, NGOs, and others for a comprehensiveexamination of injury scenario in the city ofBengaluru.

9.5. Quality control issuesQuality control at different stages of data collection,transfer and entry is crucial to obtain quality dataunder the surveillance programme. In order tomaintain internal and external validity of the wholeprogramme, mechanisms were developed to ensurethese aspects. InitiallyI. Total number of forms received was

crosschecked independently with medicalrecord division of hospital.

II. The CC team examined all forms forcompleteness and coverage from all receivedforms.

III. Random checks by coordinating centre oninformation gathering were done.

IV. Resurvey of patients (5%) was done byindependent teams on a monthly rotationalbasis to ensure accuracy & completeness of datacollection.

9.6. Classification & Coding methodsEven though ICD and ICECI are well-established injurycoding and classification methods, it was proposedto introduce this at later phases of the programme.The primary reason for this was that majority of thehealth professionals were not trained in theseclassification procedures and were unfamiliar withcoding aspects. Majority of hospitals do not use ICDclassification systems for any reporting. Hence, thecoding and classification was done at thecoordinating centre. Over a period of time,professionals from member institutions will be trainedin these aspects and will be integrated into the overallprogramme.

9.7. Computerization processA team of data manager and data entry operatorwas constituted in the beginning and trained in allaspects. A data entry format on EPI INFO windowsversion 3.3 was developed, tested and used for dataentry and analysis purposes.

9.8. Monitoring and Feedback stepsInbuilt mechanisms were developed to ensuresystematic monitoring of the programme.• At the hospital level, data collected from

casualty was cross checked with medical recordstatistics to ensure coverage of cases.

• At the ER level, the nodal officers ensuredinclusion of all cases, completeness of all forms,


transfer to a location in ER for storage andtransfer to coordinating centre at weeklyintervals. Coordinating centre staff ensureduniformity and completeness of data collectionwith random checks and independentmonitoring of 5% cases.

• A weekly meeting (Tuesday afternoon) was heldregularly to monitor progress, recognizeproblems, identify solutions and review progress.

• All received forms from different sources wereexamined for coverage and completeness.Missing information was included fromrecords, wherever possible.

• Meeting with all nodal officers once in 3months helped in reviewing progress,identifying remedial measures for problems,ensured better cooperation, and to work outfuture steps.

• Continuous contact of the CC staff with allinstitutions was an inbuilt activity underthe programme. Periodical visits andcommunication on a regular basis wasundertaken to ensure completion of all activitiesas per time schedule.

• The programme coordinator and the teamvisited police and hospital departments atperiodical intervals and held discussions withnodal officers, ER staff, medical record staffand hospital administrators.

9.9. Sharing and disseminating ofinformation

• As surveillance is an ongoing continuousactivity, the analyzed data need to be sharedwith all the partners and feedback becomes aregular feature of the programme. Asdiscussed in the stakeholders and nodalofficer’s meeting, information wasdisseminated in number of ways. The primaryreason for using so many combined methodswas to encourage people to get activelyinvolved and also to ensure that feedbackbecomes an inbuilt activity.

• All reports were developed, circulated anddisseminated under the title of “BengaluruInjury Surveillance Programme”

• Individual institutions were provided with theirrespective data for the previous 3 months (ona CD) on a regular basis. Member institutionswere encouraged to examine, use and developreports for their institutional activities.

• Data was constantly reviewed in the nodalofficers meeting and used in all trainingprogrammes.

• Information was made available to memberinstitutions as and when required.

• Mechanisms were evolved to ensure that allpartnering institutions have access to data atany time.

• It was decided to bring out a set of fact sheetsbased on data as advocacy and awarenessdocuments.

10. Results

10.1. The city of BengaluruThe city of Bengaluru is a recognizable landmarkon the national and global map for its technological,educational and economic growth. For the currentprogramme, the city of Bengaluru (as per boundariesdelineated by then BMP. A brief profile of the city isgiven in Table 5. An understanding of the programmearea is crucial for a number of activities to strengthenthe programme.

Table 6 and Figure 10 show the motorizationpattern in Bengaluru during the past decade.The motorization index (number of vehicles /

Population x 1,00,000) has increased from 164 to416, resulting in an increase in absolute number of

2500225020001750150012501000750500250

0

Vehi

cles

Reg

iste

red

(lak

hs)

1995

1996

1997

1998

1998

2000

2001

2002

2003

2004

2005

2006

2007

2008Year

2-Wheelers M/Cars A/R. Cabs

Source: www.rto.kar.nic.in/bng-veh-stat.htm, accessed on October 1, 2008

Figure 10: Vehicular Growth in Bengaluru

21NIMHANS

Table 6: Motorization Index for Bengaluru

Year

1995 594000 107000 34000 62000 797000 4850125 164.33

1996 669000 121000 39000 71000 900000 5048980 178.25

1997 758000 138000 47000 80000 1023000 5255988 194.64

1998 839000 152000 54000 84000 1129000 5471484 206.34

1999 910000 164000 55000 94000 1223000 5695815 214.72

2000 994000 184000 58000 101000 1337000 5929343 225.49

2001 1092000 207000 62000 112000 1473000 6170000 238.74

2002 1183000 226000 64000 123000 1596000 6333505 251.99

2003 1323000 253000 69000 137000 1783000 6501342 274.25

2004 1444000 277000 76000 153000 1950000 6673628 292.19

2005 1570000 318000 75000 167000 2130000 6850479 310.93

2006 1897000 400000 86000 238000 2617000 7032017 372.15

2007 2111000 469000 94000 286000 2955000 7250000 407.58

2008 2238000 505000 92000 291000 3129000 7525000 415.81

Source: www.rto.kar.nic.in/bng-veh-stat.htm, accessed on October 1, 2008

2- Wheelers M/Cars A/R. Cabs Others Total Population*Motorization

Index

Table 5: Bengaluru City A Socio Demographic Profile

Sl No Parameters

1 Area 800 sq. kms 1

2 Population 7 million 1

2 Density 2980/sq.km 2

3 Contribution to Karnataka state population 11%

4 Sex Ratio (Females/1000 males) 915 3

5 Life expectancy at birth 64.2 years

6 Crude birth rate/1000 19.1 2

7 Crude death rate/1000 7.2 2

8 Decennial growth rate 1.3%

9 Total number of slums 733 4

10 Total population in slums 4,30,501 5

11 Slum population% 8 2

12 Socially disadvantaged population (%) 40

13 Literacy rate% 83.91 6

14 Total number of schools and colleges 7674 7

15 Total number of factories 3121 8

16 Total number of police stations (35 traffic + 103 law & order) 138 9

17 Total number of hospitals (including public, private hospitals & nursing homes) 583 10

18 Total number of Drug stores 4445 11

19 Total number of General practitioners ≈5000 10

20 Total length of roads 1500 kms 1

21 Total number of police personnel (traffic) 3,102

22 Total number of police personnel (law and order) 11,908

23 Total number of registered vehicles 3.13 million 12

24 Number of alcohol selling outlets (CL-2, 4, 5, 6, 6A, 7, 9, 14 & 15) Licensees ≈2400 13

25 Indian Made Liquor sold for the year 2007 - 2008 325.48 lakh CBs 13

26 Total revenue from IML & Beer Rs.3478cr 13

Source: 1 http://www.bmponline.org; 2 www.bangaloreit.com; 3 http://www.experiencefestival.com/slum;4 http://www.hindu.com/2007/04/28/stories/2007042802250200.htm; 5 www.censusindia.com; 6 www.des.kar.nic.in;7 Karnataka Education Departments; 8 Small, Medium and Large scale industries Corporation;9 BCP Bengaluru City Police; 10 KSPCB Karnataka State Pollution Control Board; 11 Karnataka state Drugs control General12 www.rto.kar.nic.in/bng-veh-stat.htm; 13 Karnataka State Beverages Corporation Limited

vehicles from 0.8 million to 3.1 million over a 14year period. As on 31.3.08, there were 3.1 millionregistered vehicles in the city. Interestingly, among

the total vehicles, motorized two wheelers contributedfor nearly ¾th of total vehicles, registering anincrease from 0.6 million in 1995 to nearly 2.2


million by 2008. It is estimated that nearly 3 millionvehicles (including vehicles coming from outside city)traverse the city roads every day. With the growth ofpopulation, the share of pedestrian trips has alsoincreased substantially. Significantly, the publictransport systems chiefly comprising of busesincreased from 2,098 in 1998 to 5071 during 2008.The transport patterns indicate that walking, cycling,travel on motorcycles and bus travel account for amajor transport share with car and other vehicleoccupants accounting for roughly 10% of totalvehicles.

Using the methodology highlighted in the previoussections of this report, information was collectedfrom Police, transport, city corporation and hospitalsources from January 2007 (police and transport)and April 2007 (hospitals), respectively, bycombination of different methods. Overall mortalityinformation (all cause deaths) was also collectedfrom the vital statistics division of BengaluruMahanagara Palike for the year 2005 (latest yearfor which data was available). Injury mortalityinformation was collected from police sources as itcaptures death related information (due to its medicolegal nature, compensation needs and legalpurposes). Since the transport department collectsdata from most of the fatal and serious non-fatalroad traffic injuries and since the focus is different,it was collected separately, even though some of themare entered in police records. Morbidity data wascaptured from emergency rooms of 25 participatinghospitals. The data in the forthcoming sections arepresented together as fatal and non-fatal injuries andhas been examined for all injuries and separatelyfor Road traffic Injuries, suicides, falls, burns,poisoning and drowning. The transport data primarilyfocusing on involvement of bus crashes are providedin a separate report and should be read in conjunctionwith this report to obtain a total picture of road trafficinjuries in Bengaluru. Information from ruralBengaluru will be provided in future reports.

10.2. Injury burdenWith different agencies handling different types ofdata related to injuries, information was notavailable from all agencies for the year 2007 – 08.Hence, attempt has been made to examine and pooldata from 3 major sources of vital death events fromcorporation records, fatal injury data from police

records and non-fatal injury data from hospitalsources. The two data sources have been related toobtain comprehensive picture of injury burden forone year.

10.2.1. Injury deaths in Bengaluru (city deathrecords)

In 2006, injuries contributed for 9% of total deathsin Bengaluru. Out of the total of 27,314 deaths, 2,397(9%) were injury deaths as per official reports ofVital Statistics Division, Bengaluru MahanagaraPalike (20). Police sources reported higher deathsfor 2006, probably due to inclusion of deaths fromoutside city, improper documentation of causes ofdeaths in death certificates and addition ofunclassified unnatural deaths. In 2006, police sourceshad registered 4,334 deaths, while the city authoritieshad registered 2,397 deaths (MCCD deathregistration). The difference between the two couldbe due to the fact that residents of Bengaluru haveto register with city authorities, while police couldhave registered injury deaths from residents outsideBengaluru. Secondly, inclusion of hospitals andreporting practices of hospitals also influences deathsin corporation. Thirdly, since cause of death is notaccurately mentioned in death records, actual injurydeaths might be higher. Fourthly, police recordsinclude a category of “others or unspecified causes”,reasons for which are not clearly known.

Otherdeaths 91% Total Injury

Deaths 9%

Figure 11: Distribution of deaths in Bengaluru, 2006

Among the injury deaths as per vital records, Roadtraffic injuries were the major cause of death (46%),followed by burns (17%). Suicides, which includeburns, poisoning, drowning and hangingcontributed for 8% of total deaths. Falls resulted in7% of deaths. The completion, coverage and qualityof information in death certificates is known toinfluence the type of data and hence, the causes ofdeath might vary on these factors. In nearly, 9% ofdeaths, the underlying cause of injury were notmentioned clearly.

23NIMHANS

11. Burden, Pattern and profile of fatal and

non-fatal injuriesDuring the 12-months of 2007/08, 4,334 deaths and68,498 injured persons were reported from policeand 21 hospitals in the city of Bengaluru (Tables 7& 8) respectively. The actual number of non-fatalinjuries is likely to be much higher as only 21hospitals (city has more than 150 health careinstitutions where injury patients are likely to go forcare) have been included (and hence rates are notprovided due to incompleteness of the data).

In 2007, police had registered 4,334 accidental,suicidal and unnatural deaths. Detailed examinationof records revealed that deaths due to non-injurycauses were included; these have been excluded fromanalysis and 3,427 (80%) deaths due to a recognizedinjury cause are included in this report. Adding acorrection factor of 25% (due to non-reporting,deaths occurring outside city, late injury deaths,misclassification, unclassified deaths, etc.,) it isestimated that the city might have lost 5,000 livesdue to an injury in 2007.

In the hospitals, injuries contributed for 21% ofcasualty registrations, 9% of admissions and 31%of deaths during the 12 month period. (Informationon deaths was collected separately from medical

Nearly three fourths of injury deaths occurred in theage group of 15–44 years. Children and elderlyaccounted for 7% and 6% of deaths respectively. Themale to female distribution was 64% and 36% witha ratio of 2:1. This clearly highlights that injuries area problem of the young and middle-aged people, anobservation that is uniform all over the world.A selective examination of age specific mortality

Other externalcauses of

accidental Injury9%

Figure 12: External causes of injuries revealed that RTIs remained a major cause in all agegroups. Suicides emerged as a major cause in all agegroups, except 45–64 years, while burns were higherin 15–24 years and 65+ years. Women in youngerage groups had higher extent of burns in total deaths.

Month/YearJan 2007 387

Feb 364

March 394

April 390 5591 5981

May 398 5764 6162

June 366 5855 6221

July 403 6249 6652

August 367 5703 6070

Sept 346 5367 5713

Oct 321 5887 6208

Nov 304 5655 5959

Dec 294 5472 5766

Jan 2008 5878

Feb 5505

March 5572

Total 4334 68498

Fatal Non-fatal Total

Table 7: Distribution of fatal and non-fatal injuries

Figure 13: Age sex distribution of injury deaths

Total Deaths Injury Deaths

Age wise injury deaths in males Age wise injury deaths in females

Animal bites1% Late effects

8%

RoadAccidents

46%

Falls7%

Drowning1%

Burns17%

Poisoning10%

Assault1%

* Suicide classified on intent accounted for 8% Injury deaths is included in burns,poisoning, drowning, misclassification is likely.

Female36%

Male64%

Female30%

Male70%

45-6424%

>656%

<155%

15-2417%

25-4441%

15-2422%

<1511%

>657%

45-6416%

25-4441%


records). In some of the larger public sectorhospitals, almost every 5th patient in the ER wasdue to an injury. This reflects on the enormousworkload and the huge burden on staff in the casualtydepartments of all hospitals.

During the 12 months period, the enrolment of patientsinto surveillance programme increased significantly.The coverage of patients in the study period variedbetween 72–85% across hospitals with an average of80% and data was incomplete for 20% of patients.Among the 68,498 registered patients, it was possibleto collect information from 53,448 (80%) subjects.The non-availability of data for the remaining 20%were due to weekend cases, limited staff at night times,changing monthly rotation of doctors, and patientsreferred immediately upon arrival in ER. Hence, inthe following sections, data from 53,448 patients areincluded for further analysis.

Four of the hospitals viz., NIMHANS, Victoriahospital, Bowring hospital and St. John’s MedicalCollege hospital contributed for 56% of total injurypatients. From the programme point of view, it clearlypoints out that selecting few major health careinstitutions in larger cities (where injury surveillancesystems are absent) will help in building theprogramme over a period of time. The actual numberof non-fatal injuries is difficult to establish.

Using conservative figures of 1:20:50, fordeaths to serious injuries to mild injuries,in 2007, there were an estimated 5,000injury deaths, nearly 100,000 serious and250,000 mild injuries.

11.1. Injury trendsThe city has seen a constant and continuous increasein injuries over a period of time. In overall terms,injury deaths increased from 2,152 in 2000 to 4,334in 2007, while the population and motor vehiclesincreased by 20% and 150% in the same period.Increase in RTIs and suicides has been significant asRTIs increased from 500 to 1,000 during the 7 yearperiod, while suicides increased from 1,731 to 2,430in the same period (Figures 15 & 16). Detailedinformation on non-fatal injuries is not available asthis is the first large-scale attempt collectinginformation from hospitals. Even though policecollect information from reported / registered non-fatal injuries, they have been found to be incompletedue to underreporting factors.

Deaths (1)

Serious Injuries (20)

Minor Injuries (50)

5000

1,00,000

2,50,000

Figure 14: Bengaluru Injury pyramid

Table 8: Number of fatal injuries registered with Police, Jan Dec 2007

Month

Jan 59 18.9 253 81.1 312

Feb 57 19.7 232 80.3 289

March 101 31.1 224 68.9 325

April 101 30.1 235 69.9 336

May 70 21.9 250 78.1 320

June 81 27.9 209 72.1 290

July 75 22.9 253 77.1 328

August 82 28.2 209 71.8 291

September 78 28.8 193 71.2 271

October 88 35.8 158 64.2 246

November 70 31.5 152 68.5 222

December 81 41.1 116 58.9 197

Total 943 27.5 2484 72.5 3427

RTI deaths Other Injury deaths Total

Figure 15: Traffic deaths in Bengaluru (2000 - 2007)

1000

800

600

400

200

0

2000

2001

2002

2003

2004

2005

2006

2007

25NIMHANS

2500

2000

1500

1000

500

0

2000

2001

2002

2003

2004

2005

2006

2007

11.2. Injury variationsDuring the 12 month period, 4,334 deaths (averageof 361 deaths per month) and 68,498 hospitalizations(on an average of 5,708 per month) were registeredunder the programme (Table 9). As discussed insection earlier, an estimated 5,000 deaths and morethan 100,000 serious injuries are likely to occur eachyear, considering the inclusion of only 21 hospitalsand under-reporting by police.

Figure 16: Suicides in Bengaluru (2000 - 2007) 11.3. Place distributionThe broad geographical occurrence of injuries wasavailable for only deaths from police records andfound to be difficult in hospitals due to non-availability of total address among patients or theirattendants at the time of hospital contact.Information on geographical distribution of injurydeaths will help in identifying areas with highestinjury occurrence and helps to formulate andimplement area wide intervention programmes.Needless to mention, place distribution has to beexamined as per individual injury cause. With furtheruse of GIS and other systems, even micro levelinterventions for certain types of injuries (e.g., RTIs)can be developed. Among the 103 Law and OrderPolice stations, highest number of injury deaths wasreported from Wilson Garden (146), Madiwala (116),Upparapet (111), Peenya Industrial area (108) andSubramanyapura (86) areas. Lowest injury deathswere registered in Rajajinagar (28), Koramangala(28), Jeevan Bhima Nagar (29), High Grounds area

Table 9: Non-fatal injury registrations in ERs of select hospitals, April-March 2007

Sl No Hospitalcasualtyinjury

registration%

1 Bowring Hospital 8411 6961 82.8 13802 1986 14.4 917 102 11.1

2 Baptist Hospital 16660 2816 16.9 15817 67 0.4 486 42 8.6

3 Bhagavan Mahaveer JainHospital 21398 660 3.1 11316 470 4.2 340 33 9.7

4 Ravi Kirlosker Hospital 6941 557 8.0 1654 256 15.5 46 7 15.2

5 St. John Hospital & MedicalCollege 31578 5660 17.9 46701 6435 13.8 1084 99 9.1

6 Sparsh Hospital 3093 2279 73.7 1004 2726 271.5 24 28 116.7

7 Sanjay Gandhi Institute ofTrauma & Orthopaedics 1942 1872 96.4 1903 1903 100.0 51 48 94.1

8 NIMHANS 32214 10887 33.8 11878 1814 15.3 1020 623 61.1

9 D G Hospital 7399 254 3.4 1617 220 13.6 74 18 24.3

10 St. Martha's Hospital 18987 2402 12.7 19949 12 0.1 372 0 0.0

11 St. Philomena's Hospital 26275 2415 9.2 16976 430 2.5 243 24 9.9

12 Mallya Hospital 11550 1580 13.7 12065 NA 0.0 288 NA 0.0

13 Sagar Apollo Hospital 14684 2334 15.9 14468 435 3.0 299 18 6.0

14 Jayanagar General Hospital 6319 2163 34.2 9348 NA 0.0 56 NA 0.0

15 Manipal Hospital 24881 3078 12.4 29474 1103 3.7 591 75 12.7

16 M. S. Ramaiah Hospital 18582 2838 15.3 48673 1267 2.6 895 132 14.7

17 HOSMAT 5412 3197 59.1 5483 1506 27.5 79 31 39.2

18 KIMS Hospital 10151 2518 24.8 11679 728 6.2 192 30 15.6

19 Victoria Hospital 41416 12739 30.8 20720 5887 28.4 2933 1814 61.8

20 K. R. Hospital 8327 523 6.3 4027 142 3.5 144 22 15.3

21 Mallige Hospital 17867 765 4.3 3522 138 3.9 135 17 12.6

Total 334087 68498 20.5 302076 27525 9.1 10269 3163 30.8

totalcasualty

registrations%%

totaladmiss-

ions

injuryadmiss-

ions

totaldeaths

injurydeaths


and Indiranagar (27 each). The differences in injuryrates in different areas needs to be ascertained withfurther research and could broadly be due to socio-economic living standards, migration of people,transport and travel patterns, area / land utilization,varying enforcement limits and others.

