Hide Notes 

Slide 1: World report on child injury prevention
Slide 2: World report on child injury prevention Edited by Margie Peden, Kayode Oyegbite, Joan Ozanne-Smith, Adnan A Hyder, Christine Branche, AKM Fazlur Rahman, Frederick Rivara and Kidist Bartolomeos
Slide 3: WHO Library Cataloguing-in-Publication Data: World report on child injury prevention/ edited by Margie Peden … [et al]. 1.Wounds and injures - prevention and control. 2.Accident prevention. 3.Child welfare. I.World Health Organization. ISBN 978 92 4 156357 4 © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization or UNICEF concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization or UNICEF in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization or UNICEF to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization or UNICEF be liable for damages arising from its use. Cover design by INIS. Graphics by minimum graphics and L’IV Com Sàrl. Printed in Switzerland. (NLM classification: WA 250)
Slide 4: CONTENTS Contents Foreword Contributors Acknowledgements Introduction Chapter 1. Child injuries in context Background What is an injury? Who is a child? Why is child injury important? How does child injury relate to other child health concerns? Children’s injuries and the changing world The characteristics of child injury The child-injury pyramid Fatal child injuries Non-fatal child injuries Child injury and age Child injury and gender Child injury and socioeconomic factors The preventability of child injury The principles of injury prevention Learning from places with good safety records Which approaches work? Universal and targeted interventions Cost and cost-effectiveness Overcoming the obstacles Conclusion References Chapter 2. Road traffic injuries Introduction Epidemiology of road traffic injuries Mortality Morbidity Types of road user Economic impact of road traffic injuries Limitations of data Risk factors Child-related factors Vehicle-related factors Environmental factors Lack of prompt treatment Interventions Engineering measures Vehicle design Safety equipment vii ix xiii xv 1 1 1 1 1 2 3 5 5 5 7 8 9 9 12 12 16 16 18 20 20 22 22 31 31 31 31 33 34 36 36 36 36 41 41 41 42 42 43 43 WORLD REPORT ON CHILD INJURY PREVENTION III
Slide 5: Legislation and standards Developing education and skills Emergency and trauma care Potentially harmful interventions Evaluating interventions Conclusion and recommendations Recommendations References Chapter 3. Drowning Introduction Epidemiology of drowning Mortality Morbidity Economic impact of drowning Limitations of data Risk factors Child-related factors Agent factors Environmental factors Access to treatment and rehabilitation Interventions Engineering measures Environmental measures Legislation and standards Developing education and skills Managing drowning Adapting interventions Further research on interventions Conclusions and recommendations Recommendations References Chapter 4. Burns Introduction Epidemiology of burns Mortality Morbidity Limitations of data Risk factors Child-related factors Agent factors Environmental factors Protective factors Interventions Engineering measures Environmental measures Laws and regulations Educational approaches Combined strategies Managing burns Adapting interventions Evaluating interventions 46 47 48 49 49 49 49 51 59 59 59 59 62 62 63 63 63 65 66 66 66 67 67 68 69 71 72 72 72 72 73 79 79 80 80 81 84 84 85 86 86 86 87 87 88 88 89 89 90 93 93 IV WORLD REPORT ON CHILD INJURY PREVENTION
Slide 6: Conclusions and recommendations Recommendations References Chapter 5. Falls Introduction Epidemiology of falls Mortality Morbidity Cost of fall-related injury Limitations of data Risk factors Child-related factors Agent factors Environmental factors Lack of treatment and rehabilitation Interventions Engineering measures Environmental measures Laws and regulations Educational approaches Combining strategies Adapting interventions Involving a range of sectors Conclusions and recommendations Recommendations References Chapter 6. Poisonings Introduction Epidemiology of poisoning Mortality Morbidity Types of poison Cost of poisoning-related injury Limitations of data Risk factors Child-related factors Agent factors Environmental factors Lack of prompt treatment Interventions Engineering measures Environmental measures Laws and regulations Educational approaches Managing poisoning Involving a range of sectors Evaluating interventions Conclusions and recommendations Recommendations References 93 93 94 101 101 101 102 102 105 106 106 106 107 109 110 110 110 110 111 111 112 113 114 114 114 115 123 123 123 123 125 125 127 127 129 129 130 131 132 132 132 134 134 135 135 137 137 137 138 138 WORLD REPORT ON CHILD INJURY PREVENTION V
Slide 7: Chapter 7. Conclusions and recommendations Introduction Main messages from the report Child injuries are a major public health issue Injuries directly affect child survival Children are more susceptible to injuries Child injuries can be prevented The cost of doing nothing is unacceptable Few countries have good data on child injuries Research on child injuries is too limited There are too few practitioners in child injury prevention Child injuries is the responsibility of many sectors Child injury prevention is underfunded Awareness needs to be created and maintained Recommended actions Translating recommendations into reality Conclusion References Statistical annex Index 145 145 145 145 145 145 146 147 148 148 149 150 150 150 151 153 154 155 157 203 VI WORLD REPORT ON CHILD INJURY PREVENTION
Slide 8: FOREWORD Foreword Every day around the world the lives of more than 2000 families are torn apart by the loss of a child to an unintentional injury or so-called “accident” that could have been prevented. The grief that these families suffer – mothers, fathers, siblings, grandparents and friends – is immeasurable and often impacts entire communities. Such tragedy can change lives irrevocably. Once children reach the age of five years, unintentional injuries are the biggest threat to their survival. Unintentional injuries are also a major cause of disabilities, which can have a long-lasting impact on all facets of children’s lives: relationships, learning and play. Among those children who live in poverty, the burden of injury is highest, as these children are less likely to benefit from the protective measures others may receive. Child injuries have been neglected for many years, and are largely absent from child survival initiatives presently on the global agenda. Through this World report on child injury prevention, the World Health Organization, the United Nations Children’s Fund and many partners have set out to elevate child injury to a priority for the global public health and development communities. The knowledge and experience of nearly two hundred experts from all continents and various sectors were invaluable in grounding the report in the realities faced in many countries. Children’s maturity and their interests and needs differ from adults. Therefore, simply reproducing injury prevention strategies that are relevant to adults does not adequately protect children. There are proven interventions such as child car seats, cycling helmets, child-resistant packaging for medications, fencing around swimming pools, hot water tap temperature regulation and window guards, to name a few. Ministries of Health can play a central role in prevention, advocacy and research and in the care and rehabilitation of children with disabilities. Other key sectors include education, transportation, environment and law enforcement. This World report on child injury prevention should be seen as a complement to the UN Secretary-General’s study on violence against children released in late 2006. That report addressed violence-related or intentional injuries. Both reports suggest that child injury and violence prevention programmes need to be integrated into child survival and other broad strategies focused on improving the lives of children. Evidence demonstrates the dramatic successes in child injury prevention in countries which have made a concerted effort. These results make a case for increasing investments in human resources and institutional capacities. This would permit the development, implementation and evaluation of programmes to stem the tide of child injury and enhance the health and well-being of children and their families the world over. Implementing proven interventions could save more than a thousand children’s lives a day. Margaret Chan Director-General World Health Organization Ann M Veneman Executive Director United Nations Children’s Fund WORLD REPORT ON CHILD INJURY PREVENTION VII
Slide 9: VIII WORLD REPORT ON CHILD INJURY PREVENTION
Slide 10: CONTRIBUTORS Contributors Editorial guidance Editorial Committee Margie Peden, Kayode Oyegbite, Joan Ozanne-Smith, Adnan A Hyder, Christine Branche, AKM Fazlur Rahman, Frederick Rivara, Kidist Bartolomeos. Executive Editor Margie Peden. Advisory Committee Chair of Advisory Committee: Ala Din Abdul Sahib Alwan. Advisory Committee: Ileana Arias, Sebastian van As, Martin Eichelberger, Mehmet Haberal, Saad Houry, Etienne Krug, Douglas “Pete” Peterson, Joy Phumaphi, Wim Rogmans, Fernando Stein, Alan Whelpton, Fan Wu. Contributors to individual chapters Introduction Writer: Alison Harvey. Box: Alison Harvey, Amaya Gillespie. Chapter 1. Child injuries in context Writers: Elizabeth Towner, Ian Scott. Boxes: Margie Peden, Tony Kahane (Juan’s story), Margie Peden (1.1), Anuradha Bose (1.2), David Sleet, Barbara Morrongiello (1.3), Charles Mock (1.4), Karen Ashby, Ken Winkel, Julie Gilchrist (1.5). Chapter 2. Road traffic injuries Writers: Kate McMahon, Gururaj Gopalakrishna, Mark Stevenson. Working group members: Nicola Christie, Wilson Odero, Krishnan Rajam, Junaid Razzak, Eugênia Maria Silveira Rodrigues, Chamaiparn Santikarn, Isabelle Sévédé-Bardem, Jean van Wetter. Boxes: David Blanchard (Deana’s story), AKM Fazlur Rahman (2.1), Flaura Winston (2.2), Mirjam Sidik (2.3). Chapter 3. Drowning Writers: Gitanjali Taneja, Ed van Beeck, Ruth Brenner. Working group members: Alfredo Celis, Steve Beerman, Julie Gilchrist, Olive Kobusingye, Jonathon Passmore, Linda Quan, Aminur Rahman, Carolyn Staines, Biruté Strukcinskiene, Li Yang. Boxes: Safekids New Zealand (Ruby’s story), Alfredo Celis, Frederick Rivara (3.1), Erin Cassell (3.2), Ruth Brenner, Gitanjali Taneja (3.3), Joan Ozanne-Smith (3.4), Frederick Rivara (3.5). Chapter 4. Burns Writers: Samuel Forjuoh, Andrea Gielen. Working group members: Carlos Arreola-Rissa, Mohamoud El-Oteify, Alison Macpherson, Ashley van Niekerk, Michael Peck, Andrés Villaveces. Boxes: Children of Fire (Vusi’s story), Samuel Forjuoh (4.1), Reza Mohammadi, Homayoun Sadeghi-Bazargani, Mohammad Mehdi Gouya (4.2), Wijaya Godakumbura (4.3), Pam Albany (4.4), Junaid Razzak (4.5), Rene Albertyn, Sebastian van As, Heinz Rode (4.6). WORLD REPORT ON CHILD INJURY PREVENTION IX
Slide 11: Chapter 5. Falls Writers: Shanthi Ameratunga, Huan Linnan, Shaheen Sultana. Working group members: Francis Abantanga, Abdulbari Bener, Rieneke Dekker, Adisak Plitapolkarnpim, Shauna Sherker, Wendy Watson. Boxes: Aminur Rahman (Sohel’s story), Kidist Bartolomeos, Baltazar Chilundo, Orvalho Joaquim (5.1), Caroline Finch (5.2), Joan Ozanne-Smith (5.3), Margie Peden (5.4). Chapter 6. Poisons Writers: Yvette Holder, Richard Matzopoulos, Nerida Smith. Working group members: Mick Ballesteros, Anuradha Bose, Jenny Pronczuk de Garbino, Marisa Ricardo, Dinesh Sethi, Nelmarie du Toit. Boxes: Debbie Scott (Harrison’s story), Ken Winkel, Karen Ashby, Julie Gilchrist (6.1), Richard Matzopoulos (6.2), Yvette Holder (6.3), Fernando Ravindra (6.4). Chapter 7. Conclusions and Recommendations Writers: Margie Peden, Adnan A Hyder. Boxes: Anupama Kumar (Anupama’s story), Lucie Laflamme (7.1), Adnan A Hyder, Nhan Tran, Abdulgafoor Bachani, David Bishai (7.2), Susan McKenzie (7.3), David Meddings (7.4), Veronika Benešová (7.5), Margie Peden (7.6). Statistical Annex Kidist Bartolomeos, Colin Douglas Mathers, Karen Oldenziel, Mike Linnan, Adnan A Hyder. Peer reviewers Pam Albany, Rene Albertyn, Ruth Barker, Chris Brewster, Mariana Brussoni, Marie Noël Brune, Erin Cassel, Kerry Chausmer, Chrissy Cianflone, Ann Dillenger, Moira Donahue, Jacquie Dukehart, Martin Eichelberger, Robert Flanagan, Lucie Laflamme, Abdul Ghaffar, Rosa Gofin, Robin Ikeda, Denise Kendrick, Shyan Lall, Jacques Latarjet, Edilberto Loaiza, Morag Mackay, Alison Macpherson, Candida Moshiro, Milton Mutto, Anthony Oliver, Luciana O’Reilly, David Parker, Eleni Petridou, Dragoslav Popovic, Aminur Rahman, Shumona Shafi naz, David Silcock, David Sleet, Hamid Soori, Joanna Tempowski, Maria Vegega, Andrés Villaveces, Joanne Vincenten, Diane Wigle. Additional contributors Regional Consultants WHO African Region / Eastern Mediterranean Region Francis Abantanga, Hala Aboutaleb, Wahid Al-Kharusi, Jamela Al Raiby, Sebastian van As, Abdulbari Bener, Hesham El-Sayed, Mahmoud El-Oteify, Mouloud Haddak, Lara Hussein, Syed Jaffar Hussain, Olive Kobusingye, Richard Matzopoulos, Candida Moshiro, Junaid Razzak, Jamil Salim, Babatunde Solagberu, Hamid Soori, Dehran Swart. WHO Region of the Americas Carlos Arreola-Rissa, Simone Gonçalves de Assis, Yadira Carrer, Alfredo Celis, Sara Diaz, Ann Dellinger, Samuel Forjuoh, Andrea Gielen, Maria Isabel Gutierrez, Yvette Holder, Debra Houry, Sylvain Leduc, Luciana O’Reilly, Michael Peck, Maria Fernanda Tourinho Peres, Eugênia Maria Silveira Rodrigues, Maria Ines Romero, Gitanjali Taneja, Andrés Villaveces, Billie Weiss, Elizabeth Ward. WHO South-East Asia Region / Western Pacific Region Pamela Albany, Shanthi Ameratunga, Nguyen Trong An, Anuradha Bose, Rafael Consunji, Yoshikazu Fujisawa, Wijaya Godakumbura, Gopalakrishna Gururaj, Huan Linnan, Michael Linnan, Hisashi Ogawa, Joan Ozanne-Smith, Jonathon Passmore, Adisak Plitponkarnpim, AKM Fazlur Rahman, Aminur Rahman, Krishnan Rajam, Marisa Ricardo, Siriwan Santijiarakul, Chamaiparn Santikarn, Ian Scott, Isabelle Sévédé-Bardem, Richard Tan, Tetsuro Tanaka. X WORLD REPORT ON CHILD INJURY PREVENTION
Slide 12: WHO European Region Ed van Beeck, Veronika Benešová, Christine Branche, Gudula Brandmayr, Murat Derbent, Olivier Duperrex, Rosa Gofin, Loek Hesemans, Rupert Kisser, Lucie Laflamme, Jacques Latarjet, Morag Mackay, Alison Macpherson, Kate McMahon, Eleni Petridou, Dragoslav Popovic, Olga Poyiadji-Kalakouta, Francesca Racioppi, Ian Roberts, Wim Rogmans, Maria Segui Gomez, Dinesh Sethi, Biruté Strukcinskiene, Elizabeth Towner, Iva Truellova, Joanne Vincenten, Michael Watson. None of the experts involved in the development of this report declared any conflict of interest. WORLD REPORT ON CHILD INJURY PREVENTION XI
Slide 13: XII WORLD REPORT ON CHILD INJURY PREVENTION
Slide 14: ACKNOWLEDGEMENTS Acknowledgements The World Health Organization and UNICEF would like to thank the more than 180 contributors (editors, lead authors, working group members, regional consultation participants and peer reviewers) to this report from 56 countries around the world. In addition, the support and guidance offered by the report advisors, WHO regional advisors and UNICEF staff are acknowledged. Without their dedication, support and expertise this report would not have been possible. The report also benefited from the contribution of a number of other people, in particular, Tony Kahane who edited the final text of the main report and Angela Burton who edited the summary version. Joanne Vincenten and Morag Mackay prepared the final text for the summary and fact sheets. Thanks are also due to the following: Kidist Bartolomeos and Ian Scott for the day-to-day coordination of the project; Mike Linnan for the UNICEF/TASC data analysis; Kidist Bartolomeos, Colin Mathers and Karen Oldenziel for analysis and interpretation of WHO data; Adnan Hyder and Prasanthi Puvanachandra for data analysis from the multicountry study; Laura Sminkey and Steven Lauwers for communication and advocacy; Susan Kaplan for proofreading and Liza Furnival for indexing; Susan Hobbs, L’IV Com Sàrl and Aaron Andrade for graphic design; Pascale Broisin and Frederique Robin-Wahlin for coordinating the printing; and finally, Pascale Lanvers-Casasola for her administrative support and for coordinating the translation of the different versions of this report. The World Health Organization and UNICEF also wish to thank the following for their generous financial support for the development, translation and publication of the report: the Arab Gulf Programme for United Nations Development Organizations (AGFUND); the Public Health Agency of Canada, the Governments of Belgium, Mexico, the Netherlands, Norway, Sweden, and the United Kingdom; the Global Forum for Health Research; the United States Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. WORLD REPORT ON CHILD INJURY PREVENTION XIII
Slide 15: XIV WORLD REPORT ON CHILD INJURY PREVENTION
Slide 16: INTRODUCTION Introduction Child injuries are a growing global public health problem. They are a significant area of concern from the age of one year, and progressively contribute more to overall rates of death until children reach adulthood. Hundreds of thousands of children die each year from injuries or violence, and millions of others suffer the consequences of non-fatal injuries. For each area of child injury there are proven ways to reduce both the likelihood and severity of injury – yet awareness of the problem and its preventability, as well as political commitment to act to prevent child injury, remain unacceptably low. The World report on child injury prevention is directed at researchers, public health specialists, practitioners and academics. A summary of the report containing the main messages and recommendations and a set of fact sheets are available for policy-makers and development agencies. A version aimed at children – to create awareness and provide children with a sense of ownership of the issues – and a set of posters have also been produced. Aims The overall aims of the report are: – to raise awareness about the magnitude, risk factors and impacts of child injuries globally; – to draw attention to the preventability of child injuries and present what is known about the effectiveness of intervention strategies; – to make recommendations that can be implemented by all countries to reduce child injuries effectively. Main causes of death among children, World, 2004 100 Percentage of deaths 80 60 40 20 0 Under 1 1–4 5–9 Age (years) 10–14 15–19 Definition of childhood There is no universally agreed age range for what constitutes childhood – a concept that varies considerably across cultures. This report uses the definition of a child specified in the Convention on the Rights of the Child (3), and thus focuses on injuries occurring in children “under the age of 18 years”. However, it has not always been possible to reflect this age cut-off in analysing data. The reader will notice, for instance, that in some cases WHO data could not be disaggregated to <18 years, and so the category of <20 years is used instead. Some of the published literature uses still other age ranges. For the sake of clarity, age ranges are always indicated in tables and figures in the report. Injuries Noncommunicable diseases Communicable diseasesa a Includes communicable, maternal, perinatal and nutritional conditions. Source: WHO (2008), Global Burden of Disease: 2004 update. In 2005, WHO and UNICEF issued a call for a greatly expanded global effort to prevent child injury (1). This was followed in 2006 by WHO’s ten-year plan of action on child injury (2). The plan listed objectives, activities and expected outcomes on child injury and covered the fields of data, research, prevention, services, capacity building and advocacy. This joint WHO/UNICEF World report on child injury prevention brings together all that is currently known about the various types of child injuries and how to prevent them. At the same time, it recognizes that there are major gaps in knowledge. The report expands on and strengthens the areas of action set out in the 2005 Global call to action and the WHO ten-year plan. It is intended, furthermore, to help transfer knowledge into practice, so that what has proven effective in decreasing the burden of child injuries in some countries can be adapted and implemented in others, with similar results. Scope of the report The United Nations Secretary-General’s Study on Violence against Children (4) and the accompanying World report on violence against children (5) provided an in-depth review of intentional injuries to children (see box on the UN Secretary-General’s study). In addition, the World report on violence and health, published by WHO in 2002, included chapters on child abuse, youth violence and sexual violence (6). This report examines the five most common unintentional (or “accidental”) child injuries. Determining the intentionality of an injury to a child is, however, not always straightforward. Where, in discussing data for a particular type of child injury, the question of intent may be ambiguous, then intentional injuries are also touched on in that particular chapter. WORLD REPORT ON CHILD INJURY PREVENTION XV
Slide 17: The UN Secretary-General’s Study on Violence against Children: a joint initiative of UNICEF, WHO, OHCHR and ILO This in-depth study was presented to the United Nations General Assembly in 2006 by an independent expert appointed by the Secretary-General to lead the effort. Supported by UNICEF, WHO, OHCHR, ILO and a wide network of nongovernmental organizations, the study provided a global picture of violence against children, with recommendations to prevent and deal with such violence. The study examined violence against children in different settings: the family, school, community, alternative care institutions, detention facilities and places where children work. Experts from the fields of human rights, public health and child protection all collaborated in this pioneering report. Despite progress in preventing violence against children, much remains to be done, and several factors limit the impact of preventive measures. These include the lack of consistent data and incomplete knowledge of the root causes of violence against children. Furthermore, efforts to address violence against children are frequently reactive, focusing on symptoms and consequences rather than causes. Strategies tend to be fragmented, as opposed to integrated, and insufficient resources are allocated to address the problems. In addition, international commitments to protect children from violence are often not translated into action at the national level. The core message of the Secretary-General’s study is that no violence against children is justifiable; all violence against children is preventable. While governments have made commitments to protect children from all forms of violence, research and child testimonies show that these commitments are far from being fulfilled. The legal obligations lie with governments. However, all sectors of society share the responsibility to condemn and prevent violence against children and to deal with those children affected. The consequences of violence against children vary according to its nature and severity. Efforts to prevent and respond to such violence must therefore be multifaceted. They must reflect the type of violence, the setting and the nature of the perpetrator or perpetrators, and they must always take into account the best interests of the child. The principal recommendations of the study were: 1. to strengthen national and local commitment and action; 2. to prohibit all violence against children (including the death penalty, corporal punishment, harmful traditional practices, sexual violence, torture and other cruel, inhuman or degrading treatment or punishment); 3. to make prevention of violence against children a priority; 4. to promote non-violent values and raise awareness of violence; 5. to enhance the capacity of all who work with and for children; 6. to provide services for recovery and social reintegration; 7. to ensure the participation of children; 8. to create accessible and child-friendly reporting systems and services; 9. to ensure accountability and put an end to violence against children going unpunished; 10. to address the gender dimension of violence against children; 11. to develop and implement systematic national data collection and research; 12. to strengthen international commitment on the issue of violence against children. Source: The United Nations Secretary General’s Study on Violence Against Children (http://www.violencestudy.org/r25, accessed 19 May 2008). This World report on child injury prevention consists of seven main chapters. Chapter 1 places child injuries in the context of other health concerns and related global issues and discusses the fundamentals of child injury prevention. Chapters 2 through 6 examine the five major mechanisms of child injuries: road traffic injuries, drowning, burns, falls and poisonings. Each of these chapters reviews the epidemiology, the risk factors, the interventions and the effectiveness of interventions, and concludes with some important strategies to prevent or manage the particular type of injury. Chapter 7 draws together the common themes of earlier chapters. It also presents a set of broad recommendations that governments and others concerned should seriously consider implementing so as to begin reducing the burden of child injuries. In deciding which topics to include in this report, the editors were guided by the overall magnitude of each type of injury as presented in WHO’s Global Burden of Disease Project for 2004. Consequently, smothering – although a significant problem in infants – has not been included as XVI WORLD REPORT ON CHILD INJURY PREVENTION a full chapter in the report because global data is scant. Similarly, bites and stings have been addressed through boxes within other chapters as these injuries tend to be highly specific to certain regions and global data, again, are not readily available. This report relies heavily on the certain data sources, including: the WHO Global Burden of Disease project for 2004, the Global School Health Survey, and the UNICEF/ The Alliance for Safe Children community-based studies conducted in Asia. No single database is perfect. However, optimal use is made of the available data, supplemented with information from published literature. The limitations of the data are discussed briefly in each of the chapters. A more detailed overview of the methodologies employed to gather data for the various databases is presented in the Statistical Annex at the end of this report. Process The development of this report was led by an Advisory Committee and an Editorial Board and has taken place
Slide 18: over nearly three years. Based on outlines prepared by the Editorial Board, each chapter was written by two or three authors working with a small team of experts from around the world. Nearly 200 professionals from various sectors and all the regions of world provided input to the report. The examples of good practice provided in each of the topic-specific chapters (Chapters 2 to 6) and the subsequent recommendations made for each chapter were based on rigorous scientific evidence supplemented, where necessary, with “grey literature”. Based on the literature reviewed, evidence was graded as: effective, promising, insufficient evidence, ineffective or potentially harmful. Randomized controlled trials and case–control studies were used as the gold standard. Where study methodologies were robust but they were limited to a few high-income countries they were classified as promising. Where there was clear evidence that the intervenion did not work or was harmful, these were classified as ineffective and potentially harmfull, respectively. For many interventions in the area of child injury prevention there is simply insufficient evidence. The drafts of specific chapters were reviewed and revised following input from four regional consultations organized by the WHO regional offices – involving local experts, practitioners and government officials – as well as input from a set of external peer reviewers. During the regional consultations, experts had the opportunity to propose overall recommendations on child injury prevention, for inclusion in Chapter 7. Their proposals were then refined by the editors based on evidence of good practice, subjected to external peer review and finally approved by WHO and UNICEF, who advised on the report. It is anticipated that the recommendations in this report will remain valid until 2018. At that time, the Department of Violence and Injury Prevention and Disability at WHO headquarters in Geneva will initiate a review of the document. Moving forward This comprehensive global report is an important step in advancing the field of child injury prevention, but it is only one such step. It is the hope of WHO, UNICEF and all involved in the report that its launch will lead to greater awareness around the world and a much increased political will for action at all levels to combat the scourge of child injuries. References 1. Child and adolescent injury prevention: a global call to action. Geneva, World Health Organization and UNICEF, 2005 (http://whqlibdoc.who.int/publications/2005/9241593415_ eng.pdf, accessed 21 January 2008). 2. Child and adolescent injury prevention: a WHO plan of action. Geneva, World Health Organization, 2006 (http:// whqlibdoc.who.int/publications/2006/9241593385_eng.pdf, accessed 21 January 2008). 3. Convention on the Rights of the Child, 1989. New York, NY, United Nations, 1989 (A/RES/44/25) (http://www.unhchr. ch/html/menu3/b/k2crc.htm, accessed 21 January 2008). 4. Report of the independent expert for the United Nations study on violence against children. New York, NY, United Nations, 29 August 2006 (A/61/299) (http://www.violencestudy.org/ IMG/pdf/English-2-2.pdf, accessed 21 January 2008). 5. Pinheiro PS. World report on violence against children. Geneva, Switzerland, United Nations Secretary-General’s Study on Violence against Children, 2006 (http://www. violencestudy.org/a553, accessed 21 January 2008). 6. Krug EG et al., eds. World report on violence and health. Geneva, World Health Organization, 2002 (http://www.who. int/violence_injury_prevention/violence/world_report/en/ full_en.pdf, accessed 21 January 2008). WORLD REPORT ON CHILD INJURY PREVENTION XVII
Slide 19: © WHO Juan lives with his mother, father, four younger brothers and two younger sisters in a small village outside Merida, in Mexico. Aged 14 years, Juan no longer goes to school, as he has to help his father selling fruit at the roadside. OVERVIEW JUAN’S STORY The reason that he left school is related to a terrible accident that the youngest in the family, Martha, suffered 18 months ago. Martha – six years old at the time – had fallen into the water well in the back yard of the family house, while trying to retrieve a toy that she had dropped into it. Juan was the first onto the scene of the incident and had called for his father who was further up the road selling fruit. The two of them ran to the nearest clinic holding Martha, who was limp and not crying. The doctors managed to resuscitate her but she remained in a critical condition and needed to be transferred to a larger hospital in Merida, where she stayed for many weeks. Juan went to visit his sister once in hospital, but did not like it there as he said that the hospital had a strange odour. He preferred to stay at home with his grandmother and help with the other children while his mother stayed at the hospital with Martha. Martha is a beautiful girl, who is now mentally disabled and needs assistance with all her daily needs. Juan is still very affected by this incident. He feels responsible for Martha’s fall into the well, convinced that it would not have happened if he had been there. At the same time, he is proud to show visitors the wooden construction he and his father made to put over the well, to prevent a similar incident occurring.
Slide 20: CHAPTER 1 – CHILD INJURIES IN CONTEXT Chapter 1 Child injuries in context Background Every child in the world matters. The landmark Convention on the Rights of the Child, ratified by almost all governments, states that children around the world have a right to a safe environment and to protection from injury and violence. It further states that the institutions, services and facilities responsible for the care or protection of children should conform with established standards, particularly in the areas of safety and health. Safeguarding these rights everywhere is not easy, but it can be achieved by concerted action. Children are exposed to hazards and risks as they go about their daily lives and are vulnerable everywhere to the same types of injury. However, the physical, social, cultural, political and economic environments in which they live differ greatly. Their particular environments are thus very important. Th is chapter provides an overview for the report. The fi rst section sets the scene, examining why child injury is important, how the issue relates to other concerns about children, and why there is an urgency to tackle it. The second section examines major features of the problem: the multiple types and causes of injury to children, and the associations between injury and age, gender and a range of socioeconomic factors. The third section seeks to show that child injury is preventable. It describes the principles of injury prevention, the types of approaches that are successful and the problem of adapting proven interventions to different settings. It also discusses the cost and cost-effectiveness of interventions to prevent child injury. The fi nal section summarizes some of the obstacles in this field and the approaches to overcoming them. Who is a child? This report uses the definition of the United Nations Convention on the Rights of the Child, Article 1: “a child means every human being below the age of 18 years” (3). Other concepts related to children, though, are more fluid. “Childhood” is a social construction, whose boundaries shift with time and place (4, 5) and this has implications for vulnerability to injury. A 10-year-old in one country may be protected from economic and domestic responsibilities, but in another country these tasks may be the norm and considered beneficial for both the child and the family (6). Thus, childhood and developmental stages are intertwined with age, sex, family and social background, school, work and culture (6, 7). Rather than being rigidly measured, they should be viewed through “context, culture and competences” (8). Why is child injury important? Childhood injury is a major public health problem that requires urgent attention. Injury and violence is a major killer of children throughout the world, responsible for about 950 000 deaths in children and young people under the age of 18 years each year (WHO Global Burden of Disease: 2004 update). Unintentional injuries account for almost 90% of these cases. They are the leading cause of death for children aged 10–19 years. Table 1.1 shows the contributions that the various types of unintentional injuries make to the leading causes of death among children. Road traffic injuries alone are the leading cause of death among 15–19-yearolds and the second leading cause among 10–14-year-olds. In addition to the deaths, tens of millions of children require hospital care for non-fatal injuries. Many are left with some form of disability, often with lifelong consequences. Table A.2 in the Statistical Annex shows the leading causes of disability-adjusted life years (DALYs) lost for children aged 0–14 years, with road traffic crashes and falls ranking in the top 15 causes. The burden of injury on children falls unequally. It is heaviest among the poor with the burden greatest on children in the poorer countries with lower incomes (see Table A.1 and A.2 in the Statistical Annex). Within all countries, the burden is greatest on those from low-income families. Overall, more than 95% of all injury deaths in children occur in low-income and middle-income countries. Although the child injury death rate is much lower among children from developed countries, injuries are still a major cause of death, accounting for about 40% of all child deaths (WHO Global Burden of Disease: 2004 update). WORLD REPORT ON CHILD INJURY PREVENTION 1 What is an injury? Throughout the report, an injury is defined as “the physical damage that results when a human body is suddenly subjected to energy in amounts that exceed the threshold of physiological tolerance – or else the result of a lack of one or more vital elements, such as oxygen” (1). The energy in question can be mechanical, thermal, chemical or radiated. As discussed in the introductory section, the focus of this report is on unintentional injuries: traffic injuries, drowning, poisonings, burns and falls. For more information on intentional injury, see the World report on violence against children (2).
Slide 21: TABLE 1.1 Leading causes of death in children, both sexes, World, 2004 Rank Under 1 year 1–4 years 5–9 years 10–14 years 15–19 years Under 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Perinatal causes Diarrhoeal diseases Lower respiratory infections Malaria Congenital anomalies Pertussis HIV/AIDS Tetanus Meningitis Measles Protein–energy malnutrition Syphilis Endocrine disorders Tuberculosis Upper respiratory infections Lower respiratory infections Diarrhoeal diseases Measles Malaria HIV/AIDS Congenital anomalies Protein–energy malnutrition Drowning Road traffic injuries Meningitis Fire-related burns Pertussis Tuberculosis Upper respiratory infections Syphilis Lower respiratory infections Road traffic injuries Malaria Diarrhoeal diseases Meningitis Drowning Protein–energy malnutrition Measles Tuberculosis HIV/AIDS Fire-related burns Falls Congenital anomalies Epilepsy Leukaemia Lower respiratory infections Road traffic injuries Drowning Malaria Meningitis HIV/AIDS Tuberculosis Diarrhoeal diseases Protein–energy malnutrition Self-inflicted injuries Leukaemia Fire-related burns War Violence Trypanosomiasis Road traffi c injuries Self-inflicted injuries Violence Lower respiratory infections Drowning Tuberculosis Fire-related burns HIV/AIDS Leukaemia Meningitis Maternal haemorrhage Falls Poisonings Abortion Epilepsy Perinatal causes Lower respiratory infections Diarrhoeal diseases Malaria Measles Congenital anomalies HIV/AIDS Road traffic injuries Pertussis Meningitis Drowning Protein–energy malnutrition Tetanus Tuberculosis Fire-related burns Source: WHO (2008), Global Burden of Disease: 2004 update. Injuries are not inevitable; they can be prevented or controlled. In the Organisation for Economic Cooperation and Development (OECD) countries, for example, the number of injury deaths among children under the age of 15 years fell by half between 1970 and 1995 (9). Until recently, little attention had been paid to the issue of injuries in low-income and middleincome countries. The lack of awareness of the problem, compounded by the particular circumstances that these countries face, has meant that proven measures have not been implemented to the same extent as they have in high-income countries. Countries face many competing priorities and injury interventions need to be properly assessed for their effectiveness. However, a great deal more is known about preventing child injury and death than has been acted upon. Research continues to shed new light on the scale of the problem as well as on the potential that exists for saving 2 WORLD REPORT ON CHILD INJURY PREVENTION lives and preventing injuries. For example, the analyses of the South and East Asian community surveys of injury (see Statistical Annex, Table B.1) show just how significant child injury is. Injury is responsible for 30% of deaths in 1–3-year-olds, with the figure approaching 40% in 4-yearolds and 50% to 60% among those aged 5 to 17 years (10). How does child injury relate to other child health concerns? As injury is a leading cause of death and disability among children worldwide, preventing child injury is closely connected to other issues related to children’s health. Tackling child injury must be a central part of all initiatives to improve the situation of child mortality and morbidity and the general well-being of children (see Box 1.1). In recent decades, programmes related to child survival targeted infectious diseases and nutritional deficiencies in infants and children. Campaigns were conducted for
Slide 22: BOX 1.1 International contributions towards improving child health Convention on the Rights of the Child In November 1989, the United Nations Convention on the Rights of the Child set a new international standard for respecting children and their rights (3). The Convention stresses the responsibilities of society to protect children (from birth up to the age of 18 years) and provide them with appropriate support and services. It further states that children have the right to the highest attainable level of health and the right to a safe environment, free from injury and violence. World Health Assembly resolutions The World Health Assembly, the annual meeting of the world’s health ministers, has strongly promoted, through its resolutions, the recommendations contained in WHO’s World report on violence and health (11) and World report on road traffic injury prevention (12). These include Resolution WHA 56.24 on violence and health (13) and Resolution WHA 57.10 on road safety and health (14). Children are frequently mentioned in these and other resolutions as a special target group for interventions. Millennium Development Goals In September 2000, the General Assembly of the United Nations adopted a series of Millennium Development Goals. The fourth goal is to reduce, by two thirds, the mortality rate of children under the age of 5 years, between 1990 and 2015 (15). Because of the large number of deaths of children under the age of 1 year from infectious diseases and neonatal causes, injury is responsible for only around 1.5%–2.0% of deaths in this age group. However, for children aged between 1 and 4 years, injuries are a more significant cause of death, accounting for just over 6% of all deaths. United Nations Member States are committed to meeting all eight Millennium Development Goals by 2015. Not all countries will meet the fourth goal if they do not include injury prevention in their programmes. A World Fit for Children In May 2002, the United Nations General Assembly held a Special Session on children, from which a document, A world fit for children, was produced. This sets out a number of health goals for children. One of these, specific to injuries, calls on all Member States to “reduce child injuries due to accidents or other causes through the development and implementation of appropriate preventive measures” (16). Child survival Child survival has become an important issue globally, as part of a broader and growing concern for the health and well-being of children and young people. Indeed, child survival has been described as “the most pressing moral dilemma of the new millennium” (17). The Bellagio papers provide new estimates of the numbers and causes of child deaths, including injuries, and suggest that two thirds of the nearly 11 million annual deaths among children under the age of 5 years can be prevented by implementing a set of 23 proven and cost-effective interventions (18). To be most effective, child injury prevention efforts should be integrated into broader child health initiatives. breastfeeding, growth monitoring, immunization and oral rehydration therapy. Millions of lives were saved, and the lives of many more children were improved. However, unless injury prevention is included in such programmes, as these children grow up and are subjected to injuries, the impact of the large investments in immunization, nutrition and maternal and child health care may be lost (19). “If we are ultimately going to meet the Millennium Development Goal to reduce child mortality, it is imperative that we take action to address the causes of childhood injury ” Anupama Rao Singh, Regional Director of UNICEF East Asia and Pacific. Child injuries and the changing world Over fift y years ago, one child injury expert declared that: “it is now generally recognized that accidents constitute a major problem in public health” (20). A report of 1960 from the World Health Organization Regional Office for Europe shared this view: in high-income countries, it announced, injury had become the leading cause of death in children older than one year (21). However, the acknowledgement that childhood injuries are a significant problem in developing countries has been more recent. With improvements in other areas of child health and better methods of collecting data, it is now clear that injury is a leading cause of child death and ill-health in low-income and middle-income countries (22, 23). The full extent of the problem of injuries in many countries, though, is still not fully understood. Recent large-scale community-based surveys in five countries in South and East Asia (Bangladesh, China, the Philippines, Thailand and Viet Nam) of overall child mortality, have found much higher levels of death from injury – both before and after the age of five years – than had been previously thought (19). Th is approach has complemented hospitalbased and clinic-based health information systems, which often miss many injury deaths since, for example, a drowned child is almost never taken to a hospital or local clinic. Drowning, although unrecognized as a major cause of child death in earlier estimates, accounted for around half of all child injury deaths in each of the countries surveyed (19). WORLD REPORT ON CHILD INJURY PREVENTION 3
Slide 23: Tackling the injury problem is possible. Experience and research have both shown that most child injuries, and deaths from injuries, are preventable in all countries (9, 24, 25). BOX 1.2 Globalization Globalization involves a set of socioeconomic, cultural, political and environmental processes that intensify the connections between nations, businesses and people (26– 28). The more rapid dissemination of ideas and knowledge of injury prevention (29), and the growth of a global civil society (26) involving networks of formal and informal groups, can have a positive influence on injury issues. However, there are also negative effects (see Box 1.2). With greater freedom of movement of capital across national boundaries, the production of goods – often a hazardous process – can more easily shift to regions of cheaper labour (28). This, in turn, can lead to increased transport in places where road safety is poorly developed (30). Centres of cheap production often have weaker controls on occupational health and child labour. Whether globalization will increase or decrease the amount of child labour has been the subject of debate (31). According to the International Labour Organization, in 2004 there were still 218 million child labourers under the age of 15 years. However, over the past four years, there has been a global fall in the number of children working, particularly of those working in hazardous occupations (32). In some places, though – such as Gujarat state in India – economic growth has led to more children working, which is likely to lead to a greater number of injuries (33, 34). The effects of globalization on child injuries Valli was devastated. She had left her small daughter alone for a few minutes, to go out to fetch water from the communal tap. On her return, she found the child had drowned in just 10 cm of water. Valli usually carried water from the tap in the traditional kodam, but stored it in the new plastic buckets that are now cheaply available in India. With increasing globalization and a fast-expanding Indian middle class, the country’s use of plastic has soared. Plastic is everywhere – in products, packaging and bags for carrying home goods. Unlike many other countries, though, India recycles almost half of all plastic goods, converting them into other cheap plastic products such as water buckets, that are often sold without lids. Local bucket-making factories buy plastic from recycling shops for about 35 rupees (less than one US dollar) a kilogram and make cheap containers of various shapes and sizes from the processed plastic. Drowning can occur in even just a shallow amount of liquid at the bottom of a bucket. Given the shape, size and stability of these buckets, they may not tip over when a child leans into one and falls inside. The older and safer practice of storing water in a kodam – with its narrow opening that kept water cool and dirt-free and prevented drowning – has been discarded in favour of a cheaper plastic solution. A similar problem of drowning in buckets was observed by the Consumer Product Safety Commission in the United States some 15 years ago. The Commission subsequently recommended a performance standard, a ban on this type of bucket and an information and education campaign. Urbanization Urbanization, much of it unplanned and ill-resourced, is accelerating children’s exposure to risk (35). Over the next two decades, a large part of the world’s population growth will be in urban areas. The proportion of the global population in urban areas is predicted to rise from around 50% today to over 60% by 2030 (36). Most of this growth will be in Asia and Africa (37). Urbanization can promote positive attributes for health (38, 39). Medical care for injuries may be easier to provide in urban than in scattered rural areas and there are economies of scale in providing better housing and services. However, as a result of natural growth and migration, cities may expand beyond the capacity of resources to cope adequately (40, 41). Urban slums and squatter camps pose high risks of injury for children across the world (42, 43). Motorization The increase in motorization is related to trends in globalization and urbanization, yet it is worth examining separately because of its significant impact on child injury. 4 WORLD REPORT ON CHILD INJURY PREVENTION Roads have always been dangerous places for children. However, the rapid increase of traffic and the shift of transport systems around the world to roads make the issue especially pressing. Deaths and injuries from road traffic crashes are forecast to rise across the world by 67% between 1990 and 2020 (12). Improved transport and a good road infrastructure are usually considered crucial for overall development (44, 45). The OECD Development Co-operation Directorate’s Task Team on Infrastructure for Poverty Reduction (46) has pointed to benefits for the poor who need better © P. Virot/WHO
Slide 24: transport to access markets, job opportunities, education and health facilities. In Morocco, for instance, paved roads have helped increase school attendance substantially (44). A major increase in road infrastructure has been proposed for Africa by the Commission for Africa (47) as part of the efforts to achieve the Millennium Development Goals. It would be ironic, though, if pursuing the Millennium Development Goals – without strictly considering health and safety issues – led to an increase in death and injury among children from road traffic crashes or as a result of increased pollution. The child-injury pyramid Death is the most notable measure of injury but it is neither the only outcome nor the most common. Injury is often graphically represented as a pyramid, with the smallest group, that of death, at the top, hospitalized injury in the middle and the largest group, non-hospitalized injury, at the base. The fi rst study of the sizes of these groups was carried out by the Child Safety Network in the United States in the early 1980s. Their analysis showed that for every one child under 19 years of age who was fatally injured, 45 children required hospitalization and a further 1300 were seen in an emergency department and discharged (60). This pattern has been confirmed by detailed work in other regions and countries, although the exact ratios are affected by the local provision of services and the degree of access to hospital care. UNICEF and the Alliance for Safe Children have examined health histories for two and a quarter million people in five countries of South and East Asia (10). The combined data show that, for children under 18 years of age, for each death there are 12 children admitted to hospital or permanently disabled and 34 children who needed medical care or missed school or work because of an injury. Children are not only affected by injuries to themselves, but also by injury to others. This applies particularly to the loss or disability of parents or caregivers through injury, and indeed of other members of the family, and they are affected by expenses and loss of income within the family as a result of injury (61, 62). In Jiangxi Province in China, for instance, for children of primary school age or younger, about half of parental deaths are associated with injury (63). Environmental change The scale and impact of environmental risks may well be accelerating, induced by the global effects of climate change. The Intergovernmental Panel on Climate Change has predicted an increase of between 1.5 °C and 6 °C by 2100, depending on future carbon emissions (48). The causal pathways by which climate change could affect children’s health are not clear; they are often indirect and their consequences may be felt at different times (49–53). Children may be exposed to risk of injury through an increase in extreme weather conditions that pose direct hazards – such as flooding, cyclones or mud flows from heavy rains. They may also be exposed through longerterm degradation of environments – such as droughts, desertification or rises in sea level (54, 55). Children in low-income countries face the greatest problems. Squatter and other makeshift urban settlements are often highly vulnerable to flooding, and health systems in these places are generally less able to cope (56). Both extreme and long-term environmental change can lead to migration, with people ending up living in marginal, unsafe conditions. Fatal child injuries The characteristics of child injury Unintentional injuries are one of the leading causes of death, hospitalization and disability across the world. However, the pattern and aetiology of injuries and their outcome vary substantially within populations and across countries. Epidemiologic analysis has long identified broad factors that, within specific environments, pinpoint the types of injury and the groups of children most at risk (21, 57). In high-income countries, research has identified risk factors and protective factors for individual types of child injury (58, 59). Detailed work on child injury in low-income and middle-income countries began more recently and is now indicating priorities for prevention. The characteristics of children susceptible to injury vary greatly by age, gender, race and socioeconomic status. These factors are dealt with in the following section and in greater detail in the individual chapters in this report. In 2004, approximately 950 000 children under the age of 18 years died of an injury. The majority of these child injuries were the result of road traffic collisions, drowning, burns (fire or scalds), falls or poisoning (see Figure 1.1). These five categories, classified as unintentional injuries, make up 60% of all child injury deaths. A further category, labelled “other unintentional injuries”, includes smothering, asphyxiation, choking, animal or snakebites, hypothermia and hyperthermia. This group accounts for 23% of childhood deaths, a significant proportion. The rate of child injury death is 3.4 times higher in lowincome and middle-income countries than in high-income countries, but there are large variations according to the category of injury death. For fire and flame deaths, the rate in low-income countries is close to 11 times higher than in high-income countries, for drowning it is six times higher, for poisons four times and for falls around six times higher (see Table 1.2). WORLD REPORT ON CHILD INJURY PREVENTION 5
Slide 25: FIGURE 1.1 TABLE 1.3 Distribution of global child injury deaths by cause, 0–17 years, World, 2004 Other unintentionala 31.1% Road traffic injuries 22.3% Unintentional injury death rates per 100 000 children by age and country income level, World, 2004 AGE (in years) Under 1 HIC LMIC World 28.0 102.9 96.1 1–4 8.5 49.6 45.8 5–9 5.6 37.6 34.4 10–14 6.1 25.8 23.8 15–19 Under 20 23.9 42.6 40.6 12.2 41.7 38.8 War 2.3% Self-inflicted injuries 4.4% Drowning 16.8% Source: WHO (2008), Global Burden of Disease: 2004 update. Fire-related burns 9.1% Homicide 5.8% a Poisoning 3.9% Falls 4.2% “Other unintentional” includes categories such as smothering, asphyxiation, choking, animal and venomous bites, hypothermia and hyperthermia as well as natural disasters. Source: WHO (2008), Global Burden of Disease: 2004 update. TABLE 1.2 Unintentional injury death rates per 100 000 childrena by cause and country income level, World, 2004 UNINTENTIONAL INJURIES Road Drowning Fire traffic burns HIC LMIC World a b Falls Poisons Otherb TOTAL 0.4 2.1 1.9 0.5 2.0 1.8 2.6 14.4 13.3 12.2 41.7 38.8 7.0 11.1 10.7 1.2 7.8 7.2 0.4 4.3 3.9 These data refer to those under 20 years of age. “Other” includes categories such as smothering, asphyxiation, choking, animal or snakebites, hypothermia and hyperthermia as well as natural disasters. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. In an analysis of child death rates by sex, the rate of male deaths exceeds that of female deaths in nearly all categories of injury, with the exception of fire-related burns (see Figure 1.2). The female excess in fire-related burns is particularly noticeable in certain parts of the world, such as the WHO South-East Asia Region and the low-income and middle-income countries of the Eastern Mediterranean Region, where deaths of female adolescents can exceed those of males by up to 50% (see Statistical Annex, Table A.1). In most regions and countries, the gender gap for fatal injuries increases with age. At the global level, injury death rates among children under the age of 1 year, as well as those aged 1–4 years, are about the same for males and females. However, in children aged 5–9 years, male death rates are a third higher than female rates, a discrepancy that increases to 60% among those aged 10–14 years. Adolescents aged 15–17 years show an adult profile, with males in that age group accounting for more than 86% of all injury deaths, particularly in high-income countries. The association of age with injury type is found in both rich and poor countries. As can be seen in Table B.1 in the Statistical Annex, the combined results of the South and East Asian community surveys show that, in that part of the world, the main cause of injury death in children under 1 year of age is suffocation. In children under 5 years it is drowning, for those aged between 5 and 9 years drowning is joined by road traffic injuries and animal bites, while among children aged 10–17 years, road traffic deaths are the most significant unintentional injury. However, there are great differences between rich and poor countries. While drowning is the leading cause of injury death among children under 5 years in both the United States and Asia, the rate of death per 100 000 children is 30 times higher in Asia (19, 62). Table 1.3 shows that rates of injury death vary substantially by age in high-income countries with the highest rate, that for 15–19-year-olds, being four times the lowest rate, that for 5–9-year-olds. 6 WORLD REPORT ON CHILD INJURY PREVENTION FIGURE 1.2 Unintentional injury death rates per 100 000 childrena by cause and sex, World, 2004 15 Rate per 100 000 population Boys Girls 10 5 0 Road traffic injuries a b Drowning Falls Firerelated burns Poisoning Other unintentionalb These data refer to those under 20 years of age. “Other unintentional” includes categories such as smothering, asphyxiation, choking, animal and venomous bites as well as natural disasters. Source: WHO (2008), Global Burden of Disease: 2004 update.
