Pediatric injury research - what we know & what we need to know

Olive Kobusingye, MD, M.Med (Surg), MPHMakerere University School of Public Health

Uganda summary demographics 2012 mid-yr projections

Total Population 100% 35,356,900

Children (below 18 years) 56% 19,799,864

Adolescents and youth (10 – 24 years)

34.7% 12,268,844

Orphans (for children below 18 years)

10.9% 3,853,902

Infants (below one year) 4.3% 1,520,347

Children below 5 years 19.5% 6,894,596

Women of reproductive age (15 – 49 years)

23% 8,132,087

Source: Uganda Bureau of Statistics

Burden of child injury

• How do we know what we know?–Health facility data (routine & other)–Community data–Routine Police data–NGOs

Top 10 causes of hosp based deaths, all ages 2012/13, HMIS

Rank IP Diagnosis Total Under 5 Over 5 %

1 Malaria 5079 2623 2456 20.6

2 Pneumonia 2849 1427 1422 11.0

3 Anemia 2814 1339 1275 10.6

4 Perinatal conditions 1474 960 514 6.0

5 Injuries other 651 179 472 2.6

6 Meningitis other 628 114 514 2.5

7 TB other 571 99 472 2.3

8 Injuries road traffic 557 117 440 2.3

9 TB new smear +ve 464 31 433 1.9

10 Septicemia 669 310 369 2.7

11 All others 9095 3331 5764 36.9

Total 24651 10530 14121 100

Top 10 causes of hosp based deaths, Under 5, 2012/13, HMIS

Rank IP Diagnosis Under 5 %

1 Malaria 2623 24.92 Pneumonia 1427 13.63 Anemia 1339 12.74 Perinatal conditions 960 9.15 Septicemia 310 2.96 Injuries ALL 296 2.87 Meningitis other 114 1.18 TB other 99 0.99 TB new smear +ve 31 0.310 All others 3331 31.6

Total 10530

Hospital injury surveillance

• Injury Control Center – Uganda has been conducting surveillance since 1997. Recently this effort has been patchy. Data from 07/2004 – 08/2005 were analyzed to determine the pattern of injuries in children.

Hsia, R., Ozgediz, D., Jayaraman, S., Kyamanywa P, Mutto M, & Kobusingye O. Epidemiology of child injuries in Uganda: challenges for health policy. Journal of Public Health in Africa. 2011;2:e15

Most common causes of injury 2004/5Age No. % sample Top 3 causes No. % sample

> 1yr 23 3 Burn 8 35

Road traffic 7 30

Blunt injury 2 9

1- 4 yrs 120 14 Fall 31 26

Road traffic 24 20

Burn 18 15

5-14 yrs 428 49 Road traffic 123 29

Fall 110 26

Violence 47 11

15- 18 yrs 294 34 Road traffic 138 47

Violence 71 24

Animal / snake bites 25 9

Total 865 100 Road traffic 292 34

Fall 159 18

Violence 133 15

Mechanism of violent injury in children

Mechanism N %Blunt force 73 57Stab / cut 19 15Burn 12 9Fall 11 9Sexual assault 1 1Gunshot 7 5Road traffic 1 1Poisoning 1 1Other 3 2Total 128

       Age category No. (%) of top three causes0- 4.9 yrs Falls 74 (29.13)  Burns 70 (27.56)  Traffic 35 (13.78)       5-14.9 yrs Falls 259 (41.51)  Traffic 129 (20.67)  Stabs/Cuts 57 (9.13)       15-24.9 yrs Traffic 243 (37.50)  Stabs/Cuts 131 (20.22)  Falls 82 (12.65)       

Most common causes of injury 2009 (ICCU)

Other child focused research • Motto et al. Intentional injuries. Among

Uganda youth: a trauma registry analysis. Inj Prev 2010

• Hodges, Wilson & Hodges. Plastic and re obstructive surgery in Ug 10yrs experience Pead anesthesia 2009

• Ononge etal. Clinical presentation and management of alleged sexually assaulted females at Mulago hops. Afr Health Scio 2005

Community / non-hospital based sources

African Network for Prevention and Protection against Child Abuse and Neglect (ANPPCAN)

Uganda 2011 study • The specific objectives were to; • 1. Provide information about the nature,

magnitude, causes and consequences of child abuse and neglect in Uganda.

• 2. Provide an updated situation of child abuse and neglect in Uganda

• 3. Provide a comprehensive analysis on problems and challenges of child abuse and neglect in Uganda.

ANPPCAN study scope

• 8 districts drawn from Central, Western, Eastern and Northern regions to have a representative sample of the whole country at 11.5% of the 122 districts in Uganda

African Network for Prevention and Protection against Child Abuse and Neglect (ANPPCAN)

Uganda • Primary data was generated from interviews

with victims of abuse, perpetrators of child abuse, parents/caregivers as well as other duty bearers including teachers, health workers, and relevant technical staff both at the district and sub county level.

• Secondary data from Annual Police Crime Report as well as media publications by the New Vision, Daily Monitor, & Bukedde papers.

