violence -related injury surveillance (vis) deep south ......• during 2004-2007, there were 5.4...

ViolenceViolence--related Injury Surveillance related Injury Surveillance

(VIS)(VIS)

Deep South, Thailand, 2007Deep South, Thailand, 2007

Vorasith Sornsrivichai, MD, PhD, FETP Cert.Epidemiology Unit,

Prince of Songkla University, Hat Yai, Thailand

http://medipe2.psu.ac.th/~vis , [email protected]

2

WHO Conceptual Definition of Violence, 2002

• The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community

• Results in or has a high likelihood of resulting in

– Injury & death

– Psychological harm

– Maldevelopment

– Deprivation

3

Thailand’s Deep South

• 3 southernmost provinces of Thailand: Yala, Pattani and Narathiwat

• 80% of the 1.8 million population are Muslim (most of Thailand's 4% Muslim minority)

• Muslim militants fought with the government up to the mid 1980s

4

What is the Deep South Situation?

• Deep South violence

erupted in January 2004

when an army depot was

raided, 400 M16 rifles

were stolen

• Widespread terrorist

attacks targeting on

symbols of authority

(police officer, soldier,

teacher) and civilian

5Source: Srisompob Jitpiromsri, Faculty of Political Sciences, Prince of Songkla University, Pattani Campus

> 800 Deaths

Number of Violence Events in

the 3 Southernmost Provinces, Thailand, 1993-2004

6 32 27 42 83 139 10732

114 82

1843

84

0

200

400

600

800

1000

1200

1400

1600

1800

2000

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Year

Number

> 800 Deaths

6

Impact on Public Health

• During 2004-2007, there

were 5.4 violent events,

4.6 injured victims (1.8

dead) per day

• 3rd rank of DALYs

among men, 4th rank

among both genders in

2004

• Up to 2007 the recorded

direct victims are > 6,000

7

Violence-related Injury Surveillance

• Collaboration between Thailand Ministry of Public Health and Prince of Songkla University

• Implemented in January 2007

8

Objectives

• To monitor the magnitude and trend of violent events

• To identify risk factors of the victims

• To improve Emergency Medical Service (EMS) and referral system

• To allocate related public health resources

• To target the victim in need forhumanitarian relief

Method

• Setting: All (47) government hospitals

• Population under surveillance: The intentionally injured victims who underwent treatment or autopsy at the hospitals

• Data collection: By the hospital nurses

ResultsResults

Magnitude

• In 2007,

– 1,228 violent events (3.4 events/day)

– 2,362 injured persons (6.5 persons/day)

(70.8/100,000 population/year)

– 628 deaths (1.7 deaths/day)

(19.2/100,000 population/year)

• 2/3 of which died at the scene

– The case fatality rate (CFR) was 26.6%

1212

Trend of Events

VIS 2007 vs DSCC 2004-7

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DSCC (all events)

VIS (hospital-based)

Month/Year

No

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nt

Jan 04 Jan 05 Jan 06 Jan 07 Jan 08

EventEvent

14

Time Distribution of Events

(VIS, 2007)

Songkhla

Pattani

Yala

Narathiwas

TotalTime

(HH:MM)

Province

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00:00 04:00 08:00 12:00 16:00 20:00

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15

SongkhlaPattani

Spot Map of

Violent Event

(VIS, 2007)Month

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

DecNarathiwas

Yala

Songkhla

Pattani

Most (27.8%) of the events occurred while the victims were engaged in work-related activities

Majority (59.9%) of the events

occurred

on the road

External Causes of Injury

• The ICD-10 external causes of injury were:

– “assault by other and unspecified firearm

discharge” (41.8%)

• CFR = 49.3%

– “assault by explosive material” (34.2%)

• CFR = 6.6%

VictimVictim

Characteristics of Victims

by Age Group, Gender & Religion

(VIS, 2007)

19

19

0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320

0-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

>75

Male

020406080100

Female IslamUnknownBuddhism

Years

Numbers

The majority of the victims were:

• Male (82.6%)

• Median age = 34 yrs (IQR 25-45 yrs)

• Buddhist (45.9%)

• Farmers (17.5%), soldiers (16.9%)

20

Area Map of

Violence-related Injury

(VIS, 2007)

Injury rate

/100,000/ month

Narathiwas

Yala

Songkhla

Pattani

No. of injured

cases/month

InjuryInjury

Emergency Medical Services (EMS)

• Transfer from place of occurrence to hospital – Median time = 30 minutes (inter quartile

range-IQR = 15-60 minutes)

– Pre-hospital CFR = 18.2%

• Refer between hospitals (n = 527 victims)– Median referral time was 50 minutes (IQR =

30-80 minutes)

– In hospital CFR = 10.3%

2323

Quality of Care during Transfer

VIS 2007

CareGood Not good Not done

No. % No. % No. %

Airway 90 12.3 10 1.4 634 86.4

Bleeding 169 15.7 41 3.8 869 80.5

CC--Spine CollarSpine Collar 30 5.7 3 0.6 496 93.8

Splint / Slab 51 7.3 12 1.7 635 91

IV fluid 68 8.3 5 0.6 743 91.1

2424

Quality of Care during Referral

VIS 2007

CareGood Not good Not done

No. % No. % No. %

Airway 233 95.1 4 1.6 8 3.3

Bleeding 432 96.4 9 2 7 1.6

CC--Spine CollarSpine Collar 27 51.9 1 1.9 24 46.2

Splint / Slab 145 84.3 3 1.7 24 14

IV fluid 361 96 3 0.8 12 3.2

Public Health Resource Burden

Median (IQR) Total

Length of stay* (day) 1 (1-3) 5,253

Direct medical cost** (Baht) 1,037 (230-4,329) 12,513,694

26

*Most were OPD cases **Data from 1,512 patients (64%)