Slide 26: Non-fatal child injuries The types of injury associated with child death are different from those that cause non-fatal injury and can again be different from those that cause long-term effects. The community surveys conducted in South and East Asia have shown up the relative significance of nonfatal injury and how it differs from fatal injury. Similarly, in Brazil, for children under 15 years of age, the leading causes of unintentional injury death are associated with traffic-related injuries and drowning, while more than half of all non-fatal injuries are the result of a fall (64). These fi ndings also come out in the 28-country Global School Health Survey, where in all countries, except one, falls are the leading causes of non-fatal injury but account for only a small proportion of fatal child injuries (see Statistical Annex, Table A.3). Focusing on death data alone, therefore, may result in injury prevention strategies ignoring frequent injuries that are also costly to the health care system. Injuries and subsequent disability Head injuries are the single most common – and potentially most severe – type of injury sustained by children. Among minor injuries incurred by children, cuts and bruises are those seen most frequently. However, the most common category of unintentional injuries suffered by children under 15 years and requiring hospital admission are various types of fractures to the arms and legs (see Table 1.4). In addition to mortality, hospital admissions, emergency department attendances and days lost from school can all be used as markers of injury severity. There are also more specific scoring methods, including notably, the Injury Severity Score, the Revised Trauma Score and the Paediatric Trauma Score. A review of the different types of measures currently used indicates that there is no standard method to determine the severity of an injury in a particular child (65). Each type of measure has its drawbacks and may vary according to the cause of injury or access to care. Measures of disability also tend to be non-standard. TABLE 1.4 Nature of unintentional injuries sustaineda by children under 15 years, World, 2004 Type of injury sustained Intracranial injuryb – short-termc Open wound Poisoning Fractured ulna or radius Burns <20% Fractured clavicle, scapula or humerus Internal injuries Fractured femur – short-termc Fractured patella, tibia or fibula Fractured hand bones Fractured face bones Fractured skull – short-termc Fractured vertebral column Fractured ankle Injury to eyes – short term Sprains Injured nerves – long-termd Other dislocation Fractured foot bones Intracranial injuryb – long termd a b c d Rate per 100 000 population 419.4 316.9 282.4 209.3 152.7 133.8 129.3 115.8 81.1 70.1 60.1 55.2 54.5 34.8 34.3 33.7 26.1 24.1 23.2 21.0 Proportion of all unintentional injuries (%) 16.3 12.3 10.9 8.1 5.9 5.2 5.0 4.5 3.1 2.7 2.3 2.1 2.1 1.4 1.3 1.3 1.0 0.9 0.9 0.8 Requiring admission to a health facility. Traumatic brain injury. Short-term = lasts only a matter of weeks. Long-term = lasts until death, with some complications resulting in reduced life expectancy. Source: WHO (2008), Global Burden of Disease: 2004 update. WORLD REPORT ON CHILD INJURY PREVENTION 7
Slide 27: Data from the Global Childhood Unintentional Injury Surveillance conducted in four cities showed that nearly 50% of children under the age of 12 years who had suffered an unintentional injury severe enough to warrant presentation to an emergency deparment were left with some form of disability (Statistical Annex, Table C.1). Among children who had suffered a burn, 8% were left with permanent disabilities, while children injured in traffic crashes were significantly more likely to be left with some form of disability (Table 1.5). Many young people who survive major trauma are left with ongoing disabilities, with a major impact on their own lives as well as on the lives of their families. These disabilities may be physical, mental or psychological. Some of the problems encountered in the years following injury include an inability to attend school, find suitable work or engage in an active social life. There are also other more basic problems such as having to cope with continued pain. Support for these young people most often falls on their close family and friends (66). Exposure to injury risk for children also depends on the particular set of laws that are in place and the degree to which these are enforced. These laws include the legal ages for entering the formal workforce, for driving, and for drinking alcohol. There are often considerable differences between countries. Alcohol can be legally consumed at 15 years in Belgium, but not until the age of 20 years in New Zealand. A car can be legally driven in New Zealand at the age of 15 years. In Sweden the legal driving age is 18 years (70). What makes children particularly susceptible to injury? Children are not just small adults. Their physical and cognitive abilities, degrees of dependence, activities and risk behaviours all change substantially as they grow older (50, 71–75). As children develop, their curiosity and wish to experiment are not always matched by their capacity to understand or to respond to danger (76). At about 3 months of age children will start to wriggle and roll, at about 6 months they will sit up, and they will start crawling at around 9 months. Objects are reached for, grasped and put in their mouth. At 18 months they are mobile and exploring the world. Child development and behaviour is therefore highly associated with particular injuries. Poisoning, for example, is linked to the grasping and drinking behaviour of children aged 1–3 years, while falls are related to the stage of learning to walk. Analysis of injury using age ranges in years can be too broad to detect the rapid change in development and injury risk among very young children. By using 3-month age brackets, one study showed that falls were the leading cause of injury in children aged under 3 years, but that the particular items that caused their falls – such as furniture, Child injury and age Injury prevention strategies need to take into account child development in different and sometimes changing contexts. Adolescence, for example, has become a more significant developmental stage in many low-income countries, whereas before there had been a more direct transition from childhood to adulthood (67). Childhood is also changing at earlier stages in some places. In parts of sub-Saharan Africa, HIV/AIDS is creating parentless households. With young children forced to take on adult responsibilities (68) the nature of childhood in these areas has changed radically (69). TABLE 1.5 Injury severity and estimated long-term effects of unintentional injuries among childrena presenting to emergency departments in four countriesb TYPE OF UNINTENTIONAL INJURY Road traffic injuries (n = 350) Lowest score Highest score Median ISS Mean ISSc No significant disability Short term temporary disability (< 6 weeks) Long term temporary disability (> 6 weeks) Permanent disability a b c Falls (n = 913) 0 75 4 5 53% 39% 8% 1% Burns (n = 210) Poisoning (n = 66) Drowning (n = 20) 0 75 4 11 65% 20% 5% 10% Total 0 75 4 10 38% 43% 17% 3% Injury Severity Score (ISS) 0 0 75 16 3 1 5 3 Disability 51% 24% 17% 8% 80% 12% 8% 0% 0 75 4 7 56% 40% 12% 2% aged under 12 years. Bangladesh, Colombia, Egypt, Pakistan. to nearest whole number. Source: see Statistical Annex, Table C1. 8 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 28: stairs and playground equipment – were important at different ages. The study also showed that poisoning injury started to rise at the age of 9 months, continuing up to 21 to 23 months, and then declined. Burns from hot liquids were substantially higher among those aged 12 to 18 months (73). The small stature of children increases their risk in a road environment. They are less visible than adults and if hit by a vehicle, they are more likely than an adult to sustain a head or neck injury (77). At the same time, small children have difficulty seeing over vehicles, judging the speed of oncoming vehicles and discerning the distance of a vehicle from the sound of its engine (78). Other physical characteristics make children vulnerable to injuries. The skin of infants burns more deeply and quickly and at lower temperatures than the thicker skin of adults (77). Smaller airway size increases the danger of aspiration (24). In addition, certain physical characteristics of young children may affect injury outcomes. For example, children’s larger ratio of body surface area to volume means that not only will the size of a burn – for a given volume of hot liquid – be greater than for an adult, but also that there will be more fluid lost from the burnt area, thus complicating the management of the injury (79). Similarly, a given amount of a poisonous substance will more likely be toxic for a child than an adult because of the child’s smaller mass. Children’s smaller size also creates a risk of entrapment of body parts, most dangerously for the head. Many products and settings do not properly take these risks into account. Studies of children in road traffic have shown that young children may lack the knowledge, skills and levels of concentration needed to manage the road environment, no matter how benign the road conditions (80). Their physical abilities may not be matched by cognitive abilities. For instance young children, in the process of exploring their world, may fall from heights because their climbing ability is not matched by their ability to balance or reason (77). Urban planners and policy-makers know little of children’s concerns and often assume change will benefit all (84). For example, improving water supplies to a neighbourhood may result in young children – often the family water carriers – having to travel an increased distance to a standpipe to fetch water, with possible damage to their head, neck and spine (85). New products are often designed without taking into consideration their possible use by children and the consequent harm. Child injury and gender Boys tend to have both more frequent and more severe injuries than girls (1, 76). Sex differences in injury rates appear within the first year of life for most types of injury (86). According to WHO data, in children under 15 years, there are, on average, 24% more injury deaths among boys than there are among girls. Data from developed countries indicate that, from birth onwards, males have higher rates of injury than females, for all types of injury (87). The pattern is less uniform in low-income and middle-income countries, but the overall gender differential is clear, with injury death rates around one third higher for males under 20 years of age than for females. A number of reasons for these differences in injury have been put forward and investigated. One study found that sex differences were not completely explained by differences in exposure to risk and that differences in injury rates begin to appear at the same age as differences in behaviour (86). Various theories have been proposed for the difference in injury rates between boys and girls (88). These include the idea that boys engage in more risk taking than girls (89), that they have higher activity levels (90), that they behave more impulsively. Also included are the suggestions that boys are socialized in a different way from girls and are less likely to have their exploration restrained by parents (91), that they are more likely to be allowed to roam further (92), and that they are more likely to be allowed to play alone (93). Children’s worlds Young children’s behaviour differs from that of adults. A vivid illustration of this is in the home environment. “[They] crawl about the floor, climb onto the window ledge, squeeze through stair balustrades, slide down the stair handrail, swing on the gate, run from room to room and ride bikes inside as well as out, making use of their houses in ways that seem to them reasonable, but have not apparently been foreseen by the designer” (81). Physical and mental stages are important, but children are especially vulnerable to injury because they live in a world in which they have little power or control. The vulnerability of children is exacerbated by their lack of power and status (6). They find themselves in urban and rural environments constructed by and for adults (82). Their voices are seldom heard and only rarely are places designed in consultation with children (83). Child injury and socioeconomic factors As can be seen in Figure 1.3, most of the childhood injury burden rests in low-income and middle-income countries, and within these countries, poor children are disproportionately affected (94). Some of the most vulnerable groups are those who live in chronic poverty (95). They are a heterogeneous group, often living in remote rural areas or confl ict zones or else displaced. In the Islamic Republic of Iran, for example, a communitybased survey has shown that the majority of fatal unintentional injuries to children under the age of 15 years occur in remote or rural areas (96). The chronic poor have few buffers against shocks – such as income and social networks (97). The fi rst target of the Millennium Development Goals is to halve, between 1990 and 2015, WORLD REPORT ON CHILD INJURY PREVENTION 9
Slide 29: FIGURE 1.3 Rate of unintentional injuries per 100 000 childrena, by WHO region and country income level, World, 2004 45+ 30–44.99 15–29.99 <15 No data Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific LMIC 53.1 HIC 14.4 LMIC 21.8 LMIC 49.0 HIC 7.9 LMIC 25.4 HIC 41.6 LMIC 45.7 HIC 7.8 LMIC 33.8 a These data refer to those under the age of 20 years. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. the proportion of people living on less than one US dollar a day. Definitions of poverty There are two broad categories of poverty: “absolute poverty” and “relative poverty”. The former relates to the minimum requirements needed for physical survival or subsistence, the latter to the prevailing living standards of a society. It has been suggested that poverty goes beyond mere subsistence, involving also what in a particular society are considered the minimum conditions of well-being (98). The injury field abounds with different operational definitions of poverty and related socioeconomic factors. These variations have made it difficult to consistently collect comparable data on important demographic factors such as the socioeconomic status of parents, family income and education, as well as on the characteristics of particular areas, schools, medical centres and childcare centres. There is a great need for standardization of definitions and methods to improve the quality and usefulness of information. – factors related to accommodation – such as type of tenancy, type of housing, level of overcrowding and various factors describing the neighbourhood. Socioeconomic factors affect injury risk in a number of ways (74). In poor households, parents may not be able to: – properly care for and supervise their children, who may need to be left alone or in the care of siblings (see Box 1.3); – afford safety equipment, such as smoke alarms or safety helmets. Children living in poverty may be exposed to hazardous environments, including: – a high volume of fast-moving traffic; – lack of space and facilities for safe play; – cramped living conditions, with no proper kitchen and open cooking fires; – unprotected windows and house roofs, and stairs without handrails. Access, or the lack of it, to good-quality medical services is an important explanatory factor for variations in mortality rates. In a Nigerian study, 27% of 84 children admitted to hospital for a burn injury died as a result of their injury (79), in contrast with a similar study from Kuwait, where 1% of a sample of 388 children died (99). This discrepancy, though, may also be related to differences in the severity of burns seen. Socioeconomic factors and risk for injury A broad range of socioeconomic factors associated with injury risk has been identified (74). These factors include: – economic factors – such as family income; – social factors – such as maternal education; – factors related to family structure – including single parenting, maternal age, numbers occupying the household, and number of children; 10 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 30: BOX 1.3 Child supervision Supervision is widely recognized as vital to protecting children from harm. Some estimates suggest that 90% of injuries to young children occur in or around their home when they are supposedly being supervised by a caregiver. Despite the beliefs that childhood injury is often related to a lack of supervision, evidence to support this premise is limited. There have been few attempts formally to define the term “supervision” in the context of injury prevention. A reasonable definition, consistent with existing evidence, is that supervision refers to behaviours that are related to attention (watching and listening) and to proximity (touching, or being within reach). Furthermore, these behaviours are judged by how continuous they are (whether constant, intermittent or not at all). What some researchers are finding, though, is that caregivers exhibit a spectrum of patterns of supervision – ranging from almost total neglect to extreme vigilance. While there are many parallels between good parenting skills and good supervision practices, there does not seem to be any agreed-upon supervisory style that is uniformly protective. In addition, the effectiveness of supervision will be affected by whether the caregiver becomes distracted, and by the caregiver’s mental health status, use of alcohol or drugs, complacency or overconfidence. Models of supervision have focused on: – the need for supervision based on a child’s age, developmental status and exposure to possible hazards; – the supervisor’s judgement, skills and ability to influence the child; – the physical proximity of the supervisor to the child, taking into account the setting and the characteristics of the child; – the degree of verbal and physical interventions with the child; – how much of the time the supervisor is actively supervising. Tools are needed to measure these various constructs more accurately. There is considerable indirect evidence that associates supervision with a child’s risk of injury. This risk increases substantially when the child lives with a single caregiver, in a home with multiple siblings, or with a substance-abusing caregiver – all of which can compromise the ability of a caregiver to attend closely to the child. In large families, supervision of younger children by older children may be common, but is usually inadequate. Good child supervision is likely to be an important intervention to protect children from injury. However, the role of supervision and guidelines for its age-appropriate application in various settings of injury risk need further investigation. Research to improve the effectiveness of supervision as an injury prevention strategy should include efforts to define and measure different types of supervision. Models of good supervision should be developed, and cultural influences on the ways supervision is conducted should be examined. Interventions to influence the behaviour of caregivers also need to be considered. A final critical step is to evaluate different supervision strategies and measure their impact on reducing injuries. A few studies in developed countries have attempted to look at the association between childhood injuries and socioeconomic status. In England and Wales, a study examined injury mortality data by occupational group of the parents for children aged 1–15 years over two time periods – 1979–1983 and 1989–1992 (100). All childhood injury deaths had declined between the two periods of study, but the associations of injury deaths with socioeconomic factors had become stronger. Social gradients were particularly steep for certain types of injury such as homicide, fi re burns and pedestrian injuries. A recent study in New South Wales confirmed that the association between relative socioeconomic disadvantage and non-fatal injury risk among children in this Australian state was strongest for transportrelated injuries, burns and poisoning (101). There are even fewer studies from developing countries that have examined childhood injuries according to socioeconomic group. A study in South Africa explored the incidence and causes of injury across socioeconomic and environmental settings in six neighbourhoods in a poor area of Johannesburg – two informal settlements, two neighbourhoods of council houses and two of council-built apartment buildings (102). The informal settlements reported higher rates of injury than the other types of neighbourhood. A survey on the economic impacts of injury in rural Viet Nam showed that poverty was a significant risk factor for injury, and also that children in poor households had higher rates of injury sustained in the home than better-off children (103). Injuries as a cause of poverty Poor populations are particularly vulnerable to a range of calamities, which can trigger a further decline in family resources. Crises brought about by ill-health, a road traffic crash or an episode of flooding may push people into poverty (104). A study in Bangalore, India and in Bangladesh found that the burden from road crashes had pushed many households into poverty. In Bangalore, 71% of households in urban areas and 53% in rural areas were not poor before the crash; in Bangladesh the comparable figures were 33% in urban areas and 49% in rural areas (105). In Viet Nam, the cost of injury to poor households was estimated as equivalent on average to 11 months’ income. The risk of a poor household falling below the poverty line was 21% higher among those that had had an injury than among those that had not (106). HealthWORLD REPORT ON CHILD INJURY PREVENTION 11
Slide 31: care costs and the loss of income were the main factors contributing to this effect. Children are a particularly vulnerable group, either directly through being injured themselves or indirectly through the loss of their parents. In a Bangladesh slum, 40% of malnourished children came from households where the breadwinner had been incapacitated by illness or injury (107). In Ghana, a study of the economic consequences of injury within the family found that in rural households, 28% of families reported a decline in food consumption following an injury (108). A study in Bangladesh found that injury was the leading cause of children losing a parent, with about 7900 fathers and 4300 mothers dying each year (61). Certain groups of children have higher than average rates of injury. These rates may be associated with the specific circumstances and environment of the children – for instance, being refugees or being homeless. The groups that stand out most clearly with respect to their higher injury rates are indigenous populations, who also tend to experience greater relative poverty than their compatriots (109). Injury is a major cause of death and morbidity among the Maori population in New Zealand (110). In the United States and Australia, injury death rates in indigenous people are two to three times the rates for non-indigenous people (111). The death rate from road traffic injuries among indigenous Australians under 15 years of age, is two and a half times that for non-indigenous young Australians (16.7 per 100 000, compared to 6.6 per 100 000) (112). before, during and after the injury (corresponding to primary, secondary and tertiary prevention). The resulting matrix provides a means to identify, cell by cell: – strategies and priorities for injury prevention, in terms of their costs and effects; – existing research and research that needs to be undertaken; – the allocation of resources in the past and the future, and the effectiveness of such allocation. Haddon went on to describe 10 strategies to accompany the matrix, which describe the ways in which the harmful transfer of energy can be prevented or controlled in some way (119) (see Table 1.6, where Haddon’s 10 strategies have been applied to child injuries). The significance of the Haddon Matrix and Haddon’s 10 injury prevention countermeasures is that they highlight the fact that not only can society intervene to reduce injury, but that such interventions can occur at different stages (120). Public health approaches As has occurred with several other health issues, the emphasis has shifted over recent years from the individual to the environmental context in which an injury occurs. Along with this shift of emphasis, there has also been a realization that single-cause explanations of injury are incomplete and that models using a range of causes are needed instead. The public health model is therefore useful as it approaches the issue in a systematic and coordinated way, following four logical steps (Figure 1.4) – all of which call for good evidence on which to base activities. It is a model that can reveal important emerging issues in child injury prevention (see Box 1.5). FIGURE 1.4 The preventability of child injury The principles of injury prevention Injuries can be prevented or controlled. Because of their many causes and the close interrelationship between them, a wide range of prevention approaches is called for. Various prevention models have been proposed, but for the purpose of this report the classic model is used, including: – primary prevention: preventing new injuries; – secondary prevention: reducing the severity of injuries; – tertiary prevention: decreasing the frequency and severity of disability after an injury (see Box 1.4). The public health approach to injury prevention 1. Surveillance What is the problem? 2. Risk factor identification What are the causes? 4. Implementation The contribution of Haddon William Haddon Jr developed a scheme (known as the “Haddon Matrix”) in the 1960s to apply the principles of public health to the problem of road traffic safety (117, 118). It has since been used as a means of developing ideas to prevent injury of all types. The matrix consists of 12 cells. These are arranged in a table of four columns relating to the host, agent/vehicle, physical environment and social environment, and of three rows relating to the periods 12 WORLD REPORT ON CHILD INJURY PREVENTION How is it done? 3. Development and evaluation of interventions What works? A public health perspective also allows for a holistic approach to the issue of child injury. Such an approach can bring together, as partners, the diverse range of national and local agencies and organizations involved in injury prevention, and coordinate actions under a single umbrella (120).
Slide 32: BOX 1.4 Access to care Much can be done to lower the burden of death and disability from injury by strengthening trauma care services across the spectrum from prehospital care through hospital care to rehabilitation. The chain of survival starts at the scene of the incident. Prompt, quality pre-hospital care can save many lives after an injury. Where formal emergency medical services (usually with ambulances) exist, their performance can be improved by standardizing equipment, training, infrastructure and operations. Where they do not exist, starting new formal emergency medical services can be a reasonable option, especially along busy roads with high rates of crashes. However, these services can be costly. In any circumstance, and especially where there are no formal emergency medical services, pre-hospital care can be improved by building upon existing, informal systems of pre-hospital care and transport. In many cases this involves drawing upon resources in the community to train and possibly equip those whose job it is to be the first on the scene of an emergency. These may be members of the lay public, members of organizations such as the Red Cross and Red Crescent societies, or members of national emergency services, such as the police and fire services. A good example of the effectiveness of such an approach is a project, creating a two-tier system, that operated in northern Iraq and Cambodia. Several thousand villagers, forming the first tier, were trained in basic first aid. When needed, a second tier of more highly trained paramedics was called upon. This system sharply decreased mortality rates among victims of mine explosion and of other trauma, and is a good example of how pre-hospital care can be improved at low cost without developing ambulance systems (113). Similar examples can be found in WHO’s Prehospital trauma care systems (114). The treatment that an injured child receives on reaching the hospital is another point in the chain of survival where lives can be saved. Improving the organization and planning of trauma care services is an affordable and sustainable way to raise the quality and outcome of care. This includes defining a set of essential trauma care services, which every injured child should receive, as well as the required resources, both human and physical, to assure such services. Continuing education courses on trauma care should be introduced, along with quality improvement programmes, and the system for referrals between different parts of the health care system should be strengthened through inter-hospital transfer agreements. The essential elements of trauma care need not be expensive. However, the cost of care can be a barrier to access, especially where users are asked to pay in advance of receiving emergency services. It is therefore essential to ensure that the essential trauma care services can be delivered to all who need them irrespective of the ability to pay, with cost recovery coming only after the treatment is given. More detailed recommendations on strengthening trauma care at hospitals and clinics can be found in WHO’s Guidelines for essential trauma care (115). A visit to the emergency department after an injury is often the first encounter that children have with a hospital. The experience can add to their physical distress if there is a lack of understanding or information or if they feel lonely or frightened. When treating children who have been injured, health-care personnel should provide information, communicated in a manner appropriate to the child’s age, and seek to make the hospital environment less intimidating and inhospitable (116). In short, both hospitals and their health-care staff should do their utmost to be child-friendly. Finally, many injured survivors lead lives of disability. Much of this disability could be avoided with improved rehabilitation services. This would involve improving services in health care facilities and as well as access to communitybased rehabilitation. Assessments have shown that such rehabilitation services are poorly developed globally and are in fact among the least developed within the spectrum of trauma care services. Strengthening such rehabilitation services will reduce the extent of disability following an injury and help those with persistent disabilities to achieve their maximum potential and lead meaningful lives. TABLE 1.6 Ten countermeasures and examples of child injury prevention Strategy 1 2 3 4 5 6 7 8 9 10 Prevent the creation of the hazard in the first place Reduce the amount of energy contained in the hazard Prevent the release of the hazard Modify the rate or spatial distribution of the hazard from its source Separate people in time or space from the hazard and its release Separate people from the hazard by interposing a material barrier Modify the relevant basic qualities of the hazard Make the person more resistant to damage Counter the damage already done by the hazard Stabilize, repair and rehabilitate the injured person Example related to child injury prevention Banning the manufacture and sale of inherently unsafe products Speed reduction Child-resistant medicine containers Use of seat-belts and child restraints Bicycle and pedestrian pathways Window bars, pools fencing, covering wells Softer playground surfaces Good nutrition for children First aid treatment for scalds – “cool the burn” Burn grafting, reconstructive surgery and physical therapy WORLD REPORT ON CHILD INJURY PREVENTION 13 © P. Virot/WHO
Slide 33: BOX 1.5 Dog bites: injury data reveal significant public health problem Dog-bite injury has been the subject of very few scientific publications. It was only after the introduction of external cause coding of hospitalized injury cases and the setting up of emergency department injury surveillance systems that population-based rates of dog bites could be estimated. With greater injury surveillance and more country-wide or province-wide household surveys of injuries, the real burden of dog-bite injury is now becoming apparent. Death registration and injury surveillance data in high-income countries show that dog bites are a potentially serious injury and a frequent cause of hospitalization, but that they are only rarely fatal. Children are particularly vulnerable to dog attacks as a result of their size and the fact that their face is usually close to that of the dog. Bites to the head and neck are common in small children and decrease with age (121). The table below summarizes the most common circumstances resulting in a dog bite. External circumstances of dog bites Circumstance Playing with or near the dog Passing the dog (walking) Cuddling the dog Feeding the dog Passing the dog (cycling) Disturbing the dog while eating Surprising the dog Pulling the dog’s tail Interfering during a dog fight Unknown Source: reference 122 % 28 14 10 8 4 4 2 2 2 26 In high-income countries, examples of reported fatality rates from dog bites include: – Australia: 0.04 per 100 000 population; – Canada and the United States: 0.07 per 100 000 population. In these countries, children are over-represented. They account for 36% of dog-bite fatalities in Australia and between 70% and 80% in the United States (123). Similarly, published rates for hospitalization or emergency department visits in these high-income countries, as well as in some other places, highlight the over-representation of children, with those aged 0–4 years, followed by those aged 5–9 years, the most vulnerable (121, 124). There are fewer reports specifically on dog-bite injury from low-income and middle-income countries. Recently, UNICEF and The Alliance for Safe Children (TASC) collaborated with partner institutions in five Asian countries on community injury surveys. Such surveys supplement injury surveillance, and record more minor cases of bites and as well as those that are treated outside the hospital system by local practitioners, traditional healers or family members. These community surveys have revealed the previously unrecognized burden of animal-related injury, especially of dog bites, among children in low-income and middle-income countries. From these surveys, TASC has also estimated the number of days lost from school or work, following an injury, for children aged between 0 and 17 years. Data for this age group from surveys in five countries estimate the animal-related injury rate at 380 per 100 000 population, second only to falls as a leading cause of time lost from school or work (19). © Gaggero/PAHO 14 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 34: The 2001 community survey in Viet Nam showed that around 360 000 Vietnamese children suffer animal bites each year, with dog bites accounting for almost 80% of these. Every day, some 30 children in Beijing suffer animal bites, 81% of them caused by pet dogs. While two decades ago dog ownership was not allowed in China, it is now common. The cost of treatment of such bites in Beijing has been estimated at US$ 4.2 million annually (19). Dog bites in poor countries come with the added risk of rabies. In countries where rabies is endemic – including India, China and many parts of Africa – a dog bite that may not otherwise be serious can lead to death. Rabies is the tenth most common cause of death from infection worldwide. More than 99% of the 55 000 annual worldwide deaths from rabies occur in Asia and Africa (125). There is evidence that between 30% and 60% of the victims of dog bites in endemic areas of canine rabies are children under 15 years of age (126). A study in New Delhi estimated the rate of rabies from animal bites at 80 per 100 000 population, and significantly higher for 5–14-years-olds, with bites from stray dogs accounting for 90% of cases (127). A study of 2622 Thai children with rabies exposure found that 86.3% of the cases were related to dog bites (128). A Ugandan study found that the majority of dog bites were to children under the age of 15 years and that these children were at greater risk of developing rabies, in the absence of treatment, due to the location of the bites they had suffered (129). A study from the United Republic of Tanzania showed that significantly more children aged 5–15 years are bitten by a suspected rabid dog than are adults (130). Most children who die from rabies were either not treated or else received inadequate post-exposure treatment. Many bite victims do not receive rabies immunoglobulin because of a perennial global shortage. Its high price makes it frequently unaffordable in countries where canine rabies is endemic (126). In addition to human vaccination, an estimated 50 million dogs are vaccinated against rabies worldwide, either privately or through governmentorganized campaigns (125). In some countries – including China, the Islamic Republic of Iran, Thailand, South Africa and much of Latin America – a sustainable reduction in dog rabies has been achieved by programmes of improved post-exposure treatment of humans and of control measures against dog rabies. In others, including Morocco, Sri Lanka and Tunisia, such activities have at least led to rabies being contained. However, in some African and Asian countries, vaccination coverage has reached only 30%–50% of the dog population, a level insufficient to break the disease transmission cycle. In addition to training school-aged children, it is advisable to teach dog owners and parents to be alert when children are close to dogs. The blame for a dog attack should not be placed on the children. The table below summarizes some of the behaviours older children can be taught in order to minimize attacks by dogs. Code of behaviour to prevent dog bites Characteristics of dogs Dogs sniff as a means of communication. Dogs like to chase moving objects. Dogs run faster than humans. Screaming may incite predatory behaviour. Dogs may regard infants, especially new members of the family into which the dog already feels integrated, as intruders or as subordinate. Direct eye contact may be interpreted as aggression. Dogs tend to attack extremities, face and neck. Lying on the ground provokes attacks. Fighting dogs bite at anything that is near. Source: reference 122 © WHO Instructions to children Before petting a dog, let it sniff you. Do not run past dogs. Do not try to outrun a dog. Remain calm if a dog approaches. For infants and small children, do not hug or kiss a dog. Avoid direct eye contact. If attacked, stand still (with feet together) and protect neck and face with arms and hands. Stand up. If attacked while lying, keep face down and cover the ears with the hands. Do not move. Do not try to stop two fighting dogs. In conclusion, dog-bite injury is a widespread and hitherto poorly-documented global problem, disproportionately affecting children and adolescents. Good data collection systems are vital for identifying the characteristics of injuries such as dog bites. Only when good data become available can the extent and nature of such injuries be appreciated and proper prevention measures set up. WORLD REPORT ON CHILD INJURY PREVENTION 15
Slide 35: Learning from places with good safety records Experience from countries with the best safety records shows that positive leadership, together with widespread, multisectoral efforts to provide safer physical and social environments can produce sustained reductions in injury mortality and morbidity (131). In addition, those countries which have a designated government focal point with overall responsibility for addressing injury have made significant advances (132). Sweden was the first country to recognize the importance of injuries as a threat to child health and to tackle the problem in a coordinated manner (133). In the 1950s, Sweden had death rates from child injury higher than those in the United States. Since the late 1980s, it has had the lowest child injury death rates of any country in the world. Factors contributing to its success have included (134): – good surveillance data; – a commitment to research; – regulations and legislation for safer environments; – broad-based safety education campaigns involving partnerships of different agencies; – committed leadership on safety issues. In addition, Sweden was one of the few countries that followed WHO’s recommendations to set up policies for safety, to organize a national multisectoral safety promotion programme and to allow academic institutes to participate in public health policy-making (135). A sense of corporate responsibility in Sweden has greatly helped in allowing the protection of children to become a major goal of society. There have been relatively few systematic attempts to examine factors that might explain differences between countries in child injury rates. One example is the OECD study of road safety policy and practice. This used mortality data, demographic and socioeconomic indicators, exposure surveys and surveys based on questionnaires addressed to the leading informants in transportation departments in OECD countries. The study identified the pivotal role of good data. The best-performing countries in the study – those with the lowest injury rates – had a comprehensive, coordinated policy on road traffic injuries and had adopted a holistic approach (136). The importance of international networks of researchers has also been identified to encourage the rapid dissemination of ideas between countries (137). gold standard for assessing the effectiveness of injury interventions, such trials are still relatively rare in relation to child injuries. Many trials would be impractical or unethical to implement because their benefits are obvious. A recent publication on disease control priorities in developing countries included a chapter on the prevention of unintentional injuries in low-income and middle-income countries (138). Although the interventions suggested as promising or proven are for all ages, many are applicable to the prevention of child injuries. “Evidence is the foundation for setting priorities, crafting policies, and measuring results. Evidence can have great persuasive power at the policy level” Dr Margaret Chan, WHO Director-General. The sections below summarize the approaches that have been adopted in a number of countries. Examples are given for each approach, along with evidence, where available, from systematic reviews, using the Cochrane database of systematic reviews and other reviews. Legislation and enforcement Legislation is a powerful tool in the prevention of injury. It can be regarded as a “test of commitment to the cause of child safety” (9). There is evidence that legislation has increased the uptake of preventive measures and reduced childhood injuries in a number of areas. These areas include: In the road environment: – child passenger restraints (139); – seat-belts (140); – bicycle helmets (141); – motorcycle helmets. In the home environment: – smoke alarms (142); – hot water temperature legislation (143); – child-resistant containers (144). In the leisure environment: – isolation fencing of swimming pools (145). There is some evidence of the beneficial effect of legislation on the use of booster seats (restraints in cars for children who have outgrown child seats), though this was mainly from uncontrolled before-and-after studies (146). A systematic review (147) found legislation on bicycle helmets to be effective in increasing helmet use, particularly in the younger age group and in areas with previous low rates of use (148), and in reducing head injuries (141). As well as the introduction of new laws, how consistently they are applied and how rigorously enforced are important. The UNICEF league table report compared the legislative record for seven areas of injury legislation in 26 OECD countries. Only three countries Which approaches work? Interventions to prevent unintentional injuries have traditionally been considered in terms of the “three E’s”: education, enforcement and engineering – and within the framework of the Haddon matrix discussed before. While randomized controlled trials are considered the 16 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 36: had legislated in at least six of the seven areas assessed: Australia, Canada and the United States (9). Many countries have specific standards or regulations – some mandatory – for a wide range of goods and services, including: – toys and nursery furniture; – playground equipment; – items designed for childcare – such as nail clippers and hair brushes; – safety equipment such as helmets; – furniture and furnishings – such as the provision of baby gates at the top of stairs. There are also usually regulations and standards related to construction work on buildings, as well as to health and safety generally in the workplace. All these standards and regulations have an important bearing on the extent to which child injury can be prevented. Since, for many products, standards often do not exist, and the introduction of standards for individual products can be a slow process, a useful approach is to identify the particular hazards for a product and the measures and mechanisms that reduce risk. So-called “vertical standards” based on hazards compile this information so that manufacturers and regulators can identify known hazards in products and reduce them to acceptable levels. This approach is the one adopted, for instance, in ISO/IEC Guide 50: Safety aspects: guidelines for child safety (149). Risk reduction here is meant to cover the way people actually use the products and it should be for the life of the product. In 2007, for example, there was a worldwide recall of toys that had been found to contain hazardous levels of lead paint. In developed countries, the way in which legislation is enforced varies considerably. Because of a frequent lack of structures and resources, enforcement in developing countries is even more difficult. In Karachi, a study of bus safety showed that legislation was not likely to produce much effect, but that instead increases in bus drivers’ wages and small changes to the vehicles were potentially more effective (150). changes is made in products and it is difficult to attribute a reduction in injuries to any one specific change. There is considerable evidence that the introduction of childresistant closures has been effective in reducing the number of childhood deaths from poisoning (151). An evaluation of an intervention in South Africa involved the distribution of child-resistant containers for the storage of paraffin. This strategy proved an effective means of reducing paraffin ingestion and provided evidence that families will use such free devices when they are provided (152). Modification of basic cooking and heating products may also offer considerable possibilities. About half the world’s population still relies on solid fuels – including wood, animal dung, crop residues and coal for every day energy needs – and a high proportion of households burn the fuel in open fires (153). In rural Guatemala, an improved wood-burning stove, the plancha (an enclosed combustion chamber and cooking surface out of reach of young children), has been introduced. The stove has the potential to reduce not only acute lower respiratory tract infections in children, but also burns and scalds. Preliminary results have been promising for young children (153). Reducing the number of open fires would have a beneficial impact in places such as sub-Saharan Africa, where 80% to 90% of rural homes use open fires. “Adapting the environment to the characteristics of children and integrating safety into the design of products are among the most successful child injury prevention strategies” Wim Rogmans, Director, Consumer Safety Institute. Environmental modification Modifying the environment to make it more user-friendly has become an important approach in injury prevention, benefiting people of all ages, not just children, in the passive protection that it affords. Area-wide engineering solutions can lower the rate of injuries in pedestrians, cyclists and car occupants. One review examined whether traffic-calming schemes reduced rates of crash-related deaths and injuries, for all age groups (154). It concluded that traffic calming in towns did indeed have the potential to reduce the rate of injuries. As regards modification of the home environment, there is at present insufficient evidence from trials to show that such changes reduce the number of injuries (155). In high-income countries, there has been considerable progress in making the transport infrastructure safer, including around schools and kindergartens. But in low-income countries, such expensive options may not be possible. In most low-income countries, pedestrians, cyclists, cars, animals and buses share the same road space. The conflicting requirements of non-motorized vehicles need to be addressed using various models of WORLD REPORT ON CHILD INJURY PREVENTION 17 Product modification Changing the design and manufacture of products can: – reduce the risk of an injury – for instance, by manufacturing staircase railings with the gap between the upright banisters sufficiently narrow to prevent small children putting their heads through; – reduce access to a hazard – an example being the use of child-resistant closures for medicines; – reduce the severity of an injury – for instance, by modifying the design of the caps on pens to reduce the risk of fatal choking in the case of a cap being inhaled. Product modification has contributed to preventing childhood injuries. However, often a series of small
Slide 37: traffic safety, including the separation of different types of road user (156). Supportive home visits Home visiting by paediatric nurses to families at high risk of injury has been used for a wide range of purposes. These include: to improve the home environment, to prevent problems of child behaviour or supply and explain safety equipment. A review of the effects of home visits in early childhood has shown substantial positive effects for the prevention of child maltreatment (157). The greatest impacts were for programmes using professional visitors and for programmes of a longer duration. Home-visiting programmes have been shown to be associated with an improvement in the quality of the home environment as a means to reduce unintentional injuries (158). Safety devices The promotion of safety devices can lead to a fall in injuries and increased compliance in using the device. A variety of approaches has been used, including professional counselling, to encourage the use of safety devices, supported by a range of media. Some programmes have included rewards or coercion, such as fi nes, to encourage compliance. The positive effects from such programmes diminish one or two months after the intervention and more intensive programmes produce more positive results (159). Wearing a bicycle helmet dramatically reduces the risk of severe and fatal head injuries and facial injuries for bicyclists involved in a crash involving a motor vehicle (148). Community-based projects that provided free helmets along with an educational component led to an increase in the observed wearing of helmets (160). A study in Canada has shown that, despite less wearing of helmets in low-income areas, population-based bicycle helmet campaigns can still have an impact in these areas in cutting the risk of injury (161). The WHO helmet manual (162) provides a number of examples of good practice, such as the Helmets for Kids safety campaign in Viet Nam. Motorcyclists are also at high risk in traffic crashes, particularly for head injury. A review of studies concluded that helmets reduce the risk of head injury by around 69% and death by around 42% (163). Fires detected with smoke alarms are associated with lower death rates. However, one review found that programmes to promote smoke alarms only, without legislation, function modestly, if at all, and have not yet demonstrated a reduction in fires or fire-related injuries (142). injury. Clearly, education underpins many other strategies – such as legislation, the promotion of safety devices and home visiting. Education on pedestrian safety can result in an improvement in children’s knowledge and can change observed behaviour of crossing roads. Whether, though, this reduces the risk of injury or of a pedestrian suffering a collision with a motor vehicle is unknown (164). The focus of education should extend beyond the immediate caregivers of children, to include health professionals, policy-makers, the media and the business community (120, 165). Novel ways of introducing safety messages into television programmes should be explored. These might include a person testing the water temperature before bathing a child, portrayals of swimming pools surrounded by fencing, and characters in dramas putting on their seatbelts in a car (166). The PRECEDE-PROCEED model (a planning model for health education and health promotion programmes) provides a comprehensive structure to assess people’s health and quality-of-life needs. It also helps in the design, implementation and evaluation of health promotion programmes and other public health programmes to meet those needs (167). These principles have been further elaborated in a guideline on generic behaviour change. This guideline recommends collaboration between individuals, communities and organizations to plan interventions and programmes (168). Community-based studies Injury prevention, with its broad range of injury types and possible countermeasures, lends itself to community-based approaches. It is important to have long-term strategies, effective and focused leadership, collaboration between a range of agencies, appropriate targeting and sufficient time to develop local networks and programmes (169). The use of multiple interventions, repeated in different forms and contexts, can lead to a culture of safety being developed within a community. There is some evidence that the WHO Safe Communities model is effective in reducing injuries in whole populations (170). However, the countries that have evaluated their Safe Communities with a sufficiently rigorous study design are among the wealthier countries and have lower injury rates than most other countries. No evaluations are available yet from other parts of the world. Universal and targeted interventions There have been a considerable number of systematic reviews of child injury prevention. However, “the evidence on its own does not provide a complete recipe for success, or an imperative for action” (171). The findings of research need to be translated into practice, so that they are tailored to local contexts and circumstances (172). Proven interventions in developed countries may not be readily transferable across all social groups or to other Education, skills and behaviour change The value of educational programmes as a form of injury prevention has been subject to debate in the field of child 18 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 38: contexts within developed countries. They may also not be transferable to developing countries. Caution is needed here, because of the very different environments in some low-income countries (173). In these places, childhood drowning, for instance, does not generally take place in swimming pools and bathtubs as in developed countries, but in natural bodies of water such as ponds, lakes and rivers, as well as cisterns, wells, irrigation ditches and paddy fields. Closing the childhood injury gap As stated previously, within all countries, the burden of child injury falls most heavily on those from the most disadvantaged groups. The gap in injury rates between the most affluent and the most disadvantaged provides “some measure of preventability and shows that there is considerable scope for improvement and intervention and a yardstick of what is achievable” (74). There is a range of interventions known to be effective in preventing and reducing injuries (see Chapter 7). What is less well known, though, is how such approaches can be applied to close the socioeconomic gap with regard to childhood injuries. It is partly in response to this problem, where active strategies have not yet been successful, that passive solutions – that is, design solutions – may be most successful. In the broader field of health promotion, four broad approaches to tackling socioeconomic inequalities in health have been suggested (174): – strengthening individuals; – strengthening communities; – improving access to services; – encouraging macroeconomic and cultural change. Approaches for strengthening individuals can include targeting children and their carers. Prevention initiatives for parents on drowning can be integrated into existing child survival and development programmes – particularly for the period, from nine months of age onwards, when children are entering into the ‘window’ of drowning risk (61). A study conducted in a deprived community of Scotland, a high-income country, that reviewed a training programme in practical road-safety skills, found improved skills in 5–7-year-old children in crossing the road (175). Strengthening communities is an approach adopted by many organizations working on safety issues, and is the leading strategy employed in the Safe Communities network. The Waitakere Community Injury Prevention Project in New Zealand included a range of programmes targeting different indigenous and ethnic groups (176). For one of these programmes, the coordinator employed was a Maori, with experience of the culture and perspectives of the target group, and injury prevention was incorporated into a holistic view of health. The Safe Block project, based in a poor AfricanAmerican inner-city community in Philadelphia, PA, USA, used a network of community volunteers. The project involved making simple modifications to homes to prevent injuries, inspecting homes and providing information on home hazards, and educating people – with the use of cascade training – on specific injury prevention practices (177). A partnership with residents from townships in South Africa worked effectively to lobby the local government to provide a pedestrian bridge over a highway (102). There are various ways in which improving access to services can help prevent child injuries. New roads can contribute to improving access to a range of community services, including to health care, education and leisure facilities. Electrification can reduce exposure to more hazardous fuels such as kerosene. Removing dangerous debris and improving waste collection can directly reduce injuries to children. Providing sanitation can help children avoid having to walk in darkness to toilet facilities. Encouraging macroeconomic and cultural change includes: – broad land-use policies, such as locating schools away from busy roads; – transport policies that take into full account the needs of pedestrians; – the promotion of walking as a healthy activity; – the design of communities, to include safe outdoor play facilities. Financial problems and poor living conditions have been found to preoccupy adults, with the result that they spend less time supervising children (24, 76). Policies targeting poverty reduction could reduce childhood injuries in the long term, but need to be accompanied by more short-term and medium-term measures. Most researchers believe that packages of policies and intervention, rather than single policies and interventions, are needed to substantially reduce socioeconomic inequalities in health. Transfer of knowledge One study in low-income countries looked at successful interventions to prevent transport and home injuries (25). It also evaluated injury interventions developed in industrialized countries that might be usable in low-income countries. The conclusion was that several interventions could be imported by low-income countries and should be considered, including: – vehicle seat-belts, bicycle helmets and motorcycle helmets; WORLD REPORT ON CHILD INJURY PREVENTION 19
Slide 39: – – – – – speed limits; pedestrian crossing signs; adequate road lighting; the separation of pedestrians from vehicles; measures to enhance conspicuity, such as the use of reflective products; – simple safety equipment; – packaging of items to prevent poisoning. The importance of transferring knowledge in a sensitive and context-specific manner has been repeatedly stressed. The Commission for Global Road Safety (44), for instance, has stated: “Public acceptance and support, based on information and knowledge and evidence of effectiveness, will be achieved only if road safety messages are seen to be appropriate and targeted at local needs”. Interventions that appear most effective are those encompassing a variety of strategies, including legislation, environmental modification and education (178, 179). There is a general need for more interventions to be evaluated and for research experiences to be shared worldwide. Many of the principles of injury prevention can be transferred, but interventions need to be tailored to the social and physical environments of those localities. Interventions should reach across different sectors, build on existing networks and involve communities. Cost-effectiveness of interventions There are very few analyses in low-income and middleincome countries of the cost-effectiveness of injury prevention measures (183). There is also scarce data on injury epidemiology and the efficacy of interventions in these countries. One study attempted to model the costs and effectiveness of five interventions for which there were data on effectiveness in a low-income or middleincome country (184). Four out of the five interventions related to the road environment: vehicle speed control, treatment of dangerous junctions, bicycle helmet legislation and motorcycle helmet legislation. The fi ft h was on the home environment, and involved childresistant containers to reduce poisoning from paraffi n. In the United States, a survey conducted in the late 1990s on the costs of childhood unintentional injuries and the cost-effectiveness of interventions to prevent them showed that approximately 15% of medical spending resulted from an injury (185). The same study found that seven child injury safety measures – child safety seats, bicycle helmets, zero tolerance of alcohol for young drivers, provisional licensing, smoke detectors, childproof cigarette lighters and poison control centres – had similar cost-effectiveness ratios to other wellaccepted strategies to prevent childhood illness. The implementation of these strategies, though, is not yet widespread (185). As can be seen from Table 1.7, many cost-effective strategies for unintentional injury can save not only lives but costs to society as well. TABLE 1.7 Cost and cost-effectiveness The costs of injuries are enormous. In developing countries, road traffic injuries alone account for 1%–2% of gross domestic product (about US$ 100 billion) each year, or twice the total development aid received worldwide by developing countries (180). There are no global data on the cost of unintentional child injuries, but a recent evaluation in the United States has shown that the medical costs and losses in productivity as a result of all injuries to 0–14-yearolds are in the range of US$ 50 billion (181). There is thus a great need for cost-effective and well-targeted responses. Financial savings from selected injury prevention interventions Expenditure of US$ 1 each on: Smoke alarms Child restraints Bicycle helmets Prevention counselling by paediatricians Poison control services Road safety improvements Source: reference 186. Savings (US$) 65 29 29 10 7 3 Costs of safety Not much research has been carried out on the availability, price and affordability of child-safety or family-safety devices, and this is especially the case in low-income and middle-income countries. Data from 18 economically diverse countries have been compared for four effective devices: child safety seats, booster seats, child bicycle helmets and smoke alarms (182). The prices of these devices varied widely and in many countries they were very expensive. A factory worker in a low-income country had to work 11 times as long as a counterpart in a highincome country to buy a bicycle helmet, while for a child safety seat 16 times as many hours’ work were required. Low-income countries manufacturing devices for export did not generally use spare plant capacity to produce devices for local consumption. 20 WORLD REPORT ON CHILD INJURY PREVENTION Cost and cost-effectiveness analysis of interventions to reduce or mitigate child injuries is urgently called for. Such evidence can have a strong impact on policy-makers and persuade them to invest in the appropriate primary prevention interventions. Overcoming the obstacles Although considerable progress has been made during recent decades to reduce the rates of child death and injury in developed countries, more needs to be done. In
Slide 40: developing countries such efforts are just beginning. This section examines some of the fallacies, limitations and other obstacles that efforts to prevent child injury face. “Injuries are due to fate” If injury is considered to be the result of random, uncontrolled factors and that chance and bad luck or fate are the main factors, then there is little that can be done to prevent injury. However, injuries are preventable. The public health approach to injury prevention involves data collection, risk factor analysis, intervention, evaluation and the widespread implementation of proven prevention methods. Scientific research and evidence underpin this approach. of trauma deaths occur outside hospital in developing countries, so that many deaths – and other injuries – are not counted in data collection systems in these countries. An important goal in injury prevention is thus to establish reliable estimates of the level and pattern of child injury and death, especially in low-income and middleincome countries. To this end, the volume, quality and availability of national and regional data needs to be increased. This should be done through a combination of better data collection systems, improved hospital surveillance, more community-based surveys and other appropriate research. Lack of political commitment and understanding The significance of child injury in absolute and relative terms is not always widely appreciated and the possibilities of prevention are often underestimated. This lack of understanding inhibits the allocation of resources to prevention efforts and also the political and organizational will that are necessary for change. Injury must become an issue for concern and debate at all levels, not just at the global level, but at national and local levels as well. One example of high-level political commitment that led to immediate and observable reductions in injury was in France, where in 2002 the president declared road safety a national priority. This led to the formation of an interministerial committee and a national action plan (131). Between 2002 and 2004, a 34% reduction in road traffic deaths was reported, as a result of the coordinated implementation of a range of preventive measures, including: speed reduction, traffic calming, control of drinking and driving, and increased seat-belt use (187). Effective and inexpensive interventions must be developed (188). The aim should be to develop measures that give as much return on money invested as immunizing children against measles, polio or tetanus. The wide range of injury types The nature of injury presents problems. Injuries fall into a wide range of categories that occur in many different environments. They can therefore be the responsibility of a number of separate agencies or government departments, each of which may favour a different approach. Injuries need to be viewed collectively as a single “disease”, with broadly similar approaches being used to prevent them. Collaboration between a range of agencies is necessary, with some form of principal agency to coordinate activities. Limitations of data Data on the scope and patterns of injury are essential for identifying priority issues, understanding the causes of injury and identifying groups at high risk of injury. With limited data it is difficult to convince policymakers and others that there is an injury problem. It is also impossible to decide how to prioritize and develop effective programmes. It is estimated that, of the 193 WHO Member States, only 109 currently provide usable vital registration data to WHO in coded form, using the International Classification of Disease taxonomy. Unfortunately, the quality of the data tends to be weakest where the problems are greatest. In developing countries, data coverage is particularly poor in relation to child drowning, burns, poisoning, road traffic injuries and bites and stings. Data on the evaluation of interventions and the cost of injuries are also largely absent or – at best – are weak in these places. High-quality data relating to hospital usage are similarly skewed. They are available in some high-income countries, but rare in countries with the highest injury rates. The general lack of data on health care, in particular on high-cost hospital admissions and trauma care, results in the burden of injury being underestimated in many countries. It also prevents a proper analysis being made of the groups receiving such expensive and scarce health care and of the nature of their injuries. A high proportion Limited capacity All countries face limitations in their capacity to prevent injury, to provide emergency and continuing care following an injury, and to provide appropriate rehabilitation services. This is particularly the case in countries where the burden of child injury is greatest. The training of more injury prevention practitioners and researchers across the world is urgently needed, and particularly in low-income and middle-income countries. For low-income countries, incentives may be necessary to encourage professionals to remain in their country of origin and not emigrate to high-income countries. The content of training courses also needs to be carefully planned. Such syllabuses generally include principles and concepts that further knowledge and understanding. Competencies, though, also need to be taught, including skills in group work, community development, collaboration across sectors and lobbying. WORLD REPORT ON CHILD INJURY PREVENTION 21
Slide 41: Difficulties of implementation As already stated, the main aim in child injury prevention is the adaptation of proven prevention measures to local circumstances. In areas of the world where substantial progress has already been made, efforts are required to apply effective interventions more widely. A recent analysis conducted in the United States showed that child injury deaths could be reduced by one third if practices that had proved effective in certain states were adopted in other similar states (189). Lack of funding Funding levels need to reflect the importance of injury as a major cause of death and ill-health in children. “Those who control the purse strings must be persuaded that most injuries are truly preventable and that the cost of failing to do so greatly outweighs the relatively small costs of prevention” (190). to make a substantial impact in bringing down the incidence of child injury death and morbidity. Every child lost to injury or severely disabled will cost the future economy of that country. Putting into practice what is known about reducing child injury will help meet the Millennium Development Goals. It will reduce costs in the health care system, improve the capacity to make further reductions in injury rates, and will most importantly protect children. Chapters 2 to 6 of this report will discuss the five leading causes of unintentional injury. These will focus on the magnitude of the problem, the risk and protective factors for each type of injury, as well as interventions and recommendations for primary, secondary and tertiary prevention. References 1. 2. Baker SP et al., eds. The injury fact book, 2nd ed. Lexington, MA, Lexington Books, 1992. Pinheiro PS. World report on violence against children. Geneva, Switzerland, Secretary-General’s Study on Violence against Children, 2006 (http://www. violencestudy.org/a553, accessed 21 January 2008). Convention on the Rights of the Child. New York, NY, United Nations, 1989 (A/RES/44/25) (http://www.unhchr. ch/html/menu3/b/k2crc.htm, accessed 21 January 2008). James A, Prout A. Constructing and reconstructing childhood: contemporary issues in the sociological study of childhood. London, Falmer, 1990. Kabeer N, Nambissan GB, Subrahmanian R. Child labour and the right to education in South Asia. New Delhi, Sage, 2003. Lansdown G. The evolving capacities of the child. Florence, UNICEF Innocenti Research Centre, 2005 (http://www. unicef-irc.org/publications/pdf/evolving-eng. pdf, accessed 21 January 2008). Tamburlini G. Children’s special vulnerability to environmental health hazards: an overview. In: Tamburlini G, von Ehrenstein O, Bertollini R, eds. Children’s health and environment: a review of evidence. Rome, European Environment Agency, World Health Organization Regional Office for Europe, 2002 [Environmental Issue Report 29]. Alderson P. Young children’s rights: exploring beliefs, principles and practice. London, Kingsley, 2000. A league table of child deaths by injury in rich countries. Innocenti report card No. 2. Florence, UNICEF Innocenti Research Centre, 2001 (http://www.unicef-icdc.org/ publications/pdf/repcard2e.pdf, accessed 22 January 2008). Linnan M et al. Child mortality and injury in Asia: survey results and evidence. Florence, UNICEF Innocenti Research Centre, 2007 (http://www.unicef-irc.org/ publications/pdf/iwp_2007_06.pdf, accessed 21 January Conclusion Despite the many and complex obstacles, injury prevention nevertheless offers opportunities. The public health significance of road traffic injury and of violence has increasingly been recognized in recent years. There has been much experience and understanding developed on all aspects of injury prevention. These developments can create a strong basis to bring about significant and sustainable reductions in child mortality and ill-health throughout the world. All countries need to urgently investigate the full extent of the problem of child injuries. Their results should be used in developing an action plan, coordinating the activities of different sectors – including nongovernmental organizations, academic institutions and industry. Measures that are known to work should be implemented everywhere, with adaptations where necessary to suit local circumstances. Resources devoted to child injury prevention must be appropriate for the size of the problem. More investment is needed for such activities as data collection, communitybased injury surveys, capacity building, programmes aimed at local communities, and evaluations of the costs of injuries and of the cost-effectiveness of prevention measures. Child survival initiatives have been highly successful. At the beginning of the “child survival revolution”, more than 75% of the world’s children lived in countries where child mortality was high – while now, only 30 years later, less than 20% of children do so. Further improvements in child health, though, will require broad programmes for injury reduction and control for children up to the age of 18 years. Now is the right time to address this avoidable harm to children and to society. While there is much research that still needs to be carried out, there is already considerable information available. This information is quite sufficient 22 WORLD REPORT ON CHILD INJURY PREVENTION 3. 4. 5. 6. 7. 8. 9. 10.