11.4. Age and Sex distributionInjury is predominantly a problem of young people.The age groups of 16-40 years accounted for 61%of total injury deaths and 70% of total hospitalcontacts. Children up to 18 years contributed for6% of total deaths and 10% of hospital contacts,while elderly accounted for 11% of deaths and 5%of hospital contacts, respectively. The male to femaledistribution varied with a ratio of 2-3:1 as per injurycauses. In 11-25 years, there were more injuries anddeaths among women compare to men. Among fataland non-fatal injuries, men accounted for 84% and82%, respectively.

11.5. Socio-economic characteristicsGenerally, it is known that the number of deaths andinjuries are higher in lower and middle incomegroups. The poor are more vulnerable to injury andalso have limited access to care due to their inability

to pay in private hospitals and absence of insurance.Data once again showed that deaths were higheramong those with less education. In the total series,those above graduate levels were just 10% comparedto 60% of those with lower levels or no education.In addition, deaths among other injury causes weremore among those with lower levels of educationcompared to road traffic injury deaths. Theoccupational status indicated that those fromunskilled and skilled labour categories wererepresented in greater numbers (34%) as comparedto professional categories of 3%. Students accountedfor 6.3% of injury deaths. Information on place ofresidence revealed that 92% of injury deaths wereamong those residing within Bengaluru.

11.6. Place of InjuryHighest number of injury deaths occurred on roadand at home with 43% and 39%, respectively. Thepattern was similar for non-fatal injuries with roadsand home contributing for 57% and 25%, respectively.Even though injuries were seen in all other places, itwas comparatively more in construction site area,hotels and lodging establishments, major waterbodies like wells and lakes (contributing for specifictype of injuries.)

Figure 17: Age-Sex distribution of Fatal & Non-fatal injuries (%)

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male Female Total

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male Female Total

Fatal Non - Fatal

Figure 18: Place of injury

Public place6%

School1%

Home25%

Workplace9%

Road57%

Others2%

Hotel (lodgingestablishment)

1%Shopping

area2%

Home andpremise

39%

Building underconstruction

3%Work places

2%Well/lake

2%

Road43%

Religiousplace1%

Others6%

College campus1%

Fatal Non - Fatal

27NIMHANS

12. Road Traffic Injuries

Estimated deaths: 1,100Estimated serious injuries: 40,000

In 2007, 943 road traffic deaths were reported tothe Bengaluru City Police. Earlier reports on RTIsfrom NIMHANS and data from City Crime RecordsBureau have revealed that road traffic deaths andinjuries have increased over a period of time. Withregard to non-fatal injuries, a total of 26,191 patientswere registered in study hospitals providing a ratioof 1:28 for fatal to non-fatal injuries. In the sameperiod, the police had registered only 6,591 non-fatal injuries, indicating severe underreporting, even

in comparison with 21 hospitals to the extent of 75%as per the present study.

12.1. Road traffic deaths have increased fromnearly 500 to 1000 over a period of 7 years in thecity of Bengaluru (2000 to 2007). The changing trendis shown in figure 15. Earlier studies from NIMHANShave confirmed that while all deaths are reported topolice for medico-legal or compensation purposes,only serious injuries are reported to police (17).Based on data inputs from different sources, thePlanning Commission of the Government of India(21) and Sunder’s Committee (22) have estimated

11.7. Injury causesAmong the various types of injuries, 5 major causesof injury deaths were Road Traffic Injuries (943-28%),hanging (604-18%), burns (360-11%), poisoning(296-9%), and falls (209-6%). The other major injurycauses were drowning and animal bites to the extentof 1.8% and 0.4%, respectively (Figure 19a & 19b).Similarly, for non-fatal injuries, RTIs were the leadingcause for nearly half (46%) of hospital contacts,followed by assaults and violence (17%) andpoisoning (10%). RTIs (47%), assault (22%) andpoisoning (12%) were the leading causes for hospitalcontact in rural areas.

11.8 Injury IntentBased on intent, 31% were unintentional, while32% intentional and 24% and 14% being unnatural

Figure 19a: Injury Causes

Occupationalinjury1%

Otherunnatural

deaths24%

Road trafficinjury28%

Poisoning9%

Hanging18%

Fall6%

Drowning2%

Burns11%

Assault1%

Occupationalinjury1%

Stab / cut2%

Sports1%

Roadtrafficinjury46%

Poisoning10%

Others2%

Hanging1%

Fall ofobject

2%

Fall9%

Drowning1%

Burns5%

Assault17%

Animal bites3%

Urban Fatal Urban Non-Fatal

Road trafficinjury47%

Assault22%

Poisoning12%

Fall6%

Others6%

Animal bite5%

Burns2%

Figure 19b: Injury Causes for Rural Non-fatal injuries

and unknown, respectively. Among non-fatal injuries,70% accounted for unintentional, while 27% and3% were intentional and undetermined deaths,respectively.


the ratio of deaths to serious injuries to less severeinjuries as 1:20:70 for the Indian region.

Considering the above observations and inclusionof only 21 hospitals in the present study, it isestimated that there would have been 1000 deathsand 40,000 non-fatal injuries in Bengaluru in2007.

12.2. Place of RTIsInformation on place of occurrence of RTIs isimportant in number of ways. Recognizing broaderhigh crash locations helps for developing area wideinterventions in engineering, enforcement and traumacare. Identifying precise location of RTIs in each areahelps for micro level interventions, commonlyreferred to as black spot analysis. The latter approachcan help for in-depth crash investigation andanalysis, but caution has to be exercised as theseblack spots are likely to change over a period oftime.

Information on category of roads involved in RTIshelps in putting improved preventive strategies ondifferent categories of roads. For e.g., if highwaycrashes lead to more deaths, then it indicates theneed for better road safety practices on highways.Data from the present programme revealed that theplace of occurrence of crashes was primarily on citymunicipal roads in 2/3rd (64%) of road deaths while1/4th (24%) had occurred on highways originatingfrom the city in different directions (Figure 20).Among non-fatal injuries 16% had occurred onhighways. This indicates that highway crashes aremore severe resulting in more deaths and seriousinjuries.

Information on place of death in a crash indicatesthe need for different preventive strategies. Forexample, large number of crash site deaths can onlybe minimized by primary prevention, while deathsenroute to hospital and in-hospital deaths can bereduced by better pre-hospital and acute carestrategies. Nearly 29% of deaths occurred at the crashsite, 22% during transportation to a hospital andremaining 49% in the hospital (Figure 21). Thispattern varied as per road user categories as morenumber of pedestrians died at crash site comparedto other categories.

Figure 20: Place of Occurrence

City/Municipal

Road64%

Others1%

RuralRoads

1%

Inner Roads10%

Highway24%

City/Municipal

Road63%

Others1%

RuralRoads11%

Inner Roads9%

Highway16%

Fatal Non - Fatal

In the Hospital49%

At Crash Site29%

During Transport toHospital

22%

Figure 21: Distribution of RTI deaths based onplace of death

From the total list of 35 police stations reportingRTIs, the top ten areas registering highest numberof fatal and non-fatal RTIs are provided in figure22. Micro level studies are required to identify theprecise location of RTIs in these boarder geographicareas. Some of the characteristics of these areasinclude high density of population, located on theout skirts of the city, greater economic andtransportation activities, heavy movement of vehicles,poorer socio-economic sections of society anddecreased enforcement areas. Also in recent years,some amount of infrastructure expansion has beenmarked in these areas.

29NIMHANS

group of 21 – 30 years. Road deaths and injuriesamong children was 5% and 7%, while elderlyaccounted for 10% and 3%, respectively. In both thegroups, males were predominant with a ratio of 6:1and 4:1, respectively. Figure 23 indicates that roaddeaths and injuries increased from 15th year, reacheda peak during 20–30 years, remained at higher levelstill 60’s and started declining thereafter.

12.3.3. Information on education and occupationserve as proxy indicators for income (as it is difficultto calculate income in any setting, especially amidstconstraints of time and methodological issues),indicating the burden of RTIs in different sections in

12.3. Socio demographic characteristics

12.3.1. Informant categoriesInformation on notification patterns helps inunderstanding awareness in the society on RTIs and, toa certain extent on what people can do as first respondersin the event of a road crash. The informants of roaddeaths and injuries were primarily family members (28%and 45%), roadside people (14% and 20.1%), police(18% and 3%), friends and colleagues (21.9%).

12.3.2. The Age-sex distribution was almost similarfor fatal and non-fatal injuries. Nearly 29% of fataland 38% of non-fatal injuries occurred in the age

Figure 22: RTIs in Bengaluru Sl. No. Traffic P. S. Fatal Non-Fatal1. K.R.Puram 91 6502. Madivala 90 5143. Yeshwanthapura 63 4944. Bytarayanapura 53 4795. Banasawadi 52 4566. Peenya 51 4187. Adugodi 47 3838. Airport 37 3369. Vijayanagar 34 27810. R.T.Nagar 31 25911. Banashankari 31 25612. Jayanagar 30 25313. lndiranagar 26 24514. Yelahanka 25 24115. Mico Layout 25 22716. Basavanagudi 22 22517. Malleshwaram 21 21918. Hebbala 20 20919. Cubbon Park 17 20820. FrazerTown 17 20621. Ashoknagar 16 19222. K.S. Layout 16 18323. Kamakshipalya 16 17424. Shivajinagar 14 15825. Halasuru 13 15026. Halasuru Gate 12 14427. Rajajinagar 12 14028. Wilson Garden 12 12829. Sadashivanagar 11 12630. High Grounds 10 11131. Upparpet 9 10532. Chamarajapet 9 8533. Magadi Road 9 6934. Chickpet 8 6735. City Market 7 43

Figure 23: Age-sex distribution of RTI deaths (%)

20

18

16

14

12

10

8

6

4

2

0

Male Female Total

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

566

-70

> 7

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male Female Total

Fatal Non - Fatal

Traffic Fatal and Non Fatal Combined


the society. Information was not available in nearly20% of non-fatal injuries and has been excluded fromthis analysis. Nearly 30% of the killed were either noteducated or only up to primary levels of education.Those completing pre-university, graduate andpostgraduate levels accounted for 30%, 13% and 2%,respectively. Among non-fatal injuries, nearly 10% werewith lesser education, while graduates and above wererepresented to the extent of 30%. The occupationalstatus of those killed and injured revealed that majoritywere in poor and middle-income categories as theybelonged to unskilled and skilled labour categories.Those employed in professional white collar workinggroups were present among 4% of fatal and 11% ofnon-fatal injuries, respectively. Students, housewives andretired categories contributed for 7%, 7% and 5% ofdeaths, respectively. Death or hospitalization due toRTI brings sudden and unexpected financial problemsto individuals and families forcing them to generatefinances to meet the emergency situation.

12.4. Time of crashesThe time of occurrence of crashes is a vital indicatorfor developing number of programmes in preventionand hospital care. This information can sensitise roadplanners and builders on number of issues (e.g.,visibility factors) and for hospitals to be in a state ofpreparedness. Beginning from 6 am (crashes were lessduring 12 midnight to 6 am), occurrence of fatal andnon-fatal crashes reached a peak during 8 – 12noon,declined thereafter, increased further during 6 pm – 11pm. Nearly 30% of fatal and 23% non-fatal crashesoccurred between 7 pm and 12 midnight. These timingscorrespond to peak traffic hours, high density of vehicleson roads, police being primarily involved inmaintaining traffic flow in central parts of the city to

avoid traffic jams, and severe violations (speeding andovertaking) by road users as everyone is in a hurry tomove. During night times, alcohol influence andvisibility factors are also major contributing factors.

Table 10: Education & Occupation of persons in RTIs (%)

Education Non-Fatal

Illiterate 15.7 7.9 Unemployed 3.4 2.1

Primary 12.8 8.4 Retired 4.8 1.7

Middle & Secondary 10.7 16.1 Homemaker 6.6 5.8

Sec. High school & PUC 27.3 22.3 Student 6.6 14.4

Graduate 12.8 26.7 Unskilled labourer 32.9 13.3

Post graduate 2.3 1.9 Skilled labourer 17.9 13.3

Not Known 18.3 15.3 Clerical 2.1 3.5

Not applicable 0.1 1.5 Business 9.4 13.4

Professional 3.7 11.1

Others 11.0 4.3

Not known 1.6 16.0

Not applicable 0.2 1.2

Fatal Occupation Non-FatalFatal

12.5. Involvement of alcoholInformation on alcohol consumption by the killed /injured person or the driver of the counter part vehiclewas not totally available in the series. Discussionwith police and hospital personnel revealed that thiswas not specifically documented for reasons ofdifficulty in “producing evidence in courts or forcompensation purposes” and for “humanitarianreasons”. However, the available informationrevealed that 7% of the killed drivers and 1% ofcounter part drivers were under influence of alcoholat the time of crash. Among non-fatal injuries,alcohol presence was found in 13% of RTIs asdocumented by physician certification based onpresence of smell of alcohol. It is likely that a largesize of “Don’t Know” category would include thoseunder the influence of alcohol. Previous studies atNIMHANS have documented presence of alcohol inroad crashes to be between 25-35% in the city ofBengaluru (24, 25, 26).

109876543210

0-1

1-2

2-3

3-4

4-5

5-6

6-7

7-8

8-9

9-10

10-1

111

-12

12-1

313

-14

14-1

515

-16

16-1

717

-18

18-1

919

-20

20-2

121

-22

22-2

323

-00

Hrs

FatalNon- Fatal

Figure 24: Time of Crash in fatal and non-fatal injuries

31NIMHANS

12.6. Road user categoriesThere were nearly 24 categories of road users fordeaths and injuries in the heterogeneous trafficscenario of Bengaluru. For ease of understanding,smaller categories have been grouped into selectedmajor categories. Among the various road usercategories killed in RTIs, pedestrians were the largestcategory to the extent of 52%. Two wheeler ridersand pillions contributed for 26% and 11%, respectively.Bicyclists and car occupants had succumbed in roadcrashes to the extent of 5% and 3%, respectively. Autorickshaw passengers were killed in 1.8% of deaths.In sharp contrast, among non-fatal injuries, more thanhalf of injured brought to hospitals were two wheelerriders (42%) and pillions (9%), with pedestriansconstituting one fourth of the series. Car drivers andpassengers were injured in 5% of hospital contact RTIs.In the rural areas, the first and second places weretaken by two wheeler riders and pedestrians, followedby bus/truck occupants.

12.6.1. Pedestrian deaths and injuriesNearly, 500 pedestrians were killed on the roads ofBengaluru during the year 2007. The killed and injuredpedestrians were highest in the age group of 16–45 yearsand were primarily men. Interestingly, one fourth of theinjured and killed pedestrians were children and elderly.Analysis of crash patterns among fatal injuries revealed

that 24% were hit by cars, 22% by two wheelers and18% by buses. Trucks and auto rickshaws had collidedwith pedestrians in 16% and 8%, respectively (Figure26a). Activity performed at the time of crash revealedthat nearly 60% were crossing the road, 28% werewalking, 8% standing, 2% working and 2% playing onthe road. Other categories included sleeping on the roadand standing near bus stops (Figure 26b).

Figure 25a: Road User Categories in urban fatal and non-fatal injuries (%)

0 20 40 60 0 10 20 30 40 50

Others

Lorry occupant

Bus occupant

Three-wheeler occupant

Car occupant

Bicyclist

Two-wheeler pillion

Two-wheeler rider

Pedestrian

Others

Other 4 wheeler occupants

Three-wheeler occupants

Car occupant

Bicyclist

Two-wheeler pillion

Two-wheeler rider

Pedestrian

Fatal Non - Fatal

Bus / Truck Driver

Figure 26b: Pedestrian Activity at time of injury (%)

0 20 40 60 80

Don’t know

Sleeping on the Road

Playing on the Road

Working on the Road

Standing on the Road

Walking on the Road

Crossing Road

0 20 40 60

Sleeping

Going/Coming from schoolUnspecified

Working

Playing

OthersStanding on the Road

Walking

Crossing

Fatal Non - Fatal

Figure 25b: Road User Categories in ruralnon-fatal injuries (%)

0 10 20 30 40 50

UnknownOthers

Car driverOther 4-wheeler driver

Bus/truck driverThree-wheeler driver

Car occupantBicyclist

Other 4-wheeler occupantThree-wheeler occupant

Two-wheeler pillionBus/truck occupant

PedestrianTwo-wheeler rider

Figure 26a: Injury collision pattern amongst pedestrians

Van10%

Two wheeler22%

Truck16%

Tractor2%

Car/Jeep24%

Bus18%

Auto8%


12.6.2. Two wheeler deaths and injuriesIn 2007, 346 two wheeler drivers/pillions were killedin the city. Two-wheeler collision with larger trucksand buses were common to the extent of 32% and23%, respectively, followed by crash with another two-wheeler (28%) (Figure 27a). Data on collision patternindicated that hit from back (one ways have becomethe norm on many roads) was commonest (40%),followed by hit from side (15%) and head-on collision(13%) (Figure 27b). Speeding, overtaking, negotiatingturns resulting in skid and fall and sudden applicationof brakes were some of the responsible factors fordeaths. The city of Bengaluru has partial helmetlegislation in place making helmet usage mandatoryfor riders of two wheeler vehicles. The usage of helmetswas low as revealed by the finding that more thanhalf had not worn a helmet at the time of crash inboth police and hospital data. This number could bemuch higher, as injured or family members of thosekilled might have reported that person was wearinga helmet. In addition, this was not properly recorded.

Proper documentation, and field observational studiesare essential to show changing patterns of use, andimpact of helmet legislation and enforcement.

12.6.3. Bicyclist injuries and deathsBicycles are a common mode of transport, especiallyamong children. They are small in size,inconspicuous and often unprotected. Collision withheavy vehicles like trucks (28%), buses (21%), carsand jeeps (19%) had proved fatal. Collision with atwo-wheeler was responsible for 19% of deaths. Inmore than half of deaths, cyclists were hit from back,while head-on collisions and hitting a stationaryobject was responsible for 11% of deaths each.

Two wheeler28%

Van2%

Truck32%

Tractor2%

Car/Jeep8%

Bus23%

Auto1%

Hit a fixedobject

4%

Figure 27a: Collision pattern of two-wheeler rider/pillion

Hit pedestrian1%

Others4%

Skid & Fall12%

Over turn3%

Nose to tailcollision

5% Hit from side15%

Hit fromback40%

Hit a fixedobject

7%

Head on collision13%

Figure 27b: Crash pattern and type of collision amongTwo-wheeler Rider/Pillion

Figure 27c: Use of helmets among two-wheeler riders

Fatal Non - Fatal

Yes35%

No51%

Not known13%

NA1%

Yes38%

No40%

Notknown22%

Two wheeler19%

Van3%

Truck28% Tractor

1%

Car/Jeep19%

Bus21%

Auto1%

Hit a fixedobject

8%

Figure 28a: Bicyclist hit by

Others6%

Skid & Fall4%

Over turn1%

Nose to tailcollision

7%

Hit from side7%

Hit fromback53%

Hit a fixedobject11%

Head on collision11%

Figure 28b: Crash pattern and type of collision amongbicyclist

12.6.4. Car occupant(s) deaths and injuriesThe growth of motorcars in Bengaluru has beensignificant, though at a lesser pace compared tomotorcycles. An increase in young drivers andwomen in particular has been noticeable on the streetsof Bengaluru. Figures 29a-29c indicate crashcharacteristics and patterns among car occupantsin fatal injuries. Nearly 60% of those killed andinjured were in 20-35 years age group, with a maleto female ratio of 2:1. Majority of the times, the cardriver had collided with another car (57%) or witha two-wheeler (20%). Cars had hit stationary objectslike trees, median, buildings in 8% of the crashes.

33NIMHANS

Of the total collisions, rear end collisions (33%),side collisions (14%) and overturns (14%) werecommonly documented. Information on seat-beltusage among car drivers, though not accurate,revealed that only 12% of non-fatally injured drivershad worn seat-belts. This information was totallymissing in police records.

