Injury Epidemiology

An epidemic of neglect?

My perspective (and COI?)

• Published first injury paper in 1970 (child seat restraint use)

• subsequently published over 100 peer reviewed papers on injury prevention

• all studies employ epidemiologic methods • Founding editor of “Injury Prevention” (BMJ

Specialty journal) • Co- Founder of Canadian Hospitals Injury

Reporting and Prevention Program (surveillance)

Objectives

• To help you understand the current status of injury epidemiology (IE)

• To explore why it’s so neglected (especially in Canada)

• To encourage you to become involved in this field

Some hypotheses

1. Not old enough 2. Not big enough 3. Not scholarly enough4. Not taught enough5. Not costly enough6. Not unified enough7. Not Canadian enough

Another for good measure

• injuries = accidents = bad luck • hence, not preventable • so why bother?

Injury epidemiology & injury prevention (IP)

• Overlapping (most IE bears on IP & vice-versa)

Injury epidemiology

Injury prevention

Neglected?

Robertson:

• “For almost two-thirds of the 20th Century, injury deaths were listed in mortality

statistics but largely ignored by researchers in epidemiology and public health. Near

the end of the century, despite a growing body of knowledge …. important

discussions of the future direction of epidemiological research made no mention of

injury.

• A conference in 2005 on the future of Public Health included one brief mention of

injury, but more was said about Elvis impersonators…

• The WHO publication “A Safer Future” (2007) emphasizes safety from diseases (but)

has no section on injury ….

More neglected in low income countries (LICs)

• Almost every category of injury fatality is much larger in LICs than in HICs

• Difference overall is 51 vs 89 per 100,000• Largest difference is ‘war’ injuries• Next largest are ‘traffic’ and ‘drowning’

Death rate by mechanism and economic statusRate per 100,000 per year

Mock et al., Lancet 2004; 363

High income countries Low income countries

Road traffic 13.6 22.1

Poisoning 2.2 5.8

Falls 8.3 4.0

Fires 1.0 4.5

Drowning 1.7 8.4

Self inflicted 13.3 13.5

Violence 2.8 9.6

War 0.02 6.0

All injury related deaths 51.2 89.1

Less neglected in US (than Canada)

In 1985, a National Research Council/Institute of Medicine committee published

Injury in America: A Continuing Public Health Problem. The conclusion: Injuries kill

more Americans aged 1-34 than all diseases combined; (thus) they are the leading

cause of deaths up to the age of 44.

• In 1986, a Division of Injury Epidemiology and Control was created in CDC's Center for Environmental Health

• In 1987, DIE started funding specialized Injury Control Research Centers (ICRC)

• In 1992, the Division + new program for acute care, rehabilitation, and prevention of injury-related disabilities became CDC’s National Center for Injury Prevention and Control

US National Center for Injury Prevention and Control

• To prevent violence and injuries and reduce their consequences (by)– Identifying and monitoring the problem– Conducting research to guide decision making– Empowering states through funding and technical

assistance• e.g., WISQARS™ (Web-based Injury Statistics Query

and Reporting System) - an interactive, online database covering fatal and nonfatal injury, violent death, and cost based on several trusted sources

WISQARS

• Link to website

Injury Control vs Injury Prevention

The difference is subtle but important when politics, policy making, and resources are being considered. • Injury prevention is largely a matter of primary and secondary

prevention, especially secondary.• Injury control also involves tertiary prevention— preventing tragic

outcomes (death, disability, etc.) after an injury has occurred• Injury control includes prehospital care—ambulances and

emergency medical services —and emergency or casualty care and rehabilitation

• Some tension because most preventive resources are consumed by the hospital sector leaving little for traditional public health initiatives

Injury Control Research Centers (ICRCs)

• conduct research in all three core phases of injury control (prevention, acute care, and rehabilitation)

• also for training & public information • most ICRC research is interdisciplinary

(epidemiology, biostatistics, public health, medicine, engineering, law, behavioral and social sciences, biomechanics)

Current 11 ICRCs

• Columbia University• Johns Hopkins School of Public Health• University of Iowa• University of Michigan• Mount Sinai School of Medicine• The Research Institute at Nationwide Children's Hospital• University of North Carolina at Chapel Hill• University of Pennsylvania• University of Rochester Medical Center• West Virginia University• Emory University

Does it matter?

• That the US has a National Center and Canada does not?

