Trends in unintentional injury mortality in Canadian children 1950-2009 and association with selected population-level interventions

Pre-hospital mortality among pediatric trauma patients in Nova Scotia

OBJECTIVES

Limited data exist on pre-hospital pediatric trauma mortality in Canada. The Nova Scotia Trauma Registry is a provincial population-based registry that captures data from the Medical Examiner Service. This study examined the characteristics of pediatric trauma patient mortality in the pre-hospital and in-hospital settings.

METHODS

We conducted a cohort study of major pediatric traumas recorded in our provincial database from April 1, 2001 to March 31, 2018. Characteristics of pre-hospital and in-hospital deaths were compared with t tests and Chi-square analyses. Multivariate regression modeling was used to identify predictors of pre-hospital mortality. The geographic distribution of pre-hospital trauma was assessed using choropleth maps.

RESULTS

We identified 1,258 pediatric traumas, resulting in 217 deaths (137 pre-hospital, 80 in-hospital). Males accounted for 62.7% of fatalities. The 15-17 age group accounted for most deaths in both groups (pre-hospital 61.3%; in-hospital 41.3%). Injuries sustained in rural areas resulted in 74.7% of all deaths. For both groups, blunt trauma was the predominant injury type and motor vehicle collisions, the most prevalent injury mechanism. Patients who died pre-hospital had a higher mean age (13.3 vs. 10.7, p = 0.002) and a greater proportion were intentional injuries (23.4% vs. 15%; p = 0.02). Urban residency was more frequently observed in in-hospital deaths (57.5% vs. 36.5%, p < 0.001). Pre-hospital mortality was associated with increasing age (OR 1.1), higher injury severity score (OR 1.1), and intentional injury (OR 15.6).

CONCLUSION

Over 10% of major pediatric traumas resulted in pre-hospital death, primarily from motor vehicle collisions in rural areas. Compared to in-hospital mortality, patients who died pre-hospital were older with more severe injuries and more likely to have intentionally injured themselves. These results underscore the importance for emergency physicians and EMS systems to consider geographic factors and injury patterns, advocate for improved injury prevention programs, mental health supports, and delivery of on-scene critical care services.

A systematic review of the evidence for effectiveness of interventions to address transport and other unintentional injuries among adolescents

INTRODUCTION

Globally, injuries are a leading cause of mortality and morbidity for adolescents, which disproportionately affect the disadvantaged. To build an investment case for adolescent injury prevention, evidence is needed as to effective interventions.

METHODS

A systematic review of peer-reviewed original research published between 2010-2022 was conducted. CINAHL, Cochrane Central, Embase, Medline and PsycINFO databases were searched for studies reporting the effectiveness of unintentional injury prevention interventions for adolescents (10-24 years), with assessment of study quality and equity (e.g., age, gender, ethnicity, socio-economic status).

RESULTS

Sixty-two studies were included; 59 (95.2%) from high-income countries (HIC). Thirty-eight studies (61.3%) reported no aspect of equity. Thirty-six studies (58.1%) reported prevention of sports injuries (commonly neuromuscular training often focused on soccer-related injuries, rule changes and protective equipment). Twenty-one studies (33.9%) reported prevention of road traffic injury, with legislative approaches, commonly graduated driver licensing schemes, found to be effective in reducing fatal and nonfatal road traffic injury. Seven studies reported interventions for other unintentional injuries (e.g., falls).

DISCUSSION

Interventions were strongly biased towards HIC, which does not reflect the global distribution of adolescent injury burden. Low consideration of equity in included studies indicates current evidence largely excludes adolescent populations at increased risk of injury. A large proportion of studies evaluated interventions to prevent sports injury, a prevalent yet low severity injury mechanism. Findings highlight the importance of education and enforcement alongside legislative approaches for preventing adolescent transport injuries. Despite drowning being a leading cause of injury-related harm among adolescents, no interventions were identified.

CONCLUSION

This review provides evidence to support investment in effective adolescent injury prevention interventions. Further evidence of effectiveness is needed, especially for low- and middle-income countries, populations at increased risk of injury who would benefit from greater consideration of equity and for high lethality injury mechanisms like drowning.