12.6.5. Fatal and non-fatal bus crashesInformation on pattern and profile of bus crashesare provided separately in the report entitled "CrashReporting and Analysis of Fatal Bus Crashes - 2007"(26). Nearly 117 deaths were reported from BMTCcrashes during 2007. Collision of a heavy vehiclelike bus with smaller size road users resulted indeaths due to greater and sudden transfer of largeamounts of energy.

12.6.6. Environment and vehicle factors• Information on contributory vehicle factors for

crashes resulting in deaths was limited as theywere not clearly documented in the proforma.Overall, 60% of the vehicles did not have anymechanical defect while problem in remaining40% were primarily attributed to brake failures,lighting defects, steering failure, tyre defectsand axel cuts. The distribution varied slightly,particularly among the counter part vehicle

where mechanical defects were absent in 87%of vehicles. This may not be the real scenarioas this was not investigated fully andinformation was not available.

• Road and environment factors play asignificant role in road crashes. Detailedinformation was not available in majority ofcrashes. However, as per reports, significantnumber of crashes had occurred on straightroads (89%), concrete metalled roads (79%)and roads with good visibility (89%). Theseparameters indicate that there is need fordetailed crash analysis in a systematic wayand current data point to the fact that speedingand overtaking are primary contributoryfactors.

Figure 29c: Usage of Seat Belts among car drivers-Fatal & Non-fatal

Two wheeler20%

Van1%

Truck8%

Tractor4%

Car/Jeep57% Bus

1%

Auto1%

Hit a fixedobject

8%

Figure 29a: Car occupant hit By Figure 29b: Crash pattern and type of collision amongcar occupants

Others14%

Skid & Fall1%

Over turn14%

Nose to tail collision5%Hit from side

14%

Hit from back33%

Hit a fixed object13%

Head oncollision

5%

Hit pedestrian1%

Not known88% Not applicable

8%

No4%

No50%

Yes12%

Not known38%

Fatal Non - Fatal

Percent

No mechanical defect withvictim's vehicle 389 59.4

No mechanical defect withcounterpart vehicle 721 88.5

Straight road 844 89.5

Concrete road 744 78.9

Good visibility on road atcrash time 839 89.0

Frequency

Table 11: Environmental Factors


13. Suicides

Estimated deaths: 3,000Estimated serious injuries: 20,000

Suicides are a major public health problem in recentyears due to globalisation, changing values of peopleand a combination of many other factors. Suicides inyoung are a matter of great concern due to its impacton young lives. During the year 2007, there were 2429suicides as per reports from City Crime Records Bureau.Suicides have to be established on intent and therewas difficulty in ascertaining intent, and hencemisclassification was common. Due tomisclassifications between suicidal, accidental,homicidal and unknown categories; ongoinginvestigation in some cases; and inclusion of manyunknown deaths as suicides, the precise numbers weredifficult to obtain. In the total, 27% were intentionaland information available from 912 defined suicidaldeaths is included in this analysis. In the same period,21 hospitals had registered 5,328 attempted suicides.Nearly 50% of deaths were falling in RTIs and otherunnatural deaths. Precise numbers of suicides in thiswere difficult to obtain. The ratio of completed toattempted suicides was 1: 6. The real numbers couldbe much higher as data from attempted suicides wascollected from only 21 hospitals.

The incidence of completed and attempted suicide fromprevious studies have been found to be 34 and 252 per100,000 population, respectively (26). Previous hospitalbased and population based studies have shown theratio between completed and attempted suicides to varybetween 1: 8 to 1: 10 (26, 27). The ratio of completed:attempted: suicide ideators in a recent population basedstudy has been found to be 1: 7: 22 (27).

There was no significant variation across differentmonths for completed and attempted suicides.However, highest numbers of suicides were seen duringJanuary to July with correspondingly high numbersduring the months of February to May. The secondhalf of 2007 documented less number of suicides. Theprecise reasons need to be identified for this variationand a possible reason could be due to high number ofsuicides among 16 to 25 years related to academicreasons during the first half of the year.

Men and young people were represented to a higherextent in both completed and attempted suicides.Highest number of suicides was documented in theage groups of 16-40 years in the total series. Theproportional distribution in 16-20 years, 21-25 years,26-30 years, 30-35 years and 36-40 years was 16.2%,21.6%, 20.3%, 11.2% and 9.5%, respectively. Moresuicides were reported among women in youngerage groups of 15–25 years (51% completed and 57%attempted suicides), while in all other age groupsmen were higher. The male to female ratio was 2:1in the series.

Among persons completing suicides, the socio-demographic characteristics revealed that people withless than 8 grades of education (illiterates, and primary-middle school levels) constituted 60% of the total series.Less than 20% were educated beyond secondary schoolslevels including graduate and post-graduate levels.Among the various occupational categories, 30% ofsuicides were amongst skilled and unskilled labourers,while students, housewives and those in businesscategories were 10%, 18% and 6% respectively.Professional categories represented 4% of completed

Figure 30: Month of Occurrence, Suicides

12

10

8

6

4

2

0

Jan

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov Dec

14

12

10

8

6

4

2

0

Jan

Feb

Mar

Apr

May Jun

Jul

Aug Sep

Oct

Nov Dec

Completed Attempted

35NIMHANS

suicides. Housewives and students were in increasednumbers for attempted suicides (Table 12).

Home was the commonest place of suicidal act orattempt as more than 80% of the completed andattempted suicides occurred at home. The otherplaces of completing suicides were hotels and lodgingestablishments (2%), farm and agricultural areas(1%), public water bodies (1%) and others. Smallnumber of suicides also occurred in public serviceshopping areas, educational establishments andfactory premises (Figure 32).

The methods of suicides were primarily hanging(61%), poisoning (25%), burns (12%) and drowning(1%) among completed suicides (Figure 33). Insharp contrast, poisoning was more common inattempted suicides (87%) with attempt to hangingand self-immolation being 4% and 6%, respectively.Self immolation was more frequent amongyoung women in 15–34 years. There was nosignificant variation between the place of residenceor other socio-demographic characteristics. Othersincluded drowning (0.1%), falling from height(0.5%) and falling in front of moving vehicles(0.3%)

Figure 31: Age-sex distribution of completed & attempted suicides (%)

Completed Attempted30

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male

Female

Total

Male

Female

Total

35

30

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

66-7

0

> 7

0

61-6

5

AttemptedCompletedEducation

Table 12: Education & occupation levels amongcompleted & attempted Suicides (%)

Illiterate 18.36 15.6

Primary 11.14 13.0

Middle 28.15 24.9

Secondary, high school & PUC 31.21 24.9

Graduate 9.30 19.7

Post graduate & Above 1.84 1.3

Not applicable 0.5

OccupationUnemployed 8.72 5.5

Retired 1.15 0.6

Housewife 18.23 36.1

Student 9.63 21.5

Unskilled labourer 16.40 13.0

Skilled labourer 12.84 8.3

Clerical 1.61 1.5

Business 6.31 5.7

Professional category 3.56 4.1

Others 21.56 3.3

Not applicable 0.2

100.0

Figure 32: Place of occurrence of completed and attempted suicides

Completed Attempted

Home82%

Work place1%

Agriculturalarea1%

Educationcampus

1%

Hotel (lodgingestablishment)

2%

Shoppingarea2%

Well/lake1% Others

10%

Others2%

Road2%

Home86%

Workplace2%

Agricultural field1%

School1%

Play ground1%

Public place3%

Unknown2%


Figure 33: Methods of Suicide

Nearly 75% completed the suicidal act at a timewhen they were alone in the house and only 12%when other family members were around, but not inthe immediate vicinity of the affected individual.

The time of attempting suicides was primarily during9 am – 6 pm when the person was likely to be alonewithout much care and supervision from other familymembers. The time of completed suicides was highduring day time, probably linked to family membersbeing away on work or other reasons and personbeing alone at home. The pattern was slightlydifferent in attempted suicides with higher numbersreported during 4 pm - 11 pm.

by NIMHANS (24-27). There were difficulties inobtaining information on alcohol in the presentprogramme due to medico legal reasons ashighlighted in the earlier sections of this report.Informal enquiries revealed that not muchimportance was given to this issue for humanitarianreasons and difficulties in measuring alcoholpresence. The available data indicate that alcoholwas directly incriminated in 12–15 % of completedand attempted suicides. As this information maynot be accurate, it is not a realistic indicator asprevious studies have shown that nearly 30% ofsuicides are linked to alcohol (25, 28). It wascommonly observed that some of the poisonoussubstances like organophosphorus compounds anddrugs were mixed with alcohol or consumed underalcohol influence.

A number of products were used for completing orattempting suicides. These included a variety oforganophosphorus compounds, insecticides(herbicides, rodenticides and fungicides, etc.,),variety of drugs (barbiturates, sedatives, hypnotics,analgesics, etc.,), and household chemicals (likedishwashing liquids and others). The long list ofindividual products identified indicates the easyavailability and the fact that any available substancewas used for the purpose of ending one’s life. Theseproducts could be available at home or could havebeen easily bought from nearby shops without anyquestions being asked.

Understanding causes and risk factors is very crucialas preventing suicides mainly rests on this premise.The precise causes of suicides were difficult toestablish in the present study by a surveillanceapproach. Identifying risk factors requires analytical

Completed AttemptedHanging

61%

Drowning1%

Poisoning25%

Burns12%

Others1%

Poisoning87%

Burns6%

Others1%

SelfStab/cut

2%

Attempt to hang4%

Alone inhouse75%

In presence ofothers12%

Outside house13%

Figure 34: Suicide situation

109876543210

0-1

1-2

2-3

3-4

4-5

5-6

6-7

7-8

8-9

9-10

10-1

111

-12

12-1

313

-14

14-1

515

-16

16-1

717

-18

18-1

919

-20

20-2

121

-22

22-2

323

-00

Hrs

Completed

Attempted

Figure 35: Time of completing and attempting suicides

The direct and indirect association of alcohol insuicide causation is a known phenomenonworldwide. Alcohol involvement and suicides havebeen linked in number of ways in previous studies

37NIMHANS

approaches and due to non-availability of totalinformation, this has not been attempted. However,some of the major causes as listed in the policerecords were presence of physical illnesses (n=123),family problems (n=122), frustration in life(n=97), presence of mental disorders (n=52) andfinancial problems (n=43). Number of otherreasons was related to suicides as shown in Table13. There were also precipitating – triggering –

operating factors within the large group of causescited above as responsible factors. The table belowfor completed suicides is provided mainly as anindicator highlighting the need for more focussedand in-depth studies in hospitals and communities.The causes for attempted suicides was not includedfor the hospital part as it was found to be difficultto elicit this information in emergency roomsettings.

Causes Missing < 5 5-10 11-15 16-20 21-25 26-30 30-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 > 70 Total

Physical Illness 3 0 0 2 17 18 19 16 11 7 9 3 9 2 5 2 123

Family Problems 3 0 1 2 8 28 32 20 11 7 5 1 2 0 1 1 122

Alcoholism 0 0 0 0 1 5 8 5 9 0 6 3 0 0 0 0 37

Finance Problems 0 0 0 0 2 7 7 8 7 3 4 2 3 0 0 0 43

Mental disorder 0 0 0 2 6 5 17 5 3 3 4 2 3 0 0 2 52

Marriage Problems 0 0 0 0 4 6 5 3 1 0 0 0 0 0 0 0 19

Frustration in life 3 2 0 0 20 21 23 6 7 5 4 4 1 1 0 0 97

Unemployment 0 0 0 0 1 9 6 1 1 0 1 0 0 0 0 0 19

School related 1 0 0 2 3 2 0 0 0 0 0 0 0 0 0 0 8

Poverty 0 0 0 0 1 3 1 3 2 0 0 0 0 0 0 0 10

Death in family 1 0 0 0 5 4 1 1 1 1 3 1 0 0 0 0 18

Exam failure 0 0 0 2 6 3 1 0 0 0 0 0 0 0 0 0 12

Love disappointment 2 0 0 0 4 7 4 2 0 0 0 0 0 0 0 0 19

Issueless 0 0 0 0 1 5 2 1 0 0 0 0 0 0 0 0 9

Career problems 0 0 0 1 2 1 1 0 0 0 0 1 0 0 0 0 6

Business loss 0 0 0 0 0 0 2 2 3 1 0 1 0 0 0 0 9

Retired life 0 0 0 0 3 0 0 0 1 0 0 1 0 0 0 0 5

Pregnancy related 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 0 2

Suicide by friend 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1

Illicit relationship 0 0 0 0 0 1 2 1 0 0 0 1 0 0 0 0 5

Dowry harassment 0 0 0 0 2 2 1 0 0 0 0 0 0 0 0 0 5

Sexual abuse 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 2

Miscellaneous 1 0 0 4 13 9 3 2 6 2 2 0 0 0 0 1 43

Unknown cause 0 1 0 2 15 19 30 11 5 2 2 1 2 2 0 0 92

Table 13: Major causes of suicide for different age groups


14. Burns

Estimated deaths: 500Estimated serious injuries: 5,000

Burn injuries are extremely common and frequentlyreported in the media. Burns constitute an importantpublic health problem and 95% of the global burndeaths and disabilities occur in low and middleincome countries like India (29). Burns occurs dueto a variety of products ranging from electrical,thermal, mechanical and radiant in nature. Theseinjuries can be suicidal (which is very commonamong women in 15–29 years), homicidal oraccidental. WHO highlights that it is possible toreduce burn mortality and morbidity throughcombination of measures aimed not only by reducingthe likelihood of occurrence of fire but also byreducing the severity and impact of a burn injurythrough appropriate trauma care practices.However, it is a major challenge for countries likeIndia where the social, cultural and economiccircumstances and causes are different in comparisonto many high income countries. Further, theepidemiological characteristics are not wellunderstood.

Nearly 360 persons (11%) lost their lives due to burnsinjury in the city of Bengaluru in 2007 as per policereports. At the same time, 2,517 persons werehospitalized with a ratio of 1:7. It is likely thatnumbers could be higher as many of those receivingcare in other institutions and those with minorinjuries are not included in this report. The actualnumbers of deaths, hospitalisations and minor burnscould be about 500:5,000:15,000, respectively, giving

a ratio of 1: 10: 30 specifically for burns inBengaluru. One major public sector hospital (Victoriahospital) reported highest number of burns as it hasan exclusive burn injury management facility withcare available in many private health careinstitutions. Among the total, 1/3rd were suicidal,6% homicidal and 60% reported it to be accidentalin nature. It is possible that misclassification couldhave occurred with accidental deaths. Two thirds ofinjured and killed persons were brought or reportedby family members.

Highest number of burn deaths occurred in April(56), January (42), and July (37) with lowest numbersin September and December. No specific reasonscould be attributed for this variation.

In similarity with the other injuries, burn relateddeaths were high in the younger age groups of 16-40 years, with one fifth each occurring in 21-25 and26-30 years (Figure 36). Interestingly, ¼ of burndeaths occurred in less than 20 years age group.Women were overrepresented in 15–25 years in bothfatal and non-fatal burn injuries. The male to femaledistribution was 2:1 in the total series, while it was1:2 among those in younger age groups. Thisphenomenon has been reported by many Indianstudies and causes are primarily attributed to culturalissues.

Nearly 80% of burns occurred among those withlower levels of education in comparison to 4% inthe higher educational categories. Disaggregateddata based on occupation, revealed that burns

Figure 36: Age-sex distribution of Burn injuries (%)

30

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male

Female

Total

30

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male

Female

Total

Fatal Non - Fatal

39NIMHANS

among housewives higher (41%), followed bypeople in labourer categories (20%). Five percentof burns were among student population in theseries. There was no significant variation betweenfatal and non-fatal injuries with regard to educationand occupation as low income households wereat greater risk of burn injuries. Three fourths ofburn deaths and injuries occurred at home andremaining were seen in industrial areas and otherplaces.

Burn injuries, specially non-fatal injuries, were higherin evenings, while fatal injuries were common duringboth day and night times.

The involvement of alcohol was poorly documentedin both police and hospital records. Nevertheless,6% of deaths among men could be linked to alcohol

consumption based on available information.Majority of the burns were reported as stove bursts,and accidental burns and had occurred inside thehouse. Kerosene stoves, gas cylinders, oil lamps,cooking materials and hot liquids were the primaryagents responsible for burn injuries. The causes ofburns were not clearly known in majority of theinstances.

15. Poisoning


Deaths and injuries due to poisoning are commonevents. Instances of poisoning with adulterated liquorand contaminated food, though not included in thisreport, are also frequently reported in the media. Inan environment of unregulated supply andavailability of a variety of organophosphoruscompounds, Over the Counter (OTC) medicines,household products and other dangerous chemicals,poisoning can be suicidal, accidental and homicidalin nature. Causes of poisoning are unclear even at

national level as there are no reported norinvestigated causes as seen in reports of nationaland state crime record bureaus.

Nearly 300 people (9% of total deaths) lost their livesdue to a poisoning act in the city of Bengaluru during2007, while 10% of those hospitalized due to an injurywere due to poisoning. Among them, 75% were menand 25% were women. Highest number of poisoningdeaths was seen in 21-30 years (36%), while poisoningamong teenagers in 16-20 years was 13%. Among thenon-fatal poisoning cases 60% were in the age groupof 16–34 years. In similarity to burns, in both fatal

Figure 37: Place of occurrence of burns

Work place1%

Road1%

Others19%

Home79%

Home83%

Others0%

Road1%

Unknown0%

Agriculturalfield0%

Railways0%

Public place3%School

0%

Work place13%

Fatal Non - Fatal

Fatal Non-Fatal25

20

15

10

5

0

0-3

3-6

6-9

9-12

12-1

5

15-1

8

18-2

1

21-2

4

Figure 38: Distribution of burn injuries as per time


and non-fatal poisoning injuries, there were morewomen in the younger age groups (16–34 years). Morethan 90% of poisoning case occurred within urbanBengaluru area.

The number of poisoning deaths month wise variedfrom 11 in October to 29 in January. The first 6months of the year reported higher poisoning deathsand no specific reasons could be identified for thisphenomenon in this programme.

The time distribution of poisoning deaths andinjuries was similar to other injuries with a higheroccurrence from afternoons and reaching a peakby evening and night times. Available informationon socio-demographic correlates revealed thatmajority were with either no education or with lowerlevels of education and only 20% were in theeducated categories of high school and above. Onceagain, skilled and unskilled labourer categoriesaccounted for 1/3 of poisoning deaths, while it was11%, 4% and 10% among students, housewives andbusinessmen.

Information on alcohol consumption was poorly

documented; 11% of fatal and 6% of non-fatalpoisonings was linked to alcohol consumption andnearly 15% had long-term alcohol consumptionhabit.

Most of the cases of poisonings were suicidal (80%)with homicidal and accidental poisoning being about1-2% and 18-19% respectively. Home was thecommonest place for deaths (58%) and injuries(86%) due to poisoning (Figure 40). Poisoning wasalso seen in hotels, public places and educationalinstitutions, indicating the need for better vigil andsecurity. In ¾ of deaths due to poisoning, the productresponsible was primarily organophosphoruscompounds and OTC drugs. However, the range ofproducts varied from anti mosquito repellents tointensely lethal products. Similarly among drugs,all types of drugs were involved in deaths and injuriesdue to poisoning. While the source and method ofobtaining these products were not enquired, it isapparent that regulating the availability, householdsupervision and greater public awareness are requiredfor reducing poisoning deaths and injuries. Thecauses of poisoning could not be clearly documentedin the data collection process.

Figure 39: Fatal & Non-fatal poisoning - Age-sex distribution

25

20

15

10

5

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Male

Female

Total

Fatal Non - Fatal

Male

Female

Total

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

35

30

25

20

15

10

5

0

Figure 40: Place of poisoning

Fatal Non - Fatal

Work place2%

School /College

1%Public place7%

Others24%

Road8%

Home58%

Others4%

Work place3%

School /College

1%

Public place3%

Road2%

Home86%

Agriculturalfield1%

41NIMHANS

16. Falls


Falls are one of the important causes of injury deathsand disabilities. The epidemiology of falls has notbeen understood in detail as it occurs in number ofplaces like homes, roads, public places, schools,construction sites and others. A so called “simplefall in a bathroom” can turn out to be a life longdisabling condition for the injured person, while “fallat a construction site” can result in instantaneousdeath. The precise causes of falls vary as per location,context and situation requiring in-depth research fora better understanding.

During the year 2007, 209 deaths (6% of total injurydeaths) were reported due to falls. All fall deathsoccurred within the city of Bengaluru. In a one yearperiod 4,986 were brought to hospitals with a historyof fall injury. The ratio of fatal to non-fatal fall

injuries was 1:25. Once again, numbers could behigher as only smaller number of institutions wasincluded in the programme and deaths due to fallsare not routinely reported to police, unless they areof a medico legal nature.