Slide 42: 2008). (Innocenti Working Paper 2007-06, Special series on child injury No. 3). 11. Krug EG et al., eds. World report on violence and health. Geneva, Switzerland, World Health Organization, 2002 (http://www.who.int/entity/violence_injury_prevention/ violence/world_report/en/full_en.pdf, accessed 18 December 2007). Peden M et al., eds. World report on road traffic injury prevention. World Health Organization, Geneva, 2004 (http://w w w.who.int/violence_injur y_prevention/ publications/road_traffic/world_report/en/index.html, accessed 18 December 2007). Resolution WHA56.24. Implementing the recommendations of the World report on violence and health. In: Fifty-sixth World Health Assembly resolution, Geneva, 19–28 May 2003. Geneva, World Health Organization, 2003 (http://www.who.int/gb/ebwha/pdf_fi les/WHA56/ ea56r24.pdf, accessed 22 January 2008). Resolution WHA 57.10. Road safety and health. In: Fiftyseventh World Health Assembly, Geneva, 17–22 May 2004. Geneva, World Health Organization, 2004 (http://www. who.int/gb/ebwha/pdf_fi les/WHA57/A57_R10-en. pdf, accessed 22 January 2008). United Nations Millennium Declaration. New York, NY, United Nations, 2000 (A/RES/55/2) (http://www.un.org/ millennium/declaration/ares552e.htm, accessed 22 January 2008). A world fit for children. New York, NY, United Nations General Assembly, 2002 (A/RES/S-27/2) (http://www. unicef.org/specialsession/docs_new/documents/A-RESS27-2E. pdf, accessed 18 February 2008). The Bellagio Group on Child Survival. The Lancet series. Child survival [WHO press release]. Geneva, World Health Organization (http://www.who.int/child-adolescent-health/ NEWS/news_27. htm, accessed 22 January 2008). Jones G et al. How many child deaths can we prevent this year? The Lancet, 2003, 362:65–71. Linnan M et al. Child mortality and injury in Asia: policy and programme implications. Florence, UNICEF Innocenti Research Centre, 2007 (http://www.unicef-irc.org/ publications/pdf/iwp_2007_07.pdf, accessed 21 January 2008). (Innocenti Working Paper 2007-07, Special series on child injury No. 4). McFarland RA. Epidemiologic principles applicable to the study and prevention of child accidents. American Journal of Public Health, 1955, 45:1302–1308. The prevention of accidents in childhood. Report of a seminar, Spa, Belgium 16–25 July 1958. Copenhagen, World Health Organization Regional Office for Europe, 1960. Peden MM, Scott I, Krug E, eds. Injury: a leading cause of the global burden of disease, 2002. World Health Organization, Geneva, 2006 (http://whqlibdoc.who.int/ publications/2002/9241562323.pdf, accessed 21 January 2008). 23. Child and adolescent injury prevention: a global call to action. Geneva, World Health Organization, 2005 (http:// whq.libdoc.who.int/publications/2005/9241593415_eng. pdf, accessed 22 January 2008). Berger LR, Mohan D, eds. Injury control: a global view. Delhi, Oxford University Press, 1996. Forjuoh S, Guohua L. A review of successful transport and home injury interventions to guide developing countries. Social Science and Medicine, 1996, 43:1551–1560. Bettcher D, Lee K. Globalisation and public health. Journal of Epidemiology and Community Health, 2002, 56:8–17. Scholte JA. Globalization: a critical introduction. London, Macmillan, 2000. Labonte R, Schrecker T. Globalization and social determinants of health: analytic and strategic review paper. Ottawa, Institute of Population Health, 2006 (http://www. who.int/social_determinants/resources/globalization. pdf, accessed 21 January 2008). Bettcher D, Wipfli H. Towards a more sustainable globalisation: the role of the public health community. Journal of Epidemiology and Community Health, 2001, 55:617–618. Roberts I. Injury and globalisation. Injury Prevention, 2004, 10:65–66. Neumayer E, de Soysa I. Trade openness, foreign direct investment and child labor. World Development, 2005, 33:43–63. The end of child labour: within our reach. Report of the Director-General, International Labour Conference, 95th Session. Geneva, International Labour Organization, 2006 (http://www.ilo.org/public/english/standards/relm/ ilc/ilc95/pdf/rep-i-b.pdf, accessed 5 May 2008). Kambhampati US, Rajan R. Economic growth: a panacea for child labor? World Development, 2006, 34:426–445. Swaminathan M. Economic growth and the persistence of child labour: evidence from an Indian city. World Development, 1998, 26:1513–1528. Gracey M. Child health in an urbanizing world. Acta Paediatrica, 2002, 91:1–8. World urbanization prospects: the 1999 revision. New York, NY, United Nations Population Division, 2000 (http:// www.un.org/esa/population/publications/wup1999/ urbanization.pdf, accessed 22 January 2008). World population policies 2003. New York, NY, United Nations Department of Economic and Social Affairs, Population Division, 2004 (http://www.un.org/esa/ population/publications/wpp2003/Publication_index. htm, accessed 22 January 2008). Chowla L. Growing up in an urbanising world. London, Earthscan Publications, UNESCO, 2002. Stark O. The migration of labour. Oxford, Blackwell, 1991. Chaplin SE. Cities, sewers and poverty: India’s politics of sanitation. Environment and Urbanization, 1999, 11:145– 158. WORLD REPORT ON CHILD INJURY PREVENTION 23 24. 25. 12. 26. 27. 28. 13. 14. 29. 15. 30. 31. 16. 32. 17. 33. 34. 18. 19. 35. 36. 20. 37. 21. 38. 39. 40. 22.
Slide 43: 41. McMichael AJ. The urban environment and health in a world of increasing globalization: issues for developing countries. Bulletin of the World Health Organization, 2000, 78:1117–1126. Reichanheim ME, Harpham T. Child accidents and associated risk factors in a Brazilian squatter settlement. Health Policy and Planning, 1989, 4:162–167. Rizvi N et al. Distribution and circumstances of injuries in squatter settlements of Karachi, Pakistan. Accident Analysis and Prevention, 2006, 38:526–531. Make roads safe: a new priority for sustainable development. London, Commission for Global Road Safety, 2006 (http:// www.makeroadssafe.org/documents/make_roads_safe_ low_res.pdf, accessed on 21 January 2008). van de Walle D. Choosing rural road investments to help reduce poverty. World Development, 2002, 30:575–589. Task Team on Infrastructure for Poverty Reduction. Guiding principles on using infrastructure to reduce poverty. Paris, OECD, Development Co-operation Directorate, 2006 (http://www.oecd.org/dataoecd/43/45/36427725.pdf, accessed 22 January 2008). Our common interest. Report of the Commission for Africa. London, Commission for Africa, 2005 (http:// www.commissionforafrica.org/english/report/thereport/ english/11-03-05_cr_report. pdf, accessed 21 January 2008). Houghton J. Global warming: the complete briefing, 3rd ed. Cambridge, Cambridge University Press, 2004. Bunyavanich S, Landrigan C, McMichael A. The impact of climate change on child health. Ambulatory Pediatrics, 2003, 3:44–52. Prüss-Ürsün A, Corvalán C. Preventing disease through healthy environments. Towards an estimate of the environmental burden of disease. Geneva, World Health Organization, 2006. Corvalan C, Hales S, McMichael A. Ecosystems and human well-being: health synthesis. Geneva, World Health Organization, 2005 (http://www.who.int/globalchange/ ecosystems/ecosystems05/en/index.html, accessed 21 January 2008). McMichael AJ, Haines A. Global climate change: the potential effects on health. British Medical Journal, 1997, 315:805–809. Patz JA et al. The potential health impacts of climate variability and change for the United States: executive summary of the report of the health sector of the US National Assessment. Environmental Health Perspectives, 2000, 108:367–376. Haines A et al. Climate change and human health: impacts, vulnerability and public health. Public Health, 2006, 120:585–596. Roberts I, Hillman M. Climate change: the implications for injury control and health promotion. Injury Prevention, 2005, 11:326–329. 56. McCarthy J et al., eds. Climate change 2001: impacts, adaptation and vulnerability. Cambridge, Cambridge University Press, 2001 (http://www.grida.no/climate/ ipcc_tar/wg2/index.htm, accessed 21 January 2008). Gordon JE. The epidemiology of accidents. American Journal of Public Health, 1949, 39:504–515. National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. New York, Oxford University Press, 1989. Pless B, Towner E, eds. Action on injury. Setting the agenda for children and young people in the UK. Injury Prevention, 1998, 4:S1–S46. Gallagher SS et al. The incidence of injuries in 87,000 Massachusetts children and adolescents. American Journal of Public Health, 1984, 74:1340–1347. Rahman A et al. Bangladesh health and injury survey: report on children. Dhaka, Ministry of Health and Family Welfare, 2005. Grossman DC. The history of injury control and the epidemiology of child and adolescent injuries. The Future of Children, 2000, 10:23–52. Linnan M et al. Child mortality and injury in Asia: an overview. Florence, UNICEF Innocenti Research Centre, 2007 (http:// www.unicef-irc.org/publications/pdf/iwp_2007_04.pdf, accessed 21 January 2008). (Innocenti Working Paper 200704, Special series on child injury No. 1). Banco de dados do Sistema Único de Saúde (DATASUS) [in Portuguese]. Brazilia, Ministério da Saúde, Departamento de Informática do SUS (http://w3.datasus.gov.br/datasus/ datasus.php, accessed 7 March 2008). Beattie RF et al. Measures of injury severity in childhood: a critical overview. Injury Prevention, 1998, 4:228–231. Evans SA et al. Disability in young adults following major trauma: 5 year follow up of survivors. BMC Public Health, 2003, 3(8) (http://www.biomedcentral.com/1471-2458/3/8, accessed 14 February 2008). Lloyd CB. Growing up global: the changing transitions to adulthood in developing countries. Washington, DC, National Academies Press, 2005. Bourdillon M. Children in development. Progress in Development Studies, 2004, 4:99–113. Hope K. Child survival, poverty and labor in Africa. Journal of Children and Poverty, 2005, 11:19–42. On DWI laws in other countries. Washington, DC, National Highway Traffic Safety Administration, 2000 (http://www.nhtsa.dot.gov/people/injury/research/pub/ DWIothercountries/dwiothercountries.html, accessed 21 January 2008) (DOT HS 809 037). Rivara FP. Developmental and behavioural issues in childhood injury prevention. Journal of Developmental Behaviour Pediatrics, 1995, 16:362–370. Agran PF et al. Rates of pediatric and adolescent injuries by year of age. Pediatrics, 2001, 108:45–56. 42. 57. 58. 43. 59. 44. 60. 45. 46. 61. 62. 47. 63. 48. 49. 64. 65. 66. 50. 51. 67. 52. 68. 69. 70. 53. 54. 71. 55. 72. 24 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 44: 73. Agran PF et al. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics, 2003, 111:683–692. Towner E et al. Injuries in children aged 0–14 years and inequalities. London, Health Development Agency, 2005 (http://www.nice.org.uk/niceMedia/pdf/injuries_in_ children_inequalities.pdf, accessed 22 January 2008). Flavin MP et al. Stages of development and injury patterns in the early years: a population-based analysis. BMC Public Health, 2006, 6(187) (http://www.biomedcentral. com/1471-2458/6/187, accessed 21 January 2008). Bartlett S. The problem of children’s injuries in lowincome countries: a review. Health Policy and Planning, 2002, 17:1–13. Wilson M et al. Saving children: a guide to injury prevention. New York, NY, Oxford University Press, 1991. Toroyan T, Peden M, eds. Youth and road safety. Geneva, Switzerland, World Health Organization, 2007 (http:// whqlibdoc.who.int/publications/2007/9241595116_eng. pdf, accessed 18 February 2008). Kalayi G, Muhammed I. Burns in children under 3 years of age: the Zaria experience. Annals of Tropical Paediatrics, 1996, 16:243–248. Thomson J et al. Child development and the aims of road safety education: a review and analysis. Norwich, The Stationery Office, 1996 (Department of Transport Road Safety Research No. 1). Sinnott W. Safety aspects of domestic architecture. In: Jackson RH, ed. Children, the environment and accidents. London, Pittman Medical, 1977:76–90. Ward C. The child in the city. London, Bedford Square Press, 1990. Towner E, Towner J. The prevention of childhood unintentional injury. Current Paediatrics, 2001, 11:403– 408. Bartlett S. Children’s experience of the physical environment in poor urban settlements and the implications for policy, planning and practice. Environment and Urbanization, 1999, 11:63–73. Nicol A. Carrying the can: children and their water environments. London, Save the Children, 1998. Rivara FP et al. Epidemiology of childhood injuries. II. Sex differences in injury rates. American Journal of Diseases of Children, 1982, 13:502–506. Spady DW et al. Patterns of injury in children: a population-based approach. Pediatrics, 2004, 113:522–529. Morrongiello BA, Rennie H. Why do boys engage in more risk taking than girls? Journal of Pediatric Psychology, 1998, 23:33–43. Rosen BN, Peterson L. Gender differences in children’s outdoor play injuries: a review and integration. Clinical Psychology Review, 1990, 10:187–205. 90. Eaton W. Are sex differences in child motor activity level a function of sex differences in maturational status? Child Development, 1989, 60:1005–1011. Block J. Differential premises arising from differential socialization of the sexes: some conjectures. Child Development, 1983, 54:1335–1354. Saegert S, Hart R. The development of sex differences in the environmental confidence of children. In: Burnett P, ed. Women in society. Chicago, Maaroufa Press, 1990:157– 175. Fagot B. The influence of sex of child on parental reactions to toddler children. Child Development, 1978, 49:459– 465. Hyder A, Peden M. Inequality and road traffic injuries: call for action. The Lancet, 2002, 362:2034–2035. Hulme D. Chronic poverty and development policy: an introduction. World Development, 2003, 31:399–402. Soori H, Naghavi M. Childhood deaths from unintentional injuries in rural areas of Iran. Injury Prevention, 1998, 4:222–224. Hulme D, Shepherd A. Conceptualizing chronic poverty. World Development, 2003, 31:403–423. Sen AK. Poor, relatively speaking. Oxford Economic Papers, 1983, 35:153–169. Bang RL et al. Scalds among children in Kuwait. European Journal of Epidemiology, 1997, 13:33–39. 74. 91. 92. 75. 93. 76. 94. 95. 96. 77. 78. 79. 97. 98. 99. 80. 81. 82. 83. 100. Roberts I, Power C. Does the decline in child injury mortality vary by social class? A comparison of class specific mortality in 1981 and 1991. British Medical Journal, 1996, 313:784–786. 101. Reading R. Area socioeconomic status and childhood injury morbidity in New South Wales, Australia. Child Care Health and Development, 2008, 34:136–137. 102. Butchart A et al. Perceptions of injury causes and solutions in a Johannesburg township: implications for prevention. Social Science and Medicine, 2000, 50:331–344. 103. Thanh NX. The injury poverty trap in rural Vietnam: causes, consequences and possible solutions [unpublished doctoral thesis]. Sweden, Umeå University, 2005 (http:// www.diva-portal.org/diva/getDocument? urn_nbn_se_ umu_diva-627-2__fulltext. pdf, accessed 22 January 2008). 104. Sen B. Drivers of escape and descent: changing household fortunes in rural Bangladesh. World Development, 2003, 31:513–534. 105. Aeron-Thomas A et al. The involvement and impact of road crashes on the poor: Bangladesh and Indian case studies. Crowthorne, Transport Research Laboratory, 2004 (TRL Project Report 010). 106. Thanh NX et al. Does the injury poverty trap exist? A longitudinal study in Bavi, Vietnam. Health Policy, 2006, 78:249–257. WORLD REPORT ON CHILD INJURY PREVENTION 25 84. 85. 86. 87. 88. 89.
Slide 45: 107. Pryer J. When breadwinners fall ill: preliminary fi ndings from a case study in Bangladesh. Institute of Development Studies Bulletin, 1989, 20:49–57. 108. Mock C et al. Economic consequences of injuries and resulting family coping strategies in Ghana. Accident Analysis and Prevention, 2003, 35:81–90. 109. Pressley JC et al. Twenty-year trends in fatal injuries to very young children: the persistence of racial disparities. Pediatrics, 2007, 119:e875–e884 (http://pediatrics. aappublications.org/cgi/reprint/119/4/e875, accessed 21 January 2008). 110. Langley J, Broughton J. Injury to Maori I: fatalities. New Zealand Medical Journal, 2000, 113:508–510. 111. Stevenson M et al. At risk in two worlds: injury mortality among indigenous people in the US and Australia, 1990– 92. Australian and New Zealand Journal of Public Health, 1998, 22:641–644. 112. Clapham KF, Stevenson MR, Lo SK. Injury profi les of indigenous and non-indigenous people in New South Wales. Medical Journal of Australia, 2006, 184:212–220. 113. Husum H et al. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. Journal of Trauma, 2003, 54:1188–1196. 114. Sasser S et al. Prehospital trauma care systems. Geneva, World Health Organization, 2005 (http://www.who. int/entity/violence_injury_prevention/publications/ services/39162_oms_new.pdf, accessed 16 May 2008). 115. Mock C et al. Guidelines for essential trauma care. Geneva, World Health Organization, 2004 (http://whqlibdoc.who. int/publications/2004/9241546409.pdf, accessed 16 May 2008). 116. Salter E, Stallard P. Young people’s experience of emergency medical services as road traffic accident victims: a pilot qualitative study. Journal of Child Health Care, 2004, 8:301–311. 117. Haddon W. On the escape of tigers: an ecologic note. American Journal of Public Health, 1970, 60:2229–2234. 123. Ozanne-Smith J, Ashby K, Stathakis V. Dog bite and injury prevention: analysis, critical review and research agenda. Injury Prevention, 2001, 7:321–326. 124. Kreisfeld R, Harrison J. Dog related injuries. Adelaide, Research Centre for Injury Studies, Flinders University, 2005 (NISU Briefi ng). 125. Human and animal rabies. Geneva, World Health Organization (http://www.who.int/rabies/, accessed 9 April 2008). 126. Rabies. Geneva, World Health Organization, 2006 (Fact sheet No. 99) (http://www.who.int/mediacentre/ factsheets/fs099/en/index.html, accessed 9 April 2008). 127. Singh J et al. Epidemiological characteristics of rabies in Delhi and surrounding areas, 1998. Indian Pediatrics, 2001, 38:1354–1360. 128. Pancharoen C et al. Rabies exposure in Thai children. Wilderness and Environmental Medicine, 2001, 12:239– 243. 129. Fèvre EM et al. The epidemiology of animal bite injuries in Uganda and projections of the burden of rabies. Tropical Medicine and International Health, 2005, 10:790–798. 130. Cleaveland S et al. Estimating human rabies mortality in the United Republic of Tanzania from dog bite injuries. Bulletin of the World Health Organization, 2002, 80:304– 310. 131. Sethi D et al. Injuries and violence in Europe: why they matter and what can be done. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who. int/document/E88037.pdf, accessed 22 January 2008). 132. MacKay M, Vincenten J. Action planning for child safety: a strategic and coordinated approach to reducing the number one cause of death for children in Europe. Amsterdam, European Child Safety Alliance, Eurosafe, 2007. 133. Pless I, Towner E. Practitioners and policy makers. In: Aynsley-Green A et al., eds. Unintentional injury in childhood and adolescence. London, Bailliere Tindall, 1997:393–409. 134. Bergman AB, Rivara FP. Sweden’s experience in reducing childhood injuries. Pediatrics, 1991, 88:69–74. 135. Ramsay S. Child-injury death rates: do international comparisons help? The Lancet, 2001, 357:454. 136. Christie N et al. Children’s road traffic safety: an international survey of policy and practice. London, Department for Transport, 2004. 137. Whitehead M. Diff usion of ideas on social inequalities in health: a European perspective. The Millbank Quarterly, 1998, 76:469–492. 138. Norton R et al. Unintentional injuries. In: Jamison DT et al., eds. Disease control priorities in developing countries, 2nd ed. New York, Oxford University Press and the World Bank, 2006:737–753 (http://www.dcp2.org/pubs/DCP/39/, accessed 14 February 2008). 118. Runyan CW. Using the Haddon matrix: introducing the third dimension. Injury Prevention, 1998, 4:302–307. 119. Haddon W. Energy damage and the ten countermeasure strategies. Journal of Trauma, 1973, 13:321–331. 120. Christoffel T, Gallagher SS. Injury prevention and public health: practical knowledge, skills, and strategies. Gaithersburg, MD, Aspen Publishers, 1999. 121. Gilchrist J, Gotsch K, Ryan G. Non-fatal dog bite-related injuries treated in hospital emergency departments – United States, 2001. Morbidity and Mortality Weekly Report, 4 July 2003, 52:605–610. 122. Schalamon J et al. Analysis of dog bites in children who are younger than 17 years. Pediatrics, 2006, 117:e374–e379 (http://pediatrics.aappublications.org/cgi/content/ full/117/3/e374, accessed 9 April 2008). 26 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 46: 139. Zaza S et al. Reviews of evidence regarding interventions to increase use of child safety seats. American Journal of Preventive Medicine, 2001, 21(4S):31–34. 140. Dinh-Zarr T et al. Reviews of evidence regarding interventions to increase the use of safety belts. American Journal of Preventive Medicine, 2001, 21(4S):48–65. 141. Macpherson A, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews. 2007, (2):CD005401. 142. DiGuiseppi C, Goss C, Higgins JPT. Interventions for promoting smoke alarm ownership and function. Cochrane Database of Systematic Reviews, 2001, (2):CD002246. 143. MacArthur C. Evaluation of Safe Kids Week 2001: Prevention of Scald and Burn Injuries in Young Children. Injury Prevention, 2003, 9:112–116. 144. Best practices: Poisoning interventions. Harborview Injury Prevention Research Centre (http://depts.washington. edu/hiprc/practices/topic/poisoning/packaging.html, accessed 6 April 2008). 145. Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database of Systematic Reviews, 2000, (2):CD001047. 146. Ehiri JE et al. Interventions for promoting booster seat use in four to eight year olds traveling in motor vehicles. Cochrane Database of Systematic Reviews, 2006, (1):CD004334. 147. Karkhaneh M et al. Effectiveness of bicycle helmet legislation to increase helmet use: a systematic review. Injury Prevention, 2006, 12:76–82. 148. Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews. 1999, (4):CD001855. 149. ISO/IEC Guide 50:2002. Safety aspects: guidelines for child safety, 2nd ed. Geneva, International Organization for Standardization, 2002. 150. Razzak J et al. Injuries among children in Karachi, Pakistan: what, where and how. Public Health, 2004, 118:114–120. 151. Child injury prevention [Evidence-Based Health Promotion No. 4]. Melbourne, Victorian Government Department of Human Services, 2001 (http://health. vic.gov.au/healthpromotion/quality/child_injury.htm, accessed 22 January 2008). 152. Krug A et al. The impact of child resistant containers in the incidence of paraffin (kerosene) ingestion in children. South African Medical Journal, 1994, 84:730–734. 153. Bruce N et al. Prevention of burns among children in wood fuel using homes in rural Guatemala. Poster presentation at the 16th Annual Conference of the International Society for Environmental Epidemiology, New York, NY, 1–4 August 2004. 154. Bunn F et al. Traffic calming for the prevention of road traffic injuries: systematic review and meta-analysis. Injury Prevention, 2003, 9:200–204. 155. Lyons RA et al. Modification of the home environment for the reduction of injuries. Cochrane Database of Systematic Reviews, 2003, (4):CD003600. 156. Tiwari G. Traffic flow and safety: need for new models for heterogeneous traffic. In: Mohan D, Tiwari G, eds. Injury Prevention and Control. London, Taylor and Francis, 2000:71–78. 157. Bilukha O, et al. The effectiveness of early childhood home visitation in preventing violence: a systematic review. American Journal of Preventive Medicine, 2005, 28(Suppl. 2)1:11–39. 158. Kendrick D et al. Does home visiting improve parenting and the quality of the home environment? A systematic review and meta analysis. Archives of Diseases in Children, 2000, 82:443–451. 159. Grossman D, Garcia C. Effectiveness of health promotion programs to increase motor vehicle occupant restraint use among young children. American Journal of Preventive Medicine, 1999, 16:12–22. 160. Royal ST, Kendrick D, Coleman T. Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews, 2005, (2):CD003985. 161. Farley C, Laflamme L, Vaez M. Bicycle helmet campaigns and head injuries among children. Does poverty matter? Journal of Epidemiology and Community Health, 2003, 57:668–672. 162. Helmets: a road safety manual for decision-makers and practitioners. Geneva, World Health Organization, 2006 (http://www.who.int/violence_injury_prevention/ publications/road_traffic/helmet_manual.pdf, accessed 22 January 2008). 163. Liu BC et al. Helmets for preventing injury in motorcycle riders. Cochrane Database of Systematic Reviews, 2004, (2):CD004333. 164. Duperrex O, Roberts I, Bunn F. Safety education of pedestrians for injury prevention. Cochrane Database of Systematic Reviews, 2002, (2):CD001531. 165. Towner EML. The role of health education in childhood injury prevention. Injury Prevention, 1995, 1:53–58. 166. Manganello JA, McKenzie LB. Home and child safety on reality television. Health Education Research, 2008 [Epub ahead of print] (http://her.oxfordjournals.org/cgi/reprint/ cym088v1, accessed 18 July 2008). 167. Green LW, Kreuter M. Health promotion planning: an educational and environmental approach, 2nd ed. Mountain View, CA, Mayfield Publishing Co., 1991. 168. Behaviour change at population, community and individual levels. London, National Institute for Health and Clinical Excellence (NICE), 2007 (NICE public health guidance 6). WORLD REPORT ON CHILD INJURY PREVENTION 27
Slide 47: 169. Towner E, Dowswell T. Community-based childhood injury prevention: what works? Health Promotion International, 2002, 17:273–284. 170. Spinks A et al. The ‘WHO Safe Communities’ model for the prevention of injury in whole populations. Cochrane Database of Systematic Reviews, 2005, (2):CD004445. 171. Kelly M, Speller V, Meyrick J. Getting evidence into practice in public health. London, Health Education Authority, 2004. 172. Brussoni M, Towner E, Hayes M. Evidence into practice: combining the art and science of injury prevention. Injury Prevention, 2006, 12:373–377. 173. Mock C et al. Strengthening the prevention and care of injuries worldwide. The Lancet, 2004, 363:2172–2179. 174. Whitehead M. Tackling inequalities: a review of policy initiatives. In: Benzeval M, Judge K, Whitehead M, eds. Tackling inequalities in health: an agenda for action. London, King’s Fund, 1995. 175. Thomson J, Whelan K. Community approach to road safety education. London, Department of Transport, 1997 (http://www.dft.gov.uk/pdf/pgr/roadsafety/research/rsrr/ theme1/communityapproachtoroadsafet4735, accessed 22 January 2008). (Road Safety Research Report No. 3). 176. Coggan C et al. Evaluation of the Waitakere community injury prevention project. Injury Prevention, 2000, 6:130– 134. 177. Schwartz D et al. An injury prevention program in an urban African-American community. American Journal of Public Health, 1993, 83:675–680. 178. MacKay M et al. Child safety good practice guide: good investments in unintentional injury prevention and safety promotion. Amsterdam, European Child Safety Alliance, 2006. 179. Schopper D, Lormand JD, Waxweiler R, eds. Developing national policies to prevent violence and injuries: a guideline for policy-makers and planners. Geneva, World Health Organization, 2006 (http://www.who.int/violence_injury_ prevention/publications/39919_oms_br_2.pdf, accessed 22 January 2008). 180. Peden M, Hyder AA. Road traffic injuries are a global public health problem. British Medical Journal, 2002, 324:1153. 181. Doll LS et al., eds. Handbook of injury and violence prevention. Atlanta, GA, Springer, 2007. 182. Hendrie D et al. Child and family device availability by country income level: an 18 country comparison. Injury Prevention, 2004, 10:338–343. 183. Waters H, Hyder AA, Phillips TL. Economic evaluation of interventions to reduce road traffic injuries: a review of literature with applications to low and middle income countries. Asia Pacific Journal of Public Health, 2004, 16:23–31. 184. Bishai DM, Hyder AA. Modeling the cost effectiveness of injury interventions in lower and middle income countries: opportunities and challenges. Cost Effectiveness and Resource Allocation, 2006, 4:2. 185. Miller TR, Romano EO, Spicer RS. The cost of childhood unintentional injuries and the value of prevention. The Future of Children [issue on “Unintentional injuries in childhood”], 2000, 10:137–163 (http://www. futureofchildren.org/usr_doc/vol10no1Art6.pdf, accessed 7 March 2008). 186. Miller TR, Levy DT. Cost outcome analysis in injury prevention and control: eighty-four recent estimates for the United States. Medical Care. 2000, 38:570–573. 187. France: recent developments in road safety. Paris, French National Observatory for Road Safety, 2005 (http:// securiteroutiere.gouv.fr/IMG/pdf/FRDI.pdf, accessed 22 January 2008). 188. Rivara FP. Prevention of injuries to children and adolescents. Injury Prevention, 2002, 8(Suppl. 4):iv5–iv8. 189. Philippakis A et al. A quantification of preventable unintentional childhood injury mortality in the United States. Injury Prevention, 2004, 10:79–82. 190. Pless B. Action on injury: setting the agenda for children and young people in the UK [Preface]. Injury Prevention, 1998, 4:S1–S3. 28 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 48: WORLD REPORT ON CHILD INJURY PREVENTION 29
Slide 49: TRAFFIC INJURIES D E A N A’ S S T O RY Deana is my daughter. She was 17 years old when her life was cut short. Deana was with four friends going to a birthday party. They had just got out of a taxi and were trying to cross the Nile Corniche in Maadi. The traffic is heavy, chaotic. There are no traffic lights, no crosswalks, just a constant stream of speeding, weaving cars, trucks and buses. You have to dart across several lanes of traffic to get to the other side. Deana was hit and killed by a speeding bus as she tried to cross the road. The bus driver didn’t even slow down. I was in Damascus at the time, travelling for my work. My brother-in-law called me to tell me the terrible news that my baby girl had been hit. You can imagine my guilt. I should have been in Cairo. I could have driven her to the party. Deana loved so many things, she loved life. She had an infectious smile. She always had time for other people more than for herself. She wanted to be a paediatric dentist – she loved kids. She had a special love of angels. She always had pictures or figurines of angels in her room. For us, she has become the “Angel of the Nile”. Everyone was deeply affected by Deana’s death, her family her friends, the entire community. I think of ripples of pain, an ever-widening circle of those who were affected. My wife, son and I had to leave Cairo after Deana’s death. It was too painful, too many memories. We came back to Cairo just a few months ago. I guess that early on I made a decision. I could roll up into a ball in a foetal position and never wake up. It would be very easy to do this and give up. But I felt that I had tried to make sense out of the senseless, the unbelievable. I decided to do something tangible, something that would save other people’s lives. An NGO, the Safe Road Society, started because our daughter lost her life. It is dedicated to making the roads in Egypt safer for its citizens. Our first project is the building of a pedestrian tunnel under the Maadi Corniche El Nile. Governmental permits have been obtained and request for construction bids sent. Our next step is to ensure sufficient funds are raised through voluntary donations to complete this life saving project. This busy road of death runs alongside the serenity of the Nile River. Many concerned and dedicated Egyptians and foreigners have joined together with the goal to make the tunnel a reality. Also, a scholarship was started in Deana’s name at her school and every year a graduating senior who smiles and brings light to another student’s day is awarded a helping hand. By building a pedestrian tunnel we hope to save lives and, in my dreams, to see my Deana, my Angel of the Nile, looking down upon us and smiling in approval. © D. Blanchard
Slide 50: CHAPTER 2 – ROAD TRAFFIC INJURIES Chapter 2 Road traffic injuries Introduction In many places the road network is constructed without considering children. Children, though, use the roads as pedestrians, bicyclists, motorcyclists and occupants of vehicles. They may live close to a road, play on a road, or even work on the roads. All these interactions with roads, together with a range of other risk factors associated with childhood, increase the susceptibility of children to road traffic injury. This chapter examines the extent and characteristics of road traffic injuries for different types of road users among children aged 0–17 years, as well as their risk factors. Proven and promising interventions, for the different types of road user, are discussed, along with their effectiveness and cost-effectiveness. The chapter concludes with some recommendations for preventing the growing toll of road traffic injury. For the purpose of this report, a road traffic crash is defined as “a collision or incident that may or may not lead to injury, occurring on a public road and involving at least one moving vehicle”. Road traffic injuries are defined as “fatal or non-fatal injuries incurred as a result of a road traffic crash” (1). Although other definitions exist, a road traffic fatality is considered to be a death occurring within 30 days of a road traffic crash (2). This chapter focuses on children aged 0–17 years. Comprehensive data, however, are not always available across the whole age range. In particular, information is often limited for children aged between 15 and 17 years. There are also problems of under-reporting of road traffic deaths and injuries, particularly in low-income and middle-income countries, limitations that need to be taken into account when interpreting the data. The road is a dangerous place for children and young people. However, road traffic injuries do not have to be the price children and their families pay for the increasing mobility and independence of children as they grow up. There are proven and effective measures that can be put into place to reduce their risks to a minimum. Eastern Mediterranean Regions. Globally, 21% of road traffic deaths were among children. There have been downward trends in the numbers of road traffic deaths and injuries over the last couple of decades in several developed countries. Globally, though, the outlook is disturbing. By the year 2030, road traffic injuries are predicted to be the fift h leading cause of death worldwide (3) and the seventh leading cause of disabilityadjusted life years lost (4). The South-East Asia, African and Western Pacific regions are expected to see the most significant increases in road traffic injuries. Of particular concern is the fact that in India and China – each with more than a sixth of the world’s population – the number of road traffic deaths is predicted to increase, by 2020, by approximately 147% and 97%, respectively (5). Mortality In 2004, road traffic injuries accounted for approximately 262 000 child deaths among children and youth aged 0–19 years – almost 30% of all injury deaths among children (see Statistical Annex, Table A.1). Road traffic injuries are the leading cause of death among young people aged 15 to 19 years (see Table 1.1). Globally, these deaths on the roads account for nearly 2% of all deaths among children. There are significant geographic variations, however. In the South-East Asia Region, the proportion of childhood deaths due to road traffic injuries is 1.3%, while in the Americas it is as high as 4.7%. Some 93% of child road deaths occur in low-income and middleincome countries (see Statistical Annex, Table A.1). In 2004, the South-East Asia and African Regions and the low-income and middle-income countries of the Western Pacific Region accounted for two thirds of all road traffic deaths among children. Data shows that globally, the road traffic death rate among children is 10.7 per 100 000 population (see Figure 2.1). In South-East Asia, however, the rate is 7.4 per 100 000 population, while in the African Region it is 19.9 per 100 000 population. Although the mortality rate is not as high in Europe, road traffic injuries still account for around a fi ft h of all childhood injury deaths across the European Union (6). In addition to regional differences, there are also variations according to the type of road user. In 70 countries – mainly middle-income and high-income countries – that provide sufficiently detailed mortality data to WHO, about 33% of all child deaths around the world are pedestrians, while 65% are car occupants or bicycle or motorcycle riders (7). WORLD REPORT ON CHILD INJURY PREVENTION 31 Epidemiology of road traffic injuries According to the WHO Global Burden of Disease project, in 2004 nearly 1.3 million people of all ages were killed in road traffic crashes around the world and up to 50 million more were injured or disabled. The South-East Asia and the Western Pacific Regions of WHO together accounted for two thirds of all road traffic deaths. However, the highest rates of road traffic death were in the African and
Slide 51: FIGURE 2.1 Road-traffic injury mortality rates per 100 000 childrena by WHO region and country income level, 2004 15+ 8.0–14.9 <8.0 No data Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific LMIC 19.9 HIC 8.7 LMIC 7.7 LMIC 7.4 HIC 5.2 LMIC 8.3 HIC 18.3 LMIC 17.4 HIC 4.2 LMIC 8.6 a These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. Age Globally, road traffic injuries are the leading cause of death among 15–19-year-olds and the second leading cause among 5–14-year-olds (see Table 1.1). Global road traffic fatality rates increase with age (see Figure 2.2), reflecting the way children of different ages use the road. Children up to the age of nine years are more likely to be accompanied by parents when they travel, either in vehicles or as pedestrians, while older children tend to travel more independently, initially as pedestrians and later as bicyclists, motorcyclists and finally drivers. The higher rates of injury among children aged 10 years and over is a result of this increased mobility as well as of their increased tendency to exhibit risk-taking behaviours. For all age groups, except for the 15–19-year age group, road traffic fatality rates are greater in lowincome and middle-income countries than they are in high-income countries. Surveys in five Asian countries showed that road traffic injuries are the second leading cause of child mortality (see Statistical Annex, Table B.1). In Bangladesh, for instance, road traffic injuries were the second most common cause of injury deaths in children aged 1–9 years, whereas in children aged 10–14 years they were the leading cause, accounting for 38% of all child deaths. In those aged 15– 17 years, road traffic injuries accounted for 14% of injury 32 WORLD REPORT ON CHILD INJURY PREVENTION FIGURE 2.2 Fatal road-traffic injury rates per 100 000 children by age and country income level, World, 2004 20 Rate per 100 000 population HIC 16 12 8 4 0 Under 1 1–4 5–9 Age (years) LMIC 10–14 15–19 HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. deaths (8). In Thailand, 40% of injury deaths in 10–14-yearolds were from road traffic injuries (9). Gender From a young age, boys are more likely to be involved in road traffic crashes than girls. The difference in incidence rates between boys and girls increases with age until children reach 18 or 19 years of age, when the gender gap
Slide 52: is similar to that seen in adulthood (see Table 2.1). Overall, the death rate for boys is 13.8 per 100 000 population, compared to a rate for girls of 7.5 per 100 000 population. In the high-income countries of the Eastern Mediterranean Region the gender gap is greatest among young children while in the regions of Europe, the Western Pacific and the Americas the gap is more pronounced among older children (see Statistical Annex, Table A.1). TABLE 2.1 These survey results are supported by a hospitalbased study of injured children under the age of 12 years, conducted in four low-income countries. The study found that, among those suffering road traffic injuries, more than a quarter had incurred a concussion or other head injury, followed by various cuts, bruises, open wounds, fractures and sprains (see Statistical Annex, Table C.1 and Figure 2.3). FIGURE 2.3 Fatal road-traffic injury rates per 100 000 children by age and sex, World, 2004 Age ranges (in years) Under 1 Boys Girls 11.5 7.4 1–4 9.7 8.3 5–9 13.3 9.3 10–14 15–19 8.7 4.5 23.4 7.9 Under 20 13.8 7.5 Injuries sustained by childrena presenting to an emergency department as a result of a road traffic crash in four countriesb in 2007 Other 3.2% Fracture 21.1% Source: WHO (2008), Global Burden of Disease: 2004 update. Concussion 26.0% Sprain 10.7% Morbidity The number of children injured or disabled each year as a result of road traffic crashes is not precisely known, but has been estimated at around 10 million. Th is figure is based on data from health-care institutions that suggest that children make up between a fi ft h and a quarter of those involved in a road traffic crash and admitted to a hospital (10 –12). However, community-based surveys from Asia suggest that the figure could be much higher. The surveys found that, for every child who died as a result of a traffic injury, 254 presented to a hospital facility with injuries, four of whom where left with permanent disabilities (13). In children under the age of 15 years, road traffic injures rank as the eleventh cause of death and the tenth cause of burden of disease among children (see Statistical Annex, Table A.2). Globally, road traffic injuries among this age group account for 9482 disability-adjusted life years lost – 1.7% of the total disability-adjusted life years lost. In general, there is a lack of data on morbidity, particularly from low-income and middle-income countries. This is partly because not all children injured in road traffic incidents are taken to hospital and partly as a result of poor data collection systems. Bruise 13.6% Cut/open wound 25.3% a b Children were under 12 years. The four countries were Bangladesh, Colombia, Egypt and Pakistan. Source: Statistical Annex, Table C.1. Chest and abdominal injuries, although not as common as head and limb injuries, can be very serious because of the organs involved and the difficulties in managing such injuries. Multiple trauma has also been reported in approximately 10% to 20% of children involved in road traffic crashes (14). Consequences of road traffic injuries Road traffic injuries are a leading cause of disability for children. Recent surveys in Asia show that road traffic injuries are one of the five leading causes of disability for children. The exact proportion of children disabled by road traffic injuries varies by age group and across countries (15). According to these surveys, the rate of permanent disability among children aged 1 to 17 years injured as a result of a road traffic crash was 20 per 100 000 children. In addition, significant numbers of children required hospitalization or missed school as a result of their injuries (see Figure 2.4). Studies conducted among both adults and children highlight the fact that many individuals still retain some functional disability 6 to 12 months following a road traffic crash. Clearly, the type of injury sustained affects the period needed for complete recovery. Research in Bangalore, India, for instance, found that 14% of children who sustained a traumatic brain injury from a road traffic WORLD REPORT ON CHILD INJURY PREVENTION 33 Nature and severity of road traffic injuries The head and limbs are the most common parts of the body injured in children involved in road traffic crashes. The severity of injuries will vary, depending on the age of the child, the type of road user and whether protective devices were used. A recent school-based survey conducted by WHO looked at 13–15-year-olds in 26 countries. Of those children reporting an injury involving a motor vehicle in the previous 12 months, 10% had sustained a minor head injury and 37% had fractured a limb.