Child Abuse Cases Reported to Police in 2011 & 2012

Case Freq (%) 2011 Freq (%) 2012Child neglect 8075 (40.2 9809Defilement 7690 (38.2)Desertion 1973 (9.8) 2437Child abuse / torture 1775 (8.8) 1502Child stealing 261 (1.3) 307Kidnap 125 (0.7) 170Infanticide 69 (0.3) 104Child abduction 66 (0.3)Abortion 66 (0.3) 71Total 20100

Child focused community research

• Amone P'Olak . Torture against children in rebel captivity in Northern Uganda. Torture 2009; 19(2):102-17.

• Lee etal. Pedestrian injuries in school-attending children: a comparison of injury data sources in a low income country. Inj Prev 2009

Northern Uganda – a community in armed conflict

• Survey done covering period 1 January 2005 to July 2005.

• Complete demographic information was available for 30 304 individuals who had been present in the 3830 households surveyed

Northern Uganda – a community in armed conflict

• Northern Uganda has recorded highest injury rate so far, with 770 injury deaths per 100,000 persons per year (1999).

• Survey found violence third most frequent cause of death (9.4%)– occurring mostly outside of Internally Displaced People’s

camps (68.8%) and health facilities (93.5%)

– Persons killed mostly adult males (70.1%)

– 16.9% were children under 15.

Northern Uganda in conflict

• Of the 77 deaths due to violence recorded throughout Acholi region, 70.1% (54/77) occurred among older (15 years or above) males, 13.0% (10/77) among older females.

• 16.9% (13/77) among children below 15 years.

• The violence-specific mortality rate was 0.17 persons per 10 000 per day (95% CI 0.12 to 0.21), corresponding to 3971 persons (95% CI 2803 to 4905) estimated killed between January and mid-July 2005.

African Child Policy Forum

• Commissioned retrospective surveys in Ethiopia, Kenya and Uganda on young women's experiences of violence before they were 18 years old.

• Presented at the Second International Policy Conference on the African Child 2003

African Child Policy Forum

• surveyed 500 young women (ages 18 to 24)• selected through random social groups in the city

of Kampala. • Half of the young women questioned grew up in

rural areas, now residing in the capital. • Only one third of the girls were still living with

their parents at the time of the survey, • 4% of the girls had never had any schooling, yet

most (70%) had completed or quit studies at the time of the survey.

Age at which violence occurredType of violence < 5 yrs 5 – 9 yrs 10 – 13

yrs14 – 17 yrs

PercentageHit / punched 1.5 16.0 38.2 44.0

Beaten with object

0.2 19.8 57.1 22.8

Locked up / tied up

1.4 37.0 56.2 30.1

Chocked / burnt / stabbed

2.0 22.5 49.0 26.5

A retrospective survey in Ethiopia, Kenya, and Uganda

Physical violence resulting in seeking med care / missing school / work

Type of violence

Needed to see doctor%

Missed school%

Had to stay home%

Hit / punched

21.1 10.2 16.4

Beaten with object

57.3 41.9 31.5

Student health survey

• The 2003 Uganda GSHS was a school-based survey of secondary school students in yrs 1, 2, and 3. A two-stage cluster sample design. Data representative of all students in standards 1, 2, and 3 in Uganda. At the first stage,

• 1st stage: Schools were selected with probability proportional to enrollment size. 2nd: Classes randomly selected, all students in selected classes eligible. A total of 3,215 students participated

• Students self-reported their responses to each question on a computer scannable answer sheet.

• Only students aged 13-15 years are included in the analyses for the presented results.

Global Student Health Survey 2003

Total Boys Girls

% students in physical fight one or more times in past 12 months

35.5 (± 3.5)

39.3 (± 5.8)

32.2 (± 4.0)

% students seriously injured one or more times in past 12 months

63.4 (± 4.8)

67.0 (± 5.2)

60.0 (± 6.3)

% students bullied one or more times in past 30 days

45.5 (± 3.9)

50.0 (± 5.6)

41.1 (± 4.1)

Global Student Health Survey 2003Total Boys Girls

% students in physical fight one or more times in past 12 months

35.5 (± 3.5)

39.3 (± 5.8)

32.2 (± 4.0)

% students seriously injured one or more times in past 12 months

63.4 (± 4.8)

67.0 (± 5.2)

60.0 (± 6.3)

% students bullied one or more times in past 30 days

45.5 (± 3.9)

50.0 (± 5.6)

41.1 (± 4.1)

Global Student Health Survey 2003 RURAL

Total Boys Girls

% students in physical fight one or more times in past 12 months

38.5 (± 6.3)

42.0 (± 8.1)

35.1 (± 6.6)

% students seriously injured one or more times in past 12 months

69.7 (± 6.0)

71.9 (± 5.2)

67.5 (± 6.8)

% students bullied one or more times in past 30 days

52.5 (± 6.7)

59.1 (± 7.5)

45.5 (± 6.8)

Summary: what we know

• Ugandan children face a high burden of injuries - morbidity, mortality

• The very young at risk of burns, falls, violence• The older children – road traffic, falls, violence• Adolescents into young adulthood – road

traffic, violence• Most injuries happen at home or on the road• Violence – takes various forms

What we need to know

• What is the true burden to the communities? (most datasets lack denominator data)

• Mechanisms, circumstances of injury• Access to health care, barriers to access• Economic cost of child injuries• Burden of Injuries which are rapidly fatal, such

as drowning – they do not show up in hosp