Among the deaths, males and females accounted for83% and 17%, respectively. Deaths among femaleswere comparatively higher in the younger age groups(<20 years) and elderly. In both fatal and non-fatalinjuries, males accounted for 80% of falls (ratio of4:1 between men and women). Children (<15 years)accounted for 10% of fatal and 20% of non-fatalinjuries, while elderly (60+ years) accounted for 6%of fatal and 7% non-fatal injuries. Interestingly, inboth fatal and non-fatal injuries, women in youngerand elderly age groups were represented in highernumbers compared to men. Highest number of fallrelated deaths were seen in 16-40 years to the extentof 58%.

Figure 41: Age-sex Distribution, Falls

20181614121086420

Male

Female

Total

Fatal Non - Fatal181614121086420

Male

Female

Total

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0>

70

Table 14: Education and occupation distribution of non-fatal fall injuries

PercentOccupationEducation Percent

Illiterate 15.7 Unemployed 2.6Primary 19.0 Others 4.2Middle & Secondary 17.0 Not known 13.4Secondary, High-school & PUC 16.0 Not applicable 8.3Graduate 9.0 Retired 1.7Post graduate 0.6 Homemaker 5.9Not known 12.8 Student 19.0Not applicable 9.9 Unskilled labourer 25.4

Skilled labourer 12.3 Clerical 1.2 Business 3.5 Professional 2.6

> 7

0


The distribution among educational andoccupational categories was in similarity with othertype of injuries. Substantially higher number ofdeaths was seen in the poorer sections of the societycomprising of individuals with lower levels ofeducation and income primarily coming fromuneducated and manual labourer categories. Lessthan 10% of deaths were seen in higher income groupsand amongst higher levels of education.

There was no significant variation with regard tothe distribution of fall deaths in various months.Nevertheless, the first 6 months of the year registeredhigher number of fall deaths. Nearly, 40% of fallrelated deaths occurred in the morning hours and1/3 during afternoon and early evenings.

The place of fall was primarily home in 30% ofdeaths. Falls on road (18%), at construction sites(17%) were the other primary categories of falls.Falls in agricultural areas and shopping areascontributed for 2% of deaths in the total series.

Similarly for non-fatal injuries, 40% occurred athome, followed by 31% in work places and 18% onroads (Figure 42). Among children, falls on roadand play sites was commonly seen to be resulting innon-fatal injuries.

Alcohol was found to be a primary influencing factoras nearly 11% of fall deaths among men in 18+years occurred under the influence of alcohol. Mostof (75%) the deaths due to falls occurred from aheight of 10 feet and above. The cause for theoccurrence of fall was not clearly known for majorityof the deaths.

17. Drowning

Estimated deaths: 120Estimated serious injuries: 150

Even though, cases of recreational drowning arereported in a sensational way by the media, very littleinformation is available in a collective and cumulativemanner. The city of Bengaluru has not witnessedcyclones and floods as seen in other parts of India.There have been deaths due to drowning during rainyseason: people getting washed away, deaths due tobuilding collapse after heavy rains, apart fromdrowning in recreational spots both within andperipheral parts of the city. It is essential to note thatdrowning carries high mortality as many individualsdie within few minutes. The present programme triedto capture drowning deaths and injuries in totality.

In the study period, 62 individuals died and 31 werebrought to hospitals due to drowning in the year2007 in the city. Among them 75% were men and

25% were women. Nearly half of drowning deathsoccurred in 16-35 years with the highest numberbeing in 30-35 years. Majority of the drowning deathsoccurred among individuals living within the city ofBengaluru. Non-fatal drowning among children(< 15 years) and in women of middle age groupswas also observed in the study.

Contrary to the observations on educationaloccupation in other injury deaths, majority of thosewith drowning were with higher levels of educationand in student and other professional categories. Thisindicates that much of the drowning was related torecreational activities.

Nearly, half of drowning deaths occurred during thesummer months as compared to the second halfof 2007. The timing of drowning deaths waspredominantly during afternoons and late eveningsand very less in morning or late night hours. The

454035302520151050

Col

lege

Cam

pus

Cons

truc

tion

site

s

Hom

e an

dpr

emis

e

Oth

ers

Roa

d

Wor

kpl

aces

Fatal Non-Fatal

Figure 42: Place of occurrence, Falls

43NIMHANS

commonest places of drowning were wells, lakesand ponds in and around the city.

Nearly 8% of deaths were linked to alcohol

18. Animal Bites

Estimated deaths (Dog bites): 50Estimated serious injuries (Dog bites): 50,000

According to NCRB, in India, during the year 2006,301 persons were injured and 864 got killed becauseof animals. Though a specific distinction is not made,less than 1% of the reported injuries and deaths aredue to snake bites / animal bites. Of greater concernwith animal bites is the 100% fatality due to Rabies.56% of the global rabies deaths is from AsianContinent and India contributes to nearly two thirdsof this burden. With an estimated 20,000 deaths and17 million animal bites, there is one death every 30minutes and 1 animal bite every 2 seconds in India.

Recently, the city of Bengaluru has witnessedunprecedented debates and discussions on stray dogmenace and dog bites in particular. The debates haveresulted in formulation of guidelines on how strayanimals should be handled on roads and at home.The Department of Community Medicine atKempegowda Institute of Medical Sciences runs anAnti rabies clinic, conducts research on rabiesincluding rabies surveillance. The department is alsohelping BBMP in developing policies on “Preventionof human Rabies” including dog populationcontrol.

The dog census undertaken in the city of Bangalorerevealed that there were an estimated 3.2 lakhs dogs(1.8 lakhs stray dogs & 1.4 lakhs pet dogs) in BBMParea. Available reports from BBMP shows that therewere 21,121 recorded animal bite cases in Bangalorecity for the year 2007-08 and 38 human rabiescases were admitted to Epidemic Diseases Hospital(EDH), Bangalore. This obviously is anunderreported number as there is no mandatoryreporting of animal bites.

Data from BISP reveal that, less than 1% of theregistered injuries were due to animal bites. A keyreason was that animal bite cases are most oftenreferred to other centres and even when attendedthey are generally not managed in the casualty.

Over a one year period, no deaths were recordedby the police due to animal bites, while, 1,737persons were registered from one centre. Dog biteswas the commonest injury seen in the series. Homesand roads were the commonest place of bite (40%each). Cases were reported from almost all placeslike play sites, agricultural lands, public parks andnear schools and colleges. Interestingly, 35% ofanimal bites occurred in children less than 15 yearsage group.

Figure 43: Age-sex Distribution, Drowning

Male

Female

Total

Fatal Non - Fatal30

25

20

15

10

5

0

35

30

25

20

15

10

5

0

Male

Female

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

Total

< 5

6-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

55-6

0

61-6

5

66-7

0

> 7

0

consumption at the time of drowning. Majority ofthe deaths occurred in presence of others especiallywhen groups of people had gone for recreationalactivities within or outside the city.


19. Assault / Violence

Estimated deaths: 50 - 100Estimated serious injuries: 25,000

Violence is a growing problem all over the world,more so in rapidly economizing societies. Violence isa commonly used term and includes homicides,assault, rape, injuries due to riots and wars, abuse ofelderly – women – children, custodial related injuries,etc. The precise magnitude of the problem and itscauses are difficult to establish in a surveillanceprogramme and requires focused investigation.

Data from Bengaluru Injury SurveillanceProgramme (BISP) revealed that during 2007, therewere 28 deaths (<1%) and 8,499 (16%) first timehospital contacts giving a ratio of 1: 300 for fatalto non-fatal injuries. The non-fatal injuriesregistered were primarily due to interpersonalviolence and domestic violence but also includedother types of violence. Majority were brought tohospitals in a state of acute injury by familymembers or friends / acquaintance.

20. Prehospital Care

Good surveillance programmes can often reflectthe status of trauma care services and identify areasof strengthening. Previous studies in Bengaluruhave been limited and examined the pre hospital

care in road traffic injuries, traumatic brain injuriesand suicides (24, 25). A study in 2001 examinedtrauma care facilities across 25 hospitals of Bengaluru(30). However, these studies have been isolated, and

50454035302520151050

Hom

e

Fatal

Non-Fatal

Roa

d

Publ

ic p

lace

Wor

k pl

ace

Oth

ers

Un

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n

Scho

ol

Agr

icul

tura

lfi

eld

Figure 44b: Place of assault / violence

Men predominated in hospital series in a ratio of4:1 (6,777 men and 1,722 women). Nearly 2/3violence occurred in 16-34 years with highestnumbers in 21-30 years (41%). Violence wascommon (more than 80%) among individuals withlow education and income backgrounds. Alcohol wasa major factor in 9% of injured and 7% of counterpartindividuals. Three common places of violence relatedinjuries were home (35%), roads (28%) and publicplaces (28%). Six percent of the injured came directlyfrom their workplace, following an injury. Thecommonest pattern of violence was physical fights,

injuries due to commonly available objects at homeor on roads.

Figure 44a: Age-sex distribution of assault/violance injuries

Fatal Non - Fatal

Male

Female

35

30

25201510

5

0

Male

Female

25

20

15

10

5

0

5-10

11-1

5

16-2

0

21-2

5

26-3

0

30-3

5

36-4

0

41-4

5

46-5

0

61-6

5

> 7

0

< 5

5-10

11-1

5

16-2

0

21-2

5

26-3

0

31-3

5

36-4

0

41-4

5

46-5

0

51-5

5

56-6

0

61-6

5

66-7

0

> 7

0

45NIMHANS

not continuous in nature. In a surveillance programme,examination of these factors can reveal the changingpatterns and identify critical elements, helping inprioritization and policy setting process.

Trauma care issues included under surveillance were- availability of first aid, mode of transportation, timeinterval between injury occurrence to reaching one ofthe study hospitals, referral patterns and number ofhospital contacts before reaching a definitive hospital.While these formed a set of vital factors contributingfor availability, accessibility and affordability ofemergency and pre-hospital care, the quality of carenot received nor provided were included.

The provision of first aid to an injured person dependson place, nature and severity of injury along withavailability. As there are no specified first responders,people in the vicinity are the first responders, who oftenmake the decision of what should be done. Thus, it iscommon to see large number of people gathering atthe site of injury. Secondly, it depends on the knowledgeand practice of these responders and what they do.Commonly, in a road crash, the scenario is more ofconfusion, altercation and fights among people, ratherthan shifting the person to the nearest site of care (InIndia, it is common to see people fighting, beating upthe driver, setting the vehicle on fire, etc., a form ofpeople’s justice). Thirdly, it also rests with the existingmedico legal practices in the society as it is commonto see people lying unattended for fear of later legalcomplications or police enquiries among public (Thehon. Supreme court has ruled that people attending toroad crash victim need not be involved in later stages).

The definition of first aid varies in the local contextand in the present study even care in a first contacthospital was considered as first aid as this was thefirst available care. In totality, nearly one third (28%)

of fatal and half (48%) of non-fatally injured personsreceived some type of first aid more so in the firstcontact hospital. However, the number of personsreceiving first aid soon after a fatal injury varied from10–50% depending on the type of injury. In non-fatalinjuries, the numbers were slightly higher ranging from24% to 65%. In road crashes, the proportions were55% for non-fatal injuries and 21% for fatal injuries,while for burns it was 32% and 57%, respectively. Insuicides, 22% fatal and 40% non-fatal cases receivedsome first aid (figure 45).

The place of delivery of first aid is crucial as itdepends on the practice of “save and stabilize” or“scoop and run”. In Bengaluru and many parts ofIndia, at the injury site, people administer first aidwith whatever they know or can do, rather than anysystematic interventions that can save life or minimizethe extent of further damage. Further, peoplegenerally do not wait for an ambulance even if it isa severe or fatal injury. Only 7% of fatal and 2% ofnon-fatal injuries received first aid at injury site (thiswas comparatively higher for assault, burns and afterhanging / attempt for hanging). This indicates thepresence of a “scoop and run” practice as injuredwere taken to nearby hospitals by those present atthe site of injury. Nearby Government / publichospitals was the most common place of providingfirst aid in more than 50% of injuries. This was

Table 15: Place of first aid for injured persons (%) fatal injuries

Road traffic injury 2.4 16.8 33.8 1.9 7.0 0.3

Fall 1.4 52.9 32.9 4.3 4.3 4.3

Assault/Violence 28.6 14.3 57.1 0 0 0

Burns 8.1 73 14.9 2.7 0 1.4

Poisoning 1.3 46.1 34.2 6.6 9.2 2.6

Drowning - - - - 100.0 -

Hanging 17.2 13.8 62.1 3.4 3.4 0

Others 5.7 39.3 30.3 2.5 13.1 9

INJURYCAUSEAt injury

Site

Near bygovt

hospital

Near byprivatehospital

Medicalcollegehospital

Nursinghome

Others

Fatal

Non-Fatal

Suicide

0 20 40 60 80

Road traffic injuries

Poisoning

Others

Hanging

Fall

Figure 45: First aid care for persons with fatal andnon-fatal injuries

Burns

Assault/Violence


closely followed by Private health care institutionsin 32% and 42% of fatal injuries. The involvementof general practitioners and common responders likepolice was less than 1% in the series.

Who delivers first aid is an important aspect aswhat is delivered depends on the knowledge andskills of the person and the extent he/she goes intranslating that knowledge to action. In the presentstudy, as many people received their first aid inpublic or private hospitals, it was commonly thedoctor or nurse involved in delivery of first aidcare. More than 90% of first aid deliverers weredoctors.

Mode of transportation of an injured person is criticalas the aim is to reach the nearest health care centrein the safest possible way within a short period oftime. Data from non-fatal injuries revealed that thecommonest transportation vehicle was private meansof transport through private vehicles (cars or taxis)or a 3 wheeled auto rickshaw in 42% and 29% ofcases, respectively. Police vehicles extended supportby transporting 3% of injured persons. Transferthrough ambulances was seen in 19% of injuries andthis was mainly for inter-hospital referrals. Only 13%of injured persons used an ambulance for immediate

transportation of patients. Transfer throughambulance was comparatively higher for burninjuries (32%) and suicides (24%) and only 20% forRTIs. The rural component of the study revealed that13% were transported by ambulance and three outof four injured persons were shifted in privatevehicles.

Table 16: Place of first aid for non-fatal injured persons (%)

Non - Fatal

Road traffic injury 1 4.3 49.9 42.8 1.5 0.4

Assault 1.1 1.4 55.3 33.5 6.1 1.9

Burns 1 4 52.5 35.4 5.5 1.5

Drowning 0 5 55 40 0 0

Fall 1.4 4.6 43.3 46.5 2.5 0.9

Others 15.1 2.4 38.1 37.8 3.4 3.1

Poisoning 0.5 3.8 46.2 47.9 1 0.5

Suicide 0.3 3.2 48.6 46.8 0.6 0.5

INJURYCAUSEAt injury

SiteMedicalcollege

Near byGovt.

Hospital

Near byprivate

hospital/NH

GPs + Pvt.clinic

Others

Figure 46: Personnel delivering first aid for fatal and non-fatal injuries

Fatal Non - Fatal

Nurse1%

Police1%

Public3%

Familymembers

5%Others

1%

Doctor89%

Nurse1%

Selfmedication

1% Others1%

Doctor97%

454035302520151050

Priv

ate

vehi

cle

/ ta

xi

Aut

oric

ksha

w

Am

bula

nce

Gov

t.ve

hicl

e

Polic

eve

hicl

e

Wal

king

Oth

ers

Figure 47a: Mode of transportation in urban Bengaluru (%)

80706050403020100

Priv

ate

vehi

cle

/ ta

xi

Am

bula

nce

Aut

oric

ksha

w

Gov

t. v

ehic

le

Polic

e va

n

Wal

king

Oth

ers

Figure 47b: Mode of transportation in rural Bengaluru (%)

47NIMHANS

Time interval between injury and reaching a definitivehospital is crucial for preventing deaths and reducingseverity of injuries. Information on this was availablefrom 2,542 (75%) fatal and 48,775 (93%) non-fatalinjuries. Among fatal injuries, <5% reached thehospital in less than an hour, while 27% reached in<3 hours. Rest of them were referred to participatinghospitals from other referral centres for a wide varietyof reasons ranging from facilities to patient choices.Forty percent of those who died reached centres after24 hours, including 1/3 of road traffic deaths asshown in figures 48 and 49. Variations were notsignificant across injury causes. In non-fatal injuries,30% reached hospitals within 1 hour and 44%reached within 3 hours. Nearly one out of 4 patientscame to the hospital beyond 24 hours indicatingdelays in care. Data has to be interpreted cautiouslyas care provided in first contact hospitals has notbeen examined in detail.

The source of referral indicates the place of firstcontact highlighting the possibility of strengtheningservices across different institutions. Among fatalinjuries, the referral to the final hospital was mainlyfrom Government (54%) and private hospitals(22%). In contrast, overall 53% of injured personsreached a hospital on their own and this was themost common practice in assault / violence (72%),attempted suicides (60%), and accidental poisoning(62%); nearly half (47%) of injured persons in aRTI also reached directly on their own. Governmenthospitals and private hospitals referred 22% and18% of injured persons, respectively. The referralfrom private teaching hospitals was less as theavailable facilities are comparatively better in thesehospitals.

It is a common practice in Bengaluru to see patientsbeing referred from one hospital to another for anumber of reasons. Some of the common reasonsare type – nature – severity of injuries (polytraumapatients and those seriously injured are referreddepending on availability of specialties), nature ofhospital (public or private), availability of facilitiesin health care institutions and affordability of care(expenses depend on nature of hospital, injurymanagement practices and ability of patients andtheir families to pay along with availability ofinsurance with people). In the present programme,it was observed that among fatal injuries, 70% ofpatients visited more than 1 hospital. Among thosevisiting more than 1 hospital, it varied from 50%for fall related injuries to 13% in burn injuries. Innon-fatal injuries, more than 90% visited at least 1other hospital. The smaller number in burn injuriesis primarily because exclusive burns care andmanagement is available in one of the larger publicsector hospital. Among non-fatal injuries, since thefirst contact hospital was chosen the numbers werearound 10%, but majority were referred from thesehospitals to other hospitals.

Fatal Non-Fatal35

30

25

20

15

10

5

0

< 1

hr

1-3

hrs

3-6

hrs

6-12

hrs

12-1

8 hr

s

18-2

4 hr

s

1-2

days

2-3

days

> 3

day

s

Figure 48: Time interval between time of injury andregistration, Fatal & Non-fatal, all injuries

Figure 49: Time interval between time of injury andregistration, Fatal & Non-fatal, RTIs

Fatal Non-Fatal50

40

30

20

10

0

< 1

hr

1-3

hrs

3-6

hrs

6-12

hrs

12-1

8 hr

s

18-2

4 hr

s

1-2

days

2-3

days

> 3

day

s


21. Nature of injuries

Organization and delivery of trauma care servicesdepends on number of factors like nature – type –severity of injury, availability of facilities andresources and ability of people to pay for care. Headinjury was the commonest cause of death in ¾ ofroad crashes, while injury to chest and abdominalregions were documented in 23% and 1% of deaths.Among non-fatal injuries, injuries to head/face, upperlimb and lower limb were present in 66%, 35% and46% of crashes, respectively (Figure 50a, 50b & 50c).Neither detailed anatomical injury nor clinicaldiagnosis was included in the programme.

Figure 50a: Body Parts injured in RTIs

Fatal Non-FatalHead - 77

Face - 19

Neck - 4

Chest - 23

Upper limb - 25

Abdomen - 0.3

Spine - 5

Lower limb - 37

Head - 43

Face - 27

Neck - 2

Chest - 6.0

Upper limb - 35

Abdomen - 3

Spine - 2

Lower limb - 46

Figure 50b: Body Parts injured in Assault/violence

Head - 29

Face - 47

Neck - 2

Chest - 10

Upper limb - 40

Abdomen - 9

Spine - 2

Lower limb - 15

Head - 53

Face - 26

Neck - 2

Chest - 5

Upper limb - 22

Abdomen - 5

Spine - 5

Lower limb - 32

Figure 50c: Body Parts injured in Falls

Figure 51: Extent of burns (%) among fatal & non-fatal burn injuries (shown in blue)

>6064%

51-6014%41-50

10%

31-406%

21-305%

11-201%

>6024%

51-606%

41-509%

31-4010%

21-3013%

11-2020%

0-1018%

Fatal Non - Fatal

49NIMHANS

The extent of burns was more than 60% in 2/3 ofdeaths (Figure 51). Regrettably, 10% had died eventhough the extent was less than 30%. Among non-fatal burns, nearly 70% had <60% of burns.