Slide 53: FIGURE 2.4 Severity of road traffic injuries per 100 000 population among children aged 0–17 years, in five Asian countriesa 300 Rate per 100 000 children 250 200 150 100 50 0 Missed school Hospital 1–9 days Hospital 10+ days Permanent disability Death or anxiety (23). Another study found that a quarter of children were exhibiting post-traumatic stress disorder three months after the crash (22). Road traffic crashes can also have a profound psychological effort on children not directly involved in the incident themselves but who lose a parent or caregiver (see Box 2.1). Results from Asia show that among orphans, 20% to 66% have lost a father, mother or both in road traffic crashes (15). The loss of a parent or parents can leave a child with long-term psychosocial problems as well as economic impoverishment. Types of road user Children suffer injuries while in a variety of roles related to different types of transport. They may be pedestrians, bicyclists, car occupants, motorcycle riders or motorcycle passengers, or passengers on public transport. In some countries, children work on the streets, usually selling merchandise, where they weave in and out of moving traffic. a Bangladesh, China (Beijing, Jiangxi province), Philippines, Thailand, Viet Nam. Source: Reference 15. crash still required assistance with day-to-day activities six months after the crash (16). The outcome of a road traffic injury is also related to road user type. One study found that 72% of pedestrians, 64% of bicyclists struck by a car, and 59% of child vehicle occupants required assistance six months after a crash (17). In Canada, 22% of bicyclists injured without a motor vehicle being involved in the incident required subsequent assistance (18). Disabilities and impairments impede the progress of children in their early years depriving them of education and social development. Children who sustain disabilities following a road traffic crash frequently require long-term care and their quality of life is often poor. The excessive strain placed on families who have to care for their injured children may result in adults having to leave their jobs, leading to conditions of poverty. BOX 2.1 Children orphaned through road traffic deaths The Bangladesh Health and Injury Survey, a population-based survey of 171 366 households, was conducted in 2003. A verbal autopsy module was used, adapted from the WHO standards for verbal autopsy (24), with specific questions on each type of injury. Data were analysed for the causes of death of parents of children aged 0 to 17 years. Injury was a leading cause of death of parents of children under the age of 18 years. Some 4 300 mothers die from injuries in Bangladesh each year, leaving about 17 700 children without their primary caregiver. As shown in the table below, the leading cause of injury death for mothers is suicide (41%), followed by road traffic crashes (29%), burns (12%) and violence (10%). CAUSES OF INJURY-RELATED DEATHS AMONG PARENTS OF CHILDREN AGED 0–17 YEARS Psychosocial impact A number of mental health conditions have been observed in children following a road traffic crash. These include phobias, post-traumatic stress disorder and anxiety, as well as behavioural problems. These psychosocial disturbances may be exacerbated by family impoverishment following a road traffic crash, particularly if a parent or caregiver was also involved in the collision and was severely injured or died. Injured children can thus experience high levels of psychosocial distress (19) and feel isolated in their suffering (20). Several studies have reported high levels of distress in children during and immediately after a road traffic injury (17, 21, 22). One study reported that that within five days of a traumatic event, such as a road traffic crash, 98% of the children involved suffered post-traumatic stress disorder, depression or anxiety. One month after injury, 82% still had symptoms. Twelve months after injury, 44% were still having flashbacks, feared being injured again, or suffered mood disorders, body-image changes, sleep disturbances 34 WORLD REPORT ON CHILD INJURY PREVENTION Mothers Fathers Causes of all injury deaths (%) Suicide Road traffic Burns Violence Falls Other injuries 41 29 12 10 3 5 12 36 0 27 5 13 Source: Reference 8. Around 7 900 fathers die from injury annually, leaving nearly 22 100 children in households that have lost their primary wage earner. The most common causes of injury death in fathers are road traffic crashes (36%), followed by violence (27%) and suicide (12%). Children deprived of one or both parents are vulnerable to malnutrition, illness, impaired development, psychosocial trauma, exploitation and abuse. In Bangladesh, as in many countries, fatal injuries of parents are a significant cause of orphaning. This damages the children left behind and is a huge burden on society. As well as preventing injuries among children, societies need to take greater steps to reduce the incidence of injuries, both unintentional and intentional, among adults.
Slide 54: The patterns of road use among children vary by country, affecting the type of injuries they sustain (see Figure 2.5). FIGURE 2.5 Bicyclists In many countries, children are taught to ride bicycles as a form of recreation. In many parts of Asia, bicycles are also a common means of transport. This is reflected in the statistics. Bicyclists constitute 3%–15% of children injured in traffic collisions and 2%–8% of child traffic-related fatalities around the world (26). In some Asian countries, though, the latter figure can be as high as 33% (28). While there has been a decline in bicyclist deaths among children in high-income countries (27), bicycle-related injuries are increasing in many low-income and middle-income countries, particularly in South-East Asia and the Western Pacific (28). Proportion of fatal road traffic deaths among childrena by type of road user in selected OECD countries Australia Canada Czech Republic Denmark Finland France Germany Iceland Netherlands New Zealand Norway Poland Republic of Korea Spain Sweden Switzerland Turkey United Kingdom United States Motorcyclists Where motorcycles are commonly family vehicles, children may begin to travel on motorcycles at an early age, either sitting on the petrol tank or behind the driver. In some Asian countries, where motorized twowheelers are the most common form of transportation and children are legally allowed to drive small-engine motorcycles from their 15th year, motorcycle crashes are the leading cause of mortality and morbidity among teenagers (15). Young drivers 0 20 40 60 80 100 Proportion of all road traffic injuries (%) Bicyclists Car passengers Pedestrians a These data refer to children under the age of 15 years. OECD = Organisation for Economic Co-operation and Development. Source: Reference 25, reproduced with permission. Pedestrians Globally, pedestrians form the single largest category of children involved in road traffic crashes. In high-income countries between 5% and 10% of children suffering road traffic injuries are pedestrians, while in low-income and middle-income countries the proportion ranges from 30% to 40% (26). Child pedestrian injury is highest in Africa and Asia where it is usual for people to walk along roads (12, 15). Despite significant reductions in child pedestrian injury in many high-income countries, the prevention of such injury remains a problem, particularly among 5–14-year-olds. Injuries and fatalities among young drivers are a major problem in high-income countries, where a large study showed that crashes involving young drivers accounted for between 20% and 30% of all road traffic fatalities (29). In particular, young drivers are at high risk of a crash in their fi rst year of driving by themselves. Research from Sweden shows that novice drivers are 33 times more likely to have a crash than other drivers (30), while in Western Australia, drivers on a provisional licence are 15 times more likely than older drivers to be involved in a crash (31). In the United States, the risk of a crash for a driver aged 16 years is five times the average risk for all ages (32) (see Figure 2.6). Although mortality rates among young drivers have decreased in most high-income countries in recent decades, the relative proportion of young drivers among all drivers killed remains high, confi rming that greater prevention efforts are required among this category of road user. Heavy vehicles Only a few studies have specifically examined the risk to children involved in heavy vehicle crashes (33). Public transport vehicles for children are primarily buses, heavy vehicles and school transport vehicles. Unsafe buses in low-income and middle-income countries are frequently involved in major crashes involving children. In highincome countries, the greatest risk to school children is while alighting from a bus – rather than from a crash involving a school bus (34, 35). WORLD REPORT ON CHILD INJURY PREVENTION 35 Occupants Children injured or killed while travelling in cars as occupants are a serious concern in high-income countries, where such cases can account for up to 50% of childhood traffic deaths (27). As motorization increases, child occupant deaths are also an emerging problem in many middle-income countries.
Slide 55: FIGURE 2.6 Driver crash involvement per million milesa travelled by driver age, United States, 2001–2002 30 25 Crash involvement per milion miles travelled 20 15 10 5 0 16 17 18 19 20– 25– 30– 35– 40– 45– 50– 55– 60– 65– 70– 75– 80– 85+ Age (years) a 1 mile is approximately 1.60934 kilometres. Source: Reference 32, reproduced with permission. are scarce and those that are used suffer from a lack of standard definition – particularly as regards what is meant by minor, moderate or severe injuries. There are frequent disparities between data – for example, between police and health-related sources – making comparisons difficult (1). These difficulties are made worse by the fact that there is widespread under-reporting of road traffic fatalities and injuries – both in health-related and police data. In addition to these limitations, there is an additional problem of different age cut-off points when dealing with child-related road traffic injuries and deaths. This makes comparisons particularly difficult. Solid data are needed to provide a basis for decisionmaking. Establishing a simple, cost-effective system or improving systems currently in use should be priorities in improving road safety. All the same, a current lack of reliable data should not prevent other necessary measures from being undertaken. Economic impact of road traffic injuries The global losses due to road traffic injuries are estimated to be US$518 billion per annum (36), with the annual cost of road crashes in low-income and middle-income countries estimated at between US$65 billion and US$100 billion. This means that road traffic collisions and their consequences cost governments up to 3% of their gross national product (1). Information on the global cost of road traffic injuries exclusively among children is not available. The direct and indirect costs of road traffic injuries, both for those directly involved and for national economies, are numerous. The direct and indirect costs include: – permanent disabilities; – loss of schooling; – medical care; – legal costs; – vehicle repair costs; – loss of income to parents, resulting from absence from work to care for the child. In addition, there are long-term economic costs arising from: premature death; rehabilitation; the loss of healthy years in children; and the inability of those with serious disabilities to work to the full extent. The poor, who are over-represented in road traffic crash statistics, are hardest hit by these costs. Findings from research in Bangladesh and India suggest that there is a further decline into poverty when the poor are injured. This is because additional resources are needed to care for the injured person, achieved by taking on extra work, selling assets or taking out further loans (37). Risk factors Most of the factors that increase the risk of road traffic injuries for the general population do so similarly for children. Thus children are affected by speeding and drink-driving, by not using safety equipment and by factors related to vehicle safety and the road environment. However, there are also risk factors that are specific to children. The road environment is constructed with consideration for adults. It is not built for use by children, and when children come into contact with it they are placed at greater risk than need have been the case. The set of risk factors that increase a child’s susceptibility in road traffic can be considered within the conceptual framework of the Haddon Matrix (see Table 2.2). Child-related factors Physical development A child’s head, chest, abdomen and limbs are all in a state of growth. Their relative soft ness make a child physically more vulnerable to the impact of injury than an adult. Furthermore, the smaller physical stature of children can create problems, as it limits their ability to see or be seen over certain heights such as parked cars or large trucks – a known risk factor in child pedestrian injuries. Children’s sensory facilities are also less fully developed. Their ability to synthesize information, from their peripheral fields of vision and their auditory sense, is limited, which can lead to their missing critical cues of danger, thus increasing their risk of road traffic injury (38). Cognitive development Limitations of data Many countries do not have injury surveillance systems that provide reliable data on road traffic crashes and injuries. Indicators, particularly on non-fatal outcomes, 36 WORLD REPORT ON CHILD INJURY PREVENTION The developmental processes taking place in children have an effect on their ability to make safe decisions in the road environment, and these processes are closely related to age (39).
Slide 56: TABLE 2.2 Haddon Matrix applied to the risk factors for road traffic crash injuries among children Child factors Pre-event Vehicle and safety equipment Physical environment Poor road design; lack of public transport; no enforcement of speed limits; no safety barriers; lack of alcohol laws; poor infrastructure for pedestrian safety. Socioeconomic environment Poverty; single-parent family; large family size; poor maternal education; lack of awareness of risks among caregivers, childcare providers and educators. Lack of safety culture in the car and on the road. Age; gender; lack of supervi- Lack of roadworthiness of vehision; risk-taking; impulsive cle; poor lighting; poor state of behaviour; disobedience; lack brakes; speeding; overloading. of police enforcement. Size and physical development of child; lack of equipment to protect occupants, or equipment improperly used; underlying conditions in child. Event Child restraints and seat-belts Roadside objects such as trees not fitted or incorrectly used; and poles. bicycle and motorcycle helmets not used; poor design of vehicle for protection in crashes; no rollover protection. Post-event Child’s lack of resilience; Difficult access to victim; lack of Lack of availability of adequate Lack of culture of supporting child’s general condition; lack trained health-care and rescue pre-hospital care, acute care and injured people; no first aid given of access to appropriate health workers. rehabilitation. at scene. care; post-injury complications. Young children aged between five and seven years have mastered the concepts of speed and distance (40). However, they exhibit poor skills in recognizing dangerous places to cross the road, relying exclusively on the visible presence of cars in the vicinity. They are also unlikely to assess the presence of oncoming traffic with accuracy. “Blind” sections of the road, obstacles by the road that could obscure a child from a driver’s field of vision and complex road junctions are not perceived by young children as threatening situations (39, 41). Road traffic crashes involving young children include a large proportion of “dart and dash” cases. In such cases, a child pedestrian is injured through a “critical behavioural error”, where it has failed to stop or slow down before attempting to cross the road. This type of behaviour is due to a child’s “centration” – the inability of the child to switch attention from one task to another (42). These cognitive processes are more developed in children aged 11 years and older who appear to be able to recognize a given road location as dangerous and show judgement that allows them to be safe on the roads (43). Children over the age of 12 years have the capacity to modify their behaviour when faced with a situation involving two tasks. This is an area of ongoing research and new evidence relating to children’s abilities on the road is regularly published. Two issues have recently arisen in this connection, both related to cognitive development. There is growing evidence that, although the visual processes needed for a child to cross a road are fully developed as infants, the full integration of visual signals into a meaningful context is not fully developed until children are around 10–12 years old (44, 45). Cognitive processes taking place in an adolescent’s brain could affect their risk of road traffic crash as young drivers. Through the use of brain-imaging techniques, neurobiological research conducted over the past decade has found that parts of the frontal lobe – in particular the prefrontal cortex which governs judgement, decision-making, reasoning and impulse control – appears not to fully mature until the age of 20 or 25 years (46). While research linking this new evidence on brain development directly to driving has yet to be undertaken, these findings provide some insight into the biological mechanisms that may put many young drivers at risk. Risk-taking behaviour While young children may inadvertently take risks because they lack appropriate skills to do otherwise, older children and adolescents may actively seek out risk. Risk-taking behaviour may allow adolescents to feel a sense of control over their lives or else to oppose authority. Research shows that there are high levels of sensation-seeking behaviour among young adults and that there exists a need to maintain a heightened level of physiological arousal. Young people consequently seek new situations and experiences to maintain this level, irrespective of the risks inherent in the experience. Such sensation-seeking frequently focuses on risky behaviours, including while driving a vehicle or crossing a road. Sensation-seeking has been shown to rise between the ages 9 and 14 years, peaking in late adolescence or in early adulthood, and declining steadily with age (47). Risk-seeking behaviour is a significant predictor of involvement in road traffic injury among child pedestrians as it is for young adolescent drivers aged 16–17 years (48– 50). Across all ages and particularly among the young, sensation-seeking is more common among boys than among girls. Boys as young as 11 years have a greater WORLD REPORT ON CHILD INJURY PREVENTION 37
Slide 57: affinity for speed, risk-taking and competitive behaviour, all of which place them at an increased risk of road traffic injury (51). A certain amount of risk-taking is a normal physiological attribute and is necessary for a child’s growth and development. Children, though, often do not realize that they need to make a complex set of decisions to avoid harm. It is the responsibility of adults to understand the vulnerability of children in the road environment and their developmental limitations, and to ensure their safety by providing developmentally appropriate behavioural interventions. thought to contribute towards this difference include increased risk-taking and sensation-seeking. Type of road user There is no specific age at which children can be said to be safe road users. Children understand and react to complex traffic situations in different ways from adults. Younger children have different information-processing and psychomotor abilities compared to older children. Adolescents are characterized by impulsiveness, curiosity and experimentation. Developmentally, children develop at different rates and the differences between individuals can be large. Peer influence As young children become adolescents, they enter a phase where the influence of their parents is reduced, and they begin to discover and assert their independence. This transition can be expressed in their lifestyle, and in an increasing conformity with certain social norms, that in turn influence their behaviour and decision-making. For many young people, peers are of significant importance and can be the primary source of the social norms with which they strive to conform (29). Social norms, including peer pressure and the emphasis placed on rebellion in the culture of young people, can affect the manner in which young people drive a vehicle. Direct peer pressure may be exerted on the driver’s behaviour through the influence of a passenger. Research has shown that young drivers experience higher peer pressure than older drivers to commit traffic violations such as speeding, driving under the influence of alcohol and dangerous overtaking (52). There is a close link between the presence of similarly aged passengers in the car and increasing risk levels. A number of studies have shown that young drivers, both male and female, drive faster and with a shorter following distance at road junctions if they have young passengers in the car (51, 53). Pedestrians In many parts of the world the majority of children injured or killed on the roads are pedestrians, particularly in low-income and middle income countries. The physical and cognitive developmental factors already discussed increase the risk of a road traffic crash among child pedestrians, especially among younger children, where physical stature and cognitive limitations restrict their ability to make safe decisions. In many low-income and middle-income countries children use roads for playing and for conducting small roadside businesses, both of which increase their exposure significantly. Risk-taking behaviour and peer pressure may increase risk among adolescents who are pedestrians. Occupants For young children who are occupants of vehicles the main risk factor is the lack or improper use of a restraint. Children should be strapped in appropriate restraints based on their age, weight or height (Box 2.2). The rate of use of appropriate child restraints in motor vehicles varies considerably across countries – from nearly 90% in the United States (55) to almost zero in Oman (56). While many parents use car seats for infants, the use of appropriate seat restraints decreases markedly after a child has outgrown the infant device. Adolescents and young adults have the lowest wearing rates for seat-belts around the world. In a survey of youth risk behaviour, only a third of 14–17-year-olds reported that they always wore a seat-belt as a passenger in a vehicle. More than a third noted that they had been a passenger with a driver who had been drinking alcohol (60). In addition, having passengers of around the same age increases the likelihood of a novice driver, aged 16–18 years, incurring a crash (61). Gender There is evidence of a strong relationship between gender, road safety behaviour and road traffic injury. Most studies conducted show a strong male bias, with the male-tofemale ratio ranging between 3:1 and 5:1. This relationship holds true across different regions of the world and applies to fatal and non-fatal injuries. A part of the predominance of boys in road traffic injury statistics can be accounted for by differences in exposure. Research on 10–12-year-old boy pedestrians has found that the amount of exposure, together with nature of the road environment, influences injury rates among this group, particularly those from poorer areas (54). However, exposure does not account for the entire difference. Among young drivers, men have more fatal crashes per kilometre driven than do young women, even taking into consideration their increased exposure levels. Factors 38 WORLD REPORT ON CHILD INJURY PREVENTION Bicyclists The major risk to bicyclists relates to exposure (62). In most high-income countries, children ride bicycles for pleasure and so make up a small proportion of road traffic deaths, though many minor bicycle collisions
Slide 58: BOX 2.2 How child restraints prevent injuries to child passengers In the first half of the 20th century, traffic safety efforts concentrated on preventing crashes by changing the behaviour of drivers. In the 1950s, concepts already prevalent in aviation safety, including safety-belts, started to be applied to motor vehicles. Properly fitted seat-belts were found to absorb the energy caused by a rapid deceleration in a crash. In addition, a safety-belt reduced the risk of ejection from the vehicle and – if it fitted properly – spread the forces from a crash over hard bones rather than softer internal organs. The first laws came in 1966, when the United States federal government introduced regulations requiring new vehicles to be equipped with seat-belts. European engineers recognized that biological differences between adults and children would limit the effectiveness of seat-belts for children. In the 1960s, they came up, for the first time, with a design specifically for children. This was a seat with child-sized internal harnesses attached to the vehicle frame by the vehicle’s safety-belt. Various designs to accommodate growing children followed quickly. In 1963, the first rear-facing infant seat was developed. Despite the commercial availability by the late 1960s of both seat-belts and child restraint systems, their safety benefits were not widely publicized and their use remained low. As countries became increasingly motorized, the numbers of deaths from crashes continued to rise. In 1970, the Australian state of Victoria introduced a safety-belt law and by 1977, rates of seat-belt use in the state had increased to 90%. Other countries gradually followed with their own seat-belt laws. In the United States, in the late 1970s, studies found that infant deaths were over-represented among child passenger fatalities (57). The state of Tennessee, in 1978, was the first to adopt a child restraint law for all children under the age of four years. As a result, child restraint use increased from 8% to 30% and the incidence of deaths among child passengers was halved. By 1985, all of the United States and many other countries had introduced similar child restraint laws. Today, most of these laws have been amended to include requirements for the use of belt-positioning booster seats, that are effective in preventing injuries to children who have outgrown their child safety seats (58). Ideas about how best to protect child passengers continue to evolve with new scientific findings and new technology. It is important, however, always to follow the current guidelines for the safety of child passengers (59). These guidelines urge that child restraint systems that have been certified as passing national standards should be used and that children should be placed in the rear seat. In rapidly motorizing countries, child deaths and injuries can be avoided through programmes and laws to promote child restraint use, through national standards to deliver the full benefits of the child restraint systems, and through a surveillance system to identify emerging hazards to children. are never reported to the police (63). However, in many low-income and middle-income countries where cycling principally exists as a mode of transport, the proportion of road traffic deaths is considerably higher. In Beijing, for example, about a third of all traffic deaths are those of cyclists (28). Other risks associated with bicycling include: – the lack of correctly worn helmets (64); – riding in mixed patterns of traffic (33); – cycling on pavements (65); – the visibility of cyclists (66). The rate of helmet wearing among child cyclists is low in many countries, even in developed countries. A study conducted in South Africa in the late 1990s showed that only 1.4% of children presenting to an emergency department following a bicycle-related injury had worn a helmet at the time of the collision (67), although in those provinces where there were laws on helmet wearing, the rates were higher (68). Motorcyclists As with other types of road users, the greatest risk for children on motorcycles relates to exposure. In many countries children travel as passengers on a motorcycle from a very young age. The rates of helmet wearing among these small children is very low – partly as a result of the lack of appropriately sized helmets, or of their cost. In many countries adolescents are legally entitled to drive a motorcycle with a restricted engine size from the age of 15 years. This age, though, coincides with a period in the child’s development in which risk-taking behaviour is known to occur. Unsurprisingly, in some countries up to a third of all motorcycle deaths are young riders or their passengers (69). The use of helmets among motorcyclists and their passengers is low in many countries and is a significant risk factor for head injuries (70). In Viet Nam, for instance, helmet wearing rates among adolescent and young adult riders are generally lower than those among older adults (71). WORLD REPORT ON CHILD INJURY PREVENTION 39 © NCIPC
Slide 59: Studies have shown that helmet wearing is highly dependent on the presence of a law mandating helmet use (60). The absence of universal helmet laws that cover all ages, together with poor enforcement and high prices for standard helmets, may contribute to the low prevalence of motorcycle helmet use in many places. Young drivers Adolescent and young drivers are a special risk group. A number of countries have reported increased collisions and deaths among novice drivers, particularly during their first year of driving (72–75). For a given distance driven, 16-year-old drivers are more than twice as likely as drivers aged 20–24 years, and four times as likely as drivers aged 25–29 years, to be involved in a fatal passenger vehicle crash (76). A number of interrelated factors appear to place young drivers at an elevated risk for road traffic injury. Age appears to be independent of the level of driving experience (29, 75, 77). Novice drivers aged 16–19 years have more crashes than novice drivers aged 20 years and over with the same amount of driving experience (77). However, there is a sharp decrease in crash risk during the first few years of driving, mainly associated with experience rather than age. Risky behaviours among young drivers include the following. – Drinking and driving. Alcohol significantly impairs driving ability among adolescents – typically at lower blood concentration levels than is the case for adults. New evidence suggests that the physiological response of adolescents to alcohol might be different to that of adults (78), making adolescents less sensitive to signals that their ability is impaired. Research in New Zealand found that drivers aged under 20 years were five times more likely to have elevated blood alcohol concentration levels compared with drivers aged 30 years and above (79, 80). In the United States, 30% of adolescents reported driving with an intoxicated driver in the previous month. One in 10 admitted to drinking and driving themselves (81). – Speeding. Adolescents are more likely to drive at excessive speed than are older adults (82). In a survey of 20 000 drivers aged 16 to 24 years, researchers found that the younger drivers were significantly more likely than the older ones to drive at more than 20 km/h above the speed limit (83). – Non-use of seat-belts. Compared with other age groups, adolescents have the lowest rate of seat-belt use. In 2005, 10% of high school students in the United States reported they rarely or never wore seatbelts when in a vehicle with someone else (81). – Distraction. Using a mobile phone, iPod or other electronic device, even if it is operated using handsfree devices, leads to slower information processing and consequently an increased risk of a crash (84). 40 WORLD REPORT ON CHILD INJURY PREVENTION The risk is even greater than that caused by the distraction of two or more passengers in the car (85). – Fatigue. Adolescent drivers who lack adequate sleep are at greater risk of crashing. Fatigue can also exacerbate the effects of other risk factors such as alcohol, speed and inexperience (86–88). Young drivers of both sexes have a higher proportion of road traffic crashes in the evenings and early mornings. Many of these crashes involve only a single vehicle. The presence of other adolescents in the vehicle with an adolescent driver is one of the strongest predictors of a crash (73, 82, 89–91). There is a tendency among young drivers to violate traffic rules (92). A study in India found that 20% to 30% of traffic violations occurred among drivers less than 20 years of age, with more than a third of these drivers either unlicenced or having obtained a licence without taking a mandatory test (93). Lack of supervision Differences in parents’ understanding of what activities are safe, given the particular age of the child, may partly explain the variations by age, gender and socioeconomic status in the patterns of road traffic injury among children across the world. The exact role, though, that a parent’s perception of risk plays in determining the risk of a child incurring a road traffic injury is not clear. Attitudes to driving and road use appear to be formed at an age as early as 11 years, suggesting that a parent’s perception of risk has the potential to influence a child’s behaviour on the roads (51). However, there has been little research to date attempting to quantify the role that parental perception plays in a child’s risk for road traffic injury. Lack of adult supervision has often been cited as a risk factor among children for road traffic injury. However, it is just one of several interrelated risk factors. There are a number of characteristics associated with parents or caregivers with a limited ability to supervise children. These include being a single parent, being a working parent, and being a parent affected by illness or depression (94). Such characteristics are found in families across the world, and are fairly independent of the economic status of a country. Nonetheless, if there is adult supervision, the probability of a child incurring road traffic injury is significantly reduced. A Malaysian study found that the risk of injury was reduced by 57% among children supervised by their parents (95). Another study, in Canada, found that lack of parental supervision increased the risk of injury to child pedestrians and cyclists by a factor of 2.6 (96). Research that examined the risk of child pedestrian injury in connection with specific supervision practices showed a strong positive association between pedestrian injury and a lack of supervision both after school and on the journey to school (97).
Slide 60: Poverty The socioeconomic status of a family affects the likelihood of a child or young adult being killed or injured in a road traffic crash, with those children from poorer backgrounds at greater risk. This relationship is true not just between richer and poorer countries, but within countries as well. Data from both Sweden and the United Kingdom, for instance, show that the risks of children and young adults for road traffic injuries are higher if they are from poorer families (98–100). In Kenya, the choice of transport used is often related to a family’s income – with those from low-income families more likely to be vulnerable road users (101). A study in Mexico found that family size was strongly associated with the risk of pedestrian injury among children (102). Vehicle-related factors Given the small stature of children, poor vehicle design is an important risk factor for child road traffic injury. The standard design of a vehicle can have a major effect on the risk and severity of injuries sustained by a child pedestrian, particularly if the child’s head makes contact with the rigid windshield (103). Vehicle designers are now examining ways to reduce the severity of pedestrian injuries. In particular, bumpers are being redesigned so as to prevent a pedestrian’s head making contact with the front window, by allowing the impact to be absorbed by a softer bonnet (104). The adaptations of vehicle design that have successfully reduced the incidence and severity of injuries in collisions between adult pedestrians and vehicles are now being modified to benefit children. “Back-over” injuries – usually in a driveway or parking lot – result when a car is reversed over a small child. Children aged between 1 and 3 years are at particular risk because of their small size and their inability to alert the driver. Unfortunately, with the increased demand for sports utility vehicles, such injuries are becoming more common (105, 106). Many vehicles are now being fitted with reverse backup sensors that could help reduce the incidence of such injuries (107). As regards bicycle-related factors, about three quarters of the crashes in the Netherlands involving passengers – often children – carried on bicycles are associated with feet being trapped in the wheel spokes, and 60% of bicycles have no protective features to prevent this from occurring (108). Ergonomic changes in the design of bicycles can thus lead to an improvement in bicycle safety (108, 109). for the road environment to be safe so that these activities can be undertaken without the child’s safety being put at risk. Motorization and urbanization are proceeding rapidly in much of the world today. Increased and more rapid mobility tend to be the goals, while safe mobility – and particularly the safety of children – are rarely taken into account. A number of specific environmental factors increase the risk for children using the road system. These factors include the following: – sites with a volume of traffic exceeding 15 000 motor vehicles per day; – poor planning of land use and road networks, including: long, straight through-roads that encourage high vehicle speeds, together with mixed land use made up of residential housing, schools and commercial outlets (110, 111); a lack of playgrounds, resulting in children playing in the road; a lack of facilities to separate road users – such as lanes for bicyclists and pavements for child pedestrians (112, 113); the existence of street vendor businesses, in which children may work; – a lack of safe, efficient public transportation systems; – inappropriate speed, particularly in residential areas where children play or walk to and from school (97, 113–115); Lack of prompt treatment Good recovery from road traffic injuries depends upon the availability, accessibility and quality of trauma care services. Such services are either not available or else are limited in scope and capacity in many low-income and middle-income countries. The surveys conducted in Asia brought out the fact that numerous children are injured who do not receive medical care. In Beijing, this ratio of those receiving care to those injured was 1:254, while in Thailand it was 1:170 (15). The most critical problems in relation to pre-hospital and emergency care in many low-income and middleincome countries are (116, 117): – a lack of first-aid services and trained personnel; – unsafe modes of transportation to reach emergency care; – the long delay between the time of injury and reaching a hospital; – inappropriate referral services; – the absence of a triage system. The availability of good rehabilitation services is also an important requirement for the proper recovery of children following a road traffic injury. Again, such services may be limited in many countries due to the lack of rehabilitation personnel, the necessary infrastructure and the availability of guidelines and protocols for rehabilitation. WORLD REPORT ON CHILD INJURY PREVENTION 41 Environmental factors It is normal for children to carry out activities in the road environment – such as cycling, walking, running, playing and other common group activities. It is also important for their healthy development that children, from an early age, undertake such activities. For this reason, it is important
Slide 61: Interventions Much has been written over the past decade about how best to reduce the incidence of road traffic injuries. The World report on road traffic injury prevention describes proven interventions and makes six recommendations to prevent road traffic injuries at country level (1). Promoting the systems approach, the report’s recommendations are equally applicable to the prevention of road traffic crashes involving children. There are a number of interventions, though, that focus specifically on children. The systems approach is of particular value in child road safety since it moves away from the idea that children should adapt their behaviour to cope with traffic, in favour of an approach that recognizes that children’s needs should be addressed in the design and management of the whole road system. Success in improving safety for children is most likely to be achieved through a holistic approach combining measures to address the behaviour of all road users, to improve the road environment and to design vehicles that better protect both their occupants and those at risk outside the vehicle (27). The following sections discuss interventions that target younger road users. – visual changes – such as treating the road surface, and improving the road lighting; – the redistribution of traffic – by blocking roads, and creating one-way streets near schools. Where a higher speed limit is allowed there should be provision to keep pedestrians and cyclists separate from traffic by using single-lane roundabouts, footways, pedestrian signal phasing and pedestrian refuge islands, and to improve safety with better street lighting (121). Managing speed is problematic in many low-income and middle-income countries, where the effectiveness of many infrastructural measures proposed for highincome countries has yet to be tested (122, 123). Some speed reduction measures have indeed been shown to be affordable and sustainable in urban areas, such as successful introduction of speed humps in Ghana (124). The problem is how to protect vulnerable road users, particularly children, on rural roads, many of which lack essential infrastructural requirements. Safe play areas Children need access to safe spaces for play and physical exercise. If such spaces are not available, children will be tempted to play on the streets. Play spaces should be secure and well maintained, with features that children find interesting. Designing safe play areas should be incorporated into urban planning and the development of school facilities and residential complexes. In the Dominican Republic, UNICEF is working with local government authorities to develop safe play areas, under the “Child Friendly Cities” programme. Working in consultation with children and adolescents, a team of architects have planned parks where children can play safely (125). Engineering measures Creating a safe environment for children requires that space for walking and cycling is given priority and not treated as an afterthought, after space for motorized traffic has been designed. The routes that children are likely to take to reach schools, playgrounds and shops, and how these routes can be integrated into a logical, coherent and safe network for walking and cycling, need to be considered (118). Greater attention should be given to how the built environment can safely cater for the healthy pursuits of walking and bicycle riding, while at the same time focusing on sustainable public transport systems. Safe routes to school Much effort has been spent on designing ways of getting to school, particularly for children of primary-school age. The measures include the provision of buses to transport children to school and encouraging children to walk to school, using the concept of “walking buses”. In the latter, adult volunteers accompany groups of children, who walk along safe routes wearing conspicuous, possibly fluorescent, vests. Walking buses teach children how to walk safely, as well as teaching the health benefits of walking. They also reduce traffic congestion and pollution, particularly near schools (126). Although this measure has been implemented in a number of developed and developing countries, with clear health and social benefits (127), its effectiveness in reducing the incidence of child traffic injuries has yet to be calculated. Some schools in high-income countries have engaged a “school travel coordinator”, who advises teachers and parents on the safest routes to school. However, Reducing speed The policies of both Vision Zero in Sweden and sustainable safety in the Netherlands promote the design of roads and the setting of speed limits that are appropriate for the function of the road (119, 120). Survival rates for pedestrians and cyclists are much higher at collision speeds of below 30 km/h (1). This speed should be the norm in residential areas and around schools. Various measures to achieve appropriate speeds should be considered (26), including: – traffic-calming measures that reduce the speed of traffic through infrastructural engineering measures, such as: speed humps; mini-roundabouts; designated pedestrian crossings; pedestrian islands; 42 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 62: a randomized control trial conducted in the United Kingdom failed to show that the preparation of school travel plans had an effect on how children travelled to school (128). Many countries have introduced school safety zones, that include car-free areas, speed reduction measures and adult supervision to cross the road safely. In Thailand, for example, the areas around schools have been comprehensively improved and educational programmes introduced on safe routes to school. In Bangalore, India, the focus has been on better public transport, making vehicles park or stop at a given distance from the school, dedicated school buses and pedestrian crossings near selected schools, sometimes overseen by traffic wardens (129). Separation of two-wheelers Child cyclists need to be separated physically, by barriers or kerbs, or else by the demarcation of white lines, from other road users (130). In Denmark and the Netherlands, where there are large numbers of cyclists, bicycles are a feasible means of child transport if safety concerns are properly addressed. A meta-analysis of the effects of cycle lanes found an estimated 4% reduction in the incidence of injuries (122). Exclusive motorcycle lanes, separated from the main carriageway by a raised central reservation, have been shown to reduce the likelihood of crashes. In Malaysia, where there are large numbers of young motorcyclists, reductions in crash rates of 27% have been recorded since motorcycles were separated from the rest of the traffic (131). Motor manufacturers should help protect children in vehicles by providing suitable facilities to fit child restraints. Vehicles with these improved designs will result in children being less likely to strike the car’s interior in case of an impact (132). Children are at risk when vehicles are reversing. The development of better visibility aids, such as cameras, and use of audible alarms and reversing lights can all help prevent injuries caused in this way (107). Alcohol interlock systems are beginning to be used in some countries. They require a driver to blow into a device before starting the car. The ignition will not function if alcohol is present. Such devices have led to reductions of between 40% and 95% in the rate of repeat offending under drink-driving laws (1). The devices are therefore valuable for adolescents who drink and drive. Safety equipment Child restraint systems Appropriate child restraint systems are designed to take account of the child’s developmental stage. Like seat-belts, they work to secure the child to the vehicle in a way that, in the event of a crash, distributes forces over a broad body area, thus reducing the chance of a severe injury occurring. Three types of restraint systems for child passengers are used: – rear-facing restraints for infants; – forward-facing child restraints; – booster cushions or booster seats, for older children. These systems take into account a child’s physical dimensions and proportions. Child restraint systems are very effective at preventing fatalities, and are the most important “in-vehicle” safety measure for children. In the event of a crash, if restraint systems are properly installed and used, they can: – reduce deaths among infants by around 70% (133); – reduce deaths among small children, aged 1–4 years, by 54% (133); – reduce the chances of sustaining clinically significant injuries by 59% among children aged 4–7 years who are strapped in booster seats, as compared to the rate of injuries sustained using ordinary vehicle seat-belts (134). Despite the overwhelming evidence of their effectiveness, though, many children are not restrained in age-appropriate child or booster seats. In many high-income countries the use of child restraints is common, with usage rates as high as 90%. Elsewhere, though, child restraints are still rarely used. Choosing and installing the appropriate child restraint system is important. Even in countries where the use of child restraints is common – such as in Sweden, the WORLD REPORT ON CHILD INJURY PREVENTION 43 Vehicle design Vehicle design and standards contribute to the safety of children both inside and outside the vehicle. Primary safety measures for vehicles – to prevent a crash – such as braking and lighting systems, improve road safety in general but are not specifically designed for children. Some secondary safety measures, though, are child-specific. They may be either active or passive. Modern vehicles are designed with energy-absorbing crumple zones and side impact bars to limit the extent to which the vehicle will intrude into the passenger compartment in the event of a collision, thus reducing potential injuries to children (1). Redesigning car fronts has the potential to reduce injuries to pedestrians, and to children in particular, as they are vulnerable to head injuries on impact (1). The New Car Assessment Programmes in Europe, the United States and Australia include ratings for pedestrian protection, but most vehicles still obtain low scores. A new European Directive will, by 2010, require new car models to pass a crash test incorporating protection requirements for pedestrians.