• The data are inconclusive (partly because some Canadian data are not up-to-date)

US vs CanadaUS = 40.4 unintentional/100,000

Note: total US rate higher and increases 35.7 to 40.4/100,000 over same time period

My hypotheses

Not 5 but 7

1. Not old enough?• 1937, Godfrey ES. Role of the Health Department in the Prevention of

Accidents, Am J Public Health Nations Health. (? first peer-reviewed)• 1938, Holcomb RL. Alcohol in relation to traffic accidents, JAMA• 1949, Gordon JE. The epidemiology of accidents. Am J Public Health• 1952, De Havens H. The site, frequency and dangerousness of injury

sustained in 800 survivors of light plane accidents. Crash Injury Research, Cornell University

• 1964 Haddon, Suchman, Accident Research: Methods and Approaches, Association for Crippled Children

• 1980, Haddon Matrix introduced a conceptual basis for prevention, Hazard Prevention

• 1980, Haddon W. Advances in the epidemiology of injuries as a basis for public health policy, Public Health Reports

Historical landmarks• 1980 - advances in injury epidemiology voted by Epidemiology

Section of APHA as 1 of 10 landmark achievements in US epidemiology

• 1992 - US National Center for Injury Prevention and Control became independent program of CDC

• 1995 - first academic IP journal (Injury Prevention)• 1999 - reductions in MV and occupational injury mortality judged

2 of 10 great US public health achievements of 20th century • 2000 - WHO established Dept. of Injury and Violence Prevention• 2000 – E Mackenzie publishes “Epi of injuries’ in Epid Rev• 2014 - first academic IE journal (Injury Epidemiology)

Sue Baker – Pioneer (Hopkins*)

• Pilot• Artist• Epidemiologist• Great teacher• Good friend

*Johns Hopkins Center for InjuryResearch & Policy

Sue Baker – pilotI asked her when and why. Her reply -

• (Started) in 1986, when I was 56, which was old for a student pilot and stopped about 8 or 10 years ago.

• I took it up because I wanted to do research on aviation crashes, and needed to understand what is required of pilots.

• Getting my license opened a lot of doors – e.g., pilots lectured in the course I started on aviation safety – and some airlines allowed me to fly jump-seat on the flight deck, right behind the captain, on any flight where I was a ticketed passenger. (Also gave her more data about pilot behaviour)

2. Not big enough?

Consider death ratesCanada 2005

Causes of death, Canada, 2011ages 15 to 24 & 25 to 34 years

unintentional

intentional

cance

rheart

lower resp

kidney

0100200300400500600700800900

15 to 2425 to 34

Causes of death, Canada, 2011Condition Number %

Cancer 72,000 30

Heart 48,000 20

Injury (int & unintentional) 15,000 5.9

Cerebrovascular 13,000 5.5

Chronic lower respiratory 11,000 4.6

Global problem

• WHO ‘Global Burden of Disease’ -- injuries are Increasingly the major problem in ‘third world’ countries (LICs), especially MV crashes, and they are rising rapidly.

• If present trends continue, road traffic injuries are predicted to be the third-leading contributor to the global burden of disease and injury by 2020.

3. Not scholarly enough?

Books and Journals

But many injury epidemiology books

Most focus on preventionCome visit my bookshelf

Other books • Hemenway D. While We Were Sleeping: Success Stories in Injury and

Violence Prevention (2009)• Roberts I. The Energy Glut: Climate Change and the Politics of Fatness

(2010)• Li G, Baker S. Injury Research: Theories, Methods, and Approaches

(2012)• Liller K, Injury Prevention for Children and Adolescents: Research,

Practice, and Advocacy, 2nd Edition (2012)• Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International

Perspective: Epidemiology, Surveillance, and Policy • Christoffel K, Gallagher S. Injury Prevention And Public Health: Practical

Knowledge, Skills, And Strategies

…. and several key journals

peer reviewed & respectable IFs(for whatever that’s worth!)

Injury Epidemiology Contents

Journal

The contents give some idea of the range of topics included in IE

IE Scope & Policy

• Scope: magnitude, distribution, determinants, causes, prevention,

diagnosis, treatment, prognosis, and outcomes of injuries in specific

population groups, geographic regions, and environmental settings

• Policy: priority given to papers that feature contemporary theories,

innovative methods, and novel techniques applied to injury

surveillance, risk assessment, effective interventions, and

program/policy evaluation

Table of contentsOriginal Article:Using a virtual environment to study child pedestrian behaviours: a comparison of parents' expectations and children's street crossing behaviour (22 Sep 2015)Original Article:Scald burns in children under 3 years: an analysis of NEISS narratives to inform a scald burn prevention program (22 Sep 2015)Original Article:An examination of concussion education programmes: a scoping review methodology (22 Sep 2015)Original Article:Defining a safe player run-off zone around rugby union playing areas (22 Sep 2015)Original Article:Influence of voluntary standards and design modifications on trampoline injury in Victoria, Australia (22 Sep 2015)Original Article:Investigating the fall-injury reducing effect of impact absorbing flooring among female nursing home residents: initial results (22 Sep 2015)Methodology:Validation of ICDPIC software injury severity scores using a large regional trauma registry (22 Sep 2015)Anniversary Archives:Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings (22 Sep 2015)News And Notes:Global news highlights (22 Sep 2015)

And a few others

• J of Injury and Violence reserch• J of Safety Research• Safety Science• Transportation Research

4.Not taught enough? (in epi departments)