The present programme has adopted very simplemethod of classification to assess injury severity.Being a surveillance programme, it was decided toinclude this practical method as trauma carephysicians in some hospitals were not familiar withscientific methods of injury severity assessmentlike AIS, IIS, GCS, GOS, TRISS or other methods. Inaddition, detailed documentation and severityascertainment of each injury was not done; formedico-legal purposes, detailed description ofinjuries was done separately.

The injury severity was considered mild (only ERcare), moderate (requiring hospital stay upto 6 hoursand needed X-rays, blood or IV transfusion, expertconsultation etc.,) and severe (admission exceeding6 hours and intensive management). Based on thisclassification, it was observed that one third were

Severe

Assault 62.9 33.5 3.5

Burns 5.4 47.6 47

Drowning 25 68.8 6.3

Fall 42.8 41.1 16.1

Others 28.5 50.1 21.4

Poisoning 9.3 55.6 35

Road traffic injury 32.9 51.3 15.8

Suicide 8.5 50.5 41.0

Urban Total 34.0 47.4 18.6

Rural Bengaluru 40.0 42.0 18.0

ModerateInjury Cause Mild

mild in nature. One third of RTIs and less than 10%of burns, poisoning and attempted suicides wereconsidered mild injuries. Most of the RTIs, burninjuries, drowning, attempted suicides and falls weremoderate to severe in nature (Table 17), indicatingthe need for comprehensive and integratedmanagement approaches. This also reflects thatminor injuries can be provided care in nearby healthcentres or general practitioners.

Table 17: Severity of injuries in ER facilities

The status of injured person at the time of reachinghospital reflects severity of injury and the need forhospital care. The number of patients brought deadwas 1% in the series. Every tenth patient with apoisoning – drowning – attempted suicide was inan unconscious state, while reaching hospital. Semiand unconscious patients ranged from 30% inpoisoning and suicide patients to as low as 3% inassaults. Overall, 85% were conscious at the time ofhospital entry. Among road traffic injuries, one outof 8–10 patients were in semiconscious orunconscious state, necessitating the need for intensemanagement and the need to deliver efficient care.These situations also pose difficulties in patientmanagement as well as in data collection forsurveillance programme, especially when they arenot accompanied by family members or knownpersons.

Figure 52: Status of injured persons at hospital entry

Broughtdead1%

Conscious85%

Semi-conscious

8%

Unconscious6%

Information on the managerial practices of injuriesrevealed that nearly 31% were provided care anddischarged home with advice on follow-up, whilemore than half were admitted for further medicaland or surgical lines of management (Figure 53).The admission rates were highest for burns, falls,RTIs and attempted suicides. Those treated in ER

22. Management and Outcome


and further referral was high for RTIs and falls. Oneout of every 6 patients was referred to anotherhospital for number of reasons like patient choices,lack of facilities (bed, investigation, manpower,etc.,), affordability, and at times included medicolegal reasons as well.

Figure 53: Mode of management

The outcome of injuries was assessed at the end ofER stay and may not be truly indicative of realoutcome as those admitted and intervened werenot followed-up in the programme. However, itsheds light on issues like care patterns andlimitations. Majority improved in their vital statusand got stabilized after reaching casualty, butrequired further care and management. Nearly 2%of patients died in ER and combined with thosebrought dead, the total number of deaths at ERwas 3%. Highest number of deaths was seenamong those with burns and drowning, while thestatus of nearly 40% with poisoning, attemptedsuicides deteriorated indicating need for aggressivemanagement.

23. Injury: The hidden and unanswered

epidemic

Information systems and existing gapsAny prevention and control programme needs a goodfoundation to work through policies andprogrammes; such programmes obviously need goodquality and reliable information. The injuryinformation system till date in Bengaluru has beenfragmented and patchy with different systemsoperating in their individual ways as per theiradministrative and legal requirements. Four commonsources of injury information are police, corporationvital registration sources, transport and health. Policedata is the only source of injury information andeven this is of limited value for policies andprogrammes. The data is not comprehensive, qualityis moderate, not analysed, disseminated and utilizedby all stake holders at local levels (city or state).Even though health sector provides care for numberof patients in individual hospitals, there has been noinjury information system in health sector. Further,each hospital follows its own individual practices.In the absence of timely and scientific information,it has not been possible to develop – implement –monitor and evaluate any systematic policies andprogrammes.

The present programme facilitated by ICMR and WHOand coordinated by NIMHANS is the first systematiceffort to build a surveillance activity with existing datasources. Beginning with stake holder’s consultation anda series of preparatory activities, information wasgathered from nearly 4,334 injury deaths, 113 BMTCinvolved road crashes and 68,498 hospital registeredinjury patients for the year 2007. The city police,transport officials, nodal officers and theirrepresentatives in various institutions along with stafffrom Coordinating centre facilitated informationcollection and pooling. Hopefully, this jointcollaborative effort, being first and unique in thecountry will be strengthened, improved and continuedin the coming days. All partners and their teams needto be complimented for this unique collaborative effort.

Burden of Injuries• As per the death records of the Bengaluru city

police, injuries constituted 9% of total deathsand 60% of these were in 5-44 age group in2005. Injuries as an antecedent or associatedcause of death might not have been properlydocumented in death records.

Admitted formedical

surgical care53%

Others1%

Treated inemergency room &referred to another

hospital 15%

Treated inemergency room &

sent home 31%

51NIMHANS

• Nearly 4,500 deaths are estimated to occurevery year with 90,000 hospitalizations forinjury care and management. Even though it ismandatory to report all unnatural deaths, somedeaths could have been missed or misclassifieddue to various reasons. The difference betweenthe two could be due to registration of outsideand late deaths

• Further, nearly half the patients discharged fromhospitals will have varying levels of disabilitiesrequiring short term and long termrehabilitation services.

• Thus, it has been possible to assess injuryburden and to highlight that nearly 5,000deaths and > 1,00,000 hospitalisationsare likely to occur every year in Bengalurudue to injuries. Nearly half of themare discharged with disabilities andapproximately half live with long termdisabilities. A problem of this magnitudeis not to be ignored as there are individualsand families behind these numbers.Everyday, 10–15 persons lose their lives,250–300 seek hospital care and 80–100become disabled for short or longperiods of time along with severe (andunestimated) economic losses in Bengalurudue to injuries. Needless to say injuries are amajor public health problem and cityauthorities and parliamentarians should placeinjuries on the public health agenda ofprogrammes. Scientifically designed andsystematically planned programmes need to beimplemented, monitored and evaluated for

decreasing deaths and disabilities in thecoming years along with proper integration andcoordination.

• In a “do nothing” scenario or if the presentscenario continues, Injuries will result inan estimated loss of 10,000 lives, 2,00,000hospitalizations and 50,000 persons withdisabilities every year by 2015 (1). Thesenumbers are conservative estimates and arelikely to be influenced by many factors.

Profile and PatternExamination of both fatal and non-fatal injuriesreveals that Road Traffic Injury is the leading injuryin the city of Bengaluru. This is closely followed byburns, poisoning and falls as other major injuries.Based on intent, suicides are a leading cause andinclude hanging, poisoning and burns. Withgrowing urbanization, motorization, infrastructureexpansion and liberalized economic policies, it isnatural to forecast an increase in road deaths/injuries and other injuries in the coming years. InBengaluru, every year, nearly 1,100 persons diein road traffic injuries and 2,500 suicides occuralong with other injuries. Despite the enormityof the problem, there has been a glaring absenceof institutional mechanisms and injury preventionpolicies at the ground level.

In comparison to other health problems, injuriesprimarily affect young people and predominantlymen. The loss of more than 5000 young people withhospitalisations of >100,000 persons and disabilitiesof a long term nature among 30,000 persons should

Table 18: Injury pattern with reported and estimated figures

Deaths

Road Traffic injury 987 1100 26,191 40,000

Fall 209 500 4986 10,000

Burns 360 500 2517 5,000

Poisoning 300 500

Drowning 62 100 31 300

Animal bites 28 40 21,121 50,000

Violence / assault 28 8499 25,000

Hanging

Fall of objects NK NK NK NK

Mechanical injuries NK NK NK NK

Total

Estimatedserious injuries

ReportedEstimatedReported

Estimated numbers based on Annexure 3

Serious Injuries


grasp the attention of every policy maker andparliamentarian. Children saved from communicablediseases are only becoming victims of injuries at thelater stages of their life. The loss of young lives due toan injury should be a wake–up call for all concernedand realistic programmes should be in place.

Injuries and Socio-economic lossesIn the present programme, using the proxy variablesof education and occupation, it was observed thatinjury significantly affects the middle and lowersocio-economic sections of the society. At a time whenpoverty reduction programmes and a number ofother socio-economic improvement programmes arebeing implemented, it is a hard reminder that injuriesadd to the existing and growing pool of poverty inthe society. The poor and middle classes are alsounable to afford growing costs of injury care andhence, become more poorer. Injury among youngmen places enormous burden on the individual andfamily forcing them to generate resources for careand hospitalisation along with rehabilitation. Manyindividuals and families lose income and wages,make loans, sell assets, women get into forcedemployment resulting in an acute crisis. Loss ofproductivity, compensation, insurance liabilities andlong term / permanent loss are added issues. Theloss of a breadwinner brings in severe economichardships, adding to the spiralling cycle of poverty.This adds to the loss of precious human resources inour society. RTIs alone are estimated to result in lossof 3 % of GDP (Rs. 55,000 crores or 5,50,000 million)every year in India, while cost of other injuries isnot known.(6) It needs to be highlighted thatcollecting information on occupation and income isdifficult in a surveillance programme.

Urban rural differencesThe data from National Crime Records Bureau andState Crime Records Bureau indicate that nearly 15%of injury deaths, especially road traffic injuries andsuicides occur in the major 32 metros of India. Thefindings from the present programme stronglysupport this observation. Even though the presentprogramme was a urban based activity, a ruralcomponent was included with the enrolment ofdistrict hospital, medical college hospital, twocommunity health centres and two primary healthcentres to examine the feasibility of developingsimilar programme in a rural area. A future

publication will clearly outline injury burden andprofile in rural areas but preliminary results indicatethat the load on emergency departments of ruralhospitals is quite large. Coupled with the fact thatfacilities for management and rehabilitation arelimited in rural areas, majority of the injured personsare referred to urban areas for follow-up care, thusadding to the burden in urban hospitals.

Role of AlcoholSeveral independent epidemiological studies byNIMHANS have shown that nearly 1/3 of the adultIndian male population are regular alcohol usersand nearly a third of all injuries are linked to alcohol(23–25). Nearly, 30% of night road crashes areassociated with alcohol usage. Indian drinkingpatterns being different from those in the west,alcohol use is a major risk factor for the personbehind the wheel, machine or any product. In thepresent study, alcohol was documented in <15% offatal and non-fatal injuries in both police and hospitalrecords. Discussion with participating membersrevealed that documentation of alcohol was poorand limited due to medico-legal issues. A commonrefrain was that “If we mention alcohol in therecords, we need to provide evidence in Courts ofLaw at a later date. If we do not do blood and breathalcohol estimations and, if physician certification isnot accepted, from where do we get the evidence?”Secondly, it was also reported that documentingalcohol comes in the way of compensation andinsurance claims (in RTIs) and the affected familiesmay be put to greater economic hardships. Thirdly,in the absence of facilities for blood or breath alcoholestimations, border line cases are often missed out.In addition, alcohol also interferes with clinicaldiagnosis, management and outcome. Documentingalcohol information among all injuries in fatal andnon-fatal injuries is very crucial to develop anysystematic programmes.

Emergency and pre-hospital careFive important factors that determine the outcomeand impact with reference to emergency care are -availability of first aid or early care, time intervalbetween injury and hospital contact, mode oftransportation, triage and, referral services. Thepresent programme has clearly demonstrated thepoor status of emergency care in Bengaluru asrevealed by the fact that more than 50% of patients

53NIMHANS

reached hospital on their own, two thirds of patientsreached a definitive hospital beyond 3 hours, morethan 70% travelled in a three wheel auto rickshawand more than 20% were referred from more thanone hospital. The severity of injuries like burns,poisoning and attempted suicides was consequentlyhigh by the time patients reached the hospital. Theuse of ambulance was < 20%, an increase of 5%over a 10-year period. Majority of the patients wereprovided first aid by doctors and/or nurses in publicor private hospital with no involvement of firstresponders like police, teachers, students and others.The city also does not have systematic first aidprogrammes that are conducted regularly and on acontinuous basis and, earlier efforts have beenisolated efforts. It is important that first aid becomesa regular component of curriculum in schools andcolleges, police training programmes, trainingprogrammes of drivers of all categories especiallyheavy vehicles and other first responders. It is alsoimportant to make traffic alterations to allowmovement of ambulances without hindrance, as itis common to see ambulances stuck in traffic forlong period of time.

Trauma care issues - Acute CareIntegrating emergency care with acute care inhospitals is a critical requirement to improve traumaoutcomes. Hospitals and ERs should be in a state ofpreparedness to manage injury patients. Even thoughtrauma audits were not a part of the currentprogramme, data indicate the need for trauma auditsin the coming months. Generally it was observedthat facilities in public hospitals were limited in termsof manpower, beds, investigative facilities andsupportive services. More than a third of patientswere referred to the next hospital after contact withthe study hospital. Quality of care also requiresconsiderable improvement in public sector hospitalsincluding district hospitals. On the contrary, the costof care in private hospitals was found to be expensiveand beyond the reach of people without insurance.The documentation of trauma care aspects inmedical records has been found to be inadequate,since trauma audits are not a common practice inmany hospitals. Upgrading facilities (manpower,basic facilities) in public sector and private hospitals,up-scaling skills of doctors and nurses, developingguidelines and protocols for minimum care (by allhospitals) for injury patients and trauma audits

should be given importance to reduce deaths, severityand complications from injuries.

Medico-Legal aspectsInjuries are riddled with medico-legal complexitiesdue to lack of guidelines, directions, supervisory andcoordinating agencies. During the course of theprogramme, these issues were examined in detailand discussed with stakeholders and partners onmultiple occasions (copy of the report available onrequest). While there is need for tough regulations,there has to be appropriate guidelines on what ismedico legal and what is not medico legal. Thecurrent medico-legal practices interfere in numberof ways like- documenting proper information,multiplicity of records and procedures, huge timespent in documentation, confusion with regard toreporting to police, doctor’s time spent indocumenting/writing registers and attending courts,opportunities for manipulations of records atconvenience and a host of other problems. Nearly,75% of the doctors reported that these issuesinterfered in patient management due to complexityof legal issues and their attendance in courts as andwhen called for. However, their presence and sharingof information in courts had not influenced theoutcome in any significant way.

Most importantly, medico-legal complexities interferein the appropriate care for the patient and even today,significant number of health care institutions wouldnot like to get involved with the police or the law.As a result, patients would not reach the hospitalsfearing interference from police. Even when theyreach, the procedures were found to be cumbersomeand often resulted in transfer and referral of patientsfrom one hospital to another. Thirdly, the informationshared by patients and their families was often foundto be “unreal” as noticed by the fact that “most ofthe suicides are due to chronic stomach pain, burnsdue to stove bursts and poisoning being accidental”.These issues highlight the need for re-examinationof the existing practices and availability of clearguidelines along with decriminalizing injuries.Essentially, injuries are major public health problems.

Intervention and their effectivenessThe primary purpose of surveillance is to providedata for action. The data from the present feasibilitystudy has shown the type of data that can be


available to planners and policy makers toformulate strategies, approaches and action plansthat will reduce the burden of injuries in the comingyears. It needs to be highlighted that surveillanceprovides the foundation and more focused researchfrom health, transport, police, law, vehicle-productmakers and behavioral sciences are required todevelop targeted and specific interventions. The dataclearly show that road safety, home safety and worksafety are 3 major domains for further programmes.It has been acknowledged that there is no singlesolution and thus, multiple actions are required fromnumber of stakeholders. A detailed discussion onwhat interventions need to be developed is beyondthe scope of this report and is outlined in recentWHO publications and expert committee reports.A list of proven, effective, and sustainableinterventions is given in Annexure 5. It is essentialto develop mechanisms for implementation of theseprogrammes through institutional approaches.

Role of Research and need for informationInjuries are multi-factorial events with causes lyingin agent, host, environment and the systems asoutlined in the earlier sections of this report. Like

any other health problem, injuries have anepidemiological profile and characteristics that needto be unravelled to identify areas of specificinterventions. Broadly, the interventions could beprimary (injuries will not occur at all), secondary(minimize harm in the event of an injury) and tertiary(rehabilitate after an injury) and are aimed at people,products and environment through education,engineering, enforcement and emergency care. Toimplement these preventive strategies, there is needfor policies and programmes that are evidence basedand data driven. A surveillance programme of thepresent nature provides clues on changing patternsand profiles, identifies broad characteristics andshows directions for programme implementation,monitoring and evaluation, along with identifyingareas for further research. As surveillance lays thefoundation, focussed research will identify thespecific determinants of injuries for remedialmeasures. It is crucial to acknowledge at this juncturethat injury related research is limited due to lack ofresearchers, institutions, funding and supportsystems. This is an area of high importance forBengaluru and India to address injury epidemic inthe coming years.

24. Injury / RTI Surveillance: Strengths,

opportunities and limitations

StrengthsInjury surveillance is often the first step inunderstanding injuries. The present report shows thata well designed surveillance programme providesinformation on:• Magnitude of problem• Pattern and profile of injuries• Geographical distribution• Major/ Selected risk factors• Responsible product/object causing injury.• Nature – severity and outcome of injuries.

Most importantly, it is essential to realize that RTI/injury surveillance data from surveillance needs tobe supplemented with focused research activities

(e.g., trauma registries, risk factor studies) andmultidisciplinary crash investigations to developspecific and targeted interventions at locallevels.

Surveillance is an activity which drives number ofother activities by setting a platform for agendasetting, prioritisation of activities, allocation ofresources, developing policies and programmesalong with monitoring of activities. Information fromsurveillance programme will help to develop andprovides direction for a number of activities asshown in Figure 54. An example of howeffective surveillance data can be used is given inAnnexure 6.

55NIMHANS

Figure 55: Inputs for RTI prevention and control

Opportunities• There is already a system within police

department for collecting information on injurydeaths. RTIs, suicides, homicides and otherunnatural deaths are already included in thissystem. The present system can be strengthenedwith reorganization of data collectionmechanisms and effectively utilized for injurysurveillance.

• Information on characteristics of RTIs and otherinjuries can be systematically collected with afocus on getting quality information and notmere numbers. A revised format for datacollection is provided in Annexure 7. Thepresent programme has shown that it ispossible to collect data on♦ who are killed (age, sex, residence,

education, occupation),

♦ nature of RTIs (location, road usercategory, position in vehicle, maneuver,collision nature, place of death),

♦ Basic details for other injuries (nature,place, and intent needs extra effort)

♦ Vehicle details ( type and year ofmanufacture)

♦ situation and context of injuries (location– urban / rural ; highway / non highway; junction./ midblock, etc., ),

♦ use of protective equipment like helmets,seat-belts, child restraints,

♦ basic details on trauma care (first aidreferral, time interval and mode oftransport for hospital deaths), and

♦ place of death• Information on product and environment

related factors will be difficult to get in a

Road SafetyPolicy, plans and

programmes

Legislationand

human rightsInterventionProgrammesin different

settings

Organizationof pre-hospital

andtrauma care

Planning andbudgeting forRoad Safety

AdvocacyInformationsystems frompolice, health

and others

Humanresources and

training

Monitoringand

evaluation

Surveillanceand

Research

Figure 54: Pathways of research

Traumaregistries

Focused riskfactor studies

Multidisciplinarycrash / injuryinvestigation

Highwaycrash

analysis

Morbidity Injury / RTIsurveillance

Mortality

Research fromother disciplines

Inputs to policies and programmes

Vehiclerelated

research


surveillance programme and requires specialefforts.

• The Central/District Crime Records Bureaualready exist in all cities and districts. Withappropriate directions and training, these unitscan be made more functional to obtain goodquality data.Similarly, information on non-fatal injuries canbe collected in hospitals with appropriateguidelines from health and/or home ministry.Information that can be collected include♦ socio-demographic characteristics (age,

sex, place of residence),♦ nature of injury (RTIs, suicides, burns,

poisoning, drowning, falls, disasters,♦ Details of RTIs (location, road user

category, type of impacting vehicle),♦ use of protective equipment ( helmets,

seat-belts, child restraints)♦ characteristics of other injuries (situation

– context - product responsible),♦ trauma care (first-aid, referral, time

interval, transportation mode),♦ type and severity (body parts involved,

mild-moderate-severe), and♦ mode of management (admission or

referral) and outcome (death or referralor ER care). A revised format is providedin Annexure 8.