Slide 63: United Kingdom and the United States – restraints are frequently used inappropriately. A child may, for instance, be restrained in a device that is wrong for its age or weight, or the straps or harnesses may be inadequately secured or may be left entirely undone. In all these situations, the child is placed at increased risk of both fatal and non-fatal injuries (133, 134). In many places, the use of child restraints may be limited by access or cost, or else may not be practical because of the many children in the family. In addition, parents need to be aware of what type of seat to choose, where to place it and how to install it. Research in Greece found that 88.4% of parents placed their children unrestrained on the back seat, while 76.1% of those who used a restraint did not do so consistently (135). A number of measures have been shown to increase the use of child restraints. Mandatory laws on child restraint use and their enforcement can lead to reductions in the rate of severe or fatal crash injuries. Public awareness can be raised through publicity campaigns emphasizing the need for appropriate restraints for children of different ages (136). Such campaigns are most effective when backed up by enforcement. Appropriate restraints can be subsidized or distributed free to families. Loan schemes have been used in some countries, thus increasing both the accessibility and affordability of appropriate restraint systems (137, 138). A rear-facing child safety seat should never be placed in front of an airbag (139). Recent research suggests that children whose restraints are placed in the centre rear seating position incur less injuries than those placed on the outer seats, though this contradicts earlier studies that found that the centre seat was a less safe position (140, 141). Although children are best protected when secured in ageappropriate child restraints, where such restraints are not available it is still better to use an adult seat-belt on the child than to leave the child wholly unrestrained on the back seat (142, 143). drivers is noticeably less than among older occupants (29). As with child restraints, seat-belt use can be improved through: – introducing and enforcing a law mandating seat-belt use; – requiring all vehicles to be fitted with appropriate seatbelts; – conducting public awareness campaigns on seat-belts, targeted at young people. Such measures can increase awareness about the benefits of wearing seat-belts and help make seat-belt use a social norm among young people. Bicycle helmets A child’s brain is particularly vulnerable to injury. Approximately two thirds of hospital admissions among cyclists are for head injuries, and three quarters of deaths among injured cyclists are from head injuries (64). Helmets for cyclists afford protection from head injury in both traffic crashes and falls. The strongest evidence for the effectiveness of helmets comes from case-control studies. A systematic review of five such studies found that helmets reduced the risk of head and severe brain injury by between 63% and 88%, among cyclists of all ages (64). The use of cycle helmets is particularly important for older children because of their increased exposure to traffic. Helmets should be designed to match the age of the child, and when purchasing helmets parents should ensure that they are the appropriate size and fit the child’s head. A number of measures have been shown to increase the use of cycle helmets among children, including: – laws on bicycle helmet use and their enforcement; – the promotion of bicycle helmets among children; – public awareness campaigns. Although the question of bicycle helmet use as it relates to adult use has been controversial (26), promoting helmet use among children, whose basic motor skills are still developing, is more generally accepted. In the Netherlands, for instance, the road environment has been modified to make it very safe for cycling. Although there is no law on bicycle helmet use, Dutch crash data show that children in the 4–8-year age group are particularly likely to be involved in bicycle crashes and suffer head injuries, and thus helmet use among children is strongly promoted (145). While some countries, such as Australia and the United States, have introduced and enforce mandatory bicycle helmet laws for all cyclists, others have laws stipulating an age below which children must wear helmets (27). Data from before and after such laws were passed show an increase in helmet use – suggesting that reductions in head injury rates can be achieved through this strategy (27). Seat-belts For children over the age of 10 years, or above 150 cm in height, normal seat-belts should be used. Like child restraints, they serve to keep the child away from the vehicle structure in the event of a crash, prevent ejection from the vehicle, and distribute the forces of the crash over the strongest parts of the body. Wearing a seat-belt reduces the risk of being ejected from a vehicle and suffering serious or fatal injury by between 40% and 65% (144). However, rates of seat-belt use vary widely between countries, in large part as a result of the differing enforcement of seat-belt laws (1). In general, though, seat-belt use among adolescent passengers and 44 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 64: Motorcycle helmets In most high-income countries young children are rarely seen on the backs of motorcycles. However, in many places, especially in parts of South-East Asia, children are routinely transported as passengers on motorized two-wheelers. It is therefore important to protect these children by ensuring that they wear appropriate helmets (Box 2.3). Helmets, as already stated, reduce the risk of serious head and brain injuries by lessening the impact of a force to the head. Wearing a helmet is the single most effective way of preventing head injuries and fatalities resulting from motorcycle crashes (26). Wearing a helmet on a motorcycle (70): – decreases the risk and severity of injuries by about 72%; – decreases the likelihood of death by up to 39%, with the probability depending on the speed of the motorcycle involved; – decreases the health-care costs associated with crashes. A number of factors work against the wearing of helmets among child motorcycle passengers, including the following. Passengers on motorcycles may be exempt from mandatory helmet wearing laws or exempt from fines. Standard child helmets may not be available. The cost of purchasing child helmets may be prohibitive. Studies have shown that in some low-income countries, to afford a motorcycle helmet, factory workers have to work 11 times longer than their counterparts in highincome countries (146). Risk-taking behaviours among adolescent motorcycle riders may result in their not wearing helmets. In a study in Brazil, those under 18 years were significantly less likely than older people to wear a helmet, particularly if they had been consuming alcohol (147). Conspicuity Conspicuity is the ability of a road user to be seen by other road users. Vulnerable road users are at increased risk for road traffic injuries if they are not seen in time for the other road users to take evasive action and avoid a collision. Children, whose small stature means that they are less likely to be seen by motorists, are at even greater risk of not being seen. Improving the visibility of non-motorized road users is one way to reduce the risk of a road traffic crash, as it gives drivers more time to notice and avoid a collision. Interventions to increase conspicuity include the following. Retro-reflective clothing or strips on backpacks can increase the visibility of both pedestrians and BOX 2.3 Getting helmets on children’s heads: the experience of Viet Nam Since 1999, the Asia Injury Prevention Foundation in Hanoi has worked hard to get more people on motorcycles in Viet Nam to wear helmets and by doing so cut the rate of road traffic injuries among children. It has staged public awareness campaigns, lobbied the government, helped develop helmet standards for both adults and children, distributed child helmets along with information on their use, and pushed to increase the production of helmets. At the end of 2007, the Vietnamese government passed a law making helmet wearing compulsory for drivers and passengers on motorcycles. Following its introduction, rates of helmet use soared to over 90%. At the same time, hospitals began reporting reductions in the number of deaths and brain injuries resulting from motorcycle crashes. Soon, however, certain problems arose. It was pointed out that although helmets for children under 14 years were required by the new law, there was no provision to fine motorcycle drivers carrying children who were not wearing helmets. Furthermore, some doctors publicly questioned whether helmets might have an adverse effect on the development of a child’s skull, suggesting that the weight of a helmet could lead to serious neck injuries among children involved in collisions. As a result, parents were less enthusiastic about putting helmets on their children’s heads. While the proportion of adult motorcyclists using helmets remained at over 90%, helmet use among children under the age of 7 years fell to between 10% and 25% in the large cities. Most parents quoted the risk of serious neck injury when asked why they avoided helmets for their children. An effort is currently being made to tackle this problem, with measures including: – public education on the facts regarding children and helmet use, including publishing in newspapers assurances signed by international experts; – collaboration with the government to remove the loophole in the law, whereby drivers were not penalized if their child passengers were without a helmet; – further research on standards for child helmets. WORLD REPORT ON CHILD INJURY PREVENTION 45 © AIPF
Slide 65: cyclists. Although this intervention aids visibility, its actual effectiveness in reducing injuries still needs to be evaluated (148). Some programmes using this technique, though, are beginning to show promise (149–151). Daytime running lights for motorcyclists have been shown to be effective in reducing fatalities in countries, including Malaysia and Singapore, that have large numbers of motorcycles (152, 153). The colour of the helmet seems to have an effect on the conspicuity of motorcyclists. A case–control study in New Zealand found that retro-reflective or fluorescent clothing, white helmets and daytime running lights were all effective in reducing crashes (154). Drink-driving laws Various methods have been adopted to restrict drinking and driving among younger drivers, including the following. Setting lower blood alcohol concentration limits for younger drivers. The risk of a crash for inexperienced young adult drivers starts to rise at significantly lower blood alcohol concentration levels than is the case for older drivers. For this reason, many countries have set a lower blood alcohol concentration limit – usually between zero and 0.02 g/dl – for drivers under the age of 21 years. These lower limits may cut the incidence of crashes among young or novice drivers by between 4% and 24% (158). Enforcing blood alcohol limits. Consistent enforcement of blood alcohol concentration limits is essential for the law to be effective. There are two basic ways in which this can be done. – Sobriety checks, or selective breath-testing. In these checks, drivers are stopped at checkpoints or roadblocks and only those suspected of being over the alcohol limit are tested. This approach has been shown to be effective in cutting the number of alcohol-related crashes by about 20% (159). – Random breath-testing. Th is involves stopping drivers at random and breath-testing them. Australia, New Zealand and some European countries use this strategy with excellent results (160). An Australian study has found random breath-testing to be twice as effective as conducting sobriety checks at selective checkpoints (161). Raising the legal drinking age. Minimum drinkingage laws specify an age below which the purchase or public consumption of alcoholic beverages is illegal. The laws may also include penalties for the possession or consumption of alcohol by those under that age. Evidence from the United States, where over the last few years every state has raised the legal drinking age to 21 years, suggests that laws on the minimum legal drinking age have reduced drinking, driving after drinking, and alcohol-related crashes and injuries among young people (158, 162). However, in many places, the enforcement of the law is very lax. Legislation and standards Setting and rigorously enforcing road safety regulations may prevent up to half of all deaths and serious injuries (155). As with all other road safety interventions, most laws which are designed to prevent crash injuries in the general population will also help reduce the incidence of child road traffic injuries. Some laws, though, are specific to children and young people. Motor vehicle licensing In most countries the minimum age for obtaining a licence allowing unaccompanied driving is 18 years, though in some places the minimum age is as low as 16 years (1). Driver licensing systems exist to regulate the entry of new drivers and to control the conditions under which they learn to drive. These systems involve both a test on theory and a practical driving test, usually conducted in normal traffic during the day. The driving test is intended to ensure that new drivers fulfi l certain minimum performance standards and to identify drivers who are unfit to drive (122). Novice drivers are over-represented in crash statistics. As a result, many countries have introduced graduated driver licensing systems that place restrictions on new drivers, typically for the first two years of their driving (see Box 2.4). As well as restricting young drivers, the graduated driver licensing system serves to increase the amount of accompanied driving time an adolescent has – something that has been shown to produce positive results in preventing crashes (53). Child restraints Mandatory child restraint laws and their enforcement lead to an increase in the use of child restraints, and some studies show a corresponding reduction in traffic-related deaths and injuries among children. In some countries a penalty-point system is used to encourage people to comply with the legislation. In Latvia, the law on the use of child seats was revised in 2006 so that the penalty points could be incurred for failing to use a restraint. The effectiveness of such laws, though, will depend on how correctly child restraints are used. A study in Japan Motorized two-wheeler licensing In many countries children over 14 years of age are allowed to drive light mopeds with a maximum speed of 25 km/h, while more powerful mopeds, with a maximum speed of 45 km/h, and motorcycles are only permitted at 16 years. Raising the age limit for all powered two-wheelers from 16 to 18 years has been found to be effective in reducing the number of road traffic casualties (156, 157). 46 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 66: BOX 2.4 Graduated driver licensing programmes Beginner drivers of all ages lack skills in driving and in recognizing possible dangers, and are therefore at increased risk of a crash. In the case of newly-licensed adolescent drivers, their immaturity combined with limited driving experience can result in a disproportionately higher rate of crashes. Graduated licensing systems are schemes that allow for a controlled and supervised phasing-in of full driving licences for young novice drivers. The schemes protect beginners while they are learning, allowing them to obtain experience on the road under conditions of low risk. Graduated driver licensing is widely used in many high-income countries. Although the schemes vary between countries, most of them consist of a three-stage model. Stage 1: an extended period as a learner driver. The purpose of this stage is to increase the amount of supervised driving experience before receiving a full licence. Stage 2: a provisional or intermediate licence. Such a licence will contain temporary provisions, such as restrictions on unsupervised driving, latenight driving and driving with young passengers. Stage 3: a full licence. In many countries, progressing from one stage to another requires a certain number of supervised driving hours. There may also be stipulations that a proportion of these hours should be conducted at night-time. The areas that graduated driver licensing schemes typically address include the following. Alcohol restrictions. Permitted blood alcohol concentrations limits range from zero in some countries to levels somewhat below the levels for experienced drivers – for instance, 0.02 g/dl, against 0.05 g/dl for drivers with full licences. Passenger restrictions. In the first phase, most graduated driver licensing systems do not allow passengers in the same vehicle. In the second stage, passengers are usually allowed, but only if a parent or supervisor is present during the first three months, after which only immediate family are permitted as passengers. Seat-belt use. Almost all graduated driver licensing systems require that drivers and other occupants wear seat-belts. Speed. In some countries, drivers at the learning stage are prohibited from driving on any highway with a speed limit of over 80 km/h. Restrictions on driving at night. Drivers in the first stage are prohibited in some places from driving between midnight and 05:00. Mobile phone use. A number of countries have recently introduced restrictions on mobile phone use, even with hands-free devices. Evaluations of graduated driver licensing systems have reported significant reductions in crashes and fatalities. Estimates of their effectiveness have ranged from 4% to 60%, reflecting differences in the systems, in the drivers’ ages and in the methodologies used in the evaluations (163, 164). Recent data from the United States have shown a 23% reduction over a decade in crashes among 16-year-olds, with greater reductions for night-time driving and driving with occupants. The single most effective provision within graduated driver licensing schemes appears to be the extension of Stage 1, the learner period, which delays unsupervised driving (165). tried to assess the impact on child injuries of laws mandating the use of child restraints. Despite overall increases in the use of child restraints, overall rates of fatalities and serious injuries among children aged 1–5 years did not change after the law was introduced, possibly because the restraints were not being used properly (166). extended their standards to include helmets designed specially for children (26, 152). Developing education and skills Education can improve skills, behaviour and attitudes. A systematic review of safety education for pedestrians found an improvement in behaviours and attitudes that predispose people to risk-taking, but none of the studies reviewed actually recorded a reduction in injuries (167). Follow-up longitudinal studies would be needed among those children whose attitudes were changed by educational approaches to see if their risk of injury was diminished (168), though such a study would be long and expensive. Traditionally, road safety education has been conducted in the classroom and has often involved an approach based on teaching children the rules of the road. What has usually been absent in educational programmes is the WORLD REPORT ON CHILD INJURY PREVENTION 47 Helmets Legislation and the enforcement of mandatory helmet use for moped and motorcycle users is an effective intervention measure, particularly where accompanied by public awareness campaigns. In countries where these laws are enforced, helmet-wearing rates have been found to increase to 90% or higher. In places where existing laws have been repealed, wearing rates have fallen back to generally under 60% (26). Standards for helmets should also be enforced, including provisions for helmets for children. Some countries, such as Malaysia, have already © Utah Safety Council
Slide 67: application of modern ideas on educational and behaviour change. Social scientists working in injury prevention have in recent times taken an increasingly ecological approach, one that involves the interaction between the fields of child development, educational theory and behavioural theory (169). (173, 174), theatrical presentations, games and peer education. Young drivers The controversy over the effectiveness of school-based driver education has a long history (139). Both the randomized controlled trials conducted in 1999 (175) and those done by the Cochrane Injuries Group in 2001 (176) found that driver education did not reduce the number of traffic crashes or violations among students. On the contrary, driver education programmes can lead to earlier driving by novices, resulting in more crashes (139) offsetting any benefits from driver education programmes. A more recent randomized trial of the effectiveness of post-licence driver education in preventing road traffic crashes has also found no evidence of effectiveness (177). Younger children Current research on road safety education suggests that an approach that stresses behaviour, focusing on the development of practical skills, is more likely to be effective for younger children. Children learn best through methods that develop problem-solving and decision-making skills. Young children also learn by example. In any case, education is an important ingredient of any comprehensive effort to prevent injury. Some examples of effective educational approaches include the following. Roadside skills development for 6–8-year-olds. Such programmes include the Kerbcraft pilot programme in the United Kingdom that teaches a number of basic skills, such as finding a safe place to cross, crossing safely near parked vehicles, and crossing safely at junctions (170). Simulated environments that teach pedestrian and cycle skills in a safe setting off the road. Examples include the “Safety City” programmes in New York City and Puerto Rico, and traffic gardens in the Netherlands. Such programmes need to be used as part of a progressive programme, as they cannot address real interactions with traffic. Basic cycle skills can be taught both on and off the road. The Oregon bicycle education curriculum has ten modules, half of them conducted on the road. While skills are developed, evidence as regards the extent of injury prevention is lacking (171). Conspicuity is covered in many pedestrian educational programmes. In Norway, children receive caps, vests or bags in bright colours with retro-reflective materials to make them more visible, especially on dark winter evenings. In South Africa, the Drive Alive Pedestrian Visibility Campaign that does public education work has campaigned for laws to make it compulsory for all school uniforms to contain retro-reflective material, so as to increase the visibility of child pedestrians (149). Emergency and trauma care Most initiatives for cutting the incidence of road traffic injuries focus on preventing crashes and on restricting the extent of their consequences. Much, though, can be done to reduce the number of deaths and injuries from road traffic crashes by strengthening the emergency medical services – including pre-hospital care, hospital care and rehabilitation. Pre-hospital care At the scene of the crash, prompt, efficient and effective pre-hospital care can save many lives. In places where formal emergency medical services exist, usually with ambulances, they are most effective if their equipment, training, infrastructure and operations are standardized. These emergency vehicles need to be equipped with supplies and medical devices for children as well as for adults – such as airway tubes, cervical collars and blood pressure cuffs. Staff need to be trained on how to evaluate and manage injured children, and to recognize that what is normal in an adult may not necessarily be normal in a child. Where no pre-hospital trauma care system exists, the first and fundamental tier of the system should be established by teaching interested volunteers the basic techniques of first aid (178). In many countries, organizations such as the International Federation of Red Cross and Red Crescent Societies, and the St John’s Ambulance teach young people how to recognize an emergency, call for help and provide basic first aid until formally-trained health-care personnel arrive. Setting up a new emergency medical service may be a valuable step, especially along busy roads with high crash rates. These services, though, can be costly. In all cases, and especially where there are no formal emergency medical services, pre-hospital care can be improved by building upon existing – even if informal – systems of pre-hospital care and transport (178). Adolescents By the time children reach adolescence they should have mastered the skills needed to act safely as pedestrians and cyclists, though some choose to engage in risk-taking behaviour. Th is is a difficult age group to reach through educational approaches and some methods may even be counterproductive. Greater involvement of adolescents in designing programme may be helpful (172), as may the use of television programmes, such as “Soul City” 48 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 68: Trauma care Entry into the hospital is the second stage at which the life of an injured child can be saved (179). Improving the organization of trauma care services is an affordable and sustainable way of raising the quality and outcome of care. This involves improving the human resources that are required to provide care – including skills, training and staffing – and the physical resources, including equipment and supplies. The essential elements of trauma care need not be expensive, though the cost of care is often a barrier to access, especially where user fees are required in advance of services in emergency situations. safety interventions and fewer still have looked at their cost-effectiveness. More evaluation studies are needed, so as to obtain compelling evidence that will persuade policy-makers to prioritize road traffic injury prevention, particularly as it affects children. Conclusions and recommendations Around 10 million children annually are estimated to be injured or disabled as a result of road traffic injuries. Road traffic injuries are the leading cause of death in children aged 10–19 years, and are also the leading cause of disability among children generally. Over the next 15 years, significant increases in road traffic casualties are predicted, particularly in low-income and middle-income countries. In India and China in particular, in that period, the annual incidence of road traffic fatalities is expected to at least double. The road environment is constructed in most cases without consideration for children. Children on the road are therefore at greater risk than they need have been. Rises in motorization and urbanization are both fuelling road traffic tolls in many countries. A child is more susceptible to road traffic injuries because of a smaller height and other less developed physical characteristics, including sensory facilities. Young children may unknowingly take risks on the road because they lack appropriate skills to act safely. Older children and adolescents may actively indulge in risktaking behaviours, that are exacerbated by peer pressure. Children from poorer backgrounds are generally at greater risk of road traffic injury. Rehabilitation Many injured survivors of traffic crashes lead lives of disability. Much of this disability, particularly among young people, could be avoided with improved rehabilitation services. This includes improved services in health-care facilities and improved access to communitybased rehabilitation. Such rehabilitation services need to be strengthened everywhere, so as to reduce the prevalence of disability after injury and to help those with persistent disabilities to lead full and meaningful lives. Potentially harmful interventions Airbags deployed in the event of a sudden deceleration are designed to supplement, and not to replace, the protection provided by a seat-belt. Although they have proven benefits for adults, airbags pose serious risks for children. Available data indicate that, on average, children under the age of 13 years are more likely to be harmed by an airbag than to be helped by it. Children should not sit in the front passenger seat of cars with airbags unless there is absolutely no alternative or unless the airbag has been deactivated (180). In most high-income countries, parents are warned about the danger of airbags to children and advised on the correct seating positions to be used in vehicles where airbags have been fitted. A rear-facing child safety seat should never be placed in front of an airbag (139). Current research is focusing on new technological solutions that will detect the presence of a child and adjust the deployment of the airbag or deactivate it. Newer airbag designs have cut the number of injuries to children, without wholly eliminating such injuries, but have provided no additional benefit to adults (181). Recommendations Traditionally, road safety measures for children have focused largely on road safety education – with the assumption that children must be taught how to adapt their behaviour to the demands of a motorized society. However, when used in isolation, without considering the safety of vehicles and road environments, educational measures do not deliver tangible and sustained reductions in deaths and serious injuries. The systems approach has proved valuable in delivering greater road safety for children. It moves away from the idea that children should adapt their behaviour to cope with traffic, in favour of an approach in which children’s needs are addressed in the design and management of the whole road system. Large gains can be made in terms of injuries avoided and lives saved if proven and effective strategies – increasingly used in high-income countries – are adapted to the context of low-income and middle-income countries where children are at considerably higher risk (see Table 2.3). In line with the systems approach, the following actions are recommended to reduce the toll of child road traffic injury, death and disability. WORLD REPORT ON CHILD INJURY PREVENTION 49 Evaluating interventions There is no single blueprint for road safety. Many of the interventions discussed in this chapter have been evaluated only in high-income countries. It is quite possible that they will also work in low-income or middle-income countries, but their feasibility, acceptability and effectiveness in these countries have yet to be tested. While some countries have begun to implement and evaluate road safety interventions in general, few countries have evaluated child-specific road
Slide 69: TABLE 2.3 Key strategies to prevent road traffic injuries among children Insufficient evidence Ineffective Promising Effective Harmful Strategy Introducing (and enforcing) minimum drinking-age laws Setting (and enforcing) lower blood alcohol concentration limits for novice drivers and zero tolerance for offenders Utilizing appropriate child restraints and seat-belts Wearing motorcycle and bicycle helmets Forcing a reduction of speed around schools, residential areas, play areas Separating different types of road user Introducing (and enforcing) daytime running lights for motorcycles Introducing graduated driver licensing systems Implementing designated driver programmes Increasing the visibility of pedestrians Introducing instruction in schools on the dangers of drink-driving Conducting school-based driver education Putting babies or children on a seat with an air bag Licensing novice teenage drivers Source: references 1 and 139. Reducing speed. Survival rates for pedestrians and cyclists are much higher at collision speeds of below 30 km/h. This speed should be the norm in residential areas, around schools and other play areas. Separation of two-wheelers. Child cyclists should be separated physically from other road users – for instance, by using dedicated cycle lanes. Exclusive motorcycle lanes, separated from the main stream of road traffic by a raised central reservation, have been shown to reduce motorcycle casualties and should be considered. Vehicle modifications. Several modifications are already being introduced in many high-income countries. This process needs to be accelerated in high-income countries, and considered, where resources allow, in middle-income and low-income countries. Child restraint systems should always be used in cars. These include: rear-facing restraints for infants; forward-facing child restraints; and booster cushions or booster seats, for older children. Seat-belts. For children over the age of 10 years, or above 150 cm in height, normal seat-belts should be used. Bicycle helmets. Appropriate helmets always should always be worn by children cycling on the roads as their heads are even more susceptible to injury than adults. 50 WORLD REPORT ON CHILD INJURY PREVENTION Motorcycle helmets. Wearing a helmet is the single most effective way of preventing head injuries and fatalities resulting from motorcycle crashes. All drivers and passengers on motorcycles, irrespective of their ages, should wear approved helmets, appropriate for their head size and in a conspicuous colour. Drink-driving laws. Strict laws on drink-driving should be introduced and enforced. Methods include: – setting lower blood alcohol concentration limits for young drivers; – undertaking sobriety checks, or selective breathtesting; – undertaking random breath-testing; – raising the legal drinking age. Daytime running lights for motorcyclists have been shown to be effective in reducing fatalities in several countries, and should be considered as a preventive measure. Novice drivers. Countries should consider introducing graduated driver licensing systems that place restrictions on new drivers, for the initial period (possibly two years) of their driving. Teaching knowledge and skills. For younger children in particular, education is an important ingredient of any comprehensive effort to prevent injury. Measures include: – roadside skills development for 6–8-year-olds;
Slide 70: – simulated environments that teach pedestrian and cycle skills in a safe setting off the road; – basic cycle skills, taught both on and off the road. In addition to the various primary prevention measures recommended above, emergency medical care – both prehospital and hospital care – as well as rehabilitation services should be improved and equipped with the child in mind. Furthermore, emergency health-care staff should be trained on how to evaluate and manage injured children. 13. Linnan M et al. Child mortality and injury in Asia: policy and programme implications. Florence, UNICEF Innocenti Research Centre, 2007 (http://www.unicef-irc.org/ publications/pdf/iwp_2007_07.pdf, accessed 21 January 2008). (Innocenti Working Paper 2007-07, Special Series on Child Injury No. 4). Brown JK et al. Patterns of severe injury in pediatric car crash victims: Crash Injury Research Engineering Network database. Journal of Pediatric Surgery, 2006, 41:362–367. Linnan M et al. Child mortality and injury in Asia: survey results and evidence. Florence, UNICEF Innocenti Research Centre, 2007 (http://www.unicef-irc.org/ publications/pdf/iwp_2007_06.pdf, accessed 21 January 2008). (Innocenti Working Paper 2007-06, Special Series on Child Injury No. 3). Gururaj G et al. Traumatic brain injury. Bangalore, National Institute of Mental Health and Neurosciences, 2005 (Publication no. 61). Bryant B et al. Psychological consequences of road traffic accidents for children and their mothers. Psychological Medicine, 2004, 4:335–346. Macpherson AK et al. Mechanism of injury affects 6-month functional outcome in children hospitalized because of severe injuries. Journal of Trauma: Injury, Infection, and Critical Care, 2003, 55:454–458. Blanchard E, Hickling EJ. After the crash: psychological assessment and treatment of survivors of motor vehicle accidents, 2nd ed. Washington, DC, American Psychological Association, 2004. Sleet DA et al. Injury and violence prevention in the community. In: Rozensky RH et al., eds. Psychology’s role in public health. Washington, DC, American Psychological Association, 2004:185–216. Di Gallo A. Verletzung von Körper und Seele: psychiatrische Folgen von Verkehrsunfällen bei Kindern und Jugendlichen [Injury to body and soul: psychiatric consequences of road traffic accidents in children and adolescents]. Schweizerische Rundschau für Medizin Praxis, 2005, 94:467−470. Schafer I et al. Posttraumatic syndromes in children and adolescents after road traffic accidents: a prospective cohort study. Psychopathology, 2006, 39:159−164. Rusch MD et al. Psychological adjustment in children after traumatic disfiguring injuries: a 12-month followup. Journal of American Society of Plastic Surgeons, 2000, 106:1451−1458. Verbal autopsy standards: ascertaining and attributing causes of death. Geneva, World Health Organization, 2007 (http://www.who.int/whosis/mort/ verbalautopsystandards/en/index.html, accessed 23 January 2008). Christie N et al. Children’s road traffic safety: an international survey of policy and practice. London, Department for Transport, 2004 (http://eprints.ucl.ac.uk/1211/1/2004_4. WORLD REPORT ON CHILD INJURY PREVENTION 51 14. 15. References 1. Peden M et al., eds. World report on road traffic injury prevention. Geneva, World Health Organization, 2004 (http://w w w.who.int/violence_injury_preven-tion/ publications/road_traffic/world_report/en/index.html, accessed 22 January 2008). Economic Commission for Europe. Glossary of transport statistics, 3rd ed. New York, NY, United Nations Economic and Social Council, 2003 (TRANS/WP.6/2003/6) (http:// www.unece.org/trans/main/wp6/pdfdocs/glossen3.pdf, accessed 23 February 2008). World Health Statistics 2008. Geneva, World Health Organization, 2008 (http://www.who.int/whosis/ whostat/2008/en/index.htm, accessed 20 June 2008). Mathers C, Loncar D. Updated projections of global mortality and burden of disease, 2002–2030: data sources, methods and results. Geneva, World Health Organization, 2005. Kopits E, Cropper M. Traffic fatalities and income growth. Accident Analysis and Prevention, 2005, 37:169–178. Vincenten J, Michalsen A. Priorities for child safety in the European Union: agenda for action. Injury Control and Safety Promotion, 2003, 9:1–8. WHO mortality database: tables. Geneva, World Health Organization (http://www.who.int/healthinfo/ morttables/en/index.html, accessed 21 April 2008). Rahman A et al. Bangladesh health and injury survey: report on children. Dhaka, Ministry of Health and Family Welfare, 2005. Sitthi-amorn C et al. Child injury in Thailand: a report on the national injury survey. Bangkok, Institute of Health Research, TASC and UNICEF, 2006 (http://www. tasc-gcipf.org/downloads/Thai%20child%20report.pdf, accessed 22 January 2008). Bener A. The neglected epidemic: road traffic accidents in a developing country. State of Qatar. International Journal of Injury Control and Safety Promotion, 2005, 12:45–47. Nizamo H et al. Mortality due to injuries in Maputo city, Mozambique. International Journal of Injury Control and Safety Promotion, 2006, 13:1–6. Hyder AA, Labinjo M, Muzaffar SSF. A new challenge to child and adolescent survival in urban Africa: an increasing burden of road traffic injuries. Traffic Injury Prevention, 2006, 7:381–388. 25. 22. 20. 16. 2. 17. 3. 18. 4. 19. 5. 6. 7. 21. 8. 9. 23. 10. 24. 11. 12.
Slide 71: pdf, accessed 22 January 2008) (Road Safety Research Report No. 47). 26. Toroyan T, Peden M, eds. Youth and road safety. Geneva, World Health Organization, 2007 (http://whqlibdoc.who. int/publications/2007/9241595116_eng.pdf, accessed 22 January 2008). Keeping children safe in traffic. Paris, Organisation for Economic Co-operation and Development, 2004. Li G, Baker SP. Injuries to bicyclists in Wuhan, People’s Republic of China. American Journal of Public Health, 1997, 87:1049–1052. Young Drivers: the road to safety. Paris, Organisation for Economic Co-operation and Development, 2006. Gregersen N, Nyberg A, Berg H. Accident involvement among learner drivers: an analysis of the consequences of supervised practice. Accident Analysis and Prevention, 2003, 35:725–730. Palamara P, Legge M, Stevenson M. The relationship between years of licensing, traffic offences and crash involvement: implications for driver licensing in Western Australia. In: Proceedings of the Developing Safer Drivers and Riders Conference, 21–23 July 2002, Brisbane. Brisbane, 2002. Oesch SL. Statement before the Maryland House Committee on Environmental Matters. Passenger restrictions for young drivers. Arlington, VA, Insurance Institute for Highway Safety, 2005. Mohan D. Road safety in less-motorized environments: future concerns. International Journal of Epidemiology, 2002, 31:527–532. Cass DT, Ross F, Lam L. School bus-related deaths and injuries in New South Wales. Medical Journal of Australia, 1996, 165:134–137. Miller T, Spicer RS. How safe are our schools? American Journal of Public Health, 1998, 88:413–418. Jacobs G, Thomas AA, Astrop A. Estimating global road fatalities. Crowthorne, Transport Research Laboratory, 2000 (TRL Report 445) (http://www.transport-links.org/ transport_links/filearea/publications/1_329_TRL445.pdf, accessed 22 January 2008). Aeron-Thomas AA et al. The involvement and impact of road crashes on the poor: Bangladesh and India case studies. Crowthorne, Transport Research Laboratory Limited, 2004 (http://www.grsproadsafety.org/themes/ default/pdfs/The%20Poor_fi nal%20fi nal%20report.pdf, accessed 22 January 2008). Whitebread D, Neilson K. The contribution of visual search strategies to the development of pedestrian skills by 4–11 year-old children. British Journal of Educational Psychology, 2000, 70:539–557. Dunbar G, Hill R, Lewis V. Children’s attentional skills and road behaviour. Journal of Experimental Psychology: Applied, 2001, 7:227–234. 40. Siegler RS, Richards DD. The development of speed, time, and distance concepts. Developmental Psychology, 1979, 15:288–298. Zeedyk MS, Wallace L, Spry L. Stop, look, listen, and think? What young children really do when crossing the road. Accident Analysis and Prevention, 2002, 34:43–50. Pitcairn TK, Edlemann T. Individual differences in road crossing ability in young children and adults. British Journal of Psychology, 2000, 91:391–410. Ampofo-Boateng K, Thomson JA. Children’s perception of safety and danger on the road. British Journal of Psychology, 1991, 82:487–505. Kovács I et al. Late maturation of visual spatial integration in humans. Proceedings of the National Academy of Sciences of the United States of America, 1999, 96:12204–12209. Káldy Z, Kovács I. Visual context integration is not fully developed in 4-year-old children. Perception, 2003, 2:657– 666. Giedd J. Structural magnetic resonance imaging of the adolescent brain. Annals of the New York Academy of Sciences, 2004, 1021:77–85. Arnett J. Developmental sources of crash risk in young drivers. Injury Prevention, 2002, 8(Suppl II):ii17–ii23. Cross D, Hall M. Child pedestrian safety: the role of behavioural science [editorial]. The Medical Journal of Australia, 2005, 182:318–319. Bina M, Graziano F, Bonino S. Risky driving and lifestyles in adolescence. Accident Analysis and Prevention, 2006, 38:472–481. Stevenson M et al. Behavioural factors as predictors of motor vehicle crashes in young drivers. Journal of Crash Prevention and Injury Control, 2001, 2:247–254. Waylen A, McKenna F. Cradle attitudes: grave consequences. The development of gender differences in risky attitudes and behaviour in road use. Basingstoke, AA Foundation for Road Safety Research, 2002. Parker D et al. Determinants of intention to commit driving violations. Accident Analysis and Prevention, 1992, 24:117–131. McKenna FP, Crick JL. Developments in hazard perception. Final report. London, Department for Transport, 1994. Stevenson M, Jamrozik KD, Spittle JA. A case-control study of traffic risk factors and child pedestrian injury. International Journal of Epidemiology, 1995, 24:957–964. Traffic safety facts. Child restraint use in 2007: overall results. Washington, DC, National Highway Traffic Safety Administration, 2008. Survey. Salim and Salimah, Safe and Sound web site (http://www.salimandsalimah.org/survey.htm, accessed 28 April 2008). Karwacki JJ Jr, Baker SP. Children in motor vehicles: never too young to die. Journal of the American Medical Association, 1979, 242:2848–2851. 41. 27. 28. 42. 43. 29. 30. 44. 45. 31. 46. 47. 48. 32. 49. 33. 50. 34. 51. 35. 36. 52. 53. 54. 37. 55. 38. 56. 39. 57. 52 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 72: 58. Durbin D, Elliott M, Winston F. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. Journal of the American Medical Association, 2003, 289:2835–2840. American Academy of Pediatrics, Committee on Injury and Poison Prevention. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics, 2002, 109:550–553. Everett SA et al. Trends and subgroup differences in transportation related injury risk and safety behaviors among high school students, 1991–1997. Journal of Adolescent Health, 2001, 28:228–234. Shope JT. Influences on youthful driving behavior and their potential for guiding interventions to reduce crashes. Injury Prevention, 2006, 12:i9–i14. Carlin JB, Taylor P, Nolan T. A case-control study of child bicycle injuries: relationship of risk to exposure. Accident Analysis and Prevention, 1995, 27:839–844. Traffic safety facts: bicyclists and other cyclists. Washington, DC, National Highway Traffic Safety Administration, 2006. Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews, 2005, (4):CD001855. Senturia YD et al. Bicycle-riding circumstances and injuries in school-aged children: a case-control study. Archives of Pediatrics and Adolescent Medicine, 1997, 151:485–489. Rivara FP, Thompson DC, Thompson RS. Epidemiology of bicycle injuries and risk factors of serious injury. Injury Prevention, 1997, 3:110–114. Puranik S, Long J, Coff man S. Profi le of pediatric bicycle injuries. South Medical Journal, 1998, 91:1033–1037. Shafi S et al. Impact of bicycle helmet safety legislation on children admitted to a regional pediatric trauma center. Journal of Pediatric Surgery, 1998, 33:317–321. Lin M-R et al. Factors associated with severity of motorcycle injuries and young adult riders. Annals of Emergency Medicine, 2003, 41:783–791. Liu BC et al. Helmets for preventing injury in motorcycle riders. Cochrane Database of Systematic Reviews, 2007, (4):CD004333. Hung DV, Stevenson M, Ivers R. Barriers to, and factors associated with, observed motorcycle helmet use in Vietnam. Accident Analysis and Prevention, 2008, 40:1627–1633. Chen L et al. Carrying passengers as a risk factor for crashes fatal to 16– and 17–year old drivers. Journal of the American Medical Association, 2000, 283:1578–1582. Williams AF. Teenage passengers in motor vehicle crashes: a summary of current research. Arlington, VA, Insurance Institute for Highway Safety, 2001. Huber JC, Carozza SE, Gorman DM. Underage driving as an indicator of risky behavior in children and adolescents. Journal of Adolescent Health, 2006, 38:612–616. 75. Maycock G. Novice driver accidents and the driving test. Crowthorne, Transport Research Laboratory, 2002 (TRL Report 527). Fatality facts: teenagers 2005. Arlington, VA, Insurance Institute for Highway Safety, 2006 (www.iihs.org/research/ fatality_facts/teenagers.html, accessed 13 May 2008). Mayhew DR, Simpson HM, Pak A. Changes in the collision rate among novice drivers during the first months of driving. Accident Analysis and Prevention, 2003, 35:683– 691. National Research Council and Institute of Medicine. A study of interactions: emerging rapporteurs. Washington, DC, The National Academies Press, 2006. Keall M, Frith W, Patterson T. The influence of alcohol, age and number of passengers on the night-time risk of driver fatal injury in New Zealand. Accident Analysis and Prevention, 2004, 36:49–61. McAnally K, Kypri K. Alcohol and road safety behaviour among New Zealand tertiary students. International Journal of Adolescent Medical Health, 2004, 16:229–237. Youth risk behavior surveillance: United States, 2005. Atlanta, GA, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2006 (http://apps.nccd.cdc.gov/ yrbss/CategoryQuestions.asp?cat=1&desc=Unintentional Injuries and Violence, accessed 28 April 2008). Simons-Morton B, Lerner N, Singer J. The observed effects of teenage passengers on the risky driving behavior of teenage drivers. Accident Analysis and Prevention, 2005, 37:973–982. Blows S et al. Risky driving habits and motor vehicle driver injury. Accident Analysis and Prevention, 2005, 37:619–624. Hendrick JL, Switzer JR. Hands-free versus hand-held cell phone conversation on a braking response by young drivers. Perception and Motor Skills, 2007, 105:514–522. McEnvoy SP, Stevenson MR, Woodward M. The contribution of passengers versus mobile phone use to motor vehicle crashes resulting in hospital attendance by the driver. Accident Analysis and Prevention, 2007, 39:1170–1176. Lam LT et al. Passenger carriage and car crash injury: a comparison between younger and older drivers. Accident Analysis and Prevention, 2003, 35:861–867. Ferguson SA. Other high-risk factors for young drivers: how graduated licensing does, doesn’t, or could address them. Journal of Safety Research, 2003, 34:71–77. Braitman KA et al. Crashes of novice teenage drivers: characteristics and contributing factors. Journal of Safety Research, 2008, 39:27–54. Chen IG et al. Teen drivers and the risk of injury to child passengers in motor vehicle crashes. Injury Prevention, 2005, 11:12–17. WORLD REPORT ON CHILD INJURY PREVENTION 53 76. 59. 77. 60. 78. 61. 79. 62. 63. 64. 80. 81. 65. 66. 82. 67. 68. 83. 84. 69. 85. 70. 71. 86. 72. 87. 73. 88. 74. 89.
Slide 73: 90. Padlo P, Aultman-Hall L, Stamatiadis N. Passengers and other factors affecting the safety of young and older drivers. Transportation Research Records, 2006, 1937:7–13. Williams AF. Teenage drivers: patterns of risk. Journal of Safety Research, 2003, 34:5–15. Maycock G. Drinking and driving in Great Britain: a review. Crowthorne, Transport Research Laboratory, 1997 (TRL Report 232). Dandona R, Kumar GA, Dandona L. Risky behavior of drivers of motorized two wheeled vehicles in India. Journal of Safety Research, 2006, 37:149–158. Towner E et al. Injuries in children aged 0–14 years and inequalities. London, Health Development Agency, 2005 (http://www.nice.org.uk/niceMedia/pdf/injuries_in_ children_inequalities.pdf, accessed 22 January 2008). Fatimah M et al. The risk of road traffic accidents among primary school children in Kuala Terengganu. Medical Journal of Malaysia, 1997, 52:402–408. Pless IB, Verreault R, Tenina S. A case-control study of pedestrian and bicyclist injuries in childhood. American Journal of Public Health, 1989, 79:995–998. Joly MF, Foggin PM, Pless IB. A case-control study of traffic accidents among child pedestrians. In: Proceedings of the International Conference on Traffic Safety. New Delhi, 1991. La Flamme L. Social inequality in injury risks: knowledge accumulated and plans for the future. Stockholm, National Institute of Public Health, 1998. Hasselberg M, Laflamme L, Weitoft GR. Socioeconomic differences in road traffic injuries during childhood and youth: a closer look at different kinds of road user. Journal of Epidemiology and Community Health, 2001, 55:858– 862. 106. Fenton SJ et al. The prevalence of driveway back-over injuries in the area of sports utility vehicles. Journal of Pediatric Surgery, 2005, 40:1964–1968. 107. Lovette B. Back-up detection devices: what do we all need to know? Dangerous blind zones. Journal of Pediatric Health Care, 2007, 21:123–128. 108. Schoon CC. Invloed kwaliteit fiets op ongevallen. [The influence of cycle quality on crashes]. Leidschendam, Institute for Road Safety Research, 1996 (SWOV Report R-96-32). 109. Mohan D, Tiwari G. Road safety in low-income countries: issues and concerns regarding technology transfer from high-income countries. In: Reflections on the transfer of traffic safety knowledge to motorizing nations. Melbourne, Global Traffic Safety Trust, 1998:27–56. 110. Clifton KJ, Kreamer-Fults K. An examination of the environmental attributes associated with pedestrian vehicular crashes near public schools. Accident Analysis and Prevention, 2007, 39:708–715. 111. Bly P, Dix M, Stephenson C. Comparative study of European child pedestrian exposure and accidents. London, Departments of the Environment, Transport and the Regions, 1999. 112. Kweon SS, Shin MH. [An epidemiological study for child pedestrian traffic injuries that occurred in school-zone] (article in Korean). Journal of Preventive Medicine and Public Health, 2005, 38:163–169. 113. Roberts I et al. Effect of environmental factors on risk of injury of child pedestrians by motor vehicles: a casecontrol study. British Medical Journal, 1995, 310:91–94. 114. Mueller BA et al. Environmental factors and the risk for childhood pedestrian-motor vehicle collision occurrence. American Journal of Epidemiology, 1990, 132:550–560. 115. Stevenson M. Childhood pedestrian injuries: what can changes to the road environment achieve? Australia New Zealand Journal of Public Health, 1997, 21:33–37. 116. Gururaj G, Reddi MN, Aeron-Thomas A. Epidemiology of road traffic injuries in Bangalore. In: Proceedings of the 5th World Conference on Injury Prevention and Control. New Delhi, Macmillan India, 2000. 117. Joshipura MK et al. Trauma care systems in India. Injury, 2003, 34:686–692. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. Hippisley-Cox J et al. Cross-sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992–7. British Medical Journal, 2002, 324:1132–1134. 101. Nantulya WM, Reich M. The neglected epidemic: road traffic injuries in developing countries. British Medical Journal, 2002, 324:1139–1141. 102. Celis A et al. Family characteristics and pedestrian injury risk in Mexican children. Injury Prevention, 2003, 9:58–61. 103. Mizuno K, Kajzer J. Head injuries in vehicle-pedestrian impact. In: Proceedings of the Society of Automotive Engineers World Congress, 6–9 March 2000, Detroit, Michigan. Warrendale, PA, Society of Automotive Engineers, 2000 (http://www.sae.org/servlets/ productDetail?PROD_TYP=PAPER&PROD_CD=200001-0157, accessed 22 April 2008). 104. Crandall JR, Bhalla KS, Madeley NJ. Designing road vehicles for pedestrian protection. British Medical Journal, 2002, 324:1145–1148. 105. Holland A et al. Driveway motor vehicle injuries in children. The Medical Journal of Australia, 2000, 173:192–195. 54 WORLD REPORT ON CHILD INJURY PREVENTION 118. Mohan D. Traffic safety and city structure: lessons for the future. Salud Pública de México, 2008, 50:S93–S100. 119. Tingvall C, Haworth N. Vision Zero: an ethical approach to safety and mobility. Paper presented to the 6th Institute of Transport Engineers’ International Conference on Road Safety and Traffic Enforcement: Beyond 2000, Melbourne, 6–7 September 1999 (http://www.monash.edu.au/muarc/ reports/papers/visionzero.html, accessed 23 January 2008). 120. Advancing sustainable safety in brief. Leidschendam, Netherlands, Institute for Road Safety Research, 2006 (http://w w w.swov.nl/rappor t/DMDV/Advancing _ Sustainable_Safety_brief.pdf, accessed 23 January 2008).