27

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Comparison between District of

Occurrence(Acute Service)

& District of Victim’s Home

(Long-term Service)

Home address

Place of

Occurrence

28

Humanitarian Relief

• Up to 2006, estimated 20,000 dependants of the victim

• < 70% coverage of relief activity, thousands waiting for the essential support from the government

• PSU’s Deep South Coordination Center-DSCC(http://medipe2.psu.ac.th/~dscc/) was established in mid 2006 under the National Reconciliation Committee Fund to coordinate academic activities to support the victims & their dependants

29

Humanitarian Relief

• At DSCC, VIS data was linked withmilitary, police & media news clipping to create integrated database

• Then supplied to every hospital’s Mental Health Crisis Center to help its community psychologists & psychiatric nurses in identifying the people in need

30

Deep South Integrated Database

31

Humanitarian Relief

• Not only as essential rehabilitation/tertiary prevention, but also a reconciliation and peace making--it is a primary preventionfor the new generation of neglected person taking revenge

Multidisciplinary Cooperation

• Cooperation with Military College of Medicine to utilize VIS data to improve the high CFR (~ 30%) of soldiers

33

Multidisciplinary Cooperation

• The Deep South Watch project (http://www.deepsouthwatch.org) was set up by academics, rural doctors and the Thai Journalists Association to serve in the area of situation analysis, investigative journalism and balanced information for right understanding of the Deep South situation

34

www.deepsouthwatch.org

Deepsouth Bookazine

Vol.2

35

Conclusions

• VIS is used to improve violence-related health services and facilitate humanitarian relief

• However, the physical and psychosocial health burden of Deep South violence is enormous and increasing

• Multidisciplinary peace and reconciliation programs are urgently needed

Thank youThank you

ObrigadoObrigado

39

Any Room for the Academic?

• Health Care System Management in the Deep South Crisis Project in 2004-2008 (HSRI-PSU)

• Surveillance System Development in the Lower South of Thailand, 2005-2007 (MoPH)


• 3 MSc theses (public health, pharmacy, nursing)

• 2 PhD theses (epidemiology, economic)

• 3 Practicum (2 FETP, 1 MSc in peace study & conflict management)

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Injury Surveillance – VIS, January – May 2005)

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2 publications in national MMWR-like journal


• Panel discussion “Trans-Pacific Case Studies:

Experience from Thailand's Deep South

Violence” in APRU World Institute Workshop

“The Role of Universities in Addressing

Emerging Public Health Threats in the Asia

Pacific Region” April 2007, China

• Oral presentation “Man-made Disaster:

Violence in the Deep South of Thailand” in

“Public-Private Mix: a Public Health Fix?

Strategies for Health Sector Reform in South

and Southeast Asia” June 2007, Thailand

44

httphttp://://medipe2medipe2..psupsu..acac..thth//~vis~vis

45

VIS Web 2.0 MindMap(http://medipe2.psu.ac.th/~vis/mindmap)

45

46

46

VIS Web 2.0 MindMap(http://medipe2.psu.ac.th/~vis/mindmap)

47

VIS Web 2.0 WebStat: http://medipe2.psu.ac.th/~vis/webstat

47

49

How Do Epidemiologists Get Involved?

• A survey conducted in Mid 2004 showed little effect on health care service, however 85-98% of local health professions were concerned most about their security

• So far, 28 health care officers were attacked (9 dead) 12 health centers and 10 health center officer’s houses were burned down, 5 hospitals were shot/bombed/mobbed

50

• A group of volunteer epidemiologist, rural doctor & Medecins Sans Frontieres (MSF) developed a package of security preparedness in the health care setting

• We subsequently cooperated with Military College of Medicine in development of Incidence Action Plan and Emergency Incident Command System

How Do Epidemiologists Get Involved?

51

Online Security &

Safety Resourcehttp://medipe.psu.ac.th/

security&safety/

What’s Next?

• Collaboration with WHO Collaboration Centre for Research on the Epidemiology of Disasters, Belgium (CRED) and Karolinska Institute, Sweden to study impact from Deep South violence on public health system

• Method

– Secondary data linkage

– Comparative analysis: before VS after, high VS low violence area

– Associative analysis

What’s Next?

Public health system indicators

1. Surveillance system: coverage, completeness, validity and timeliness of notifiable disease surveillance system

2. Disease prevention: vaccine coverage, vaccine management system

3. Disease control: TB’s cure rate, default rate; Malaria’s active case finding, residual spray

4. Health care service utilization: inpatient hospitalization,length of stay, direct medical cost

5. Burden of disease: TB, malaria, vaccine preventable disease incidence, DALY of violence-related injury

violence -related injury surveillance (vis) deep south ......• during 2004-2007, there were 5.4...

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