Doctors, nurses, PG students, interns, medicalrecords personnel can be involved in datacollection, depending on availability of staff.This will also be a part of their training andwill equip them with skills to understand injuryand trauma related issues. Computerizationwill overcome problems existing in paper basedsystems.Injury surveillance can be expanded in a phase-wise manner. As health systems have beensensitized on surveillance through IDSP and NCDrisk factor surveillance, ample opportunitiesexist for introducing injury surveillance.The major focus of surveillance should be onRTIs and suicides in medical college – apex –specialty hospitals – proposed level 1 traumacare centres in phase 1, concentrating onmoderate and severe injuries. Surveillance canalso be facilitated with development of traumaregistries in selected institutions.

After initial strengthening of programme it canbe expanded to larger hospitals. If informationcan be captured from upto 70% of institutionsin a geographical area, it will be helpful inunderstanding RTIs/injuries in that area.Hospital data will not bring out clear and totalinformation on product and environmentrelated factors and requires additional inputs.

Barriers and limitationsInjury surveillance as a component of larger injuryprevention and control is yet to make its beginningin a perceptible way in Bengaluru and India. Thepresent programme is the first of its kind beingdeveloped on a scientific approach in an integratedmanner with participation of all sectors andprofessionals in a coordinated manner. As theprogramme is in its early stages, several barriersand limitations have been identified that need to beovercome for sustainability in the long run.

• Despite the enormity of the injury burden andimpact, there is no national injury prevention andcontrol policy, programme or a plan in India orin Karnataka or in Bengaluru. Road safetypolicies are just emerging and have includedaccident analysis and research as a majorcomponent. Each of the sectors workindependently on their priorities and programmeswithout information, coordination andintegration. There is need for a central agency orunit or division at national, state and city levelscapable of guiding, coordinating, implementing,monitoring and evaluating IPC programmes.

• Sustainability of ongoing data collection,analysis, interpretation and application iscrucial for success of injury surveillanceprogramme. The capacity for the same withinpolice and health sectors, both at the local ornational level, does not exist and needs to benurtured and developed over a period of time.

• Police collect large amounts of informationfrom injury deaths and reported injuries.However, these data remain buried in records,as mechanisms to analyse and examineinformation in totality are not part of thesystem. Information on numbers, age, sex,region, type and broad causes are reported tohigher levels in pre-specified formats. Further,the quality of data collected also needs

57NIMHANS

re-examination. The collected data is neitherapplied nor utilized for IPC programmes atlocal or national levels.

• Till date, health sector and hospitals have theirown independent information systems. Injuryrelated information is collected more from apolice/medico legal perspective or formonitoring patient progress and management.Hence, much of the data required fordeveloping IPC programmes are not routinelyavailable in health or police records.

• Doctors in casualty / emergency rooms ofhospitals (especially public sector hospitals)are overburdened with heavy caseload.Hospitals for varying reasons maintainaccident register, MLC register, ER register,police intimation register and several others.For medico legal reasons doctors arecompelled to fill these registers. It is possibleto reduce the documentation overload withthe introduction of an Emergency Trauma CareRecord in ERs, which can serve alladministrative and legal purposes. Extractingdata from existing records has its inherentlimitations, as there is no uniformity acrosshospitals / or ER personnel. In this scenario,the only alternative is to develop uniform“Emergency Trauma Care Record” asapplicable to all institutions with uniformityin documentation. The present programmehas attempted to initiate this process and needsto be built over a period of time.

• Co-operation of hospitals, doctors and policeare crucial to build injury surveillanceprogrammes. Resistance of staff at various levelsis a significant problem. Training, capacitydevelopment, feedback, and data utilizationneeds to be promoted in a systematic way.

• There are several perceived and real medicolegal hurdles prompting doctors not to deviatefrom existing systems as they are repeatedlycalled to legal corridors as witnesses ininvestigations. This has made the necessity ofcontinuing with large numbers of registers,police intimations, documenting events andother complicated procedures. There is needto overcome these problems with appropriatechanges and guidelines.

• Many of the health care institutions are notcomputerized and manual systems are still in

practice. Use and applications of informationtechnology needs to be strengthened as this willfacilitate injury surveillance programmes.

• In major hospitals, one full time person may berequired to ensure coverage and completenessof data collection. Unless institutionalized aspart of the routine data collection, suchinitiatives are difficult to sustain.

• The present programme was built on an initialseed grant provided by ICMR, WHO, Indiacountry office and NIMHANS to develop afeasibility module for RTI surveillance. At thelocal level, it has been expanded into injurysurveillance programme. Budgetary allocationsshould be made within the department of policeor health / corporation for continuation andsustainability of the programme.

• Data utilization and application is more crucialand vital for injury surveillance and IPC tocontinue and sustain. Professionals from police,health and other sectors would not just like tocollect data or extract data, if their work doesnot result in positive benefits to their institutionsor the local community. As any integratedmechanism does not exist as of now, it needsto be created.

• Proper co-ordination mechanism between allthe sectors and partners is crucial to developevidence based intervention programmes. Atpresent, such a mechanism or platform fordiscussing injury related issues and identifyingsolutions does not exist and needs to be createdat local level. The city Road Safety Councilhas been a recommendatory body and does nothave authority for implementation. Thisapproach is very relevant for RTI / Injurysurveillance programme as data needs to beapplied at different levels for planning anddelivery of interventions.

• The sustainability of RTI / Injury surveillance isfar more difficult in district and rural areas asthe scenario is far more complicated. Thepresent programme has made an initial attemptat developing injury surveillance in a rural areain coordination with police, a district hospitaland a medical college hospital.

• ICD coding is not widely used and henceretrospective identification of cases frommedical records section or from police recordis a major challenge (almost impossible, given


25. Inputs to policies and programmesA major aspect of any surveillance programme is todevelop interventions based on evidence. In thisdirection, the Bengaluru injury/road traffic injurysurveillance programme will develop mechanisms toinput data into various policies and programmes. Thecollaborating team will jointly discuss the findings andidentify areas of intervention. This would be discussedwith concerned stakeholders to translate data intoactionable and sustainable intervention programmes.

At present, several ministries and governmentdepartments at state and national level have theresponsibility of developing injury preventionprogrammes within their own sphere of activities. Inthe city of Bengaluru, the various stakeholders involvedin injury/road traffic injury prevention are - police,transport, health, law and judiciary, urban and rural

development, social welfare, Bengaluru MahanagaraPalike, excise, education, information and broadcasting,NGOs, media and several others (Figure 56). However,there is no established forum for developing integratedand coordinated injury prevention programmes.

Over a period of time, a platform to discuss injuryrelated issues should be developed in the city withall stakeholders, professional organizations,professionals from different backgrounds, mediarepresentatives and NGOs to focus on specific areas.

Thus, there is a need for a designated agency/organization with authority, status and budget toaddress injury prevention and control activities. Thisagency should be an independent agency free frompolitics and run by professionals.

Transport

Health Police

Law

Revenue

Insurance

All others

RuralDevelopment

Civil Society

Media

Education

InformationUrban

Development

Figure 56: Need for an intersectoral approach

the huge number of cases). Prospective ICDcoding systems should become part of hospitalinformation systems.

• Lastly, surveillance across the world, especiallyin HICs has had different experiences and thereare merits and demerits of this programme. Itis essential to realize that vast amounts of datacan be collected, analyzed, converted to graphsand figures, included in reports etc., But, datashould be used for prevention and control. If

this is not achieved, surveillance is like generaleducation programmes with little impact onfinal expected result. Hence, along with withcost effective surveillance activity, cityadministrators need to act on data andimplement prevention programmes. At present,multiple stake holders are not united and thereis no lead agency bringing all of them together.This mechanism needs to be developed, forsurveillance to become meaningful.

59NIMHANS

26. Sustainability issues

For any programme to be effective, administrativesupport – resource availability – professional’swholehearted participation – necessary back upservices – continuous feedback – and data utilization/ application for policies and programmes arecrucial. Injury surveillance, especially for Road trafficinjuries and suicides, should become an inbuiltcomponent of injury prevention and controlprogrammes. Sustainability, cost effectiveness andfeasibility should be addressed from the beginning.Experience thus far, reveals that some crucial issuesneed to be considered from the early stages. Somesuggestions and follow through activities asapplicable to Bengaluru are provided below

1. The Chief Minister’s 10 point programme forBengaluru city has included “Road safety” alongwith improvement of traffic scenario inBengaluru. Accident analysis and reductionprogramme and School safety programme arerecognized as important components of thisprogramme. Further, B-TRAC 2010 programmehas also identified development of a road safetyplan for accident reduction. Road traffic injurysurveillance programme should be integratedunder this broader programme as it providesnecessary data for reducing accidents by 30 %by 2010, through engineering – enforcement –education and emergency care.

2. At the city level, a central agency like CCRBcould take the lead along with support fromlocal organizations in technical areas.Alternatively, an experienced unit (an injuryprevention centre or Community medicinedepartment of a medical college) can be giventhe responsibility of leading data collection andanalysis activities. The initial focus ofsurveillance should be on road traffic injuriesand suicides.

3. The Directorate of Health or State HealthMinistry should take initiative and inform allmajor hospitals for introduction of Emergencytrauma care record on a regular basis from2009 onwards. Necessary administrative

notifications should be sent to all partneringhealth institutions.

4. Injury surveillance capacity strengtheningprogrammes for senior and mid level policymakers and training programmes for other stafffrom police and health sector should be heldat periodical intervals. This will ensuremonitoring of programme along with datainputs for other activities at different levels.

5. Training for all those involved in data gatheringshould be conducted (at least twice in a year)for members of all participating institutions(police at mid and junior levels and ER staffmedical record division of selectedparticipating hospitals) to elicit bettercooperation. The required training manualsand training courses should be developed jointlyfor ensuring uniformity in training.

6. Information should be disseminated to allthrough reports, fact sheets, websites and otherchannels for sensitisation, awareness buildingand use of data.

7. The local decision making bodies andrespective departments at higher levels shouldutilize and apply data for development –implementation of interventions and for largerdecision making process as well. Theprogramme should be monitored continuouslyand evaluated once a year for furthermodifications and improvements.

8. No programme can be successful without thewholehearted participation of professionals.A programme of this nature will requirecooperation – participation – support of stakeholders, police and transport officials, hospitaladministrators, nodal officers and teams incasualty departments. Inputs to strengthen thiscomponent through training programmes,information sharing, continuous feedback,using data at individual and hospital levels,and joint collaborative programmes needs to


be promoted. In addition, data leading toaction will be a source of inspiration for all,as a method of recognizing and rewardingone’s work.

9. Resources are required in the long run forcontinuous running of the programme. Aninitial investment is very much required till theprogramme gets established. The requiredfunds at this stage can be provided through

B-TRAC 2010 programme/ city corporation/Directorate of health/or any other agency.

10. All programmes need direction, vision, missionand a passion. It is important to develop a citylevel action group with the primary mission ofsaving young lives from injuries. Children savedtoday from polio and other diseases need notbe victims of road crashes, nor attempt suicideafter an examination.

Recommendations

With research studies pointing that nearly 13-18%of total deaths are due to injuries and an estimateddeath of nearly 1 million people in the country,injuries are no more police, transport, social andeconomic problems, but significant public healthproblems as well. It is estimated that for every death,20–30 hospitalizations occur to an estimated levelof 2.5 – 3 million hospitalizations every year. Thenumber of minor injuries is immeasurable, probablyto the tune of 50 – 100 million. Each death results inimmeasurable loss, suffering and agony for thefamilies. Any amount of compensation or findingsof enquiry committees will not replace lives nor canreplace broken heads and bones. The economic lossesto the country are huge, probably to the tune of 3 –5% of GDP, due to direct and indirect impact ofinjuries. This is occurring at a time when it ispossible to predict and prevent injuries even withexisting knowledge. There is need to build systematicprogrammes (both by integrating with ongoingprogrammes and with new programmes) and IPCactivities in the coming years.

For this to happen effectively, there is a need toidentify the extent, burden, dimensions and impactof the problem. Reliable data are needed to providea solid foundation for road safety planning, injuryprevention and control and for decision makingpurposes. Making correct and scientific decisionsare only possible when good quality information isavailable to all concerned stakeholders. Such datashould drive and lead policies and programmes intransport safety, urban development, environment

protection, suicide prevention, and prevention andcontrol of other injuries. Surveillance is the firststep in this direction, by bringing issues to thepublic domain for recognition and action by allministries and parliamentarians, policy makers,programme managers, industry, NGO’s, media andothers.

The present programme in Bengaluru, India,faciliated by ICMR and WHO, India Country officewas conducted by NIMHANS in collaboration withBengaluru city police, Bengaluru metropolitantransport Corporation, 25 leading hospitals (urbanand rural) and few NGO’s. The major objective ofthe programme was to develop a methodology forInjury / RTI surveillance and to examine thefeasibility of implementing the same in one of therapidly progressing city of India, Bengaluru. Startingwith stake holder’s consultation, number ofpreparatory steps and joint planning of operations,information was gathered from 4,334 injury deaths,113 BMTC involved crashes and 68,498 hospital firstcontact injury contacts along with 2,152 injurypatients from rural Bengaluru. The various problemsencountered were jointly discussed and solutions wereidentified for further changes. The followingrecommendations are based on a situation analysisof ongoing activities in the present scenario, analysisof data, opinion of partners and recommendationsof various meetings held in Bengaluru. The followingrecommendations are placed under 2 headings ofStrengthening surveillance; and injuryprevention and control activities.

61NIMHANS

1. Strengthening Surveillance and informationsystems1. Injury surveillance is an important

component of injury prevention andcontrol and should be strengthened in aphase wise manner. The presentexperience in Bengaluru has shown thatit is possible, feasible, sustainable andcan be a cost effective way for recognizingthe magnitude of problem, identifyingpatterns and broad determinants,prioritizing areas of interventions and inmeasuring the impact of interventions.Data on both fatal and non-fatal injuriesshould be combined to obtain total pictureof injury burden and impact, with aninitial focus on Road traffic injuries andsuicides.

2. Instead of building new systems, theexisting systems need to be recognized,limitations identified and, strengthenedwith additional inputs and resources.

3. At the national level, NCRB is entrustedwith the responsibility of data collection.The existing systems and methods shouldbe strengthened with a focus on collectingdata that will help formulate policies andprogrammes. The annual reports of NCRBshould stimulate action and furtherresearch.

4. A technical injury prevention wing shouldbe constituted in SCRB and CCRB alongwith lead injury prevention centre/community medicine department/technical agency to promote injurysurveillance. Help and support fromtechnical institutions (referral institutionsand community medicine departments ofmedical colleges) should be drawn at theinitial stages to achieve competency andsustainability in the programme.

5. Information on fatal events can beobtained from a combination of policerecords and corporation / districtauthorities. Review by the presentprogramme and previous review oninjuries reveal nearly 90% of RTI andsuicide deaths are captured inthe system, while there is significantunderreporting with regard to workplace

injuries, falls, burns, poisoning and others.Police records should be used for thispurpose with improvement in quality ofdata.a) Since information collected on

deaths varies from place to place, auniform pattern of informationgathering should be put in place andall deaths registered with policeshould be documented in a uniformway across the state and city and itsdifferent traffic/crime divisions.

b) Documenting information shouldmove beyond medico legal concernsand should be from injury preventionand control perspective. The focusshould be on identifying realcharacteristics, risk factors (e.g.,information on alcohol, use ofprotective equipments like helmetsand seatbelts), context and situationof injury occurrence, essentials oftrauma care. The format used inBengaluru is provided in Annexure 9for both RTIs and other injuries.

c) The amount of information to becollected on each injury deathshould be decided a priori. It isessential to note that surveillanceaims at collecting small quantity ofgood quality information that ishelpful for programmes and not forcriminal or legal proceedings. Thetype of data that can be collected isdiscussed in section 24

d) With data flowing from variouspolice stations, compilation,analysis and dissemination has tooccur at a central level for developingand implementing injury preventionand control programmes.

e) For this to happen effectively at thecity level, a designated leadorganization has to be identifiedwith development of similar teamsin each city/state district. Additionalresources in terms of manpower,computer facilities and otherresources should be provided alongwith capacity building of teams at


local level for data analysis,reporting and dissemination.

f) In parallel to this aspect, there isneed to strengthen vital deathregistration at city and state leveland in systems like SRS and MCCDto supplement police information.

6. For non-fatal injuries, collectinginformation from health systems is theobvious choice. Since this system is inrudimentary state under the healthinformation of India, a new approach andstrategy has to be developed. Agencies likeICMR, CBHI should take a lead role inthis process and should be developed in aphase wise manner with equal importanceto urban and rural areas.a) Selection and inclusion of institutions

should be in a phased manner withinclusion of medical collegehospitals - apex / tertiary carecentres – and private specialtyhospitals in urban areas (with morethan 100 beds) and small numberof major hospitals in district (withemergency care services,geographical coverage, goodhospital systems with medical recorddepartments / units). In rural areas,district hospitals and rural medicalcolleges are to be included in phase1 of the programme.

b) Type, amount, extent and quality ofinformation to be collected has beenreviewed earlier and a uniform“Emergency Trauma Care Record”should be in place.

c) In each of the hospital, the casualtyteams (doctors, nurses and medicalrecords staff) should be providedbrief training on importance,procedures, and usefulness ofsurveillance. Necessary trainingmanuals and operational guidelinesshould be developed for this purpose.Manual paper versions should bechanged to electronic and web basedsystems in future.

7. Information collected should be analyzedat local and state levels for effective

decision making purposes. Areas ofpotential and possible interventions shouldbe identified through systematic analysisand used for policies and programmes.

8. Brief reports on injuries (as Injury Monitor)from these centres should be disseminatedto all stakeholders (police, transport,health, judiciary, economics and all otherministries at state and city levels) forinitiating appropriate action. A variety ofother channels like fact sheets, alerts, webbased communication, stakeholdersmeeting should be used to disemminatecollected information. This should happenfor RTI and suicides to begin with andexpanded to other injuries over a periodof time.

9. The centres can also be developed overtime with technical and financial inputsto undertake in-depth investigation andanalysis of prioritized injuries based onsurveillance data and also provideinformation for industry, productmanufacturers, and different departmentsalong with additional tasks of qualitycontrol steps.

Since it is proposed to include RoadTraffic Injury Surveillance under Phase3 of Integrated Disease SurveillanceProgramme, Government of India, it isessential to keep in mind the issues raisedin earlier parts of this report. Theprogramme can begin in metros andselected districts of identified states in aphase wise manner. Larger pilot studiesare required for further strengthening ofthe proposed methodology withappropriate administrative directions,training and capacity development,establishing methods for disseminationof information, to be followed by actionby appropriate authorities. Informationfrom medical colleges, city crime recordsbureaus and City Corporation should bebrought under one roof and integratedfor both deaths and injuries. This requiresstrengthening existing mechanisms orsetting up of new agencies to developcoordinated mechanisms.

63NIMHANS

10. The programme can be expandedsystematically to cover larger numberof institutions in a phased manneracross the state. The breadth of datacollection systems should becomplemented with trauma registries,focussed risk factor studies andmultidisciplinary crash investigationsover a period of time.

2. Strengthening Injury Prevention andControl1. There is need for a central coordinating

and regulatory authority to be set up atnational level and corresponding bodiesat state/city level with specific goals ofreducing injury deaths, morbidity,disabilities and socio-economic losses.The body should be independent,managed by technical experts, withadequate financial and technicalresources and powers. This body shouldbe entrusted with responsibilities ofguiding, coordinating, integrating,supervising, developing guidelines andstandards, monitoring and evaluatingactivities with the primary objectives ofinjury prevention and control. Examplesalready exist like National DisasterManagement Authority, NationalPollution Control Board, National AidsControl Organisation and a recentlyproposed Directorate for Road safety(22). A similar body should beestablished for Injury prevention andControl and Road safety at all levels.

2. An Injury Prevention and control policywith focus on prioritized injuries likeRoad traffic injuries, suicides andoccupational injuries should bedeveloped. The policy should set forthguidelines and mechanisms forprogrammes and plan of action withattainable short term, medium term andlong term objectives.

3. An Implementable action plan of shortterm, medium term and long termactivities with specified (achievable andsustainable) activities should be

developed, specifying roles andresponsibilities of stake holders along withmode of implementation.

4. Capacity strengthening of professionals,policy makers and others should beundertaken for IPC. These programmesshould be interdisciplinary and multi-sectoral in nature leading to sharedresponsibilities.