Slide 74: 121. Retting RA et al. A review of evidence-based traffic engineering measures designed to reduce pedestrian– vehicle crashes. American Journal of Public Health, 2003, 93:1456–1463. 122. Elvik R, Vaa T, eds. The handbook of road safety measures. Amsterdam, Elsevier Science Ltd, 2004. 123. Bunn F et al. Area-wide traffic calming for preventing traffic related injuries. Cochrane Database of Systematic Reviews, 2003, (1):CD003110. 124. Afukaar FK, Antwi P, Ofosu-Amaah S. Pattern of road injuries in Ghana: implications for control. Injury Control and Safety Promotion, 2003, 10:69–76. 125. Dominican Republic: child friendly municipalities. International Secretariat for Child Friendly Cities web site. Florence, UNICEF (http://www.childfriendlycities. org/networking/dominican_republic.html, accessed 8 May 2008). 126. Steps to creating a safe routes to school program. Safe Routes to School Online Guide. Chapel Hill, NC, University of North Carolina Highway Safety Research Center (http:// www.saferoutesinfo.org/guide/steps/index.cfm, accessed 5 July 2008). 127. Mackett RL et al. A methodology for evaluating walking buses as an instrument of urban transport policy. Transport Policy, 2003, 10:179–186. 128. Rowland D et al. Randomised controlled trial of site specific advice on school travel patterns. Archives of Diseases in Children, 2003, 88:6–11. 129. GRSP in Bangalore. Global Road Safety Partnership web site (http://www.grsproadsafety.org/?pageid=27#GRSP%20 in%20Bangalore, accessed 5 July 2008). 130. Safety of vulnerable road users. Paris, Organisation for Economic Co-operation and Development, 1998 (http:// www.oecd.org/dataoecd/24/4/2103492.pdf, accessed 23 January 2008). 131. Vulnerable road users in the Asian and Pacific regions. Manila, Asian Development Bank, 2003 (http://www. adb.org/Documents/Books/Road-Safety-Guidelines/ vulnerable-road-users.pdf, accessed 23 January 2008). 132. Test procedures: child protection. EuroNCAP web site (http:// www.euroncap.com/Content-Web-Page/cec92835-f0824bd4-b4a3-2958ec66cbee/child-protection.aspx, accessed 5 July 2008). 133. Zaza S et al. Reviews of evidence regarding interventions to increase use of child safety seats. American Journal of Preventive Medicine, 2001, 21:31–47. 134. Anund A et al. Child safety in cars: literature review. Stockholm, Swedish National Road and Transport Research Institute, 2003 (VTI report 489A). 135. Tsoumakas K et al. Parents’ knowledge and attitudes about preventing injuries in motor vehicle accidents in children in Greece. Traffic Injury Prevention, 2008, 9:129–134. 136. Ehiri JE et al. Interventions for promoting booster seat use in four to eight year olds traveling in motor vehicles. Cochrane Database of Systematic Reviews, 2006, (1):CD004334. 137. Motor vehicle occupant injury: strategies for increasing use of child safety seats, increasing use of safety belts and reducing alcohol impaired driving. Mortality and Morbidity Weekly Report, 2001, 50:1 (http://www.cdc.gov/ mmwr/preview/mmwrhtml/rr5007a1.htm, accessed 22 January 2008). 138. Kedikoglou S et al. A maternity hospital-based infant car-restraint loan scheme: public health and economic evaluation of an intervention for the reduction of road traffic injuries. Scandinavian Journal of Public Health, 2005, 33:42–49. 139. Dellinger A et al. Interventions to prevent motor vehicle injuries. In: Doll L et al., eds. Handbook of injury and violence prevention. New York, NY, Springer, 2007:55–79. 140. Kallan MJ, Durbin DR, Arbogast KB. Seating patterns and corresponding risk of injury among 0- to 3-yearold children in child safety seats. Pediatrics, 2008, 121:e1342–e1347. 141. Lund UJ. The effect of seating location on the injury of properly restrained children in child safety seats. Accident Analysis and Prevention, 2005, 37:435–439. 142. Hertz E. Revised estimates of child restraint effectiveness [research note]. Washington, DC, National Highway Traffic Safety Administration, 1996. 143. Johnston C, Rivara FP, Soderberg R. Children in car crashes: analysis of data for injury and use of restraints. Pediatrics, 1994, 6:960–965. 144. Traffic safety facts 2004: occupant protection. Washington, DC, National Highway Traffic Safety Administration, 2004. 145. Helmets: a road safety manual for decision makers and practitioners. Geneva, World Health Organization, 2006 (http://www.who.int/violence_injury_prevention/ publications/road_traffic/helmet_manual.pdf, accessed 22 January 2008). 146. Hendrie D et al. Child and family safety device affordability by country income level: a comparison of 18 countries. Injury Prevention, 2004, 10:338–343. 147. Liberatti CLB et al. Helmet use by motorcyclists injured in traffic accidents in Londrina, southern Brazil. Pan American Journal of Public Health, 2003, 13:33–38. 148. Kwan I, Mapstone J. Interventions for increasing pedestrian and cyclist visibility for the prevention of death and injuries. Cochrane Database of Systematic Reviews, 2002, (2):CD003438. 149. Van Niekerk EC. Pedestrian visibility: final report. Pretoria, Centre for Scientific and Industrial Research, 2003 (CR 2002/78). 150. Thornly SJ et al. Conspicuity and bicycle crashes: preliminary findings of the Taupo Bicycle Study. Injury Prevention, 2008, 14:11–18. 151. Kobusingye O, Tumwesigye NM, Atuyambe L. Protecting vulnerable road users through visibility improvement: a WORLD REPORT ON CHILD INJURY PREVENTION 55
Slide 75: pilot study. Sydney, Road Traffic Injury Research Network, 2004 (http://www.rtirn.net/PDFs/RTIRN%20Facsheet_ Uganda.pdf, accessed 8 July 2008). 152. Umar RS. Helmet initiatives in Malaysia. In: Proceedings of the 2nd World Engineering Congress, Kuching, 22–25 July 2002. Kuching, Institution of Engineers, 2002:93–101. 153. Yuan W. The effectiveness of the “ride bright” legislation in Singapore. Accident Analysis and Prevention, 2000, 32:559–563. 154. Wells S et al. Motorcycle rider conspicuity and crash related injury: case-control study. British Medical Journal, 2004, 328:857. 155. Police enforcement strategies to reduce traffic casualties in Europe. Brussels, European Transport Safety Council, Working Party on Traffic Regulation Enforcement, 1999 (http://www.etsc.be/oldsite/strategies.pdf, accessed 29 April 2008). 156. Norghani M et al. Use of exposure control methods to tackle motorcycle accidents in Malaysia. Serdang, Road Safety Research Centre, Universiti Putra Malaysia, 1998 (Research Report 3/98). 157. Schoon CC, Goldenbeld C. Jonge brom- en snorfietsers: kan hun ongevalskans sterk omlaag? Effecten van maatregelen en draagvlak daarvoor onder jongeren en organisaties. [Young mopedists and light-mopedists: can their accident chance be greatly reduced? Effects of measures and support for them among the young and organizations]. Leidschendam, Institute for Road Safety Research, 2003 (SWOV Report R-2003-13) (http://www.swov.nl/ rapport/R-2003-13.pdf, accessed 22 January 2008). 158. Shults R et al. Review of evidence regarding interventions to reduce alcohol-impaired driving. American Journal of Preventive Medicine, 2001, 21:66–84. 159. Elder RW et al. Effectiveness of sobriety checkpoints for reducing alcohol involved. Traffic Injury Prevention, 2002, 3:266–274. 160. Barbar T et al. Alcohol: no ordinary commodity. Oxford, Oxford University Press, 2003. 161. Henstridge J, Homel R, Mackay P. The long-term effects of random breath testing in four Australian states: a time series analysis. Canberra, Federal Office of Road Safety, 1997. 162. Hingson RW, Assailly J-P, Williams AF. Underage drinking: frequency, consequences, and interventions. Traffic Injury Prevention, 2004, 5:228–236. 163. Hedlund J, Shults R, Compton R. What we know, what we don’t know, and what we need to know about graduated driver licensing. Journal of Safety Research, 2003, 34:107– 115. 164. Hedlund J, Compton R. Graduated driver licensing research in 2004 and 2005. Journal of Safety Research, 2005, 36:4–14. 165. Preusser DF, Tison J. GDL then and now. Journal of Safety Research, 2007, 28:159–163. 56 WORLD REPORT ON CHILD INJURY PREVENTION 166. Desapriya EBR et al. Child motor vehicle occupant and pedestrian casualties before and after enactment of child restraint seats legislation in Japan. Injury Control and Safety Promotion, 2004, 11:225–230. 167. Duperrex O et al. Safety education of pedestrians for injury prevention: a systematic review of randomised control trials. British Medical Journal, 2002, 324:1129. 168. Robertson L. Injury epidemiology, 3rd ed. New York, NY, Oxford University Press, 2007. 169. Gielen A, Sleet DA, DiClemente R, eds. Injury and violence prevention: behavioral science theories, methods and applications. San Francisco, CA, Jossey Bass, 2006. 170. Thomson JK, Whelan KM. A community approach to road safety education using practical training methods. London, Department for Transport, 1997 (Road Safety Research Report No. 3). 171. Rivara F, Metrik J. Training programs for bicycle safety. Seattle, WA, Traffic Safety Commission, 1998 (http:// safety.f hwa.dot.gov/ped_bike/docs/b_training.pdf, accessed 22 January 2008). 172. Towner E et al. What works in preventing unintentional injuries in children and young adolescents? An updated systematic review. London, Health Development Agency, 2001. 173. Soul City Institute: health and development communication. Soul City web site (http://www.soulcity.org.za/, accessed 28 April 2008). 174. Scheepers E et al. Evaluating health communication: a holistic overview of the impact of Soul City IV. Health Promotion Journal of Australia, 2004, 15:121−133. 175. Vernick JS et al. Effects of high school driver education on motor vehicle crashes, violations, and licensure. American Journal of Preventive Medicine, 1999, 16(1 Suppl.):40–46. 176. Roberts I et al. School based driver education for the prevention of traffic crashes. Cochrane Database of Systematic Reviews, 2001, (3):CD003201. 177. Ker K et al. Post-licence driver education for the prevention of road traffic crashes: a systematic review of randomized controlled trials. Accident Analysis and Prevention, 2005, 37:205–213. 178. Sasser S et al. Prehospital trauma care systems. Geneva, World Health Organization, 2005 (http://www.who. int/entity/violence_injury_prevention/publications/ services/39162_oms_new.pdf, accessed 14 May 2008). 179. Mock C et al. Guidelines for essential trauma care. Geneva, World Health Organization, 2004 (http://whqlibdoc. who.int/publications/2004/9241546409.pdf, accessed 22 January 2008). 180. Cummings P et al. Air bags and passenger fatality according to passenger age and restraint use. Epidemiology, 2002, 13:525–532. 181. Braver et al. Deaths among drivers and right-front passengers in frontal collisions: redesigned air bags relative to firstgeneration air bags. Traffic Injury Prevention, 2008, 9:48–58.
Slide 76: WORLD REPORT ON CHILD INJURY PREVENTION 57
Slide 77: RUBY’S STORY Christmas is a joyous time for most, but for parents Scott and Amanda and older sister Abby, Christmas Eve 2006 was the day they found their 14-month-old daughter Ruby face down in their home pool grey, lifeless and without a heartbeat. The family was preparing for Christmas when Scott and Amanda realized Ruby was missing. Scott’s first instinct was to check the pool which had a makeshift fence while they were landscaping, but he couldn’t see her and returned inside to continue looking. Unknown to them, children sink when they drown and Ruby was actually at the bottom of the pool. It wasn’t until Amanda re-checked the pool from a different angle that she discovered every parent’s worst nightmare. Ruby was pulled from the water and Scott began CPR while Amanda frantically called an ambulance which took 40 minutes to reach their house. Fortunately Amanda had her GP’s home number and she and her husband – both doctors – rushed to assist. Ruby was given CPR but still remained unresponsive and without a heartbeat. As a last resort the lifesaving decision was made to give her an adrenalin injection straight to the heart. To everyone’s relief her heart began to beat and she was rushed to hospital. Ruby was given a 10% chance of survival and Scott and Amanda were warned that if she did survive long-term brain damage was highly likely. But after spending Christmas day in an induced coma and a total of three weeks in the Paediatric Intensive Care Unit and Neurological ward, against all odds, Ruby made a miraculous recovery. Ruby slowly regained her strength and learned to crawl and walk again and has begun to talk. Her fine motor skills were affected so she visits with an occupational therapist and physiotherapist every two weeks. The family have been told that it is now a matter of ensuring Ruby meets milestones and that if there is any long-term neurological damage it is likely to become evident when Ruby starts school. Although Ruby’s survival and miraculous progress are not typical of children who have experienced a non-fatal drowning, the circumstances in which it occurred are very common. A lapse in adult supervision even for very short periods of time is a major contributing factor to children drowning. Big sister Abby was also deeply affected by the incident and Amanda says that she is an extremely anxious mother now, and so much more aware of potential hazards. Amanda says: “Before this happened I was very relaxed as a mum, maybe too much so, and thought that nothing would ever happen to my child. It’s terrifying how quickly things can happen. I don’t even want to dwell on what could’ve been, we are amazingly lucky. So many people have stories that don’t all turn out as well as ours.” Safe Kids New Zealand Media Release, 10 October 2007 http://www.safekids.org.nz/. DROWNING © S. Cooper
Slide 78: CHAPTER 3 – DROWNING Chapter 3 Drowning Introduction Water touches every aspect of children’s lives. They need it to grow, they are comforted by it, they are cleaned and cooled by it – and without it they cannot survive. Water to most children means fun, play and adventure – in a pool, pond, lake or simply in the road following a rain storm. Water, though, can be a dangerous medium. A small child can drown in a few centimetres of water at the bottom of a bucket, in the bath, or in a rice field. Drowning is an injury that displays epidemiological patterns that change according to age group, body of water and activity. In most countries around the world, drowning ranks among the top three causes of death from unintentional injury, with the rates highest among children under five years of age. Th is chapter describes the magnitude of the phenomenon of childhood drowning around the world, in terms of deaths, morbidity and disability – pointing to the likelihood that the true size of the problem has been substantially underestimated. It summarizes the risk and protective factors, with the Haddon matrix as a framework, and sets out the various prevention strategies, both proven and promising. The chapter concludes with recommendations, urging that confronting this preventable injury should be made a priority and given proper resources for research and prevention efforts. For the purpose of this chapter, drowning refers to an event in which a child’s airway is immersed in a liquid medium, leading to difficulty in breathing (1). This event may result in death or survival. The definition used in this report – the process of experiencing respiratory impairment from submersion/immersion in liquid (2) – is one agreed upon by experts at a recent world conference on drowning. This definition is simple and comprehensive, encompassing cases that result in either death, a certain level of morbidity or no morbidity (2). High-income countries, such as Australia and United States, have seen dramatic reductions in death rates from drowning, which have most likely come about as a result of both changes in exposure to risk and the implementation of specific interventions (3, 4). The lessons learned from these countries may be applicable to other countries around the world in helping to develop prevention programmes. (see Statistical Annex, Table A.1). Fatal drowning ranked 13th as the overall cause of death among children under 15 years old, with the 1–4 year age group appearing at greatest risk. The overall global rate for drowning among children is 7.2 deaths per 100 000 population, though with significant regional variations. The drowning rate in low-income and middle-income countries is six times higher than in high-income countries (with rates of 7.8 per 100 000 and 1.2 per 100 000, respectively). For those children who survive drowning, many are left with long-term consequences and disability that create enormous difficulties for families, with prohibitively high costs of health care. Global data show that approximately 28% of all unintentional injury deaths among children are due to drowning and 1.1% of all disability-adjusted life years (DALYs) lost for children under 15 years of age in low-income and middle-income countries are from nonfatal drowning (see Statistical Annex, Table A.2). Available data show that there are substantial differences in drowning fatality rates across the globe. Comparisons, though, are difficult because of the use of different defi nitions, different categories counted or excluded in the data, the frequent lack of comprehensive national data and the variable quality of data. For some countries, mostly high-income ones, the pattern of fatal drowning is well documented. It now appears that there can be considerable differences both within and between countries and regions with regard to the nature and scale of childhood drowning. Although drowning rates have declined significantly in recent decades in some highincome countries, there are few established risk factors along with proven preventive strategies. Th is highlights the need for well-designed research to study the causes and origins of drowning injuries and to evaluate prevention measures. Mortality In 2004, approximately 175 000 children and youth under the age of 20 years died as a result of drowning around the world. The overwhelming majority, 98.1% of these deaths, occurred in low-income and middle-income countries (see Statistical Annex, Table A.1). The low-income and middle-income countries of the WHO Western Pacific Region have the highest rate of drowning deaths (13.9 per 100 000 population), followed by the African Region (7.2 per 100 000), the low-income and middle-income countries of the Eastern Mediterranean Region (6.8 per 100 000) and the South-East Asia Region (6.2 per 100 000) (see Figure 3.1). WORLD REPORT ON CHILD INJURY PREVENTION 59 Epidemiology of drowning According to the WHO Global Burden of Disease estimates, 388 000 people died in 2004 as a result of drowning around the world, of whom 45% were under the age of 20 years
Slide 79: FIGURE 3.1 Fatal drowning rates per 100 000 childrena by WHO region and counry income level, World, 2004 10.0+ 6.0–9.9 2.0–5.9 <2 No data Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific LMIC 7.2 a HIC 1.3 LMIC 3.4 LMIC 6.2 HIC 0.6 LMIC 4.0 HIC 6.2 LMIC 6.8 HIC 1.2 LMIC 13.9 These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. The overall death rate in high-income countries is 1.2 per 100 000 population. However, the high-income countries within the Eastern Mediterranean Region have a rate of 6.2 per 100 000 – comparable to that of the low-income countries of the South-East Asia Region. Even within high-income countries, there appears to be considerable variability. According to the International Lifesaving Federation, drowning rates for Australia, Germany, Sweden and the United Kingdom in 2003 ranged between 0.6 per 100 000 and 1.5 per 100 000 – with children under the age of 18 years accounting for between 8% and 28% of these deaths (5). The actual number of drowning deaths in the world is likely to be much higher than the Global Burden of Disease figures suggest, particularly in certain regions of the world. In South and East Asia, for example, recent community surveys in five countries have indicated that drowning has been greatly underestimated by traditional methods of surveillance. In the countries studied, drowning was the leading cause of death among children under the age of 18 years (6). The death rate for drowning in these five countries was 30 per 100 000 population (see Figure 3.2), in stark contrast to the rate obtained by the Global Burden of Disease project of 6.6 per 100 000 population for the South-East Asia region and 13.9 per 100 000 for the Western Pacific Region in which these countries are located. For 60 WORLD REPORT ON CHILD INJURY PREVENTION example, the Bangladesh study found that the incidence of drowning fatalities among children aged 1 to 4 years was 86.3 per 100 000 children (7). In the Thai study, the rate for 5–9-year-olds was 31.2 per 100 000 population, with twoyear old males having a drowning rate of a staggering 106.8 per 100 000 (8). One possible reason for this disparity is that the Global Burden of Disease estimates of death rates from drowning exclude submersions as a result of floods and water transport incidents. This exclusion is likely to lead to a significant underestimate of the death rates in low-income countries experiencing seasonal or periodic flooding (9). Variability in drowning mortality rates within a region or within a country is also apparent. A possible explanation here is the exposure to open water. In Bangladesh, for example, a country with hundreds of rivers and tributaries, drowning was found to be the leading cause of death for children aged 1 to 9 years of age (7). Data from Beijing, China, on the other hand, showed a very low rate of drowning mortality (2.6 per 100 000 population) (10), possibly due to the fact that Beijing and its neighbouring districts have fewer bodies of water. However, in largely rural Guangxi province, which borders the ocean, drowning mortality rates are high – approaching 30 per 100 000 for children aged 0 to 4 years of age (11).
Slide 80: FIGURE 3.2 Age The death rates for drowning, by age group, for children and young people less than 20 years old show a rather higher rate in children in the 0–4-year age bracket, as compared with the rates for the other five-year age groups (see Figure 3.3). Data from the studies conducted in South and East Asia show that drowning accounted for 90% of all injury deaths for children aged 1–4 years and over 50% of injury deaths for children aged 5–9 years (6). In Bangladesh, 26% of all deaths in children between the ages of 1 and 4 years are due to drowning (12). Drowning is the leading cause of injury death in children aged 1 to 2 years in the United States (13) and among 1–14-year-olds in China (14, 15). In Brazil, drowning is the leading cause of injury death in 1–4-year-olds, and 26% of all unintentional injury deaths in children aged 0 to 14 years are from drowning (16). Fatal injury rates per 100 000 children aged 0–17 years in fivea Asian countries Drowning Road traffic injuries Suffocation Falls Animal bites Suicide Electrocution Sharp objects Poisoning Blunt objects Burns Falling objects 0 5 10 15 20 25 30 Rate per 100 000 children a Bangladesh, China (Beijing, Jiangxi), Philippines, Thailand, Viet Nam Source: reference 6. Gender Boys are overrepresented in every region of the world with regard to drowning death rates (see Table 3.1). In 2004, the overall fatality rate for boys under the age of 20 years was 9 per 100 000 population, nearly twice as high as the rate for girls (5.2 per 100 000 population). A similar skewing towards boys was found in the South and East Asian surveys (see Statistical Annex, Table B.1). FIGURE 3.3 Fatal drowning rates per 100 000 children by age and country income level, World, 2004 12 Rate per 100 000 population HIC 10 8 6 4 2 0 Under 1 1–4 5–9 Age (years) 10–14 LMIC Location Every year 70 Member States – mainly middle-income and high-income countries –submit to WHO mortality data that include the fourth digit of the International Classification of Disease codes, which allows disaggregation into subtypes of drowning. Analysis of these data show that even in these relatively better-off countries, information on where the drowning occurs is poorly documented. In more than 50% of cases the place is given as “unspecified”, making analysis of place of drowning difficult (17). Some countries, however, do have alternative sources of data. In Brazil, for instance, more than 60% of drowning occurs in natural bodies of water (16), while in South Africa the location of drowning is strongly related to socioeconomic status. Among wealthier communities 15–19 HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. TABLE 3.1 Fatal drowning rates per 100 000 childrena by sex, country income level and WHO region, World, 2004 Africa LMIC Boys Girls 9.0 5.4 HIC 1.8 0.7 Americas LMIC 5.0 1.8 South-East Asia LMIC 7.1 5.2 HIC 0.8 0.3 Europe LMIC 5.5 2.4 Eastern Mediterranean HIC 10.7 1.6 LMIC 9.0 4.5 Western Pacific HIC 1.7 0.7 LMIC 17.5 9.9 a These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. WORLD REPORT ON CHILD INJURY PREVENTION 61
Slide 81: in South Africa, swimming pools and the sea are the major sites of drowning, while for poorer communities the majority of drowning among children occurs in rural areas, typically in rivers, lakes and dams (18). The place of drowning is also related to age. In the United States, infants most commonly drown in baths and buckets, 1–4-year-olds in swimming pools, and children over 5 years of age most often in pools, rivers and lakes (19, 20). Most young children who drowned in pools were last seen in the home, had been out of sight for less than five minutes, and were in the care of one or both parents at the time (21). In some industrialized countries such as the United Kingdom, despite a reduction in overall drowning rates among children, the number of children dying in garden ponds or other ornamental water features has increased over the past decade (22). Morbidity Estimates of the number of serious non-fatal cases of drowning are more difficult to obtain. Reporting of nonfatal cases is generally less standardized and reporting to a central health statistics system is often not mandatory. This is true of most countries, regardless of income, although some countries are able to provide estimates from hospital data. Nevertheless, for children aged 0–14 years, WHO global estimates for non-fatal drowning range between 2 and 3 million. Among reported drowning cases, case fatality rates are high. Once a drowning is significant enough to warrant reporting, there is a high likelihood that the event has resulted in death or significant disability. For each fatality, it is estimated that there are between one and four nonfatal events serious enough to result in hospitalization (23). Improvements in medical treatment are unlikely to change this pattern significantly in the near future. There is thus a need to focus on primary prevention, rapid and effective rescue, and immediate resuscitation in cases of drowning. reported from a South African study, which found that 12% of children admitted for drowning subsequently died and 6% suffered from a severe neurological deficit (28). In studies in both the United States (23) and the United Kingdom (27), all children who had suffered drowning and who were alert on admission to hospital fully recovered. In the United States review, half of all children who were confused or comatose on admission had a poor outcome, 35% died and 15% had a severe neurological deficit (23). A high proportion of child drowning cases with poor outcomes has also been observed in a paediatric respiratory care unit in Thailand, where the mortality rate was 26% and 36% suffered from neurological long-term consequences (29). Due to differences in patient populations and study designs, the figures on the health consequences of nonfatal childhood drowning are not properly comparable across countries. Moreover, many studies lack detailed information on functional outcomes. There is a need for studies measuring the consequences of drowning in childhood – and non-fatal drowning in particular – using comparable methodologies and international guidelines (30). This would allow for sound estimates of the prevalence of brain damage and other permanent disabilities resulting from non-fatal drowning in childhood. Impact on families and communities The lifelong health consequences of non-fatal drowning have a great impact on families, and include psychosocial consequences for those who have suffered drowning, their siblings, parents and other caregivers. Disability-adjusted life years (DALYs) lost for drowning vary widely (see Statistical Annex, Table A.2). For children younger than 15 years, the higher figures come from lowincome and middle-income countries of the WHO Western Pacific Region, where drowning is responsible for 4% of DALYs, from all causes (see Statistical Annex, Table A.2). The impact of drowning on communities can be further estimated in terms of potential years of productive life lost and valued years of potential life lost. Both these measures estimate the loss of productivity due to premature death before the usual age of retirement at 65 years. The cases of Bangladesh, China and Viet Nam provide good examples of the huge impact on the economy of drowning (6). A study in China showed that injury death by far exceeded other major diseases – such as heart disease, cancer and infectious diseases – as a contributor to losses in production. The study also found that drowning ranked second, after motor vehicle traffic injuries, among all causes of injury, in terms of both potential years of productive life lost and valued years of potential life lost (31). Consequences of non-fatal drowning The long-term health consequences of non-fatal childhood drowning are not well known, as few studies have assessed functional outcome after drowning (23–25). An Australian study on drowning for the five-year period 1999–2000 to 2003–2004, for hospital admissions of all ages, showed on average that 22.3% of cases were left with severe or persistent respiratory or neurological consequences (26). The study also indicated that at least 5% of child survivors from drowning who had been admitted to hospital were discharged with severe neurological deficits (meaning that they would survive in a vegetative state). In the early 1990s, a British study reported that among all drowning cases in children younger than 14 years of age who were admitted to hospital, 8% died and 5% had a severe neurological deficit (27). Similar findings were 62 WORLD REPORT ON CHILD INJURY PREVENTION Economic impact of drowning Studies to assess the costs of injury in several parts of the world (32–36) have up to now largely neglected or
Slide 82: else underestimated the economic impact of drowning. In spite of the scarcity of accurate and comparable data, available estimates indicate that non-fatal drowning may have serious economic consequences. Specific studies into the costs of hospitalizations for non-fatal drowning in the United States (34, 36, 37) have shown that while most cases can be discharged on the same day or after a single night’s stay, a small proportion need to receive intensive treatment for very long periods. For this reason, the mean direct costs associated with hospitalization have been reported at $US 13 000 to $US 14 000 per case (36, 37). For cases with severe long-term consequences, such as brain damage, treatment costs alone can exceed $US 100 000. In a cost of injury study undertaken in Australia, non-fatal drowning was found to have the highest average lifetime cost – an estimate that includes direct and indirect costs – per patient of any injury type (38). Studies of the impact of childhood drowning on families and communities show that the cost is highest for those low-income and middleincome countries in which families rely on older children for income (39). Many countries classify deaths according to the International Classification of Disease (ICD) E-codes. These data are then used to characterize drowning in the region. The most recent (tenth) revision of the ICD is an improvement over previous editions of the ICD in that the newer codes are more specific as to the location of drowning. However, most countries do not use the fourth character of the ICD code which details where the drowning occurred. Risk factors Knowledge of risk factors is a critical prerequisite for the effective prevention of drowning (see Table 3.2). Available studies on drowning suggest that people living in countries – particularly countries that are densely populated – with a large amount of open water are at a higher risk of drowning. Other risk factors, such as gender and age, appear to be almost universal. Child-related factors Age and development As already stated, children under five years of age appear to have the highest drowning mortality rates worldwide, with rates among all age groups peaking in 1–4-yearolds. In late adolescences another, smaller peak is seen. This pattern is generally consistent across the world. The likely explanations for these peaks relate to developmental processes in young children and experimentation among adolescents, especially with substances such as alcohol. With child drowning, risk and circumstances are generally related to the developmental stage of the child. Because infants under one year of age are usually unable to access water by themselves, unintentional drowning at this age is mostly the result of a child being left alone or with an unqualified caregiver – such as a young sibling – in or near water. By contrast, children who are more mobile and inquisitive, but still too young to have developed an awareness of hazards or avoidance skills, often wander away from the supervising adult and fall or climb into a nearby body of water (3, 43–45). Often the parent or caregiver is unaware that the child has approached or has fallen into the water (46). The increased risk during adolescence is possibly as a result of less supervision and increased independence, increased risk-taking and greater exposure to open water during work or leisure (6, 26). Limitations of data Statistics on drowning are based on a broad range of data sources. Although much progress has been made around the world in collecting data, the availability and quality of data on drowning varies greatly between countries, depending on the surveillance systems in place and the availability and quality of other statistical resources. Data on drowning deaths are lacking or unreliable in many lowincome and middle-income countries, despite periodic surveys or local data that suggest that these countries have the highest rates of fatal drowning (40). Even in countries where counts of drowning deaths appear relatively complete, important basic details about the event are often lacking, including information on the location of drowning, the intent and the circumstances. There are two main reasons for this lack of information. First, the data collection systems employed may not capture all the relevant information – such as the age of the person concerned and their swimming ability, the type of water in which the drowning occurred, the cause of immersion, whether there were immediate attempts at resuscitation, and the presence of any barriers. Second, the information may not be available at source. Many incidents are not witnessed and it is not always possible to reconstruct the specific circumstances around the event (41). Both lack of information and misclassification have an effect on overall estimates of the impact of drowning. In cases where a person survives drowning for a period of time in hospital, but dies some days later, the primary cause of death may be coded as something other than drowning – for example, as respiratory failure. Underreporting also occurs because of the ways that intent can be classified (42). Gender Based on global data, rates of fatal drowning are higher in males than females. This is true in all age groups with the exception of infants less than one, where rates among females are higher than males (see Table 3.3). Infanticides of females, misclassified as unintentional events, may be a factor here. Among males, drowning death rates peak WORLD REPORT ON CHILD INJURY PREVENTION 63
Slide 83: TABLE 3.2 Haddon Matrix applied to the risk factors for childhood drowning Factors Phases Pre-event Child Agent Physical environment Lack of barriers; unfamiliar environment; slippery, uneven, unstable or steep surfaces near or in water; weather conditions, e.g. floods; strong sea currents; inadequate physical infrastructure, such as bridges or safe crossings; lack of safe water supplies; lack of warning of severe weather Socioeconomic environment Lack of supervision or child care; reliance on peer or older child supervision; poverty; large families; unemployed or illiterate parents; failure of authorities to remove or protect hazards; lack of pool-fencing legislation; lack of water safety instruction and community awareness programmes Poor access to information and resources for minimizing risk; inadequate communications or infrastructure to call for emergency health services Developmental issues; gender; vul- Unprotected water hazards; nerability; underlying medical condi- unsafe watercraft; overtion, e.g. epilepsy; lack of supervision; loaded watercraft lack of knowledge about water risks; need to access water for functional purposes, e.g. drinking, washing or fishing; transport on water; recreational use of water; alcohol consumption by adolescent swimmers or caregivers Event Child not wearing personal flotation device; rescuer unable to swim; lack of swimming and/or water survival skills; overestimation of swimming ability; lack of strength; lack of comprehension of situation; panic response; swimming alone; lack of personal alerting devices or knowledge of emergency signals (such as waving arms) Deep water; strong river water current; ocean rip current; very cold water; big waves; lack of personal flotation devices or other life-saving devices in boat; lack of lifeguards Variable water depth; unstable footing; lack of escape mechanism, e.g. ladder, ropes, flotation device; snags in water Post-event Delay in rescue; inaccessible first-aid Victim carried away from Long emergency or fire department kits; lack of knowledge by caregiver shore by current response time; inadequate rescue about what to do immediately; lack of and treatment skills; poor access alerting mechanisms (such as mobile to water; inadequate transport for phone, flares) prompt medical care Inadequate care; poor access to acute care hospitals and rehabilitation services; little community support for victims and families in the 1–4-year age group. In females, rates are highest in infants and decline thereafter. The greatest difference in drowning death rates by gender occurs in adolescents aged 15–19 years, where rates among males are 2.4 times greater than rates among females. This gender pattern is seen across the world, irrespective of a country’s wealth (4, 47, 48). Males in the WHO African and Western Pacific Regions have the highest drowningrelated mortality rates worldwide (39). In most regions, with the exception of the Americas and the Eastern Mediterranean, males’ death rates from drowning are roughly double those of females. The reason for this may be that boys are more involved than girls in work that takes place in or near open bodies of water, and that they indulge to a greater extent in recreational aquatic activities. This is illustrated by the high number of young males who drown in Uganda while working on fishing boats (49). There is some evidence from high-income countries that greater risk-taking behaviour also contributes to higher drowning rates among boys. There is also evidence that, during aquatic activities, they are more likely than girls to swim alone, to swim at night and to consume alcohol when swimming or boating (47, 50–53). Poverty TABLE 3.3 Fatal drowning rates per 100 000 children by age and sex, World, 2004 Age ranges (in years) Under 1 Boys Girls 6.4 9.8 1–4 11.8 7.6 5–9 7.8 4.9 10–14 8.3 4.0 15–19 9.3 3.8 Under 20 9.0 5.2 Source: WHO (2008), Global Burden of Disease: 2004 update. As previously noted, even within a given region of the world, there are considerable differences in drowning mortality rates between high-income and low-income countries. This is also the case within certain countries. A lack of educational opportunity, associated with poverty, may be one factor involved. There is some evidence to suggest that drowning in children is affected by the level of education of the family head or the caregiver. A study in Guadalajara, Mexico, for example, found that the risk of a child aged 1 to 4 years dying from drowning was higher 64 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 84: among those children from households where the head of the family had not completed elementary school (54). In Bangladesh, children whose mothers had only primary education were at significantly greater risk of drowning compared to children whose mothers had secondary or higher education (9). Against this, the study of child drowning in Xiamen, China found that the educational level of the father or mother was not a risk factor for drowning mortality (55). Within countries, social and demographic factors also appear to affect the risk of drowning. Evidence from child drowning studies in low-income and middle-income countries such as China (6, 11, 55) Uganda (24) and Bangladesh (9, 12) consistently show that rural children have much higher drowning rates than those in urban areas. Many of these deaths occur in fishing communities where water transport takes place in non-motorized watercraft (49). In Bangladesh, the annual drowning rates in children aged 1–4 years are 136.9 per 100 000 in rural areas and 18.9 per 100 000 in urban areas (7, 9, 12). Case-control studies conducted in this country (9, 12) also found that child drowning risk increased as maternal age and family size increased. This pattern, though, was not observed in the study of child drowning in Xiamen, China (55). Within high-income countries, there are suggestions of large discrepancies in fatal drowning rates between population subgroups, with an increased risk of between two and four times for children and young people from racial or ethnic minority groups (13, 56, 57). In the United States, ethnic minorities and foreign-born young men have higher rates of drowning compared with their white counterparts (56, 58). In the Netherlands, ethnic minorities experience a nearly three-fold higher risk of drowning death than the native Dutch population (57). The factors that contribute to disparities in risk of drowning among different ethnic groups are not well understood. Suggested explanations include differences in swimming ability and experience in the water, lack of opportunities to learn to swim, and lack of supervision in environments where population groups are at high-risk swim (58, 59). Agent factors Lack of safety equipment The lack of availability or accessibility of safety equipment in water transportation vessels are additional risk factors. Flotation devices such as life jackets are indispensable on all vessels, whether used for transportation or for pleasure. In the United States, for example, in 2005 the Coast Guard received reports for 4969 boating incidents. In these incidents, 3451 participants were reported injured and 697 died. Among those who drowned, 87% were not wearing life jackets (66). In addition to the lack of flotation devices, the poor maintenance of such equipment is an additional risk. Safety equipment used by children while swimming should meet minimum safety standards. Items such as supporting rings or “water wings” may give parents a false feeling of safety, resulting in lapses in supervision with devastating consequences. The use of blow-up toys, rafts and air mattresses has also been recognized as being unsafe (67). Unsafe vessels on water There are regular media reports of the deaths of adults and children as a result of being transported in unsafe or overcrowded boats. Many of these boats are unseaworthy and will have been further compromised by turbulent weather conditions. These incidents account for unknown numbers of drowning deaths every year. In low-income countries, the capsizing of boats, launches and ferries is sadly commonplace, especially during the rainy season and at periods, such as national holidays, when there are high levels of mobility. Alcohol consumption Risk-taking behaviour figures strongly in unintentional drowning cases, particularly among adolescents. Alcohol use has been linked to between 25% and 50% of adolescent and adult deaths associated with water recreation (68). Alcohol influences balance, coordination and judgement, and its effects are heightened by exposure to the sun and heat (69). Alcohol consumption by parents and other caretakers while supervising children in water should also be considered. While many studies have investigated the direct contribution of alcohol to drowning, little work has been done to estimate the risk to children of alcohol consumption by those supervising them (40). Estimates of the extent of alcohol involvement in drowning vary widely. This is because of differences in recording age groups or incomplete testing. Apart from affecting judgement and performance, alcohol is believed to have direct physiological effects that may affect survival once submersion has occurred – through mechanisms such as increasing hypothermia and retarding the protective WORLD REPORT ON CHILD INJURY PREVENTION 65 Underlying conditions Epilepsy is known to increase the risk of drowning death in all sources of water, including baths, swimming pools, ponds and other natural bodies of water (60, 61). A casecontrol study conducted in Norway found that children with epilepsy were significantly more at risk of submersion and drowning than children who did not have epilepsy, in both baths and swimming pools (62). In this study, though, it was found that no child died of submersion if an adult was present. In Sweden, 10% of those with a history of epilepsy died from drowning over the period 1975–1995 (63). Other conditions that are likely to increase the risk of drowning are autism (22, 64) and certain cardiac arrhythmias, although the latter are less frequent in children (65).
Slide 85: involuntary muscular contraction of the laryngeal cords (70). Environmental factors Type of body of water Perhaps the strongest risk factor for child drowning mortality is exposure to a “risky” body of water. Patterns of child drowning across countries generally reflect the type of water to which the child is exposed. In low-income and middle-income countries, most drowning deaths happen during daily activities that involve playing, working, washing, collecting water and crossing water – for instance, to reach school. The bodies of water involved include ponds, ditches, lakes, rivers and water collecting systems, both above and below ground, such as buckets, barrels, wells and cisterns (24, 54, 71). By contrast, in high-income countries, most childhood drowning occurs in recreational settings. For younger children this is often a swimming pool and for older children a lake or river used for swimming. While approaches to prevention are transferable, specific prevention strategies and measures should be tailored for specific types of exposure. In general, most children drown in or around the home. The younger the child, the closer to home the event is likely to occur. Baths are a very common location, though children mostly drown in them only when left unattended (72). For young children in high-income countries, the presence of a residential pool, particularly one that is inadequately fenced, is the strongest exposure factor (51), while in many low-income countries, the presence of open bodies of water or a well is strongly related to the risk of drowning. For instance, a study in a metropolitan area of Mexico found that children living in homes with a well experienced a seven-fold increased risk of drowning as compared with those in homes without a well (54). In Bangladesh, most young children aged 12–23 months who died from drowning did so in ditches and ponds, reflecting the fact that they were highly exposed to these water sources (71). A study of Australian farm injuries found that 78% of drownings in children under 5 years of age living on farms occurred in farm dams and irrigation channels (73). their own country or abroad. In Australia, between 1992 and 1997, 4.7% of all non-boating drowning cases, 18% of surf and ocean drowning cases and 25% of scuba drowning cases were among foreigners (75). Another Australian study, covering the period mid-2001 to mid-2005, showed that almost 25% of drowning deaths were among foreign tourists, including children (76). It has been reported that many more children from the United Kingdom drown in swimming pools abroad than in swimming pools in their home country. This finding is presumably related both to the increased exposure to water when on holiday and exposure to a new situation (77). Access to treatment and rehabilitation Several studies have confirmed that most lives are saved by the immediate action of bystanders at the scene, either lay people or professional rescuers. Without such immediate first aid – including basic cardiopulmonary resuscitation – subsequent advanced and invasive life support techniques appear to be of little value in most cases (78). Following the initial attempts at resuscitation, rapid deployment to an emergency department of a hospital is essential to prevent further neurological damage or death. The initial management of non-fatal drowning should involve continued resuscitation and treatment of respiratory failure, after which the child should be gradually rewarmed. Outcome studies have shown that submersion for longer than 25 minutes, a continued need for cardiopulmonary resuscitation for more than 25 minutes, and lack of pulses on arrival at the emergency room are all predictors of severe long-term neurological consequences or death (1, 79, 80). However, the existence of case reports of children surviving neurologically intact after prolonged submersion in icy water suggests that more aggressive interventions can be helpful in these cases (1). Interventions Given the complexity of drowning events, strategies for prevention require a holistic approach, based on the particular pattern of drowning observed in a given location. Passive prevention strategies – such as improving safety design – that require no action or else only a single action on the part of the individual, are generally regarded as more effective than active strategies, such as adopting safer behaviours, requiring repeated actions. However, for many types of drowning there are a limited number of passive strategies – or even none at all. Climate Worldwide, large numbers of drowning deaths are associated with cataclysmic floods and ocean waves, which, in a single event, can leave thousands dead. Children accounted for about one third of those who died during the Indian Ocean tsunami in 2004 (74). Holiday activities A number of studies have found an increased risk of fatal drowning among both adults and children on holiday in 66 WORLD REPORT ON CHILD INJURY PREVENTION Most drowning deaths could be prevented by a sustained effort to implement safety interventions. The task ahead is clear - to translate what is now known into action on the ground (UNICEF Bangladesh).