Self-reported injuries among Canadian adolescents: rates and key correlates

INTRODUCTION

Injuries sustained by adolescents in Canada represent a costly public health issue. Much of the limited research in this area uses administrative data, which underestimate injury prevalence by ignoring injuries that are not treated by the health care system. Self-reported data provide population-based estimates and include contextual information that can be used to identify injury correlates and possible targets for public health interventions aimed at decreased injury burden.

METHODS

The 2017 wave of the Canadian Community Health Survey was used to calculate the prevalence of self-reported total, intentional and unintentional injuries. We compared injury prevalence according to age, sex, employment status, presence of a mood disorder, presence of an anxiety disorder, smoking and binge drinking. Analyses were performed using logistic regression to identify significantly different injury prevalence estimates across key correlates.

RESULTS

Overall past-12-month injury prevalence among adolescents living in Canada was 31.4% (95% CI: 29.4%-33.5%). Most injuries were unintentional. All provinces had estimates within a few percentage points, except Saskatchewan, which had substantially higher prevalence for both overall and unintentional injury. Smoking and binge drinking were significantly associated with higher injury prevalence in most jurisdictions. Remaining correlates exhibited nonsignificant or inconsistent associations with injury prevalence.

CONCLUSION

The data suggest that injury prevention interventions aimed at reducing alcohol consumption, particularly binge drinking, may be effective in reducing adolescent injury across Canada. Future research is needed to determine how provincial context (such as mental health support for adolescents or programs and policies aimed at reducing substance use) impacts injury rates.

Methodological considerations in MVC epidemiological research

Background

The global burden of MVC injuries and deaths among vulnerable road users, has led to the implementation of prevention programmes and policies at the local and national level. MVC epidemiological research is key to quantifying MVC burden, identifying risk factors and evaluating interventions. There are, however, several methodological considerations in MVC epidemiological research.

Methods

This manuscript collates and describes methodological considerations in MVC epidemiological research, using examples drawn from published studies, with a focus on the vulnerable road user population of children and adolescents.

Results

Methodological considerations in MVC epidemiological research include the availability and quality of data to measure counts and calculate event rates and challenges in evaluation related to study design, measurement and statistical analysis. Recommendations include innovative data collection (eg, naturalistic design, stepped-wedge clinical trials), combining data sources for a more comprehensive representation of collision events, and the use of machine learning/artificial intelligence for large data sets.

Conclusions

MVC epidemiological research can be challenging at all levels: data capture and quality, study design, measurement and analysis. Addressing these challenges using innovative data collection and analysis methods is required.

Child injuries in land vehicles that do not require restraints

The goal of this study was to determine the injury profiles of Canadian children who presented to the Emergency Department from 1990 to 2016 due to an injury caused while traveling in a form of land transportation that did not require child restraint. A case series was conducted using data from the electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP). Children who were injured while travelling on land transportation for which child restraint is not required, who presented to a Canadian Emergency Department that participates in eCHIRPP between April 1, 1990 to August 29, 2016, were included. Overall, 1856 children sustained 2139 injuries (mean age: 9.8 years (SD 4.5), 45.5% male). The majority of children were injured on a school bus (49.3%). The most commonly injured body part was the head or neck (52.6%). The most common type of injury was a superficial or open wound (33.1%), followed by traumatic brain injury (19.3%). Overall, 39.4% of injuries required no treatment in hospital. Overall, approximately 70 children presented to eCHIRPP EDs per year on a land transportation vehicle that does not require restraints. Biomechanical studies are needed to improve safety on land transportation vehicles that do not require seatbelts.

How can we support best practice? A situational assessment of injury prevention practice in public health

BACKGROUND

To effectively impact the significant population burden of injury, we completed a situational assessment of injury prevention practice within a provincial public health system to identify system-wide priorities for capacity-building to advance injury prevention in public health.