5. A description of all known and proveninterventions for different injuries isbeyond the scope of this report. However,a list of proven and sustainable ones isgiven in Annexure 5 as an example. Theseshould be implemented in a uniform,visible manner immediately, as these areproven to work and will decrease burdenof injuries. It is crucial to note that evensome of the proven interventions have notbeen implemented in totality in India.Laws and regulations on paper andconcern for injuries alone are not enoughbut require action at ground level.

6. A safety wing should be established withinpolice department with trainedmanpower as they are primarily entrustedwith the responsibility of preventing trafficinjuries, managing violence, respondingto threats, investigating suicides, probeinto work related injuries, investigationand reporting of injuries. This team shouldhave trained and skilled manpower toundertake these activities.

7. All these activities should be driven bydata - evidence and research and not byadhoc decisions. Injury surveillance, crashinvestigations and analysis, productrelated research, research into relatedareas of human behaviour, and othersshould be part of this decision makingprocess. Surveillance is the first stepin this direction.

8. Health sector should take lead role insurveillance and research, advocacy,capacity development and monitoringchanges along with measuring the impactof interventions. The real change over aperiod of time should be in actual reductionin deaths, injuries and disabilities.


The way forward

The programme was initiated in January 2007, withanalysis, reporting, and dissemination continuingin 2008. The report, fact sheets and public healthalerts will be shared with stakeholders and opinionsought on continuation of activities. The data fromBMTC involved crashes has already been submittedto authorities and activities are strengthened for thecurrent year. The methodology needs to bestrengthened from 2009 onwards as a regular activity,with focus on building next phase of activities. RTIs

and Suicides should be the focus of surveillance andexpanded subsequently. In the coming months, thefirst Bengaluru Injury surveillance collaboratorsgroup will meet to outline further activities. The needfor evidence-based programmes, which would resultin a noticeable reduction in deaths andhospitalizations, has been acutely felt. It is hopedthis joint partnership programme with leadinginstitutions and organizations in the city ofBengaluru would pave the way to formulate effectiveinjury prevention policies and programmes in thecoming years.

65NIMHANS

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1. Gururaj G. Injuries in India: A National Perspective. In:

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• Is possible and feasible.

• Requires establishment of an independent safety agency with authority, status andresources to guide – develop – coordinate – implement – and evaluate safety aspects.

• Needs political commitment, policy maker’s cooperation, professional’sparticipation, and public involvement along with media contribution.

• Is an intersectoral activity with combined inputs and joint efforts from all partnerslike health, transport, police, social welfare, education, information, media andseveral others.

• Is dependent on development of institutional mechanisms for understandingproblems and priorities and for joint coordinated activities with independentmonitoring and supervision of research, policies and programmes.

• Should be developed and implemented on a public health approach of identifyingthe problem, delineating risk factors, implementing right interventions andevaluating them for cost effectiveness - sustainability - culture specificity andmeasured by actual reduction of deaths and injuries.

• Is an integrated activity as multiple interventions need to be combined andimplemented to get maximum benefits and greater success within each intervention.

• Is based on combined approaches of education, engineering, enforcement,emergency care and evaluation.

• Requires implementation of more and more passive countermeasures as theseare more beneficial given the limitations of human behaviour.

• Requires increased resources that need to be invested in prevention and controlat the primary level to see that society has safe people, safe vehicles, safeenvironments with adequate support and care for injured.

• Activities should be based on programmes developed on local, regional and nationalanalysis of data collected through well-designed information systems.

• Is not possible if unspecific, adhoc, knee jerk reactions and populist measures arepromoted.

Injury prevention and control

67NIMHANS

Annexure - 1The cases of Injured and Killed in India for various causes, 2007

Sl. No. Causes

A Unintentional injuriesI Air-Crash 0 1 0 1 0 11II Collapse of Structure (Total) 0 4 1 199 669 26231 House 0 0 0 71 239 10112 Building 0 2 1 11 146 3093 Dam 0 0 0 0 2 474 Bridge 0 0 0 0 17 1715 Others 0 2 0 117 265 1085III Drowning (Total) 5 96 76 1968 780 270641 Boat Capsize 0 0 0 35 84 9012 Other Cases 5 96 76 1933 696 26163IV Electrocution 2 40 18 351 452 8076V Explosion (Total) 0 1 0 16 1024 6691 Bomb Explosion 0 0 0 0 798 2702 Others (Boilers, Gas Cyld. etc.) 0 1 0 16 226 399VI Fall (Total) 13 161 13 516 1829 104971 From Height 13 145 13 472 743 86622 Into Pit/Manhole 0 16 0 44 1086 1835

VII Factory 0 2 0 33 474 12711 Machine Accidents 0 2 0 25 454 8362 Mines or Quarry Disaster 0 0 0 8 20 435

VIII Fire (Total) 18 371 30 1587 2793 207721 Fireworks/Crackers 0 0 0 0 224 4292 Short-Circuit 4 12 4 75 124 10173 Cooking Gas Cylinder/Stove Burst 14 101 14 292 249 38304 Other Fire Accidents 0 258 12 1220 2196 15496IX Fire-Arms 0 3 0 28 957 2046X Killed by Animals 0 2 0 61 194 1007

XII Poisoning (Total) 7 140 12 1619 4987 254471 Food/Accidental intake of Insect. etc. 0 14 2 68 1657 84252 Spurious/Poisonous liquor 0 8 0 142 165 12513 Leakage of gases etc. 0 1 0 20 14 1984 Snake Bite/Animal Bite 1 7 2 637 1952 80265 Other 6 110 8 752 1199 7547

XIII Stampede 0 15 0 24 50 75XIV Traffic Accidents (Total) 6591 961 61438 10009 470639 1405601 Road Accidents 6591 961 61413 8762 465352 1145902 Rail-Road Accidents 0 0 25 15 177 23693 Other Railway Accidents 0 0 0 1232 5110 23601

XV Other Causes 8 580 16 1058 3422 35992XVI Causes Not Known 0 547 111 1920 539 16907

Total of unintentional injuries 6644 2924 61715 19390 488809 293017B Intentional injuries

XVII Intentional Injury Deaths1 Homicides 0 253 0 1593 0 359622 Dowry deaths 0 54 0 251 0 80933 Suicides 0 2429 0 12304 0 122637

XVIII Other Intentional Injuries1 Attempt to commit murder 264 0 1251 0 27401 02 Rape 62 0 436 0 20737 03 Kidnapping and abduction 119 0 680 0 27561 04 Molestation 187 0 1828 0 38734 05 Sexual harassment 2 0 28 0 10950 06 Cruelty by husband and relatives 290 0 2507 0 75930 07 Other IPC crimes 10969 0 60853 0 829206 08 Others 15156 0 53023 0 959154 0

Total of intentional injuries 27049 2736 120606 14148 1989673 166692Grand Total (A+B) 33693 5660 182321 33538 2478482 459709Ratio of Killed:Injured 1:6 1:5 1:6

Bengaluru

Injured Killed

Karnataka

Injured Killed

India

Injured Killed

Source: NCRB report 2007


Annexure - 2aPolice Information System

Annexure - 2b Flow of information from traffic police stations to City Crime Records Bureau

AccidentSpot

GeneralPolice Station

Hospital

Telephone/Wireless

Traffic PoliceStation

90%

10%

Witness/100

Traffic police station

Visits accident spot Visits reporting hospital

Complaint + Preliminary enquiry

Complaint registered Complaints not registered

FIR (3 copies) +Investigation mahajar

Court ACP (for information)

Weekly & monthlyconsolidated reportDCP Traffic police

State Crime Record Bureau

3 - Commissionorate unit27 - District unit1 - Railway unit31 - Units

National Crime Record Bureau

69NIMHANS

Annexure - 3Injury related deaths in Bengaluru

2006 2007(10% rise)

2007 + 10%underreporting

B'lorePolice

RTIs 919 1011 1112 943Other road 72 80 88Falls 90 99 109 209Drowning 163 180 198 62Poisoning 558 614 675 296Burns 315 346 380 360Hanging 749 824 906 604Fall of objects 25 27 30Fall from height 49 54 59Homicides 28Mechanical injuries 36Causes not known 222 244 268Others 761 837 921 778Other accidental causes 321 353 388Total 4244 4669 5134 3316

Accidental & Suicidal deaths in Karnataka & Bengaluru

AccidentalRTIs 7939 7939 919 919Other road 1200 1200 72 72Falls 445 445 90 90Drowning 1756 1133 2889 74 89 163Poisoning 1732 4331 6063 169 389 558Fire (burns) 1122 692 1814 190 125 315Hanging 3548 3548 749 749Fall of objects 117 117 25 25Fall from height 118 118 49 49Below moving vehicle 335 335 1 1Homicides 0 0Mechanical injuries 37 37 0Causes not known 2139 2139 222 222Others 1489 2073 3562 512 604 1116Other accidental causes 2305 2305 321Total 20281 12230 32511 2594 2006 4279

Suicidal TotalKarnataka

Accidental Suicidal TotalBengaluru


Annexure - 4Details of the training programmes held for Police personnel

Date Training ProgrammeNo. Of

Participants

12th April 2007 Writers of Traffic Police stations NIMHANS 26

26th June 2007 Writers of Traffic Police stations NIMHANS 37

11th July 2007 Writers of Law and Order Police stations NIMHANS 120

11th September 2007 Writers of Law and Order Police stations NIMHANS 140

24th September 2007 Writers of Traffic Police stations NIMHANS 42

20th November 2007 Writers of Traffic Police stations NIMHANS 38

22nd November 2007 Writers of Law and Order Police stations NIMHANS 118

Place oftraining

Details of the training programmes held for personnel in partner hospitals

Date Training Programme No. ofParticipants

1 3rd March 2007 Training programme for Nodal Officers(All partner institutions) NIMHANS 40

2 5th March 2007 Training programme for doctors and staff Jayanagar General Hospital 20

3 16th March 2007 Training programme for doctors and staff Bowring and Lady CurzonHospital 60

4 20th March 2007 Training programme for doctors and staff(All partner institutions) NIMHANS 74

5 28th March 2007 Training programme for doctors and staff Siddhartha Medical College,Tumkur 16

6 4th April 2007 Orientation on Injury prevention Sanjay Gandhi AccidentHospital and Research Centre 48

7 12th April 2007 Training programme for writers of variouspolice stations NIMHANS 26

8 13th April 2007 Training programme for Doctors and staff District Hospital, Tumkur 16

9 24th April 2007 Training programme for Nurses District Hospital, Tumkur 22

10 24th April 2007 Training programme for Nurses District Hospital, Tumkur 18

11 24th April 2007 Training programme for Doctors and CMOs District Hospital, Tumkur 14

12 7th July 2007 Training programme for Nurses NIMHANS 3

13 21st July 2007 Training programme for CMOs and staff nursesin M S Ramaiah hospital M S Ramaiah hospital 20

14 7th august 2007 Training programme for staff and students ofmedicine department in Victoria hospital Victoria hospital 25

15 16th August 2007 Training programme for staff and students ofOrthopedics, general surgery departments inVictoria hospital Victoria hospital 70

16 18thaugust 2007 Training programmes for MOs and staff pf CHCand PHC in Tumkur Tumkur 8

17 3rd September 2007 Training programmes for MOs and staff nursesof DG hospital D G Hospital 10

18 22nd September 2007 Training programmes for doctors, nurses,medical record officers in KIMS hospital KIMS hospital 32

Place oftraining

No.

71NIMHANS

Annexure - 5List of interventions

Selected Violence and Injury Prevention Interventions, by Cause, Effectiveness and HealthSector Role

Intervention Effectiveness

Unintentional injuries

Road traffic injuries Increasing the legal age of motorcyclists and drivers from16 to 18 years Effective

Introducing and enforcing laws on blood alcohol concentrationlimits Effective

Graduated driver licensing systems Effective

Traffic-calming measures Effective

Daytime running lights on motorcycles Effective

Introducing and enforcing seat-belt laws Effective

Child-passenger restraints Effective

Introducing and enforcing motorcycle helmet laws Effective

Speed-introduction measures Effective

Fires Electrification of housing Promising

Banning the manufacture and sale of fireworks Promising

Reducing storage of flammable substances in households Promising

Smoke alarms and detectors Promising

Improving building standards Promising

Modifying products - for example, kerosene stoves, cookingvessels and candle holders Promising

Promoting use of cold water for first aid of burns Effective

Poisoning Child-resistant containers Effective

Poison-control centres Effective

Better methods of storage, relating both to the nature of storagevessels and where they are placed Effective

The use of warning labels Promising

Restricting availability of most hazardous pesticides Effective

Drowning Use of personal floatation devices Effective

Introduction and enforcing laws on pool fencing Effective

Teaching how to swim Effective

Covering bodies of water, such as wells Effective

Safety standards for swimming pools Promising

Clear and simple signage Promising

Properly trained and equipped lifeguards Promising

Ensuring availability of weather reports to fishermen andothers working on rivers and seas Promising

Falls Safety mechanisms on windows, such as window bars inhigh-rise buildings Effective

Stair gates Effective

Impact-resistant surfacing material on playgrounds Effective

Safety standards for playground equipment Promising

Muscle-strengthening exercises and balance training forolder adults Promising

Checking and if necessary modifying potential hazards in thehome, where there are individuals at high risk Promising

Educational programmes encouraging safety devices toprevent falls Promising

Encouragement/ evolution of safer working techniques andharnesses for construction workers and window cleaners whowork at heights and tree climbers Promising


Intentional and unintentional injuries

Reducing the availability of alcohol during high-risk periods Promising

Reducing economic inequalities Promising

Stand-alone education programmes focusing only on changingrisky behaviors Ineffective

Strengthening social security systems Unclear

Intentional injuries

Suicides Early recognition and management of individuals with suicidal Promisingideations and behaviour

Improved care for those with history of attempted suicides, Promisingviolent behaviors and alcohol problems

Training of health care personnel Promising

Expansion of mental health services (including counseling) Promising

Life skills programmes in all institutions Promising

Limiting the availability of lethal products (manufacture and sale) Promising

Establishing social and crisis support mechanisms Promising

Parental supervision and guidance for at risk children. Promising

Better media reporting practices Promising

Improving trauma care practices Promising

Child maltreatment Home visitation programmes Effective

Training programmes for parents Effective

Improving the quality of and access to prenatal and postnatal carePromising

Preventing unintended pregnancies Promising

Training health-care providers to detect child maltreatment Unclear

Youth violence Life skills training programmes Effective

Preschool enrichment, to strengthen bonds to school, raiseachievement and improve self-esteem Effective

Family therapy for children and adolescents at high risk Effective

Educational incentives for at-risk high-school students Effective

Home-school partnership programmes promoting theinvolvement of parents Promising

Peer mediation and counseling Ineffective

Education on the dangers of drug use Ineffective

Intimate partner & sexual violence School-based programmes to prevent violence indating relationships, Effective

Training health care providers to detect intimate partner violenceand to refer cases Unclear

Teaching women survival tactics Unclear

Promoting gender and social equality both through social andeducational policies Promising

Elder abuse Building social networks of older people Promising

Training older people to serve as visitors and companions toindividuals at high risk of victimization Promising

Developing policies an'd programmes to improve theorganizational, social and physical environment of residentialinstitutions for the elderly Promising

Self-inflicted violence Restricting access to the means of self-inflicting violence - suchas to pesticides, medications and unprotected heights Effective

Preventing and treating depression, alcohol and substance abuse Effective

School-based interventions focusing on crisis management, theenhancement of self-esteem, and coping skills Promising

Phone in help lines or hotlines for crisis management Effective

All types of violence Reducing demand for and the availability of firearms Promising

Sustained, multimedia prevention campaigns aimed at changingcultural norms Promising

Intervention Effectiveness

Source: WHO 2006; Mohan D, 2004; Gururaj G, NIMHANS Series 2003

73NIMHANS

Annexure - 6Harrison's Story

(Reproduced with permission from - Injury Issues Monitor, No. 38, January 2007.)

The Use of Emergency Department InjurySurveillance Data to Effect Change in theCommunity

I’d like to start with a brief history of QISU and anexplanation of the data we hold. The QueenslandInjury Surveillance Unit collects data on injury frompatients who present to an emergency departmentfor treatment of that injury.

QISU is a small unit housed in the Mater Children’sHospital in Brisbane. We have two clerks, a part-time statistician/data analyst, a media manager,myself as manager and 3 emergency medicinespecialists. We currently collect data from 16hospitals around Queensland. These hospitals includeurban, regional and rural and remote campuses—the information we collect paints a very good pictureof injury in Queensland.

Our data is Level 2 NDS-1S, which means we collectspecifics about products and activities (down to rugbyunion for example instead of just ‘sport’).

At the moment we have eight hospitals that collectinformation from a paper-based system where theinformation is sent through to us in Brisbane andtrained coders code and enter that data. In the biggerhospitals that have EDIS software, the triage nursecollects and enters the information when the patientis being assessed. This data is then sent to QISU tobe cleaned and then analysed.

Now I’d like to tell you a bit of a story. The photoson the next pages are of a wee boy called Harrison.Al the time this all started he was a typical busy,exuberant toddler and the youngest of five children.One day, just before Christmas in 2004 Lisa, Harrison’smum, went to put a video on for his five year oldsister. In the couple of minutes that it took to put thevideo in and turn on the television, she heardHarrison screech from the kitchen. When she racedback to the kitchen she was horrified to see Harrison

sitting on the floor screaming with blood comingfrom his mouth. She rang the ambulance, grabbedthe container of dishwasher powder he had taken aswallow from and finally, they arrived at the MaterHospital Emergency Department. Dr Barker, anemergency department (ED) specialist, who alsoworks with QISU, was waiting for Harrison. Shestabilised him and sent him oft to theatre. At thatpoint there was doubt about whether or not Harrisonwould even survive. The dishwasher powder he’dingested was obviously highly caustic and, while itwas burning his oesophagus, it was also causingswelling to his airways and making it difficult forhim to breathe.

Dr Barker arrived in the QISU unit after havingtransferred Harrison to theatre and explained whatshe had just seen. We were particularly concernedthat it was so easy for Harrison to gain access tosuch a caustic substance.

These issues were identified:• the 2-click mechanism of the child resistant

closure;• pH of dishwashing powder; and the• scheduling of dishwashing powder compared

to dishwasher gel or liquid.

The first thing we did was look at the issuessurrounding Harrison’s poisoning.

The bottle itself was a concern. The cap looked likea child resistant closure. This instilled confidence in


Lisa that her children couldn’t access the contents ofthe bottle. What she didn’t realise was that the lidrequired 2 clicks to engage the child resistantmechanism. When she put the bottle in the cupboardshe thought it was closed safely, but the child resistantfeature of the bottle cap hadn’t been engaged. Therewas no warning or instruction anywhere on the bottleto suggest that there were varying levels of closure.

The pH of the powder in the bottle was 13.4! This ishighly caustic. The pH of liquid Drano is more like12— we all accept that it is dangerous and treat itwith extreme caution. The dishwashing powderHarrison accessed was 13.4. On a logarithmic scalethis is a huge difference.

Next, we did a data search to find out if Harrison’swas a one-off case or whether this sort of poisoningwas common. We learned that 4% of all non-medicinal ingestions were from dishwasherdetergents, and many of these were severe. Triagenurses assign a category from 5 to 1 to indicate howquickly a person requires treat-ment when they arrivein the ED. Anything less than 3 means a person needstreatment in less than half an hour. 1 indicates thatthe person requires immediate treatment or death islikely. In our database there were 19 children under5 who arrived in the ED having been poisoned witha non-medicinal substance who were categorized asa 1. Three of these children had ingested dishwasherpowder.

Now that we knew that dishwasher detergentingestions were a real problem for Queenslandtoddlers, we were able to move on and see what wecould do to change this.

I rang the manufacturer and spoke to their productsafety officer. He was horrified to hear aboutHarrison’s injuries, but was also very careful toexplain that the product complied with all legalrequirements. When I gave him more details aboutthe number of toddlers in our database who hadhad similar experiences to Harrison’s, he agreed thatsomething had to be done and promised to get backto me with some strategies. (Now keep in mind,they’ve not done anything technically wrong here...they were within the law in their packaging andlabelling and the closures were far from unique tothis particular brand.)

Within a couple of months there were warning labelson all the packages saying that it required 2 clicks toclose the caps on the powder containers, and then theentire bottle was redesigned to incorporate a flow limiteron the bottle and a 1-click mechanism on the cap.

This meant that one, product was safer, but therewere still shelves full of dishwasher powder in thesupermarket, many of which were no more than acardboard box with a spout.