Slide 86: Engineering measures Eliminating hazards Eliminating a hazard – where this is possible – is the most effective prevention method, since it does not rely on barriers or other protective measures which may be ineffective. Buckets and baths, for example, should be left empty when not in use, as children could drown in them if they contained a liquid. Similarly, holes in the ground, dug for building purposes, should be drained of rainwater or fi lled in to prevent water collecting. Small containers, such as washing tubs, should be safely stored so that they will not fi ll with rainwater (81). Passive strategies relating to the creation of infrastructure include the building of safe bridges and the installation of piped water systems, both of which have historically been factors in reducing drowning rates in developing countries. Having piped water to hand means that people can avoid open bodies of water to bathe or wash clothes in or to collect drinking water from. It also makes exposure to stored rainwater and wells less likely, both of which are potential hazards (81). Providing safe venues for recreational swimming can also help prevent drowning. Natural bodies of water contain a number of associated hazards for swimmers. The depth of water in them may be unknown and there may be underwater obstacles, sudden and unseen changes of depth or deep holes. Strong currents and a low temperature of water can create further problems. The provision of suitably designed pools, whose depth is known at each point and in which obstacles and currents are absent, makes it possible for children to learn to swim in an environment with considerably fewer hazards. Covering wells In low-income and middle-income countries, creating barriers between young children and the bodies of water to which they are exposed can be an effective measure to prevent drowning. Covering wells or open barrels with grills, creating an embankment or fenced barrier near ponds and riverbanks, and building flood-control embankments, are all effective in preventing drowning (54) (see Box 3.1). Similarly, creating fencing around a dwelling where there is a hazard of open water outside the house can also provide protection. BOX 3.1 Covering wells in Mexico Wells and underground cisterns are important sources of household water. The former are common in rural areas, while the latter are used in some cities without a reliable community water source. A common characteristic of both is an opening large enough to allow access. This can create a major drowning risk for children, especially in developing countries. One study found that the presence of wells in homes increased the risk of drowning in the home by a factor of nearly seven, while cisterns increased the risk two-fold (54). Using accepted strategies as well as the experience of swimming pool fencing, a child’s risk of drowning could be substantially reduced if the opening to these household water sources was closed by a locked hatch. This preventive strategy is familiar to the Mexican public, who have a popular saying, “close the well after the drowned child.” Because water must be drawn daily, wells and underground cisterns cannot be sealed the whole time. The most hazardous method of obtaining water would be through a hatch or lid large enough to admit a bucket – and therefore also large enough to let a small child pass through. A more effective preventive measure would be to draw water using a manual or electric pump. This would make it easier to obtain household water and would eliminate the risk of children drowning. Environmental measures Pool fencing Another passive intervention is the creation of an effective barrier between child and hazard (see Box 3.1). In highincome countries it has been found that surrounding private swimming pools and spas with safety barriers that prevent unsupervised young children entering significantly reduces their risk of drowning (82–86). A meta-analysis of three case–control studies showed a significantly decreased risk of drowning in a fenced pool, as compared to an unfenced one (87). Furthermore, the study found that a barrier isolating the pool from all other structures – a four-sided fence – was shown to be far more protective than perimeter fencing, a three-sided fence where the house or another structure forms the fourth side of the barrier (87). Research in the United States and Australia has found that laws and regulations requiring pool fencing are insufficient if perimeter fencing is not accompanied by adequate enforcement to ensure the self-closing system of the gate and the latching system are functioning properly (83, 88). © M. Peden/WHO WORLD REPORT ON CHILD INJURY PREVENTION 67
Slide 87: In Australia, farm safety researchers are investigating the feasibility of a “virtual fence”. The technology for an alarm system signalling that a child under adult supervision has wandered beyond predetermined limits from the home already exists. The researchers are examining whether this technology can be applied effectively to increase child safety in low-income countries, especially in relation to the risk of drowning in bodies of water such as dams. Legislation and standards Pool fencing laws and their enforcement In many high-income countries, legislation requiring isolation pool fencing for all swimming pools (including private ones) has been recommended and sometimes also enacted and enforced. Such legislation has proved effective in decreasing drowning rates, though not to the extent that had been anticipated (86, 89, 90). This may be due to a lack of knowledge of the law and its inadequate enforcement. This is particularly the case with regard to swimmers who are unskilled or tired or who panic. If a young child wearing a properly-designed personal flotation device falls into the water, the device should keep the child afloat long enough to be rescued. Only certain types of personal flotation device will ensure that the child floats face-up. These devices should therefore be seen as shortterm solutions and not as a substitute for supervision. The provision of personal flotation devices for all occupants of ferries and other vessels has the potential to save many lives (see Box 3.2). Laws on alcohol General minimum-age drinking laws and lowering the alcohol level do not appear to be associated with a reduction in drowning rates among adolescents (96). However, it is known that consuming alcohol before or during activities in bodies of water increases the risk of drowning. Adolescents should therefore be encouraged not to drink and swim. In addition, advertising that encourages alcohol use during boating and the sale of alcohol at water recreational facilities should be restricted. Personal flotation devices Although not yet thoroughly evaluated, wearing a properly-fitted personal flotation device, such as a life jacket, is a promising strategy to prevent drowning (91). BOX 3.2 Personal flotation devices and drowning Lifejackets were developed to prevent drowning in emergencies at sea. In the water, they turn wearers to a position where the face points up, and with the head supported and the mouth out of the water. Buoyancy material is concentrated in front of the wearer, which makes the jacket bulky, uncomfortable and restrictive. Newer buoyancy devices are designed to keep the wearer afloat but do not meet the high performance requirements for lifejackets, with regard to buoyancy and keeping the face up. They are considered appropriate, though, for use by children, recreational boaters and water sports participants, who are undertaking activities in calm waters, close to the shore or close to help from rescuers. The broader term “personal flotation device” is now used in many countries to cover all these new flotation devices as well as the lifejacket. Many governments now require all recreational vessels to carry one wearable personal flotation device, of a specified type, for each person on board. However, since drowning during recreational boating usually occurs suddenly or unexpectedly, lifejackets stored on board offer little protection unless they are actually worn. Various studies have shown that up to 50% of drownings resulting from boating-related incidents could have been prevented if the person had been wearing an appropriate personal flotation device (92). Two main strategies – education and, to a lesser extent, regulation – have been employed by governments to try to increase the wearing of personal flotation devices among recreational boaters, including water sports participants. Only two evaluations of educational campaigns on personal flotation devices have been published, both reporting modest effectiveness (93, 94). Although the use of personal flotation devices among all boaters increased, the impact of the campaign on childhood drowning was undetermined. Some countries have made the wearing of personal flotation devices mandatory. Preliminary data from an Australian study, which evaluates both the wearing rates and the effectiveness of regulations, shows promising results (95). The available evidence therefore suggests that the use of personal flotation devices is potentially a strong measure to prevent drowning among recreational boaters, including children, and that regulation is more effective than education in increasing the use of these devices and preventing drowning. 68 WORLD REPORT ON CHILD INJURY PREVENTION © Marine Safety Victoria
Slide 88: Developing education and skills Teaching swimming and improving skills Most studies show that swimming instruction improves swimming ability, but no conclusive evidence exists that swimming ability confers protection against the risk of drowning. There are, however, indications that swimming instruction and the consequent increased ability at swimming, as well as greater survival skills, do provide some protection, even at relatively young ages. Longitudinal studies of child drowning are hampered by the lack of data regarding the proportion of children who can swim and the level of swimming ability of those who drown. A study conducted in the United States (see Box 3.3), a recent study in rural China of child drowning (46) and research in Bangladesh (7) all suggest that swimming lessons may be protective. Even in the face of this preliminary evidence, there should be caution in recommending swimming lessons as a protective strategy for young children. Several studies show children as young as 24 months can improve their skills, but their learning period is much longer than that of older children (98). Concern has been voiced that mass training in swimming skills for children could lead to more children, especially young ones, being exposed to water and becoming overconfident in it. Ultimately, according to this view, drowning rates in children could increase rather than decrease (99). A study in Australia, however, suggested a link between swimming lessons and decreased drowning rates in children (100). However, this may have also been because more safe places for swimming were opened, including large numbers of public pools (see Box 3.4). BOX 3.3 Teaching children to swim One possible strategy to prevent drowning is to improve children’s swimming skills through formal instruction. Few studies have examined the association between either swimming skills or swimming instruction and drowning risk. While it seems intuitive that more skilled swimmers would be less likely to drown, it is also the case that skilled swimmers drown. Among older children especially, it is possible that those who are comfortable in water or who perceive themselves to be good swimmers might seek out water-related activities. These activities might occur in more risky settings – such as in deeper water or at locations without lifeguards or other appropriate supervision. Preliminary results of a study in the United States (97) found that past participation in formal swimming lessons offered a protective effect for drowning. In this study, the families of children who had drowned and the families of matched controls were asked about their child’s past participation in formal swimming lessons. For children aged 1–4 years, interviews were conducted with 61 families of children who had drowned and the families of 134 matched controls. In the 5–19-year age group, interviews were conducted with 27 families of drowning cases and 79 matched controls. For the younger age group, 3% of those who drowned had participated in formal swimming lessons, against 26% in the matched controls. This represents a 90% reduction in drowning risk among those who had swimming lessons. Among older children, 27% of the drowning cases had taken formal swimming lessons against 53% of the controls – an association that was not statistically significant. In general, increased swimming skills also appear protective with respect to drowning risk. This is particularly true in children over 5 years of age, with several of the skills showing a protective effect in adjusted analyses, despite the small sample size. For example, in the older age group, drowning cases were less likely to be able to swim on the stomach for a distance of 5 metres. However, among those aged 5–19 years, many of those who drowned were relatively skilled swimmers. Of those who drowned in this group, 58% were reported to be able to swim continuously for at least a minute and 48% to be able to swim at least 15 metres. This study had a number of limitations, including the relatively small sample sizes in both age groups and a reliance on reports, rather than on observation, of swimming skills. In addition, it is quite possible that parents who enroll young children in swimming lessons could differ from parents who do not do so. These differences are difficult to measure and could have an effect on a child’s risk of drowning. In spite of these shortcomings, these early results, together with a previous study in rural China (46) that also identified a protective association between swimming instruction and drowning risk, suggest that formal instruction in swimming ought to be a component of a strategy to prevent drowning. However, those designing prevention programmes, and those targeted by them, must be aware that even the most skilled swimmers can drown. Swimming lessons and the teaching of water survival skills should therefore be regarded as one important component of a multiple approach to prevention. WORLD REPORT ON CHILD INJURY PREVENTION 69 © Naser UNICEF
Slide 89: More good intervention studies are needed to evaluate the effectiveness of swimming lessons in preventing drowning in young children, and to specify what sort of swimming and survival skills should be taught. Imparting knowledge and skills beyond the basic swimming strokes is certainly necessary. This includes teaching children to swim safely in open water, to identify hazards such as rocks, currents and dangerous weather conditions, and to recognize, avoid and – if necessary – escape from rip currents. safe behaviour, actively controlling the risk-taking actions of swimmers, monitoring water and weather conditions, and prohibiting or restricting swimming in the sea if behaviour or conditions pose a hazard. Lifeguards, furthermore, provide rescue and resuscitation to limit cases of drowning resulting in death or brain damage (103). For their work to be effective, though, they require ongoing training and need to adhere to high standards of performance, particularly as regards surveillance (104). Supervision by parent or caregiver Supervision by lifeguards Lifeguards (also known in Australia, New Zealand and South Africa as lifesavers) – both voluntary and paid – have provided protection at swimming pools and natural bodies of water in various parts of the world since the 19th century. Voluntary lifeguarding still exists, particularly around natural bodies of water. At the same time, paid lifeguards are increasingly being employed in public and commercial swimming venues. There have been no published studies formally evaluating the effectiveness of lifeguarding as a primary prevention measure. Australian studies, based on rescue and resuscitation data from associations of lifeguards, do, however, point to some effectiveness (101, 102). Trained lifeguards on beaches and at public swimming pools are likely to decrease the risk of drowning by being models for Educating parents and caregivers about the risks for drowning is an important step for changing knowledge, beliefs and attitudes which in turn determine behaviour. People often underestimate the risk of drowning and are unaware of who is particularly at risk (6). A study of Americans of Vietnamese origin found that both parents and adolescents often attributed drowning to fate (105). Parents and caregivers need to understand that young children should never be left alone or with another young child in or around any body of water (see Box 3.5). They also need to learn basic life-saving and first-aid skills. Numerous studies have shown that inadequate supervision is an important contributory factor for paediatric drowning of all types, especially drowning in the bath (106). However, the effectiveness of supervision as a drowning prevention measure has not been formally BOX 3.4 A mass primary school swimming instruction campaign From the 1950s onwards, a major collaborative swimming instruction campaign was implemented across the state of Victoria, Australia. The programme was named after a daily newspaper, The Herald, which had launched it and gave it publicity. Supported by the Education Department and the local government and championed by an ex-olympic swimmer, the campaign also coincided with the Olympic Games held in Melbourne in 1956. The campaign was aimed at the later years of primary school children. These children received a “Herald Certificate” when they swam the target distance of 23 metres, and the annual award rates were published by the newspaper. By the summer of 1962–63, over a million children had participated in the Herald campaign. All children aged 10–12 years were covered by this programme, which was associated with a reduction in the drowning rate. This mass swimming campaign, together with an increase in the number of safe places to swim and other drowning prevention strategies, resulted in a significant reduction in the drowning rate (see accompanying figure). 90 000 Number of certificates awarded 80 000 70 000 60 000 50 000 40 000 30 000 20 000 10 000 0 1935 P 1937 # 1939 # 1941 # 1943 # # 1945 1947 # 1949 Year P 1951 # 1953 1955 1957 1959 1961 1963 Certificates Rates 9 8 7 6 5 4 3 2 1 0 Drowning deaths per 100 000 population 70 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 90: Interventions for adolescents BOX 3.5 Adult supervision and swimming training for very young children In New Zealand, children under five years of age have the highest death rate from drowning of any age group in the country. In an attempt to prevent such deaths, a number of organizations have promoted swimming lessons for very young children, despite a lack of evidence that swimming instruction in this age group is effective in teaching protective skills. Some experts have warned that swimming lessons at this age may actually be harmful, making young children less fearful of water and giving parents a false sense of security. A study to examine the beliefs of adults about the benefit of swimming instruction was conducted, with 555 parents who had enrolled their preschool children in swimming lessons, together with a control group of 327 parents of similar children who had not (107). The study found that parents believed that children as young as two years could learn to swim, and that a sizable proportion thought that swimming classes were the best way to prevent small children from drowning. A third of parents considered it better to develop the swimming ability of their children than to rely on adult supervision in order to prevent drowning. The study brought out parents’ misconceptions over their young children’s ability to be safe. Parents often place their children in situations where there is a mismatch between the child’s skills on the one hand, and the demands of the tasks required for safety on the other. This has been shown not only for drowning, but also for pedestrian safety, driving skills and safety with firearms. Such misconceptions need be combatted with a range of educational, regulatory and other interventions so as to reduce the risk of inadvertent injury to children. Adolescent drowning usually occurs in open water while swimming, boating or undertaking other leisure activities. Those who drown have generally been swimming with one or more friends of a similar age who do not recognize they are in trouble or cannot rescue them. Adults are usually absent, and there may be peer pressure to indulge in risk behaviours, such as consuming alcohol. With alcohol consumption, the risk of drowning increases as blood alcohol concentration levels rise. Measures to prevent the use of alcohol and recreational drugs around water activities are therefore likely to reduce the rate of adolescent drownings (108, 109). From early adolescence onwards, preventive interventions for drowning should increase a person’s cognitive skills around water. These skills include: – better recognition of hazards; – recognition of personal limits, including knowledge of one’s swimming ability; – the ability to resist peer pressure to take part in activities for which skills are lacking. Such interventions, though, have not been properly developed or tested. For children and adolescents, a particular problem is to provide safe sites for swimming that are also attractive. To this end, trained and equipped lifeguards need to be present at places and at times that adolescents are most likely to congregate. In rural areas, safe settings for swimming need to be made available. Otherwise, children and adolescents are likely to gather at unsafe places such as irrigation ditches, quarries and other open water sites. evaluated. What constitutes adequate adult supervision for bathing and water safety has only recently been studied. Those who supervise children in and around water should receive appropriate training in rescue and resuscitation skills. Infants and other children who lack mobility require continuous supervision on the site while in the bath. The age up to which children need such supervision has not been determined but is likely to extend to at least five years. Beyond this age, reported drownings in a bath are almost always related to seizures (62). For children and adolescents with epilepsy, being in a bath poses the highest risk for unintentional death. Children with epilepsy should therefore always use a shower rather than a bath and adhere strictly to other seizure control measures (62). In some communities it is common to rely on other children of the same age or older to protect a young child. In the case of drowning, such a form of care appears to provide insufficient protection. A historical review of drowning in Australia found that throughout the 19th and 20th centuries many child drowning deaths occurred in the company of other children (81). Because drowning happens rapidly, companions are often unable to rescue the drowning child and may themselves drown in the process. Managing drowning Drowning injuries arise because a person cannot adequately breathe and obtain oxygen. Even if a person is quickly retrieved from the water while drowning, they may have stopped breathing, and suffer brain damage as a result of a lack of oxygen. A secondary prevention strategy, therefore, for all age groups, is training in resuscitation techniques. The strongest predictor of outcome following drowning is the mental status of the person being rescued (110). Support from bystanders Studies have shown that children who receive immediate resuscitation from bystanders – before the arrival of medical personnel – have improved outcomes (111, 112). Attempts by bystanders to provide “mouth-to-mouth” resuscitation to the child may stimulate the return of the child’s spontaneous breathing. If the child does not begin to breathe, providing such resuscitation is critical for survival. Advanced life support provided by medical personnel may save a child who has deteriorated to a state of cardiac arrest. However, even in high-income countries WORLD REPORT ON CHILD INJURY PREVENTION 71
Slide 91: with local paediatric intensive care facilities, the window of opportunity for intervention is at the scene of the drowning (113, 114). Psychosocial support Coping with a sudden unexpected death, such as occurs with drowning, is always difficult. When the person in question is a child, the loss is generally even more devastating and one over which the parents frequently experience feelings of guilt. Childhood death is also stressful for health care providers. There needs to be greater support for families in which a childhood drowning has occurred, as well as for the health care providers. Greater attention should also be devoted to the long-term care of children who have become neurologically damaged through drowning (78). effectiveness. Many interventions still require rigorous evaluation. Above all, the debate around whether children under the age of five years should be taught to swim needs to be resolved, so that an unequivocal message can be given to parents. Research is also needed as to why pool fencing laws do not live up to expectations, including an examination of both the knowledge of users as well as their attitude to newer fencing. For young children, close supervision is a vital strategy for prevention. Such supervision includes safe play areas for children which have been proposed but not evaluated (118). What qualifies as “adequate” supervision, though, needs defining and evaluating. Conclusions and recommendations Drowning is a public health issue calling for worldwide attention. Recent community-based surveys indicate that the problem of drowning is likely to be much greater than present global estimates would suggest. This relatively neglected injury problem should be given a much higher priority by policy-makers and donors. In 1997, drowning was described as “the fi nal frontier of injury prevention” (119), because of the scarcity of evidence for the effectiveness of intervention strategies. Since that time, though, a certain amount of progress has been made. Th is chapter has described the many effective and promising interventions now available to reduce childhood drowning (see Table 3.4). More scientific investigation, though, is still required to identify significant risk and protective factors in drowning. Adapting interventions To maximize their effectiveness, prevention strategies and measures against drowning should be appropriate to the child’s developmental stage. While a barrier, for example, might be effective in preventing drowning in young children, this measure is not in general likely to keep older children and adolescents from accessing water. The cultural acceptability to children and parents of possible interventions also needs to be borne in mind. Affordability and availability are further factors that may determine whether interventions are implemented. Fencing works well for swimming pools, for instance, but it may not be the solution in regions where canals and irrigation ditches are ubiquitous. As another examples, items such as personal flotation devices may not be locally available. Measures to overcome this obstacle include the setting up of local loan schemes for such devices. Recommendations An agenda to address drowning, with targets appropriate to the local situation, should be set up by every country. Because of the high rates of drowning fatalities, the main focus needs to be on primary prevention strategies. Partnerships between governments, communities, industry, private sector bodies and public health agencies should be created to address drowning. While the type of strategies to prevent drowning and treat children and adolescents will vary greatly between countries and regions, cooperative efforts at every level – including at the global level – are essential. To enable countries to compare data and share experiences and intervention strategies more effectively (120), the following need to be done: – the collection of consistent epidemiologic data; – the use of standard definitions; – the use of coding schemes. Further research to evaluate protective factors is urgently called for, using large intervention trials, examining the effect of measures such as providing instruction in swimming and survival skills. The design and evaluation of interventions in specific settings needs ongoing research. Potentially harmful interventions Baby bath seats and flexible solar pool covers are not designed to prevent drowning, though they are sometimes used for that purpose. Several small studies have documented drowning among infants who were left unattended in a baby bath seat (115, 116). While in most cases it was not the bath seat itself that was unsafe, its use tended to make parents feel more comfortable about leaving their young child unattended. Similarly, flexible solar pool covers do not prevent drowning from occurring. There have been cases where unsupervised children drowned, having become trapped in them or hidden from view (117). More rigid, heavier devices may offer protection, though these have not been tested for effectiveness and are considerably more expensive, although they are sometimes used on public swimming pools. Further research on interventions For all interventions to prevent drowning, accurate and comprehensive data are vital for evaluating their 72 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 92: TABLE 3.4 Evidence for key strategies to prevent drowning among children Insufficient evidence Potentially harmful Brussels, Strategy Removing (or covering) water hazards Requiring isolation fencing (4-sided) around swimming pools Wearing personal flotation devices Ensuring immediate resuscitation Ensuring the presence of lifeguards at swimming areas Conducting targeted awareness-raising on drowning Teaching children older than 5 years to swim Introducing laws on pool fencing Introducing a law on the use of personal flotation devices Promoting drowning prevention through doctors Restricting access to areas unsafe for swimming Teaching children younger than 5 years to swim Introducing laws on blood alcohol content for swimmers Conducting prevention campaigns, such as on advertising hoardings, for drowning Promoting solar pool coversa Using baby bath seatsa a These are not primarily designed as drowning prevention interventions. Source: references 121, 122. Proven interventions should be implemented where their relevance has been demonstrated. These include: – the elimination of water hazards; – the creation of barriers between children and hazards; – the use by children of personal flotation devices. Immediate resuscitation, prior to the arrival of paramedical personnel, should be promoted everywhere. Such resuscitation significantly increases the likelihood of a good outcome – irrespective of age, gender, duration of submersion or the presence of hypothermia. References 1. Idris AH et al. Recommended guideline for uniform reporting of data from drowning: the “Utstein style”. Resuscitation, 2003, 59:45–57. Van Beeck EF et al. A new defi nition of drowning: towards documentation and prevention of a global public health problem. Bulletin of the World Health Organization, 2005, 83:853–856. Cass DT, Ross F, Lam LT. Childhood drowning in New South Wales 1990–1995: a population-based study. The Medical Journal of Australia, 1996, 165:610–612. Brenner RA, Smith GS, Overpeck MD. Divergent trends in childhood drowning rates, 1971 through 1988. Journal of the American Medical Association, 1994, 271:1606–1608. World Drowning Report, 2007 edition. International Lifesaving Federation, 2007. 2. 3. 4. 5. “Considering that drowing is the second leading cause of unintentional injury death worldwide and the single leading cause of child death (including disease) in some countries, the focus this critical report brings to the problem and viable preventive measures is immensely valuable. Now comes the time for action.” Alan Whelpton, World President, International Wife Saving Federation. 6. Linnan M et al. Child mortality and injury in Asia: survey results and evidence. Florence, UNICEF Innocenti Research Centre, 2007 (http://www.unicef-irc.org/ publications/pdf/iwp_2007_06.pdf, accessed 21 January 2008). (Innocenti Working Paper 2007-06, Special Series on Child Injury No. 3). WORLD REPORT ON CHILD INJURY PREVENTION 73 Ineffective Promising Effective
Slide 93: 7. Rahman A et al. Bangladesh health and injury survey: report on children. Dhaka, Government of the People’s Republic of Bangladesh, ICMH, UNICEF and TASC, 2005. Sitthi-amorn C et al. Child injury in Thailand: a report on the Thai National Injury Survey. Bangkok, Institute of Health Research, 2006. Rahman A et al. Drowning – a major but neglected child health problem in rural Bangladesh: implications for low income countries. International Journal of Injury Control and Safety Promotion, 2006, 13:101–105. Jing RW et al., eds. Beijing injury survey, child injury report. Beijing, Chinese Field Epidemiology Training Program, China Centers for Disease Control, 2004. Yang L et al. Epidemiological profi le of mortality due to injuries in three cities in the Guangxi Province, China. Accident Analysis and Prevention, 2005, 37:137–141. Ahmed MK, Rahman M, Ginneken JV. Epidemiology of child deaths due to drowning in Matlab, Bangladesh. International Journal of Epidemiology, 1999, 28:306–311. Brenner R. Prevention of drowning in infants, children, and adolescents. Pediatrics, 2003, 112:440–445. Annual Statistics Book. Beijing, Ministry of Health, 2001. Zhang P, Chen R, Deng J. [A prospective study on accidental deaths among 0–14 year old children in Jiangsu, 1994–1995] (article in Chinese). Zhonghua Liuxingbingxue Zazhi, 1998, 19:290–293. Afogamentos [Drownings]. São Paulo, Criança Segura Brasil (http://www.criancasegura.org.br/dados_acidentes_afogamentos.asp, accessed 20 April 2008). WHO mortality database: tables. Geneva, World Health Organization (http://www.who.int/healthinfo/ morttables/en/index.html, accessed 21 April 2008). Matzopoulos R, ed. A profile of fatal injuries in South Africa: third annual report of the National Mortality Surveillance System. Cape Town, Medical Research Council, 2001 (http://www.sahealthinfo.org/violence/ nimssannual2001.htm, accessed 20 April 2008). Brenner, RA et al. Where children drown, United States, 1995. Pediatrics, 2001, 108:85–89. Hyder AA et al. Childhood drowning in low- and middleincome countries: Urgent need for intervention trials. Journal of Paediatrics and Child Health, 2008, 44:221– 227. Present P. Child drowning study. A report on the epidemiology of drowning in residential pools to children under age five. Washington, DC, United States Consumer Product Safety Commission, 1987. Silbert J et al. Preventing deaths by drowning in children in the United Kingdom: have we made progress in 10 years? Population based incidence study. British Medical Journal, 2002, 324:1070–1071. 23. 24. Meyer RJ, Theodorou AA, Berg RA. Childhood drowning. Pediatrics in Review, 2006, 27:163–169. Kobusingye O, Guwatudde D, Lett R. Injury patterns in rural and urban Uganda. Injury Prevention, 2001, 7:46– 50. Polinder S et al. Prevalence and prognostic factors of disability after childhood injury. Pediatrics, 2005,116:e810–e817. Kreisfeld R, Henley G. Deaths and hospitalizations due to drowning, Australia 1999–2000 to 2003–2004. Adelaide, Australian Institute for Health and Welfare, 2008 (Deaths and Hospitalisations Injury Research and Statistics Series, No. 39). Kemp AM, Sibert JR. Outcome in children who nearly drown: a British Isles study. British Medical Journal, 1991, 302:931–933. Kibel SM et al. Childhood near-drowning: a 12-year retrospective review. South African Medical Journal, 1990, 78:418–421. Susiva C, Boonrong T. Near-drowning in Pediatric Respiratory Intensive Care Unit, Siriraj Hospital. Journal of the Medical Association of Thailand, 2005, 88(Suppl. 8):S44–S47. Van Beeck EF et al. Guidelines for the conduction of follow-up studies measuring injury-related disability. Journal of Trauma, 2007, 62:534–550. Lam LT et al. Different quantitative measures of the impact of injury deaths on the community in the Guangxi Province, China. Accident Analysis and Prevention, 2005, 37:761–766. Lindqvist KS, Brodin H. One-year economic consequences of accidents in a Swedish municipality. Accident Analysis and Prevention, 1996, 28:209–219. Thanh NX et al. The economic burden of unintentional injuries: a community-based cost analysis in Bavi, Vietnam. Scandinavian Journal of Public Health, 2003, 62(Suppl.):S45–S51. Corso P et al. Incidence and lifetime costs of injuries in the United States. Injury Prevention, 2006, 12:212–218. Meerding WJ, Mulder S, van Beeck EF. Incidence and costs of injuries in the Netherlands. European Journal of Public Health, 2006, 16:272–278. Ellis AA, Trent RB. Hospitalizations for near drowning in California: incidence and costs. American Journal of Public Health, 1995, 85:1115–1118. Joseph MM, King WD. Epidemiology of hospitalization for near-drowning. Southern Medical Journal, 1998, 91:253–255. Watson W, Ozanne-Smith J. The cost of injury to Victoria. Clayton, Monash University, 1997 (Monash University Accident Research Centre Report 124). Peden M, McGee K. The epidemiology of drowning worldwide. Injury Control and Safety Promotion, 2003, 10:195–199. 8. 25. 9. 26. 10. 27. 11. 28. 12. 29. 13. 14. 15. 30. 31. 16. 32. 17. 33. 18. 34. 35. 19. 20. 36. 37. 21. 38. 22. 39. 74 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 94: 40. Smith GS. The global burden of drowning. In: Bierens JJLM, ed. Handbook on drowning; prevention, rescue, treatment. Germany, Springer-Verlag, 2006:56–61. Quan L, Cummings P. Characteristics of drowning by different age groups. Injury Prevention, 2003, 9:163–168. Smith GS, Langley JD. Drowning surveillance: how well do E codes identify submersion fatalities. Injury Prevention, 1998, 4:135–139. Blum C, Shield J. Toddler drowning in domestic swimming pools. Injury Prevention, 2000, 6:288–290. Agran PF et al. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics, 2003, 111:e683–e692. Rowntree G. Accidents among children under two years of age in Great Britian. Injury Prevention, 1998, 4:69–76. Yang L et al. Risk factors for childhood drowning in rural regions of a developing country: a case–control study. Injury Prevention, 2007, 13:178–182. Howland J et al. Why are most drowning victims men? Sex differences in aquatic skills and behaviours. American Journal of Public Health, 1996, 86:93–96. Rahman A et al. Pattern and determinants of child deaths due to drowning in rural Bangladesh [Published abstract]. In: Proceedings of the 6th World Conference on Injury Control and Prevention, Montreal, Canada, 12–15 May 2002. Montreal, University of Montreal Press, 2002:477– 478. Kobusingye OC. The global burden of drowning: an African perspective. In: Bierens JJLM, ed. Handbook on drowning: prevention, rescue and treatment. Germany, Springer-Verlag, 2006:61–62. Wintemute GJ et al. Alcohol and drowning: an analysis of contributing factors and a discussion of criteria for case selection. Accident Analysis and Prevention, 1990, 22:291– 296. Recommendations: World Congress on Drowning, Amsterdam, Netherlands, 26–28 June 2002. Amsterdam, World Congress on Drowning, 2002. (http://www. drowning.nl/pdf/Recommendations.pdf, accessed 20 April 2008). Morgan D, Ozanne-Smith J, Triggs T. Measurement by direct observation of drowning risk exposure for surf beach bathers. Journal of Science and Medicine in Sport, 2008 (in press). Morgan D, Ozanne-Smith J, Triggs T. Self reported water and drowning risk exposure at surf beaches. Australian and New Zealand Journal of Public Health (in press). Celis, A. Home drowning among preschool age Mexican children. Injury Prevention, 1997, 3:252–256. Fang Y et al. Child drowning deaths in Xiamen city and suburbs, People’s Republic of China. Injury Prevention, 2007, 13:339–343. 56. Karr CJ, Rivara FP, Cummings P. Severe injury among Hispanic and non-Hispanic children in Washington state. Public Health Reports, 2005, 120:19–24. Stirbu I et al. Injury mortality among ethnic minority groups in the Netherlands. Journal of Epidemiology and Community Health, 2006, 60:249–255. Saluja G et al. Swimming pool drownings among US residents aged 5–24 years: understanding racial/ethnic disparities. American Journal of Public Health, 2006, 96:728–733. Mael FA. Staying afloat: within-group swimming proficiency for Whites and Blacks. Journal of Applied Psychology, 1995, 80:479–490. Besag FMC. Tonic seizures are a particular risk factor for drowning in people with epilepsy. British Medical Journal, 2001, 321:975–976. Nei M, Bagla R. Seizure-related injury and death. Current Neurology and Neuroscience Reports, 2007, 7:335–341. Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics, 1993, 91:612– 616. Jansson B, Ahmed N. Epilepsy and injury mortality in Sweden–the importance of changes in coding practice. Seizure, 2002, 11:361–370. Shavelle RM, Strauss DJ, Pickett J. Causes of death in autism. Journal of Autism and Developmental Disorders, 2001, 31:569–576. Ackerman MJ et al. A novel mutation in KVLQT1 is the molecular basis of inherited long QT syndrome in a near-drowning patient’s family. Pediatric Research, 1998, 44:148–153. Boating Statistics – 2005. United States Coast Guard, Department of Homeland Security, 2006 (http://www. uscgboating.org/statistics/Boating_Statistics_2005.pdf, accessed 21 April 2008). Life jackets and life preservers. Chicago, IL, American Academy of Pediatrics (http://www.aap.org/family/ tippslip.htm, accessed 23 April 2008). Howland J, Hingson R. Alcohol as a risk factor for drownings: A review of the literature (1950–1985). Accident Analysis and Prevention, 1988, 20:19–25. Smith GS, Kraus JF. Alcohol and residential, recreational, and occupational injuries: a review of the epidemiologic evidence. Annual Reviews of Public Health, 1988, 9:99– 121. Smith GS, Brenner RA. The changing risks of drowning for adolescents in the US and effective control strategies. Adolescent Medicine, 1995, 6:153–170. Hyder AA et al. Death from drowning: defining a new challenge for child survival in Bangladesh. Injury Control and Safety Promotion, 2003, 10:205–210. Drownings and other water-related injuries in Canada 1991–2000. Ottawa, Canadian Red Cross, 2003 (http:// WORLD REPORT ON CHILD INJURY PREVENTION 75 41. 42. 57. 58. 43. 44. 59. 60. 45. 46. 61. 62. 47. 63. 48. 64. 65. 49. 66. 50. 67. 51. 68. 52. 69. 53. 70. 54. 55. 71. 72.
Slide 95: www.redcross.ca/cmslib/general/10drwn_english.pdf, accessed 20 April 2008). 73. Mitchell RJ et al. Farm-related fatalities involving children in Australia, 1989–1992. Australian and New Zealand Journal of Public Health, 2001, 25:307–314. Tsunami disaster: UN relief efforts. UNICEF, 2004 (http:// w w w.un.org/events/UNART/tsunami_disaster.pdf, accessed 20 April 2008). Mackie IJ. Patterns of drowning in Australia, 1992–1997. Medical Journal of Australia, 1999, 171:587–590. Morgan D, Ozanne-Smith J, Triggs T. Descriptive epidemiology of drowning deaths in a surf beach swimmer and surfer population. Injury Prevention, 2008, 14:62–65. Lunetta P et al. How well does a national newspaper reporting system profi le drowning? International Journal of Injury Control and Safety Promotion, 2006, 13:35–41. Bierens JJLM, ed. Handbook on drowning. Germany, Springer-Verlag, 2006. DeNicola LK et al. Submersion injuries in children and adults. Critical Care Clinics, 1997, 13:477–502. Causey AL, Tilelli JA, Swanson ME. Predicting discharge in uncomplicated near-drowning. American Journal of Emergency Medicine, 1995, 18:9–11. Staines C, Ozanne-Smith J, Davison G. Child and early adolescent drowning in developing communities: Victoria, a case study. Melbourne, Monash University Accident Research Centre, 2008. Pitt WR, Cass DT. Preventing children drowning in Australia. Medical Journal of Australia, 2001, 175:603– 604. Pitt WR, Balanda KP. Toddler drowning in domestic swimming pools in Queensland since uniform fencing requirements. Medical Journal of Australia, 1998, 169:557– 558. Fergusson DM, Horwood LJ. Risks of drowning in fenced and unfenced domestic swimming pools. New Zealand Journal of Medicine, 1984, 97:777–779. Stevenson MR et al. Childhood drowning: barriers surrounding private swimming pools. Pediatrics, 2003, 111:E115–E119. Logan P et al. Childhood drowning and fencing of outdoor pools in the United States, 1994. Pediatrics, 1998, 101:E3. Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database of Systematic Reviews, 2000, (2):CD001047. Morgenstern H, Bingham T, Reza A. Effects of pool-fencing ordinances and other factors on childhood drowning in Los Angeles County, 1990–1994. American Journal of Public Health, 2000, 90:595–601. Fergusson DM, Horwood LJ, Shannon FT. The safety standards of domestic swimming pools 1980–1982. New Zealand Medical Journal, 1983, 96:93–95. 90. Morrison L et al. Achieving compliance with pool fencing legislation in New Zealand: a survey of regulatory authorities. Injury Prevention, 1999, 5:114–118. Personal flotation devices. Seattle, WA, Harborview Injury Prevention and Research Center (http://depts.washington. edu/hiprc/practices/topic/drowning/f lotation.html, accessed 20 April 2008). O’Connor P. National assessment of boating fatalities in Australia 1992–1998. Rozelle, NSW, National Marine Safety Committee, 2004 (http://www.nmsc.gov.au/ documents/Fatal%20Report_screen.pdf, accessed 29 January 2007). Treser CD, Trusty MN, Yang PP. Personal floatation device usage: do educational efforts have an impact? Journal of Public Health Policy, 1997, 18:346–356. Bennett E et al. Evaluation of a drowning prevention campaign in King County, Washington. Injury Prevention, 1999, 5:109–113. Cassell E et al. Evaluation of the effectiveness of the 2005 Victorian personal flotation device (PFD) wear regulations: a pre- and post-observational study (Report to Marine Safety Victoria). Melbourne, MUARC, 2007. Howland J et al. Did changes in minimum age drinking laws affect adolescent drowning (1970–90)? Injury Prevention, 1998, 4:288–291. Brenner RA et al. The association between swimming lessons and drowning in childhood: a case-control study. Archives of Pediatrics and Adolescent Medicine, (in press). Asher KN et al. Water safety training as a potential means of reducing risk of young children’s drowning. Injury Prevention, 1995, 1:228–233. Smith GS, Howland JH. Declines in drowning: exploring the epidemiology of favorable trends. Journal of the American Medical Association, 1999, 281:2245–2247. 91. 74. 92. 75. 76. 93. 77. 94. 78. 79. 80. 95. 96. 81. 97. 82. 98. 83. 99. 84. 100. Ozanne-Smith J, Wigglesworth E, Staines C. Swimming instruction and drowning [Abstract]. In: World Congress on Drowning, Amsterdam, 26–28 June 2002. Amsterdam, Consumer Safety Institute, 2002. 101. Manolios N, Mackie I. Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10-year study, 1973–1983. Medical Journal of Australia, 1988, 148:170–171. 102. Fenner PJ et al. Success of surf lifesaving resuscitations in Queensland, 1973–1992. Medical Journal of Australia, 1985, 164:580–583. 103. Branche CM, Stewart S, eds. Lifeguard effectiveness: a report of the working group. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2001 (http://www.cdc. gov/ncipc/lifeguard/08_economic_costs.htm, accessed 19 April 2008). 104. Schwebel DC, Simpson J, Lindsay S. Ecology of drowning risk at a public swimming pool. Journal of Safety Research, 2007, 38:367–372. 85. 86. 87. 88. 89. 76 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 96: 105. Quan L et al. Beliefs and practices to prevent drowning among Vietnamese-American adolescents. Injury Prevention, 2006, 12:427–429. 106. Lee LK, Thompson KM. Parental survey of beliefs and practices about bathing and water safety and their children: guidance for drowning prevention. Accident Analysis and Prevention, 2007, 39:58–62. 107. Moran K, Stanley T. Parental perceptions of toddler water safety, swimming ability and swimming lessons. International Journal of Injury Control and Safety Promotion, 2006, 13:139–143. 108. Lunetta P, Penttilä A, Sarna S. Water traffic accidents, drowning and alcohol in Finland, 1969–1995. International Journal of Epidemiology, 1998, 27:1038–1043. 109. Cummings P, Quan L. Trends in unintentional drowning: the role of alcohol and medical care. Journal of the American Medical Association, 1999, 281:2198–2202. 110. Graf WD et al. Predicting outcome in pediatric submersion victims. Annals of Emergency Medicine, 1995, 26:312–319. 111. Kyriacou DN et al. Effect of immediate resuscitation on children with submersion injury. Pediatrics, 1994, 94:137– 142. 112. Wigginton J. The key role of layperson actions in drowning incidents. In: World Congress on Drowning, Amsterdam, 26– 28 June 2002. Amsterdam, Consumer Safety Institute, 2002. 113. Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics, 1992, 90:909–913. 114. Suominen et al. Does water temperature affect outcome of nearly drowned children. Resuscitation, 1997, 35:111–115. 115. Byard RW, Donald T. Infant bath seats, drowning and near-drowning. Journal of Paediatrics and Child Health, 2004, 40:305–307. 116. Rauchschwalbe R, Brenner RA, Smith GS. The role of bathtub seats and rings in infant drowning deaths. Pediatrics, 1997, 100:E1. 117. Sulkes SB, van der Jagt EW. Solar pool blankets: another water hazard. Pediatrics, 1990, 85:1114–1117. 118. Bugeja L, Franklin R. Drowning deaths of zero- to five-year-old children in Victorian dams, 1989–2001. Australian Journal of Rural Health, 2005, 13:300–308. 119. Pless IB. The challenge of drowning prevention. Injury Prevention, 1997, 3:237–238. 120. Passmore JW, Smith JO, Clapperton A. True burden of drowning: compiling data to meet the new defi nition. International Journal of Injury Control and Safety Promotion, 2007, 14:1–3. 121. Quan L, Bennett EE, Branche CM. Interventions to prevent drowning. In: Doll LS et al., eds. Handbook of injury and violence prevention. Atlanta, GA, Springer, 2007:81–96. 122. Norton R et al. Unintentional injuries. In: Jamison DT et al., eds. Disease control priorities in developing countries (2nd edition). New York, Oxford University Press and the World Bank, 2006:737–753 (http://www.dcp2.org/pubs/ DCP/39/, accessed 14 February 2008). WORLD REPORT ON CHILD INJURY PREVENTION 77
Slide 97: © Children of Fire Five years ago, when he was 13 years o old, Vusi suffered serious burns. He woke up one night to find his blanket and bedroom ablaze from a candle that had fallen over. The flames injured his face, hands and feet. VUSI’S STORY After many months in hospital, he left wearing a brown elasticized pressure garment around his face and hands so that his scars would not become thick and raised, as often happens. From the start, Vusi was very sensitive about his appearance. People on the streets and at school used to tease him about the mask-like pressure garment, comparing him to a masked television entertainer. The long hospital stay and the psychological stress led to problems at school and his education was delayed. Despite all he went through, though, Vusi has become a charming, friendly person with an engaging smile. He loves music and voluntarily spends time with blind children and others with disabilities, encouraging them to exercise more. Africa’s first burns charity, “Children of Fire”, has, for the past twelve years, been helping severely burned children to obtain complex surgery, therapy and education. They now also work on community safety, teaching those at risk how to prevent fire burns, as well as imparting first aid and fire-fighting skills. The organization also helps inventors of safer paraffin or biofuel stoves to publicize their inventions more widely, and in a similar way promotes the use of safer candlesticks. In June 2007, 15 teenaged burns survivors, along with other young volunteers, climbed Mount Kilimanjaro in a campaign to raise awareness of burn injuries and how to prevent them, and to increase tolerance of disability and disfigurement. Vusi was one of those who climbed to above 5000 metres and 12 others reached the summit. Adapted from the Children of Fire web site (http://www.firechildren.org, accessed 9 June 2008). BURNS
Slide 98: CHAPTER 4 – BURNS Chapter 4 Burns Introduction Children are naturally curious. As soon as they are mobile, they begin to explore their surroundings and play with new objects. In this way, they acquire the skills they need to survive in the world. At the same time, though, they come into contact with objects that can cause severe injuries. Playing with fire or touching hot objects can result in burns. This is a debilitating condition accompanied by intense pain and often by longer-term illness that creates suffering not only for the child but for the wider family and community. Fortunately, the prevention, acute care and rehabilitation of burns have improved greatly over the past few decades. There is now ample evidence that a number of measures are effective in preventing burns. These include the introduction and enforcement of items such as smoke alarms, residential sprinklers and fire-safe lighters, and laws regulating the temperature of hot-water taps. Nonetheless, considerable disparities exist between countries in the extent of their prevention, care and rehabilitation of burns. This chapter describes what is currently known about childhood burns and how to prevent and manage them. In doing so, it summarizes the epidemiology of burns in children and the risk factors and discusses in detail both proven and promising interventions. The chapter concludes with a set of recommended interventions and a description of areas where further research is required. For the purpose of this chapter, a burn is defined as an injury to the skin or other organic tissue caused by thermal trauma. It occurs when some or all of the cells in the skin or other tissues are destroyed by hot liquids (scalds), hot solids (contact burns), or flames (flame burns). Injuries to the skin or other organic tissues due to radiation, radioactivity, electricity, friction or contact with chemicals are also considered as burns (1). Burns may be distinguished and classified by their mechanism or cause, the degree or depth of the burn, the area of body surface that is burned, the region or part of the body affected, as well as the extent. Box 4.1 summarizes three of the most commonly used classifications. burn) or to brief contact with hot substances, liquids or flash flames (scalds). First-degree burns heal within a week with no permanent changes in skin colour, texture, or thickness. Second-degree or partial-thickness burns result when damage to the skin extends beneath the epidermis into the dermis. The damage does not, however, lead to the destruction of all elements of the skin. – Superficial second-degree burns are those that take less than three weeks to heal. – Deep second-degree burns take more than three weeks to close and are likely to form hypertrophic scars. Third-degree or full-thickness burns are those where there is damage to all epidermal elements – including epidermis, dermis, subcutaneous tissue layer and deep hair follicles. As a result of the extensive destruction of the skin layers, third-degree burn wounds cannot regenerate themselves without grafting. In adults, a full-thickness burn will occur within 60 seconds if the skin is exposed to hot water at a temperature of 53° C (4). If, though, the temperature is increased to 61° C, then only 5 seconds are needed for such a burn. In children, burns occur in around a quarter to a half of the time needed for an adult to burn. Classification by extent of burn The extent of burn, clinically referred to as the total body surface area burned, is defined as the proportion of the body burned (5). Several methods are used to determine this measurement, the most common being the so-called “rule of nines”. This method assigns 9% to the head and neck region, 9% to each arm (including the hand), 18% to each leg (including the foot) and 18% to each side of the trunk (back, chest and abdomen). The “rule of nines” is used for adults and children older than 10 years, while the Lund and Browder Chart is used for children younger than 10 years (6). The calculation assumes that the size of a child’s palm is roughly 1% of the total body surface area (7). BOX 4.1 Classification of burns There are several ways of classifying burns. The following are three commonly used typologies, based respectively on the cause, extent and severity of the burn. Classification by mechanism or cause Causally, burns may be classified as thermal or inhalational. Thermal burns involve the skin and may present as: – scalds – caused by hot liquid or steam; – contact burns – caused by hot solids or items such as hot pressing irons and cooking utensils, as well as lighted cigarettes; – flame burns – caused by flames or incandescent fires, such as those started by lighted cigarettes, candles, lamps or stoves; – chemical burns – caused by exposure to reactive chemical substances such as strong acids or alkalis; – electrical burns – caused by an electrical current passing from an electrical outlet, cord or appliance through the body. Inhalational burns are the result of breathing in superheated gases, steam, hot liquids or noxious products of incomplete combustion. They cause thermal or chemical injury to the airways and lungs (2) and accompany a skin burn in approximately 20% to 35% of cases. Inhalational burns are the most common cause of death among people suffering fire-related burn (3). Classification by the degree and depth of a burn Burns may also be classified by depth or thickness: First-degree or superficial burns are defined as burns to the epidermis that result in a simple inflammatory response. They are typically caused by exposure of the unprotected skin to solar radiation (sun- WORLD REPORT ON CHILD INJURY PREVENTION 79
Slide 99: Epidemiology of burns According to the WHO Global Burden of Disease estimates for 2004, just over 310 000 people died as a result of firerelated burns, of whom 30% were under the age of 20 years (see Statistical Annex, Table A.1). Fire-related burns are the 11th leading cause of death for children between the ages of 1 and 9 years. Overall, children are at high risk for death from burns, with a global rate of 3.9 deaths per 100 000 population. Among all people globally, infants have the highest death rates from burns. The rate then slowly declines with age, but increases again in elderly adults. The long-term consequences and the disability that can result from burns place a considerable strain on individuals and their families, as well as on health-care facilities. According to WHO data, approximately 10% of all unintentional injury deaths are due to fire-related burns (see Statistical Annex Table A.1). In addition, fire-related burns are among the leading causes of disability-adjusted life years (DALYs) lost in low-income and middle-income countries (see Statistical Annex A.2). Mortality Globally, nearly 96 000 children under the age of 20 years were estimated to have been fatally injured as a result of a fire-related burn in 2004. The death rate in low-income and middle-income countries was eleven times higher than that in high-income countries, 4.3 per 100 000 as against 0.4 per 100 000 (see Statistical Annex, Table A.1). However, as can be seen in Figure 4.1, burn-related deaths show great regional variability. Most of the deaths occur in poorer regions of the world – among the WHO regions of Africa and South-East Asia, and the low-income and middle-income countries of the Eastern Mediterranean Region. The death rates in the Americas and the highincome countries of the Europe and the Western Pacific regions are among the lowest in the world. Every year 70 Member States – mainly middle-income and high-income countries –submit to WHO mortality data that include the fourth digit of the International Classification of Disease codes, which allows disaggregation into subtypes of burns. Analysis of these data show that, in 2002, fire-related burns made up 93.0% of all burn deaths, scalds contributed 5.4% and the rest, 1.6%, were as a result of contact, chemical or electrical burns (8). Studies from high-income countries suggest that smoke inhalation is the strongest determinant of mortality from burns, mostly from house fires or other conflagrations. For children over three years of age, smoke inhalation is strongly associated with mortality, despite improvements in the care of burns (9). FIGURE 4.1 Mortality rates due to fire-related burns per 100 000 childrena by WHO region and country income level, 2004 4+ 0.5–3.9 <0.5 No data Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific LMIC 8.7 HIC 0.7 LMIC 0.6 LMIC 6.1 HIC 0.2 LMIC 1.1 HIC 0.4 LMIC 4.7 HIC 0.3 LMIC 0.6 These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. a 80 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 100: Age Figure 4.2 shows child death rates from burns by age group. Infants have the highest rates, while those aged between 10 and 14 years have the lowest rates. The death rate climbs again in the 15–19-year age range, possibly as a result of greater exposure, experimentation and risk-taking, as well as the fact that many in that group are beginning employment. FIGURE 4.2 Morbidity Global data on non-fatal outcomes from burns is not readily available. However, the WHO Global Burden of Disease project for 2004 makes it clear that burns are an important contributor to the overall disease toll in children in the low-income and middle-income countries of the African, South-East Asia and the Eastern Mediterranean regions (see Statistical Annex, Table A.2). While burns from fire contribute to the majority of burnrelated deaths in children, scalds and contact burns are an important factor in overall morbidity from burns and a significant cause of disability. Chemical and electrical burns among children, though, are relatively rare (10–12). Fatal fire-related burn rates per 100 000 children by age and country income level, World, 2004 12 Rate per 100 000 population HIC 10 8 6 4 2 0 Under 1 1–4 5–9 10–14 15–19 LMIC Age In high-income countries, children under the age of five years old are at the highest risk of hospitalization from burns, although 15–19-year-olds, as already stated, are also a group at high risk. Nearly 75% of burns in young children are from hot liquid, hot tap water or steam. Infants under the age of one year are still at significant risk for burns, even in developed countries. The burns they suffer are most commonly the result of scalds from cups containing hot drinks or contact burns from radiators or hot-water pipes (13). The following give an indication of the situation in some high-income countries: In Canada, in a single year, there were over 6000 visits to emergency departments in the province of Ontario (whose population is about 12 million) due to burns (14). Almost half the cases of burns are among children under five years of age (15). In Finland, an 11-year study found that scalds were responsible for 42.2% of children being admitted to two paediatric burns units. Among children under three years of age, 100% of burns were the result of hot water. In the 11–16-year group, 50% of burns were due to electricity, with the other 50% resulting from fire and flames (16). In Kuwait, the incidence of burns in children under 15 years of age was 17.5 per 100 000 population. Scalds (67%), followed by flames (23%), were the leading causes of burns (17). In the United States, one of the leading causes of injury from scalding in children is hot soup, particularly prepackaged instant soup (18). In low-income and middle-income countries, children under the age of five years have been shown to have a disproportionately higher rate of burns than is the case in high-income countries. In Kenya, for example, 48.6% of children presenting to the Kenyatta National Hospital were under the age of five years. Although scalds were the most common type of burn, those caused by open flames were also prominent (19). Other examples from low-income WORLD REPORT ON CHILD INJURY PREVENTION 81 under 20 Age (years) HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. Gender Burns are the only type of unintentional injury where females have a higher rate of injury than males. The firerelated death rate for girls is 4.9 per 100 000 population, as against 3.0 per 100 000 for boys. The difference is particularly pronounced in infants and also in adolescents between the ages of 15 and 19 years (see Figure 4.3). The greatest gender discrepancies are found in the WHO South-East Asia Region and in the low-income and middle-income countries of the Eastern Mediterranean Region. In these regions, girls in the 15–19-year age bracket have death rates that are substantially higher than rates for the same age group in any other region (see Statistical Annex, Table A.1). FIGURE 4.3 Fatal fire-related burn rates per 100 000 children by age and sex, World, 2004 14 Rate per 100 000 population 12 10 8 6 4 2 0 Under 1 1–4 5–9 Age (years) Boys Girls 10–14 15–19 Source: WHO (2008), Global Burden of Disease: 2004 update.