Canadian responses

Email to 20+ Canadian chairs

… indicate if your department at present (or in the last decade) offers a course on injury epidemiology … if you don’t offer one and care to elaborate on why you don’t, please do• 9 responses• None said they teach IE and none explained

why

5. Not cost enough?

Various cost of injury estimates

Cost of Injury (Canada)

• The Cost of Injury in Canada Report – financial & societal burden on people, health care,

economy is rising & not sustainable• $27 billion lost to economy • 3.5 million visits to emergency rooms• > 60,000 disabilities• costs more than heart and stroke • Loss of life equivalent to one jumbo jet crashing

every 10 days

Cost of injury (UK)savings from prevention

If we prevented one child from being admitted to hospital for treatment as a result of liquitab ingestion, this would represent an average cost saving of approximately £19,500 to the NHS

Cost of Injury (Canada)

• From Parachute launch

• “As Minister of Health, nothing is more important that the health and safety of all Canadians” (Rona Ambrose)

Impressed?

• I am NOT• many such reports in Canada and elsewhere• have had little or no proven effect on policy,

programs, etc.• unfortunate that in this instance Parachute uses

report as fund-raiser• clock will not be stopped ‘if we all joined the

movement”, as Parachute suggests, unless the power it gave was used to change government policy, esp. a National Center

The flip side – too little funding-- research, programs, etc.?

• No industrial support, no advertisers, no pharmas, few commercial applications

• No major charities or ‘victim groups’• Few advocacy groups e.g., CSC, Parachute

OF TOTAL $1 BILLION BUDGET, POSSIBLY$900,000 FOR INJURY RESEARCH (3 PROJECTS)

Reviewed CIHR funding decisions 2014

CIHR funding, 2014

Investigator initiated $732m priority-driven $254m • ebola, cancer, HIV vaccine, vaccines, neuroinflammation, critical

care trials, rare diseases nutrition biomarkers, knowledge translation, adverse reactions,, aging, cancer prevention, mental health, longitudinal cohorts,, breast cancer, blood supply, genetics, aboriginal, bioethics, aging, ALS, drug safety, epigenetic, gastroenterology, IBD,

• applied public health chairs, Canada research chairs, new investigator priority, Canada excellence research chairs,

Injury related• safe active school travel 199k, booster seat and helmet laws

199k, suicide prevention 500k

6. Not unified enough?

Too many components to “injury”

Field is diverse

• Unintentional: burns, drowning, falls, traffic, sports, recreation

• Intentional: violence, suicide• Other IE: methods, models, surveillance

Consequences of diversity

• diversity means no lobbying, no parent groups, no charities & no (political) pressure

• it means less money for research, implementation of research findings via programs, policies, legislation, regulation

• but is this less unified than ‘cancer’?

7. Not Canadian enough

Eh?

No …. too Canadian!

• if the Americans do it (have a National Center) why should we bother?

• not just a Harper (Tory) view because successive governments have rejected the idea

• excuse is that ‘health is a provincial matter’ but we have had all sorts of ‘national strategies’ e.g., breast cancer, mental health, aboriginal, pharmacare, e-records, AIDs,

• and at least one National Center – the Canadian Center for Occupational Health and Safety

No National Center

After 30 years of pressing the issue we are no closer to having a National Center comparable to what exists in CDC and light years away from comparable funding for research. Nor do we have anything that remotely resembles the Swedish model that appears to have been so successful. Instead, one Health Canada publication gives these examples of success: the Back to Sleep campaign, a statement about the need to combine education with other tactics and with the onus placed on not-for-profit organizations. The section on “legislation, products and standards” refers to the importance of product standards and regulations and playground standards are the shining example. However, compliance with these standards is voluntary. The same mixed message emerges from the other example given – the importance of legislation – using bicycle helmets as an example while noting that many provinces refuse to pass such laws.

Neglected or Rejected?

• examples of (failed) advocacy (mine & others)– many meetings with Deputy Ministers and some

with Ministers– many letters to the editor (journals, newspapers,

etc.)– many keynote presentations– many editorials and some op-eds

the need for a Canadian equivalent of National Center for Injury Control consistently rejected

Semantic Scholar

• Found in recent issue of “The Scientist”• a search engine described as ‘A Literature Database

with Smarts’ launched Nov 2 by Allen Institute for Artificial Intelligence

• uses machine reading to extract meaning and impact from scientific papers

• aims to help researchers find most relevant papers • helps users make sense of papers, how often

reference has been cited? which papers are of highest quality? who else Is working on this problem?

Semantic scholar results ‘injury epidemiology’

• Found 51 papers in 2015 • They ranged from ‘fall detection’ to

‘environmental determinants in Canadian North’ to ‘Lushan Earthquake’

• Interesting alternative to Google Scholar (GS)• But ‘no cigar’ --- too many missed• GS came up with 35,400 in 2015Moral remains: Why is IE so neglected?

Thank you

Time for questions, or - better still - suggestions