The next step was to draw in some partners whounderstood the issues and had a vested interest inseeing a reduction in ingestions of this kind. Aworking parly was formed and included membersof Kidssafe Queensland, the Department of FairTrading’s Product Safety Unit, Queensland Health’sEnvironment and Poisons Unit and the QueenslandPoisons Information centre. The beauty of this groupwas that each of us were keen to see the lawssurrounding dishwasher powder changed, but weeach came from different organisations with varyingexpertise and perspectives.

Queensland Health had people who sat on committeeswithin the Therapeutic Goods Administration (TGA)who could advise us about which procedures weshould follow in trying to effect change.

Staff of the Poisons Information Centre was able tosupplement our data with their own. The Departmentof Fair Trading could lobby from the perspective ofits requirement to provide safe products to consumers.Kid safe has a key role to play in lobbying for injuryreduction in children and in the education of parentsand caregivers about the potential for injury withdishwashing powders.

Poisons are scheduled by the TGA. Dishwasherdetergents were included in a Schedule 5 if they hada pH of greater than 11.5. This meant they had tohave a child-resistant closure and very specificwarnings on the labels. BUT, somewhere along theline, it was decided that children were unlikely todrink powders because they were so unpalatable, sopowders were exempted from this schedule.

The working group decided to put in a formalsubmission to the TGA via the National Drugs andPoisons Scheduling Committee (NDPSC) asking to

75NIMHANS

have the powders re-scheduled and a limit placedon the availability of such caustic products for thedomestic market.

We also decided to approach Standards Australia tohave the standard for child resistant closuresreviewed so that this ‘2-click’ mechanism couldn’tbe included as a compliant closure, but also to ensurethat if something appeared to be a child resistantclosure, it had to function as such. The aim was toremove any ambiguity for a consumer as to the safetyof any container available in the marketplace.

Rather than make these submissions as one workinggroup, we each did so from our own organisation,using our own perspective to support the argumentfor change.

We implemented a public awareness campaign. Weembarked on this campaign by alerting the publicto the problem. Lisa was very keen to ensure thatthis never happened to another family so was happyto appear and speak about what had happened toher son Harrison, and she was very passionate andeloquent. We also engaged professional associationsto raise awareness through their networks andnewsletters.

At this point Lisa was able to say that, while Harrisonhad been discharged from the Intensive Care Unitand was finally home after 7 weeks in hospital, hewas having to go into hospital every fortnight tohave his oesophagus dilated so he could swallowhis own saliva. He had to be fed from a tube directlyinto his stomach because of the scar tissue, and thefact that his epiglottis had been burned away meantthat he would run the risk of aspiration if he atenormally. As you can imagine, this reality hit hometo lots of people! Because the media outlets had a‘face’ to attach to the story, it was picked up locally,

and on a state and national level (Choice and theToday Show).

So what happened?

The TGA accepted the statistics and submissions and,as of 1 September, all powders with a pH of > 11.5will have to be packaged in the same way as liquidsand gels with warning labels and child resistantclosures. If any dishwashing detergent has a pH of >12.5, it is no longer available for the domestic market.This is great, because manufacturers are movingtoward using oxygen bleaches and enzymes, so allthe products will be safer. Standards Australia havebeen less ‘easy’. Initially they couldn’t reconvene theHE-016 committee because there was no projectofficer, so a new project officer was appointed.Correspondence was sent to members of the committeeand now the project officer has left and we’re waitingfor a replacement to be appointed to further the issue.

Harrison turned three in June. He’s a gorgeous boywith mischief in his eyes. He and his mother callinto the Unit regularly when he has to come to theMater Hospital for treatment, and I always demandand get a hug hello and a kiss goodbye. He’s stillhaving fortnightly dilations and is fed through a tube.

Doctors are optimistic that eventually he won’t haveto be 100% tube fed, but it’s not a given. The goodnews is that, with the changes we’ve seen, this soilof severe damage from dishwasher detergents isunlikely to happen to any other toddlers.

In summary, change was brought about because ofclinical concern that could be supported with soundevidence. With this sound evidence base we wereable to form partnerships and, through thesepartnerships, make a tangible difference for thecommunity.

Debbie Scott([email protected])


Annexure - 7

Data Capture format for injury deaths (Police)

1. Police Station name:

2. FIR No./Cr. No.: 3. Date of registration (DD/MM/YY):

4. Time of registration (HH:MM): 5. Date of Occurrence of Injury:

6. Time of Occurrence of Injury: am / pm 7. Date of death (DD/MM/YY):

8. Time of death (HH:MM): am / pm 9. Name of deceased:

10. Age (years): 11. Sex (M/F):

12. Place of residence: 1. Urban Bengaluru 2. Rural Bengaluru 3. Others, specify _________________

13. Address:

14. * Education (in completed years):

15. * Occupation: 1. Unemployed 3. Student 5. Skilled 7. Business 9. Others2. Retired 4. Homemaker 6. Unskilled 8. Professional 10. Unknown

16. Cause of death:1. Road accident 4. Poisoning 7. Drowning 10. Mechanical injury 13. Others, specify _________2. Assault 5. Burns 8. Self inflicted cuts/stabs 11. Sports injury3. Fall 6. Hanging 9. Fall of object 12. Disaster, specify _________

17. Place of Injury Occurrence: 1. Road 6. Residential area 11. Industry2. Home 7. Construction site 12. Unknown3. Workplace 8. Railway 13. Others, specify __________4. School/college 9. Playground/play site5. Public place 10. Agricultural field

18. Object/Product causing injury:

19. Activity at time of Injury:1. Traveling in vehicle 7. Crossing2. Walking 8. Playing3. Standing on road 9. Sleeping4. Working 10. Unspecified5. Going/Coming from school 11. Others, specify ______________6. Doing household work

20. Intent: 1. Unintentional (accidental) 3. Intentional (assault/violence)2. Suicidal 4. Unknown

21. Alcohol consumption by: 1. Injured 3. Both 5. Unknown2. Counterpart 4. Not applicable 6. No

A. ROAD TRAFFIC INJURY:

22. Road User category of the deceased:1. Pedestrian 6. Three-wheeler occupant 11. Other 4-wheeler driver (maxi cab, tempo, etc)2. Pedal cyclist 7. Car driver 12. Other 4-weeler occupant3. Two-wheeler rider 8. Car occupant 13. Others, specify _______________4. Two-wheeler pillion 9. Bus / truck driver 14. Unknown5. Three-wheeler driver 10. Bus / truck occupant

23. Crash Type: 1. Hit & Run 5. Hit a fixed object 9. Fall from moving vehicle2. Head on collision 6. Run off the road 10. Pedestrian run-over3. Hit from the back 7. Overturn 11. Others, specify ____________4. Hit from the side 8. Skid & fall

24. Place of crash: 1. City roads 3. State Highway2. National Highway 4. Rural Roads

25. Crash location name:

77NIMHANS

26. Crash location details:i. T-junction iv. Cross road vii. Sudden narrowing x. Others, specify___________ii. Y-junction v. Round about viii. Curvesiii. Straight road vi. Bridge/culvert ix. Road hump/rumble strips

27. Lane type: i. Single lane with one way iii. Double separatedii. Single lane with two ways iv. More than 3 lanes

28. Deceased Hit by:

29. Position of the deceased (for car, bus, lorry, HCVs): 1. Front passenger seat 3. Open space2. Back passenger seat 4. Passenger seat area

30. USE OF HELMET (if Two-wheeler rider/pillion): 1. Yes 2. No 3. Not known

31. USE OF SEAT BELT (if Car driver/occupant): 1. Yes 2. No 3. Not known

B. ASSAULT:

32. Nature of assault/violence: 1. Individual 2. Family 3. Group 4. Communal

33. Perpetrator (relationship): 34. Major cause:

C. SUICIDE:

35. Situation of committing suicide: 1. Alone at home 2. In presence of others 3. Outside house

36. Suicide Method: 1. Fall from height, goto D 4. Drowning, goto G 7. Others, specify ___________2. Poisoning, goto E 5. Self inflicted cut/stab, goto H3. Self-immolation, goto F 6. Hanging

39. Name of the product:

D. FALL:

40. Height of Fall:

41. Nature of landing surface: 1. Soft 2. Hard3. Rock 4. Not known

E. POISONING:

41. Name of the product:

42. Product availability: 1. Available at home 2. Brought from outside

F. BURNS:

43. Extent of burns (in %):

44. Product causing burn: 1. Kerosene/Petrol 3. Hot water 5. Cylinder burst 7. Others, specify_____2. Hot Oil 4. Electricity 6. Stove burst

G. DROWNING:

45. Place of drowning: 1. Bath tub 3. Well 5. Canal 4. Sea2. Swimming pool 4. Lake/pond 6. River

H. SELF INFLICTED CUT / STAB INJURY:

46. Product used for cut/stab: 1. Blade 2. Knife 3. Glass 4. Scissors 5. Wire

I. PREHOSPITAL CARE:

47. Any FIRST-AID given before death: 1. Yes 2. No 3. Not known

* If Q47 is yesWHERE was First Aid given: 1. At injury site 3. Nearby Pvt. Hospital / Nursing home 5. Others, specify________

2. Nearby Clinic 4. Nearby Govt. hospital

WHO gave first-aid: 1. Health worker 3. Nurse 5. Public 7. Others, specify ___________2. Doctor 4. Police 6. Self medication

48. NUMBER of hospital/s visited before registering death:

49. Place of death:1. At injury site 3. In the hospital, name; ________________________________2. During transport to hospital 4. After discharge

* Optional items


Annexure - 8

EMERGENCY TRAUMA CARE RECORD

1. Name of the hospital:

2. Hospital Id. No.:

3. Police Id. No.:

4. Date of registration (DD/MM/YY):

5. Time of registration (HH:MM): am / pm

6. Information provided by: 1. Family member 2. Known person 3. Police 4. Not known 5. Self

7. Date of injury (DD/MM/YY):

8. Time of injury (HH:MM): am / pm

9. Place of injury: 1. Within Bengaluru 2. Outside Bengaluru

10. Name of injured:

11. * Education (in completed years):

12. * Occupation: 1. Unemployed 3. Student 5. Skilled 7. Business 9. Others2. Retired 4. Homemaker 6. Unskilled 8. Professional 10. Unknown

13. How was the person Injured:

1. Road accident 5. Burns 9. Sports 13. Disaster, specify _____________2. Fall 6. Poisoning 10. Animal bites 14. Others, specify_______________3. Assault 7. Drowning 11. Fall of object4. Self inflicted cuts/stabs 8. Hanging 12. Mechanical injury

14. Location of injury: 1. Road 6. Residential area 11. Industry2. Home 7. Construction site 12. Unknown3. Workplace 8. Railway 13. Others, specify_______________4. School/college 9. Playground/play site5. Public place 10. Agricultural field

15. Object/Product causing injury:

16. Activity at time of Injury:1. Traveling in vehicle 4. Working 7. Playing 10. Others, specify __________2. Walking 5. Going/Coming from school 8. Sleeping3. Standing on road 6. Doing household work 9. Unspecified

17. Intent: 1. Unintentional 2. Suicidal 3. Intentional (assault) 4. Unknown

18. Alcohol consumption by: 1. Injured 3. Both 5. Unknown2. Counterpart 4. Not applicable 6. No

19. Place of occurrence: 1. City roads 2. National highway 3. State highway 4. Rural roads

20. Road User category of the injured:1. Pedestrian 6. Three-wheeler occupant 11. Other 4-wheeler driver (maxi cab, tempo, etc)2. Pedal cyclist 7. Car driver 12. Other 4-weeler occupant3. Two-wheeler rider 8. Car occupant 13. Others, specify__________________4. Two-wheeler pillion 9. Bus / truck driver 14. Unknown5. Three-wheeler driver 10. Bus / truck occupant

21. Crash Type: 1. Hit & Run 5. Hit a fixed object 9. Fall from moving vehicle2. Head on collision 6. Run off the road 10. Pedestrian run-over3. Hit from the back 7. Overturn 11. Others, specify _______________4. Hit from the side 8. Skid & fall

22. Injured person Hit by:

79NIMHANS

23. USE OF HELMET (if Two-wheeler rider/pillion): 1. Yes 2. No 3. Not known

24. USE OF SEAT BELT (if Car driver/occupant): 1. Yes 2. No 3. Not known

25. FIRST-AID given before reaching this hospital: 1. Yes 2. No 3. Not known

* If Q25 is Yes, WHERE was First Aid given:1. At injury site 4. Medical college2. Nearby Govt. hospital 5. Private Clinic3. Nearby Pvt. Hospital / Nursing home 6. Police

7. Others, specify___________

* If Q25 is Yes, WHO gave the first aid: 1. Health worker 4. Police 7. Others, specify ___________2. Doctor 5. Public3. Nurse 6. Self medication

26. Source of REFERRAL: 1. Directly on their own 3. Govt. Hospital2. Clinic 4. Pvt. Hospital / Nursing Home

27. NUMBER of hospital/s visited before reaching this hospital:

28. MODE of transportation:1. Ambulance 4. Autorikshaw (3-wheeler) 7. Others, specify___________2. Private vehicle (personal car/taxi) 5. Police vehicle3. Public transport (bus/truck/train) 6. Walking

29. STATUS of the injured at the time of entry: 1. Brought dead 2. Unconscious 3. Conscious

30. Type of injury: 1. Mild 2. Moderate 3. Severe

31. PART OF THE BODY injured (tick the appropriate part/s of the body):Head Face Neck Chest Abdomen Spine & vert. column Upper limbs Lower limbs GroinUpper back

32. * NATURE OF INJURY (tick the appropriate nature of injury):Abrasion Brain injury Cut or open woundLaceration Fracture Burns (indicate %)Contusion Injury to internal organ Blunt injurySprain Haematoma Crush injury

33. Treatment: 1. Treated in emergency room & sent home2. Admitted for medical / surgical care3. Treated in emergency room & referred to another hospital

34. Outcome (at the end of casualty stay): 1. Improved 2. Not improved 3. Referred to ________ 4. Dead

35. If referred, place of referral:

EXAMINATION / FINDINGS* (all injuries should be documented in total) (OPTIONAL)

TREATMENT GIVEN*

PATIENT IDENTIFICATION*

SIGNATURE

* Optional items

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

o

McMahon K, Gururaj G, Stevenson M. Chapter 2 : Road traffic Injuries. In : Peden M, Oyebgite K, Ozanne – Smith J, et al, eds. World Report on Child Injury Prevention. Geneva, World Health organization and UNICEF, 2008.

Gururaj G . Road traffic deaths, injuries and disabilities in India: Current scenario. National Medical Journal of India Vol 21, No, 2008, 14-19.

Norton R, Hyder A & Gururaj G: Injuries - An international Perspective. In: International Public Health: Disease, Program, Systems and Policies. (eds) Merson MH, Black RE and Mills AG. Second Edition. Jones and Bartlett Publishers, Boston, 2006.

Gururaj G: Road Traffic Injury Prevention in India, NIMHANS Publication No. 56, Bangalore 2006.

Gururaj G: Head injuries and Helmets: Helmet Legislation and Enforcement in Karnataka and India, NIMHANS Publication No. 62, Bangalore, India, 2006.

Gururaj G, Girish N, Benegal V: Alcohol use and abuse in South East Asia: gaining less or losing more, South East Asia Regional Office, World Health Organisation, New Delhi, 2006.

Gururaj G, Girish N, Benegal V: Burden and Socio-economic impact of alcohol: The Bangalore study, South East Asia Regional Office, World Health Organisation, New Delhi, 2006.

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Gururaj G. Injuries in India: A national perspective. In: Burden of Disease in India; Equitable development - Healthy future. National Commission on Macroeconomics and Health. Ministry of health and family welfare, Government of India. New Delhi, 2005, 325 - 350.

Gururaj G: Road safety in India: Role of community health professionals and institutions. Proceedings of the 31st Annual Conference of Indian association of preventive and social medicine, Chandigarh, Jan 2005.

Gururaj G: Final report of the project “Profile and Characteristics of violence prevention programmes in Bangalore city”, World Health Organization, Geneva, October 2005.

Gururaj G. Alcohol and road traffic injuries in South Asia: Challenges for prevention. Journal of College of Physicians and Surgeons of Pakistan, 14(2), 2004, 713-718.

Gururaj G, Das BS, Channabasavanna SM. The effect of Alcohol on Incidence, Severity and Outcome from Traumatic Brain Injury. Journal of Indian Medical Association, 102 (03), March 2004, 157-63.

Gururaj G, Isaac MK, Subbakrishna DK and Ranjani R. Case Control Study of completed suicides in Bangalore, India. Injury Control and Safety Promotion, 11(3), 2004, 193-200.

Gururaj G. Developing Safe Communities in South East Asian Countries: Challenges and Opportunities. In: Proceedings of the Second Asian Conference on Safe Communities, Dhaka, 2004.

Aeron Thomas A, Jacobs GD, Sexton B, Gururaj G and Rahman F. The involvement and impact of road crashes on the poor - India and Bangladesh case studies. Transport Research Laboratory, PR/INT/275/2004.

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Gururaj G et al. Injuries in South East Asia: Cause for concern and call for action. Report submitted to Division of Injury and Disability Prevention, Word Health Organization, South East Asia Regional Office, 2004.

Gururaj G, Isaac MK. Suicide Prevention: Information for Women and Child Development Organizations; NIMHANS/ EPI/SUI.Prevn/Women & Child.2003.

Gururaj G, Isaac MK. Suicide Prevention: Information forNon-Governmenta l Organiza t ions ; NIMHANS/EPI/ SUI.Prevn/NGO.2003.

Gururaj G, Isaac MK. Suicide Prevention: Information for Educational Inst itutions; NIMHANS/EPI/SUI.Prevn/ Education.2003.

Gururaj G, Isaac MK. Suicide Prevention: Information for Police Personnel; NIMHANS/EPI/SUI.Prevn/Police.2003.

Gururaj G, Isaac MK. Suicide Prevention: Information for Family Physicans; NIMHANS/EPI/SUI.Prevn/Family.2003.

Gururaj G, Isaac MK. Suicide Prevention: Information for Health Professionals; NIMHANS/EPI/SUI.Prevn/Health.2003.

Gururaj G, Isaac MK. Suicide Prevention: Information for Media Professionals; NIMHANS/EPI/SUI.Prevn/Media.2003.

Davis A, Quinbly A, Odero W, Gururaj G and Hijar M. Improving Road Safety by reducing impaired driving in developing countries: A scoping study (Unpublished document PR/INT/724/03).

Gururaj G. Epidemiology of Traumatic Brain Injuries: Indian Scenario, Neurological Research, 24, 1-5, 2002

Gururaj G, Ahsan N, Isaac MK, Lateif MA, Abeyasinghe R and Tantipiwatanaskul P. Suicide Prevention- Emerging from darkness. World Health Organization, South East Asian Regional Office, 2001.

World Health Organization. Injury surveillance Guidelines (eds) Holder Y, Peden M, Krug E, Lund J , Gururaj G and Kobusingye O. 2001.

Gururaj G and Isaac MK: Epidemiology of Suicides in Bangalore. NIMHANS Publication 44, 2001.

Gururaj G and Isaac MK: Suicides - Beyond Numbers. NIMHANS Publication 43, 2001.

Gururaj G, Das BS, Kaliaperumal VG - The status and impact of prehospital care on outcome and survival of head injured persons in Bangalore. Journal of Academy of Hosp. Adm., 11(1), 1999, 7-8.

Gururaj G, Sateesh VL - Assessment of facilities at casusalty and emergency services in hospitals at Bangalore. Journal of Academy of Hosp. Adm., 11(1), 1999, 9-10.

Gururaj G, Peek Asa C, Kraus JF: Epidemiologic features of facial injuries among motorcyclists. Annals of Emergency Medicine 32: 4, 1998, 425-430.

Gururaj G: Need and scope of rehabilitation services for traumatic brain injury survivors. ACTIONAID Disability News, 9(1), Jan, 1998, 27-31.

Select resource materials available from Department of Epidemiology, WHO Collaboratingcentre for Injury Prevention and safety Promotion, NIMHANS.

(more details available from www.nimhans.kar.nic.in/epidemiology/epidem.who.htm)

Select resource materials available from Department of Epidemiology, WHO Collaboratingcentre for Injury Prevention and safety Promotion, NIMHANS.

(more details available from www.nimhans.kar.nic.in/epidemiology/epidem.who.htm)

World Health Organization,New Delhi

Ministry of Health &Family Welfare, New Delhi

Indian Council of Medical Research, New Delhi

In Collaboration with

Bangalore CityTraffic Police

BANGALORE

ESTD 1980

SagarHospitals

BengaluruBengaluru

Surveillance ProgrammeSurveillance ProgrammeInjury / Road Traffic InjuryInjury / Road Traffic Injury

bengaluru injury / road traffic injury surveillance programme

Documents