METHODS

A descriptive qualitative study was used to collect data on the current practice, challenges and needs of support for injury prevention. Data was collected through semi-structured interviews (n = 20) and focus groups (n = 19). Participants included a cross-section of injury prevention practitioners and leadership from public health units reflecting different population sizes and geographic characteristics, in addition to public health researchers and experts from academia, public health and not-for-profit organizations. Thematic analysis was used to code all of the data by one reviewer, followed by a second independent reviewer who coded a random selection of interview notes. Major codes and sub codes were identified and final themes were decided through iterations of coding comparisons and categorization. Once data were analysed, we confirmed the findings with the field, in addition to participating in a prioritization exercise to surface the top three needs for support.

RESULTS

Major themes that were identified from the data included: current public health practice challenges; capacity and resource constraints, and; injury as a low priority area. Overall, injury prevention is a broad, complex topic that competes with other areas of public health. Best practices are challenged by system-wide factors related to resources, direction, coordination, collaboration, and emerging injury public health issues. Injury is a reportedly under prioritized and under resourced public health area of practice. Practitioners believe that increasing access to data and evidence, and improving collaboration and networking is required to promote best practice.

CONCLUSIONS

The results of this study suggest that there are several system level needs to support best practice in public health injury prevention in Ontario including reducing research to practice gaps and supporting opportunities for collaboration. Our research contributes to the literature of the complexity of public health practice, and presents several mechanisms of support to increase capacity at a system level to improve injury prevention practice, and eventually lessen the population burden of injury.

Effect of anti-malarial interventions on trends of malaria cases, hospital admissions and deaths, 2005-2015, Ghana

Background

Since 2005, the Government of Ghana and its partners, in concerted efforts to control malaria, scaled up the use of artemisinin-based combination therapy (ACT) and insecticide-treated nets (ITNs). Beginning in 2011, a mass campaign of long-lasting insecticidal nets (LLINs) was implemented, targeting all the population. The impact of these interventions on malaria cases, admissions and deaths was assessed using data from district hospitals.

Methods

Records of malaria cases and deaths and availability of ACT in 88 hospitals, as well as at district level, ITN distribution, and indoor residual spraying were reviewed. Annual proportion of the population potentially protected by ITNs was estimated with the assumption that each LLIN covered 1.8 persons for 3 years. Changes in trends of cases and deaths in 2015 were estimated by segmented log-linear regression, comparing trends in post-scale-up (2011–2015) with that of pre-scale-up (2005–2010) period. Trends of mortality in children under 5 years old from population-based household surveys were also compared with the trends observed in hospitals for the same time period.

Results

Among all ages, the number of outpatient malaria cases (confirmed and presumed) declined by 57% (95% confidence interval [CI], 47–66%) by first half of 2015 (during the post-scale-up) compared to the pre-scale-up (2005–2010) period. The number of microscopically confirmed cases decreased by 53% (28–69%) while microscopic testing was stable. Test positivity rate (TPR) decreased by 41% (19–57%). The change in malaria admissions was insignificant while malaria deaths fell significantly by 65% (52–75%). In children under 5 years old, total malaria outpatient cases, admissions and deaths decreased by 50% (32–63%), 46% (19–75%) and 70% (49–82%), respectively. The proportion of outpatient malaria cases, admissions and deaths of all-cause conditions in both all ages and children under five also fell significantly by >30%. Similar decreases in the main malaria indicators were observed in the three epidemiological strata (coastal, forest, savannah). All-cause admissions increased significantly in patients covered by the National Health Insurance Scheme (NHIS) compared to the non-insured. The non-malaria cases and non-malaria deaths increased or remained unchanged during the same period. All-cause mortality for children under 5 years old in household surveys, similar to those observed in the hospitals, declined by 43% between 2008 and 2014.

Conclusions

The data provide compelling evidence of impact following LLIN mass campaigns targeting all ages since 2011, while maintaining other anti-malarial interventions. Malaria cases and deaths decreased by over 50 and 65%, respectively. The declines were stronger in children under five. Test positivity rate in all ages decreased by >40%. The decrease in malaria deaths was against a backdrop of increased admissions owing to free access to hospitalization through the NHIS. The study demonstrated that retrospective health facility-based data minimize reporting biases to assess effect of interventions. Malaria control in Ghana is dependent on sustained coverage of effective interventions and strengthened surveillance is vital to monitor progress of these investments.