Slide 101: and middle-income countries show rather different age patterns and leading causes. In Shandong Province, China, a 5-year review of data from the burns unit revealed that children under the age of 10 years were admitted in the greatest numbers, followed by adults aged between 20 and 30 years. Scalds and fire-related burns were seen in roughly similar numbers (20). Burns from boiling liquids, most frequently water boiled for bathing, were among the leading causes of injuries to children under the age of 10 years in Cuernavaca, Mexico (21). In Maiduguri, north-east Nigeria, the commonest cause of burns was scalds (64.4%). Children under the age of three years were disproportionately represented (22). In Brazil, Côte d’Ivoire and India, infants account for nearly half of all childhood burns (23–25). In Fars Province in the Islamic Republic of Iran, the annual hospitalization rate for children under 15 years was 11.8 per 100 000 population. Scalds accounted for 46.2% of the burns, whereas flames accounted for 42.8%. Most burns occurred at home (26). Similar results have been found in a recent study in four low-income countries. In this study, 53% of burns in children under 12 years of age were the result of a hot liquid, followed by fire and flame in 19% of cases and electricity in 14% of cases (see Statistical Annex, Table C.1). Infants in Africa under one year of age have an annual incidence of fire-related burns of 35 per 100 000 – more than three times the world average for this age group (27). Gender The gender distribution of non-fatal burns differs between countries – a fact that may be related to cultural practices, particularly with regard to cooking. Some African and Asian countries – including Angola, Bangladesh, China, Côte d’Ivoire, Kenya and Nigeria – report a higher number of cases among males (19, 20, 22, 24, 28, 29). Others, such as Egypt and India, have a greater proportion among girls, particularly teenage girls (30–32). The increasing proportion of burn injuries recorded in girls as they grow older might be explained by the changing activities of the two genders. While girls are increasingly involved in the kitchen, helping their mothers – and therefore more exposed to fire, and hot liquids and other substances – boys tend to stay more outdoors (see Box 4.2). In some cultures, “bride burning” is still practised and may be linked to a higher incidence of burns in adolescent females (33). BOX 4.2 Burns to young working females in work and home settings Burns are the leading cause of deaths from injury in many developing countries. Work-related burn injuries are relatively rare in children. Nonetheless, they are an important public health problem for young people employed in the catering industry and children working in residential kitchens. Work-related childhood burn injuries – in whatever setting – often go unreported, especially in developing countries, either because safety regulations are not being enforced, or because of a lack of regulation and supervision. Three types of workplaces are typically involved in employmentrelated burn injuries in children. Catering and restaurant industry: The most common sources of burn injuries in restaurants and kitchens are cooking oils, hot water, steam and heating equipment. A study in the state of Washington, United States for the period 1989–1993, found that 2076 workers under 18 years of age suffered burn injuries, representing 7.6% of all work-related burn injuries. The most common sector in which they occurred was the food services industry. Young people working in fast-food outlets and restaurants made up 62% of these cases – as against only 32% of burn injuries in 125 other occupations combined (34). Similar findings for the state were also found for the period 1994–1998 (35). Other industrial settings, including metal industries: Children have the lowest rates of burns in large-scale industrial settings, presumably because they are generally unsuitable for this work and therefore have little exposure to its risks. Where they are involved and suffer burns, though, their burns are on the whole more severe than in other settings. In both industrial settings and in food services, males are more affected than females by burns. House kitchens: Unlike the situation in other workplace settings, employment-related injuries in house kitchens principally involve girls. Girls working as house maids are generally responsible for cooking as well as other household tasks. They often work without contracts and may be deprived of legal support. Due to their young age, they are on average less skilful and more prone to burns than adults. In addition, their work conditions are frequently unsafe. Some young females are employed in households that are not their own, while others are obliged to work in their home as family members. The flammable and loose clothing often worn by young women in developing countries further increases the risk of burn injuries (36). In the Islamic Republic of Iran, burn injuries are the most common unintentional home-related injury (37). Iranian injury registry databases show that during the period 1999–2001, 58% of all reported burn injuries were in children. In the Ardabil province of Iran, a recent study found that 65% of children suffering burns in the kitchen were girls, and that girls aged 16–17 years were three times as likely to be burned in the kitchen as were boys. The study also found that children younger than 12 years were having to help in cooking-related work in kitchens, with an average starting age of 8 years (see Table). Children helping in household kitchen jobs, Ardabil province, Islamic Republic of Iran, 2006 Kitchen jobs Cooking Preparing tea Carrying hot food Lighting the oven Proportion of children helping in kitchen (%) 21.2 37.2 37.5 24.0 Mean age of starting to help in kitchen (years) 8.7 8.0 7.9 – 82 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 102: Location Most studies suggest that burns in children occur most frequently in the home, or else – among older children – in the workplace. A study in four low-income countries found that 65% of childhood burns had occurred in and around the home (Statistical Annex, Table C.1). The kitchen is usually the most common part of the house. In this room, children may upset receptacles with hot liquids, be injured by exploding stoves, stand on hot coals or be splashed with hot cooking oil. Most burns occur in urban areas. Those burns that take place in rural areas with inadequate prehospital care, though, can lead to greater volumes of illness and disabilities. attention should also be paid to managing pain as well as psychological issues such as anxiety, post-traumatic stress, phobias and isolation (43, 44). The most common physical long-term consequences following a burn include hypertrophic scarring, extensive contractures, the formation of keloids and the need to amputate an extremity (43). Hypertrophic scarring in particular has been found to be one of the most significant long-term consequences of childhood burns, occurring in almost half of severe cases (45). Keloid formation is relatively more common among children of African descent (46). “My worst experience took place on a crowded bus. Other passengers kept looking at me so I took my jacket off and covered my head. I just wanted to be invisible and I wanted them all to disappear too.” (Michael, aged 17, Changing Faces – a United Kingdom nongovernmental organization for people with disfigurements) Nature and severity of burns Few empirical studies have described burn injuries by the body part affected. Among those that have, though, the most common sites are reported to be the following: – from scalds: the trunk and upper extremities (24, 38); – from flame-related burns: the lower extremities (38, 39); – from contact burns: the hands (40); – from electrical burns: there may be little external evidence of the burn but extensive internal damage. Small children who bite or suck on extension cords can burn their mouth and lips. Such burns may cause cosmetic deformities and impair growth of the teeth, mandibles and maxilla (41). – from chemical burns: the site depends on whether the chemical is ingested, splashed or inhaled. The total surface area of the body that is affected depends on the cause of burn, the mechanism of injury and the age of the child. In general, scalds and contact burns are less severe than fire-related burns. Lung damage, as a result of inhalation injuries, is the most frequent cause of death and is largely unpreventable (42). The outcome following a burn depends on a number of interrelated factors. These include: – the child’s age; – the body part affected; – the proportion of body surface area burned; – the length of time from injury to care; – the type of care applied – such as dressings or debridement (the removal of damaged tissue from a wound); – post-burn complications. Burns to the face resulting in gross disfiguration can lead to poor self-esteem in children and adolescents (47). Children suffering burns when they are young, though, appear to be very resilient, adapting to their disfiguration with greater ease than those similarly affected during adolescence. A recent study from India showed that only adolescents in the study required psychosocial rehabilitation (48). As one of the factors in the child’s long-term social adjustment is that of self-esteem (49), social support networks may help the process. This is the case not only for the child, but also for parents, and in particular mothers, who often experience post-traumatic stress disorder after their child has suffered a large burn (50, 51). Nongovernmental organizations can play an important role in providing such support. So can “burn camps” for children, that were first set up in 1983 (52). Siblings of a child who has suffered burns should also be taken into consideration, as overprotecting the child can have an adverse behavioural impact on other children in the family (53). Consequences of non-fatal burns The study already mentioned that was conducted in four low-income countries found that the average injury severity score for children who had been burned was 5. In addition, 49% of affected children suffered some form of disability after a burn, with 8% being left with a permanent physical disability (see Table 1.5 in Chapter 1). There were similar results in Bangladesh, where a communitybased survey revealed an annual disability rate of 5.7 per 100 000 children as a result of burns (29). Burns can result in significant long-term consequences which – in the absence of a comprehensive and coordinated rehabilitation programme – can leave children scarred, physically and psychologically, for the rest of their lives. Most rehabilitation programmes seek to prevent longterm problems – such as scarring, contractures and other physical problems that limit functioning. However, Impact on families and communities Evaluating the cost of burns and their treatment is difficult. It is certain, though, that burns create a heavy economic WORLD REPORT ON CHILD INJURY PREVENTION 83
Slide 103: load on health-care services. A study of hospitalizations in Bangkok, for example, found that the cost of burn injuries was not sufficiently reimbursed to the hospitals. As a result, the hospitals had to divert resources from other areas of care (54). The cost of treating burns is dependent on the type and severity of the burn. In the United Kingdom, a recent study found the average cost of an uncomplicated minor paediatric scald to be £1850 (US$ 3618) (55). Another study from the United States found that the cost of hospitalizations from burns ranged from US$ 1187 for scalds to US$ 4102 for those resulting from fires (56). In addition there are also costs to the families of children associated with hospitalization, the need for long-term rehabilitation, lost school days and education, possible future unemployment, social rejection and other psychosocial issues (51, 57). The potential to reduce individual and societal costs by carrying out effective burn prevention interventions is huge. A recent study in Ontario, Canada (58), for instance, found that – through a combination of educational and legislative measures – preventing scald burns could save 531 Canadian dollars (US$ 507) per scald. children, the data still underestimate the total number of burns cases. This could be rectified if more countries submitted data that included the 4th digit of the ICD coding. While there is no global morbidity database, there now exist many studies from both high-income and lowincome countries on the epidemiology and risk factors for burns. Using these hospital-based studies researchers have tried to estimate the global extent of non-fatal burns. However, these attempts have been hampered by the lack of population-based information and also by the differing definitions of the age range of childhood (59). Risk factors Various studies, using descriptive and case-control designs, have found a range of risk factors for childhood burns. However, because of the way in which burns are coded in many countries, it is often impossible to distinguish between the different mechanisms that lead to burns. For example, the risk factors for burns caused by chemical agents, and the population most frequently affected by such burns, are both very different from the risk factors for and populations affected by scalds from boiling fluids. Thus, while the existing data identify children and young people as a high-risk population for burns, information on mechanisms and causal factors is largely missing. This section makes use of the Haddon matrix (60) to highlight the child, agent and environmental risk factors. Some risk factors are applicable, of course, only to certain types of burns (see Table 4.1). Limitations of data There are wide differences between countries in data on childhood burns – as regards their availability, quality and reliability. The WHO Global Burden of Disease project data used in this chapter relies only on fire-related burns. Although these account for nearly 97% of fatal burns in TABLE 4.1 Haddon Matrix applied to the risk factors for fire-related burns among children Phases Pre-event Factors Child Developmental issues, including experimentation; gender; vulnerability – including disabled children, refugees, street children; lack of supervision; parents smoking in the home or in bed; lack of knowledge about risks of fire in the home. Unmaintained smoke alarms and sprinkler systems; child not wearing flame-retardant clothing; poor knowledge about evacuation procedures. Inaccessible first-aid kits; lack of knowledge by caregivers and community about what to do immediately after a burn. Agent Storage of flammable substances in the house; combustibles, matches or lighters accessible to children; unsafe stoves or lamps; fireworks. Physical environment Housing in slums or congested areas; overcrowded households; no separation between cooking area and other areas; absence of flame-retardant household materials. Lack of functioning smoke alarms; lack of clear and easily accessible escape routes; lack of access to telephone to call for help. Poor emergency or fire department response time; poor rescue and treatment skills; lack of access to water; inability to transport to medical care promptly. Socioeconomic environment Poverty; unemployment, illiteracy among parents; sibling who died of burns; lack of fire-related building codes and their enforcement; lack of policies or laws on smoke alarms, sprinkler systems, access to hydrants; lack of policies or laws on flammability standards. Poor access to information and resources to minimize risk; inadequate communications infrastructure for calling emergency health services. Inadequate burns care; inadequate access to burn centres and rehabilitation services; insufficient community support for those who have suffered burns. Event Lack of sprinkler systems; lack of fire hydrants or other access to a supply of water. Flammability of household materials and children’s clothing; toxicity of smoke and burning household materials. Post-event 84 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 104: Child-related factors Age and development Burns in very young children often occur from a mixture of curiosity and awkwardness. In children under the age of four years, the level of motor development does not match the child’s cognitive and intellectual development and injuries can thus occur more easily (61). Infants under the age of one year are in a particular category, as their mobility starts to develop and they reach out to touch objects (13). Consequently, burns to the palms of the hands are particularly common, as a result of touching heaters or hot-water pipes. Because a child has thinner skin on the palms and slower withdrawal reflexes, such contact burns may be deep and thus require prolonged and careful therapy during the healing phase to prevent flexure contractures of the hand (40). Scald burns are the most frequent type of burn among children under the age of six years – an observation that appears to cut across geographic and economic groups. Typical scald burns occur when a child pulls down a container of hot fluid, such as a cup of coffee, onto his or her face, upper extremities and trunk. These are typically superficial second-degree burns. Apart from the pain they cause the child and the distress for the parents, these burns will typically heal within weeks, leaving little or no permanent damage. As children grow older, they become less likely to be injured by common household objects and more interested in the world outside. There is then an increased likelihood that they will be involved in serious fires. In particular, boys older than 6 or 8 years of age often become curious about fire, leading to experimentation with matches, lighters or fireworks. In some cases, younger siblings are injured while watching the experimentation of an older brother or sister (62). a result of the more inquisitive nature of boys and their greater risk-taking behaviours (63, 64). Local customs of using open fires for cooking and heating, together with the wearing of loose-fitting clothing, particularly among teenage girls in the South-East Asia and Eastern Mediterranean regions (30), are associated with an increased rate of burns among young women (1). Vulnerability Some children are more vulnerable to burns than others. Disabled children have a significantly higher incidence of burn injuries than non-disabled children (65). Although not specific to children, those who suffer from uncontrolled epilepsy appear to be at greater risk for burn injuries. Such injuries are often severe enough to require admission to hospital (66). Other vulnerable groups – such as children of asylum seekers (67), those living in high-income countries but born to foreign parents (68), as well as children in rural areas distant from medical care – have higher incidences of burns and of their consequences (69). Among street children, there have been numerous journalistic reports, though few scientific studies, on how they may be burned while sleeping in derelict buildings, underground sewers or close to open fires. Apart from the danger from flames, the inhalation of hydrocarbons or the sniffing of glue among street children can lead to burns of the trachea (70). Studies have also found that the children of parents who smoke while in bed are at higher risk of burns than those who do not have parents who smoke (71). Poverty Mortality and morbidity from burns are strongly associated with poverty. In addition to the markedly higher incidence of burns among children in low-income and middle-income countries, there are also differences by socioeconomic class within high-income countries, with studies from Sweden and the United Kingdom showing an increased risk of burns among poorer children (72, 73). In Sweden, the relative risk of being hospitalized for a burn was 2.3 times higher for children in the poorest socioeconomic group than among those in the most prosperous group. Furthermore, within Gender As already mentioned, burns are the only type of fatal injury that occurs more frequently among girls than boys in three WHO regions (see Table 4.2). For non-fatal burns, the pattern is not quite as clear, and in some settings boys may be at a greater risk of burns than girls, perhaps as TABLE 4.2 Fatal fire-related burn rates per 100 000 childrena by sex, WHO region and country income level, World, 2004 Africa LMIC Boys Girls 8.9 8.5 0.7 0.6 Americas HIC LMIC 0.7 0.6 South- East Asia LMIC 3.3 9.1 Europe HIC 0.2 0.2 LMIC 1.3 1.0 Eastern Mediterranean HIC 0.6 0.1 LMIC 3.6 5.8 Western Pacific HIC 0.3 0.3 LMIC 0.4 0.8 a These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. WORLD REPORT ON CHILD INJURY PREVENTION 85
Slide 105: the poorest group, the risk for burns was greater than for any other childhood injury (73). In Australia, too, the risk of fire-related burns and scalds requiring a hospital stay was found by one study to increase as income decreases (74). This finding was confirmed by a systematic review of the risk factors for injury in a house fire. The review found that those in the lowest quintile of income were 2.4 times more likely to die in a house fire than those in the highest two income quintiles (71). Environmental factors Cooking and living areas The overwhelming majority of childhood burns occur in the home, and in particular in the kitchen. It has been suggested that the location within the home of the heating equipment and the structure of the kitchen may present significant risks to children (86). In South Africa, for example, many homes consist of one or two main rooms, that are divided by temporary internal divisions made of curtains or cardboard. These rooms are utilized for functions such as sleeping, washing, cooking and eating, depending on the time of day and the requirements of the family (86, 87), or else as a work space (88). This type of domestic arrangement may greatly increase the exposure of a child to domestic equipment and sources of heat (89, 90). Agent factors Unsafe equipment Heat, light sources and cooking equipment – especially those relying on fossil fuels – all carry inherent risks (75). In particular, heating or cooking on open fires that are not enclosed or that stand at ground level pose significant dangers to children. There are similar dangers in the use of small kerosene stoves or lanterns, candles for lighting, and other volatile or highly flammable fuels within the house (75–78). Easy access for children to cooking appliances or pots with boiling liquids is a further risk factor for burns (76, 79, 80). Unsafe electrical appliances, plugs, wires and other connections all increase the risk of electrical burns for children (21, 80). Socioeconomic environment A number of case-control and descriptive studies conducted in different parts of the world have identified several socioeconomic factors that increase the risk of childhood burns (74, 75, 77, 79, 91–93). These factors include: – a low rate of literacy within the family; – living in overcrowded dwellings or with cluttered areas in the home; – a failure of proper supervision of children; – a history of burns among siblings; – the absence of laws and regulations relating to building codes, smoke detectors and flammable clothing. Flammable substances Flammable substances such as kerosene and paraffi n should not be stored in the house. However, for practical reasons, they are not usually stored in this way. Apart from the obvious danger of fire, they are also a poisoning risk for small children, being frequently kept in containers lacking child-resistant closures (see Chapter 6). Time of incident Two peak times of the day have been reported for incidents involving burns – the late morning, when domestic tasks are being done, and around the time for the evening meal (29, 94). There have also been peaks noted, in some regions of the world, by season of the year. In tropical climates, where heating, even in winter, is not generally required, there is a fairly even distribution of cases of burns throughout the year (28, 38). In places where the winters are cold, though, an increased incidence of burns tends to be recorded during winter (94–97). The association, in many countries, of incidence of burns with public or religious holidays has already been noted. Fireworks Many countries celebrate religious or national festivals by setting off fireworks and many burn injuries regularly occur around these holidays (75, 81, 82). Fireworks pose a significant risk for children, particularly adolescent boys. In Greece, 70% of firework burn injuries recorded by the country’s injury surveillance system involved boys aged 10 to 14 years, usually as a result of setting off the fireworks themselves. Girls who were injured by fireworks were usually bystanders (81). In Australia, 50% of those injured by fireworks were boys under 18 years of age (83). Fireworks have been banned in many high-income countries unless they are safely set off by professionals as part of a public display. In most low-income and middleincome countries, there are no laws restricting the use of fireworks. However, in some countries that ban the private use of fireworks, injuries from them nevertheless occur, usually in adolescent males (62, 83, 84). In the state of Minnesota in the United States, after a law banning private fireworks had been repealed, there was an increase in the number of children suffering burns (85). 86 WORLD REPORT ON CHILD INJURY PREVENTION Lack of access to water Inadequate access to a good supply of water – in the form of a tap, hosepipe or sprinkler system – to douse flames or stop the flames spreading, is a strong risk factor (74). Similarly, a lack of smoke detectors or the presence of non-functioning smoke detectors appears to be related, in some developed countries, to an increased risk for childhood burns (98). Protective factors Several protective factors have been shown to reduce the risk of burns or to minimize their consequences (74, 75, 77, 99), including:
Slide 106: – literacy, particularly among mothers; – knowledge of the risk of burns and of health-care services; – ownership of the house; – having living rooms separate from the kitchen; – the use of fire-retardant fabrics for clothes; – the installation of smoke detectors and water sprinklers; – appropriate first-aid and emergency response systems; – the existence of good quality health-care services. of burns, in particular first aid, and the value of dedicated trauma centres and of proper rehabilitation are discussed in a separate section. Engineering measures Safer lamps and stoves In many low-income and middle-income countries, the lamps and stoves for lighting and heating use fossil fuels. These lamps and stoves are commonly linked to childhood burns. Developing safe stoves and moving them out of doors and off the ground would not only reduce the number of burns sustained by children but also reduce their exposure to indoor fumes. A trial in rural Guatemala of an improved wooden stove produced a decrease in both acute lower respiratory infections and fi re-related burns. Rigorous evaluation of this trial is still in progress (100). In Sri Lanka, an intervention using safe lamps for lighting is being implemented (see Box 4.3). Although this project too is awaiting evaluation, the initial results appear promising. Interventions This section summarizes some of the interventions to prevent various types of burn injuries among children. The main protective factors for burns are briefly listed, and three broad approaches for prevention are described, namely: – engineering, design and environmental measures; – the introduction of legislation and standards; – educational measures. A fourth, and effective, approach consists of a combination of the three earlier ones. The management BOX 4.3 Cheap and safe alternatives to traditional paraffin lamps Paraffin oil (also known as kerosene) is a flammable fuel, used widely in some countries for lamps. According to the World Bank Global Data Monitoring Information System1, only 29% of households in sub-Saharan Africa are electrified, while in most countries in South Asia two out of three houses have electricity. While there are efforts in all these countries to provide more homes with electricity, progress is often slow. The global use of paraffin is therefore likely to continue for many years. At the same time, there is an urgent need for cheap and safe paraffin lamps. A properly designed paraffin lamp it is not by itself unsafe for use in the home, even though it carries a flame. Like the kitchen knife, it is safe if well-designed and used with the proper basic safeguards. Unfortunately, paraffi n lamps designed with safety in mind are relatively expensive. Around the world, millions of families use makeshift paraffin lamps that are very cheap – but unsafe. Poverty is the main factor here, though ignorance of the fact that their lamps pose a serious danger also plays a part. In Mozambique, people use a lamp known as a xiphefo, consisting of a tall bottle with a wick-carrier placed on its top. In Sri Lanka, some lamps are made out of discarded medicine bottles, while others are burnt-out light bulbs fitted with a wire frame and metal base. Both types are light in weight and could easily topple, igniting the clothes of a child sitting or sleeping nearby. People in these places have been accustomed to their traditional lamps from childhood. Marketing a safe alternative that is radically different would be difficult to accomplish. A strong promotional campaign on safety is therefore needed. People should be told how to use paraffin lamps safely, and, among other things: – not to add paraffin to burning lamps; – not to place lamps at the edge of a table or other raised surface; – not to hang the lamps on walls; – not to use containers for paraffin that previously contained petrol. The unsafe, makeshift lamps that are used by poor people cost very little. Therefore any alternative that is proposed has to be as cheap as possible. There are two options. The first is the use of a safer oil, in place of the paraffi n in the existing lamps. Vegetable oils such as those of coconut, sesame, neem and mustard are safe, but their disadvantage is that they do not rise in the wick-carrier. The second option is for a lamp that is safe, even with paraffin. Such a lamp is, in fact, currently being marketed in Sri Lanka to good effect. Its principal features are: It is short and heavy, so that it does not easily tip over. It has two flat sides, so that even if it tipped over, it would not roll. It has a screw-on metal lid, to prevent oil spilling if it tips over. Its design is simple and it can be mass-produced at low cost. It has a near-globular shape and is made of thick glass, so that it does not crack if it falls. There are no delicate or moving parts, so that it can be used for several years. The use of such a lamp, with appropriate basic care being exercised, could prevent the many paraffin burns that occur around the world each year, though its efficacy has yet to be subjected to rigorous evaluation. 1 Available at web site: http://ddp-ext.worldbank.org/ext/GMIS/gdmis.do?siteId=1&menuId=IDA14RMS10 WORLD REPORT ON CHILD INJURY PREVENTION 87
Slide 107: Families in many developing countries will continue to use fossil fuels for heating and cooking, until such time as the cost of electricity and of essential electrical appliances becomes affordable (101). Environmental measures Promising environment modifications that may reduce the incidence of burns include, among others: – introducing new or stricter building codes and standards; – modifying or improving construction materials; – improving heating and lighting equipment in homes; – raising cooking facilities off the ground; – separating cooking areas from living areas. Unfortunately, although promising, such prevention measures have not been well evaluated, particularly in low-income and middle-income countries. A Cochrane review of interventions that altered the home environment to reduce all types of injury, including burns, concluded that there is still insufficient evidence to determine their effectiveness (109). Smoke alarms Evidence for the effectiveness of interventions exists most markedly in the case of smoke detectors, which have been found to reduce the risk of deaths by over 70% (102). The problem, though, is to make sure that all homes have working smoke alarms on all levels of the residence, including in the sleeping areas. People often remove the batteries from their smoke detectors to avoid the nuisance of false alarms, or else do not check the batteries regularly. For optimum protection, most smoke detectors require that they be tested monthly and that their battery be changed twice a year. However, there are new devices, which – while more expensive – make use of a 10-year battery. Fully integrated, hard-wired smoke alarms often now come with the new types of residential construction, at least in some developed countries. A systematic review of controlled trials of interventions promoting smoke alarms found that approaches that used only education produced only modest benefits. Programmes that provided and installed smoke alarms appeared to reduce fire-related injuries (103). However, programmes that combined legislation on smoke alarms with installation and education seemed to result in the greatest benefit (104). A study in the United States (105) evaluated the costeffectiveness of smoke detectors and found the ratio of the cost of detectors to the saving in health-care costs to be 1:26. Laws and regulations Laws and regulations are one of the most efficient ways to get people to adopt safe behaviours. In addition to legislation enforcing smoke detectors, which has proven effective in many high-income countries, three other measures appear to be effective – laws on the temperature of hot-water taps, banning fireworks and standards for child-resistant lighters. Temperature of hot-water taps Interventions to prevent scald burns focus primarily on education together with laws and their enforcement regulating the temperature of hot water from household taps (110). In the United States, the control of hot-water temperature in taps in the state of Washington reduced the number of domestic hot-water scalds by combining an educational programme with laws cutting the temperature in preset water heaters from 60°C to 49°C (111, 112). As a result, 84% of homes changed to lower temperature. Other educational interventions in Norway (113) and New Zealand (114) aimed at reducing the hot-water temperature were also successful in reducing burns. A Canadian study evaluated the effectiveness of a combined educational and legislative approach to reduce thermostat settings and found a 56% reduction in scald burns (58). Residential sprinklers Fire sprinkler systems have been proved to be effective (106) and can now be found widely in public and commercial property in many countries. Home sprinkler systems, on the other hand, are recommended but not widely used, though in some countries governments require them to be installed in the construction of new homes. Fire-retardant household materials Modifying products associated with fire-related burns is a promising approach. Following the introduction in Australia of fire-retardant material for children’s bedclothes in 1979, the annual number of burns related to clothing dropped from around 300 to 30 (107). In the United States, children’s bedclothes are regulated by the United States Product Safety Commission. Certain types and sizes of clothes need to pass a flammability test or else be tight-fitting, so as to reduce the risk of burns (108). In addition, many countries require that bedding, mattresses and upholstered furniture be fireretardant. 88 WORLD REPORT ON CHILD INJURY PREVENTION Child-resistant lighters A survey in the United States in 1985 showed that children playing with lighters were the cause of residential fires resulting in 170 deaths and 1150 injuries annually in the country (115). As a result, the United States Consumer Product Safety Commission developed a standard for cigarette lighters that applied to all products manufactured or imported into the country. A study after this standard was introduced found that fires, deaths and injuries caused by young children playing with lighters had been reduced by as much as 58%, saving over half a billion US dollars in
Slide 108: societal costs in 1998 alone (116). Other countries followed the United States example. In 2007, the European Union introduced laws requiring manufacturers and importers to comply with the European standard for child-resistant lighters (117). Although child-resistant lighters are not a substitute for parental supervision, considerable savings to the health sector and society could be made if all countries adopted similar standards. BOX 4.4 “Hot water burns like fire” In 1992, the Australian state of New South Wales launched the country’s first state-wide prevention campaign for scalds in children, entitled “Hot Water Burns Like Fire”. This followed a report on injuries in emergency departments that showed scalds as the fourth-leading cause of hospitalization among young children. The main agents of scalds identified were: hot tap water, hot beverages, kettles and saucepans. As a result of this campaign, the whole of Australia now has laws mandating a maximum temperature of 50° C for hot water taps in bathrooms – for new installations fitted and old ones that are replaced. The first phase of the campaign aimed to raise awareness about the causes of scalds to children, the most serious and preventable one being hot tap water. This phase involved community heath-care staff, health promotion personnel, retailers, plumbers and the members of the hot-water heating industry. The second phase, beginning in 1994, focused on how to modify temperatures of hot-water taps in bathrooms. Following meetings involving experts in infection control and manufacturers of hot-water heating, an amendment to the national standards on hot water delivery for personal purposes was introduced. Each state was then obliged to change its plumbing code so that the delivery of hot water in homes was capped at 50° C. This involved the use of a temperature testing card and a brochure with instructions on how to test and modify the temperature. Between 1989 and 1996, the rate of hospitalizations for scalds involving young children aged 0–4 years fell by 13%. In the same period, the duration length of hospital stay dropped by 18%. The combined effect of the reduced number and severity of cases resulted in a net 27% fall in the total number of hospital beds utilized. Rates for the most serious scalds (involving a stay of 10 days or more) showed the greatest decline – a reduction of 30% for the two years following the second stage of the campaign. In all, there was an annual saving to the health care system of between 3.8 and 6.5 million Australian dollars, based on an average cost of treating a serious scald. Banning of fireworks Many high-income countries have banned firework purchase or ownership by children. A recent review in the United Kingdom revealed that since the introduction of the Fireworks Act in 2003 and the Fireworks regulation in 2004 which limited the sale of fireworks to the three weeks surrounding Bonfire Night, and banned the sale or possession of fireworks by under 18 year olds, more than 80% of children’s firework injuries were seen in the three weeks surrounding Bonfire Night. They concluded that the law had a definite impact on reducing non-Bonfire related firework injuries, but that stricter enforcement was required (118). Educational approaches Increased knowledge about burns among young children has been shown to result from educational programmes in schools and communities (119). It is unclear, though, whether these programmes have any effect in reducing the incidence of burns, as they lack a rigorous evaluation of the long-term outcomes of burn injuries (120). Community programmes to ensure good supervision of children, particularly those with disabilities, to educate parents about burns and to advise against the storage of flammable substances in the home, have all been proposed as primary prevention strategies for burns (92). A programme in Bangladesh involves children being placed in nurseries for a number of hours each day. The purpose is to give the mothers free time for their domestic tasks, so that they can be more attentive when the children return home. The programme has yet to be evaluated for its effectiveness in preventing burns or drowning. Educating parents about the use of safety equipment has been shown to result in increased knowledge, but again it has not been possible so far to demonstrate that as a result there is better use of such equipment (121, 122). The effectiveness of home visitation programmes is similarly uncertain. In general, educational programmes appear more successful when coupled with increasing access to safety products or with changes in the law. Combined strategies Strategies which combine legislation and standards, product modification and education appear to have the most far-reaching effects in reducing the incidence of burns (see Box 4.4). © K McGee WORLD REPORT ON CHILD INJURY PREVENTION 89
Slide 109: Managing burns Access to treatment and rehabilitation Although the care of burns depends largely on the availability of financial and human resources, many countries still manage to deliver good quality care despite limited health budgets. A number of cheaper options for burns management are currently being evaluated. These include: – open, as against closed techniques to manage wounds (123); – less costly grafting techniques (124). In addition, practical guides for managing paediatric burns are being promoted in developing countries (125). In many places the cost of treatment is high and only those who are well-off can afford to take their children to hospital (38). This can result in delayed healing, contractures and superimposed infections. Families frequently resort to using traditional methods of healing before attempting to access modern medicine, because of the difficulty of accessing such health care (27, 126). The remainder had either received no first aid or else inappropriate treatment – such as raw eggs, toothpaste, mashed potato or oil being rubbed into the burn (32). In Viet Nam, a study compared children who had received immediate cooling with water after a burn with those who had not. It turned out that those who had received proper first aid needed 32% less subsequent graft ing (128). Education on the effect of immediate application of cool (not ice cold) water to burns should be promoted widely as an effective first-aid treatment. Acute management of burns Medical care for burns has markedly improved survival. In the United States in 1940, 50% of children with burns involving 30% or more of their total body surface died. In 2000, a study in the same country found no deaths in children with burns involving as much as 59% of body surface area (129). In Pakistan, on the other hand, burns of over 40% in children are still often fatal (see Box 4.5). Once a child suffering burns has been transported to an acute care facility, assessment and stabilization initially focus on a survey of airway, breathing and circulation. There should also be a careful examination of the child from head to toe, looking for other signs of trauma. Children with second-degree burns usually present with intense pain and typically hold the affected limbs immobile in a position of comfort. The site of the burn should immediately be assessed to determine its severity. Pain management in such cases is essential. For reasons that are not yet understood, when the size of a burn exceeds 15% to 20% of body surface area of the affected child, the inflammatory response extends beyond the local site of injury. Blood pressure becomes dangerously low, and if fluids are not given fast enough, the child will go into shock and die. If the child does survive the first 48 hours, there is still a risk of death from infectious complications, since the barrier to bacteria is broken and the immune system suppressed. The overall aim of managing burn wounds is to close the wound as quickly as possible, either by allowing the First aid for burns Following a burn, the child should be stabilized before being transported to hospital. This is usually done by family, bystanders or first responders and should follow the basic rules of what should and should not be done in these circumstances (see Table 4.3). The overall aim must be to cool the burn, prevent ongoing burning and prevent contamination. There are many studies assessing the first aid of burns in high-income countries, and from these, examples of good practices – such as to “cool the burn” – are drawn. Cooling the burn surface is one of the oldest methods of treatment (127). However, only a handful of studies have examined burn interventions in low-income and middle-income countries. A survey in India found that only 22.8% of patients had received appropriate first aid for their burns. TABLE 4.3 First aid for burns What not to do Do not commence first aid before ensuring your own safety (switch off electrical current, wear gloves for chemicals, etc.). Do not apply paste, oil, kumkum (a paste made from turmeric) – or raw cotton to the burned area. Do not apply ice. Do not open the blisters with a needle or pin. Do not apply any material directly to the wound as it might become infected. Avoid application of topical medication until the patient has been placed under appropriate medical care. Source: reference 1. What to do Stop the burning process by removing clothing and irrigating the wounds. Apply cold water or allow the burnt area to remain in contact with cold water for some time. In flame injuries, extinguish the flames by allowing the patient to roll on the ground, or by applying a blanket, or using water or other fireextinguishing liquids. In chemical burns, remove or dilute the chemical agent by copiously irrigating the wound with water. Obtain medical care. 90 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 110: BOX 4.5 Managing burns in Pakistan Burns are one of the most neglected areas of health care in developing countries. These countries have 90% of global burn injuries, with 70% of these injuries occuring in children. While there have been major improvements in burn care in many high-income countries, making it quite possible for patients with burns of more than 90% of body surface area to survive, in countries such as Pakistan, burns of over 40% are frequently fatal. Even minor burns can lead to significant illness as a result of recurrent wound infections, delayed wound healing and the formation of contractures. There are various reasons for this poor outcome. Access to care may be impeded by difficult terrain, as well as by a lack of pre-hospital services and inefficient chains of referral. Even if the patient manages to reach a health-care facility, initial resuscitation procedures are frequently inadequate. Appropriate airway management, mechanical ventilation and aggressive fluid resuscitation are often not provided in the first few hours. Burn care has become highly specialized and is performed at dedicated centres. These specialized institutions not only provide comprehensive clinical care but also serve as important research centres. In several developed countries, burn centres have existed for more than 60 years. Today, the United States has 70 burn centres. In Pakistan, there are only eight specialized burns units for a population of 150 million people. Their standards of care vary considerably, depending on the workload, the availability of funding and the quality of management. There are no nationally-agreed standards or ways in which to enforce standards. In the whole of Pakistan, there are currently only 15 to 20 surgeons who are burn care specialists. The ability of health-care specialists to manage sepsis and inhalational injury often defines the eventual outcome in patients with burns. Managing sepsis requires meticulous aseptic wound treatment and surgical debridement, and the early recognition and aggressive treatment of sepsis and septic shock, as well as nutritional support. Similarly, inhalational injury often requires long periods of mechanical ventilation under the supervision of an experienced critical care worker. Burn care is also expensive. In Karachi, the daily average cost of treating a patient with a major burn of 25% or more of body surface area is around US$120, and a hospital stay can last as long as 8 to 10 weeks. The economics of burn care discourages the creation of burns centres in the private sector and fails to attract committed staff. skin to heal by secondary intention (allowing the wound to heal over on its own) or through surgical closure (graft ing). The management of small, deep second-degree burns has evolved into an efficient and effective plan of treatment that nowadays produces highly satisfactory cosmetic and functional results with minimal morbidity. The treatment plan has two components: excising the burn wound before suppuration occurs; and covering the excised wound with synthetic or biological wound coverings. However, large, deep second-degree or third-degree burns, particularly in children, continue to pose a significant problem for the burn surgeon. The surgical approach to early excision and grafting of burn wounds involves trained personnel and safe and effective resources. As removing the burn wound is a procedure associated with a high volume of blood loss, the operation cannot be performed unless there are facilities in the hospital to provide blood for transfusions. The management of children around the time of such an operation is very complicated and requires collaboration with experienced anaesthesiologists (125). The postoperative care of the grafted wounds and the areas from which skin has been taken for the grafts calls for a team of trained nurses and occupational and physical therapists. For these reasons, early excision and grafting may not be © A. Harry/AFRO an appropriate course to be taken in some low-income countries. Sadly, the usual fate of a child with an extensive thirddegree burn in a low-income country is death. The risk of mortality from burns covering over 30% of total body surface area is roughly 50%. The risk of burns covering more than 50% of total body surface area is nearly 100% (56). For those children who survive such severe burns, most are left with unsightly scarring, resulting in both physical and psychological disability. Dedicated trauma centres Not all children require treatment from a dedicated trauma centre. A large number of countries now have such centres and criteria exist for deciding which patients are transferred to them. The American College of Surgeons and the American Burn Association recommend that children with the following conditions should be treated in a burns centre (130): – partial thickness (second-degree) burns greater than 10% of the total surface area of the body; – burns involving the face, hands, feet, genitalia, perineum or major joints; – full-thickness (third-degree) burns; WORLD REPORT ON CHILD INJURY PREVENTION 91
Slide 111: – – – – electrical burns, including injuries from lightning; chemical burns; injuries from inhaling smoke; pre-existing medical disorders that could complicate the management of burns, prolong recovery or affect survival; – accompanying trauma, where the burn injury poses the greater risk of morbidity or mortality. While it is well established that trauma systems prevent unnecessary deaths in patients with blunt or penetrating injuries (131), there are few data to sustain this argument in the care of burn patients (132). Nonetheless, expert opinion supports the claim that patients with serious burns will have better outcomes and with less costly management if they are in a dedicated burn centre (133). Rehabilitation facilities Children who sustain burns deserve the best rehabilitation facilities available, so that they are able to return to productive and meaningful roles within their community. The requirements for rehabilitation should be discussed during the acute phase and should involve not only physical but also psychological therapy (see Box 4.6). Inadequate rehabilitation can result in physical and psychological damage with a serious lifelong effect. BOX 4.6 Rehabilitation for paediatric burn survivors in South Africa Burn injuries are tragic, largely preventable and frequently have lifelong consequences for the young patient. In South Africa these injuries are on the increase. This is due to factors such as poverty, illiteracy, a lack of resources, urban migration and the consequent rising number of makeshift housing settlements. New developments and improvements in burn care generally have led to increased survival rates and a fall in the death rate. However, paediatric burn survivors need more than excellence in wound care, surgery and nursing. They also require in-depth rehabilitation, consisting not only of physiotherapy and occupational therapy, but also of emotional support and reintegration into the community. An estimated 90% of children who have survived burns are not followed up. Once a child is discharged from hospital, the parents often do not recognize that follow-up rehabilitation or long-term reconstructive surgery may be needed. For those who do receive rehabilitation services, the emphasis is largely on physical rehabilitation, rather than emotional support and community reintegration. South Africa has an acute shortage of appropriately-trained professionals to provide for the complex rehabilitation needs of burn survivors. At Cape Town’s Red Cross Hospital burns unit, up to 96% of children admitted are from disadvantaged communities. A study at this hospital in the late 1970s found that up to 70% of severely burned children either attempted or actually committed suicide. In 2002, health professionals at the hospital set up a three-tiered pilot rehabilitation project for burned children and their families. The first phase of rehabilitation starts as soon as possible during the admission stage. At this point individual physiotherapy, occupational therapy and the management of pain is arranged. A community worker will also become involved, responsible for parental support during this first phase and for long-term follow-up of disfigured children during the final phase of rehabilitation. The Red Cross Hospital is unique in including touch therapies – such as reflexology and aromatherapy – in the management of burns, along with more traditional treatments such as music and art therapy. This holistic approach thus attempts to deal with stress and anxiety, as well as with the general emotional well-being of the child. The second phase is on an out-patient basis and continues what was started in the first phase. The previous therapies are again offered, along with such things as children’s yoga and creative play. The use of the African drum (jembe) has been found to be particularly successful in music therapy. The third and final phase of rehabilitation focuses mainly on community and school reintegration. Information is disseminated through the mass media on the situation of disfigured children and their needs. Teachers from 63 township schools have received training around the prevention of burns and the reintegration into the education system of children disfigured by burn injuries. Continuous education for children is the single most important outcome of their successful rehabilitation. Disfigured children are often reluctant to return to school for fear of being ostracized. If they stay uneducated they are more likely to be unemployable. In South Africa, this could lead to the child’s ending up on the streets or in prison. Through this programme, the Red Cross Hospital aims to provide for the emotional needs of children who have suffered burns and help them become fully reintegrated into society. For financial reasons, only the first phase of the three-phase programme is being offered at present. Community reintegration of burned children can be achieved, even in the developing world. However, this requires dedicated, trained staff and the substantial financial resources which are sadly lacking. 92 WORLD REPORT ON CHILD INJURY PREVENTION © R. Albertyn, RXH
Slide 112: Adapting interventions The extent to which interventions that work in one socioeconomic setting can be effectively transferred to another depends on several factors. The advantage of transferring an established intervention – if that is possible – is that resources are conserved. A decision, though, to implement a particular intervention measure in a particular place should always be based on solid scientific evidence, considerations of cost, cultural appropriateness and sustainability (134). modifications, parental education and product safety (see Table 4.4). Special attention needs to be paid to the kitchen, the scene of the majority of burns. Programmes are needed to ensure proper supervision of children and their general well-being, particularly of those with disabilities. Parents should receive better information about all types of burns. There must be much greater awareness everywhere about the dangers of storing flammable substances in the home. Recommendations A range of measures to prevent burns have been discussed in this chapter. Many of these still require rigorous evaluation, particularly in low-income and middle-income countries. Those prevention interventions that have proved effective include: – laws and enforcement for the installation of smoke alarms; – child-resistant lighter standards; – laws to regulate hot-water temperature. A number of other prevention interventions are considered highly promising. These include: – the use of safe lamps; – the separation of cooking areas from living areas; – the development of safer stoves. As regards measures taken after the event, two fire related measures are strongly recommended: – smoke alarms; – residential sprinkler system. The management of burns, from first aid to rehabilitation, is an essential component of secondary and tertiary prevention strategies. Children who suffer burns require the best care available so as to minimize the potentially serious physical and psychological longterm consequences of this type of injury. Educational programmes convey knowledge to children and parents. They are useful for creating a climate in which campaigns for changes in behaviour and in products will be supported. For prevention purposes, educational programmes are often combined with programmes involving legislation and standards and product modifications. Education and counselling on their own, though, whether at the individual level or within schools, appear to be ineffective in reducing the incidence of burns. “Thermal burns are a common cause of accidental death in children worldwide. Despite various methods of prevention and care, such injuries are on the rise. Only through a deeper understanding of the underlying causes can we develop truly viable alternative solutions. If the proposals outlined in this report are implemented correctly, they can bring about the necessary changes.” Mehmet Haberal, President, International Society for Burn Injuries. Potentially harmful interventions First-aid treatment for burn injuries is best accomplished with cool water (127, 135). Traditional treatments, though, continue to be practised. These include putting butter or oil on sunburn, and ice, aloe, sugar water, toothpaste or other household products on a second-degree burn. All these traditional practices can be harmful, as they can cause the skin to slough away, leaving the tender lower layers susceptible to infection. Although some agents – such as honey or commercially available cold packs – may indeed have some beneficial effects, they are better avoided. Instead, people should be advised to use only cool, clean water. Evaluating interventions A number of evaluation studies have been conducted in high-income countries. These include an economic analysis of 1990 that found that three quarters of childhood fi re-related deaths in the home could be prevented if there were working smoke alarms, sprinkler systems, anti-scald devices, slow-burning cigarettes and childproof lighters (136). There are no systematic evaluations, though, of burn prevention strategies in low-income and middle-income countries. Nevertheless, a number of interventions appear promising. Among them are: separating cooking areas from living areas; eliminating the storage of flammable substances in the house; placing cooking surfaces higher than ground level; introducing smoke alarms; making fi rst aid available; and increasing awareness about burns and their prevention (137). At the same time, others, such as community-based interventions and campaigns (138) and home visitation programmes for at-risk families (139), have insufficient evidence for them to be promoted as good practices. Further research in these areas is needed so that model intervention programmes can be developed for implementation in countries that share a similar pattern of childhood burns. Conclusions and recommendations There is overwhelming evidence that childhood burns are largely environmentally conditioned and preventable (93). It would therefore seem natural that the prevention of burns should focus on a mixture of environmental WORLD REPORT ON CHILD INJURY PREVENTION 93
Slide 113: TABLE 4.4 Key strategies to prevent burns among children Insufficient evidence Ineffective Promising Effective Harmful Strategy Setting (and enforcing) laws on smoke alarms Developing a standard for child-resistant lighters Setting (and enforcing) laws on hot-water tap temperature and educating the public Treating patients at dedicated burns centres Separating cooking areas from living areas Developing standards and codes for fire-retardant garments Banning the manufacture and sale of fireworks Promoting the use of safe lamps and stoves Providing first-aid for scalds – “cool the burn” Conducting home visitation programmes for at-risk families Installing residential sprinklers Distributing smoke alarms on their own (without accompanying laws) Conducting community-based campaigns and interventions Storing flammable substances correctly Modifying the environment, e.g. home alterations Conducting school-based burns prevention programmes Using traditional remedies on burns Source: references 120, 137, 138. References 1. Facts about injuries: burns. Geneva, World Health Organization and International Society for Burn Injuries, 2006 (http://www.who.int/entity/violence_injury_prevention/ publications/other_injury/en/burns_factsheet.pdf, accessed 17 April 2008). Davies JW. Toxic chemicals versus lung tissue: an aspect of inhalation injury revisited. Journal of Burn Care and Rehabilitation, 1986, 7:213–222. Saffle JR, Davis B, Williams P. Recent outcomes in the treatment of burn injury in the United States: a report from the American Burn Association patient registry. Journal of Burn Care and Rehabilitation, 1995, 16:219–232. Moritz AR, Henriques FC. Studies of thermal injury II: the relative importance of time and surface temperature in the causation of cutaneous burns. American Journal of Pathology, 1947, 23:695–720. Lund C, Browder N. The estimation of areas of burns. Surgical Gynecology and Obstetrics, 1944, 79:352–358. MacLennan N, Heimbach D, Cullen FB. Anesthesia for major thermal injury. Anesthesiology, 1998, 89:749–770. Walton J, Mandara AR. Burns and smoke inhalation. Anesthesia and Intensive Care Medicine, 2005, 6:317–321. 8. WHO mortality database: tables. Geneva, World Health Organization (http://www.who.int/healthinfo/ morttables/en/index.html, accessed 21 April 2008). Barrow RE et al. Influence of demographics and inhalation injury on burn mortality in children. Burns, 2004, 30:72– 77. Achebe UJ, Akpuaka FC. Chemical burns in Enugu. West African Journal of Medicine, 1989, 8:205–208. Chuang SS, Yang JY, Tsai FC. Electric water heaters: a new hazard for pediatric burns. Burns, 2003, 29:589–591. Nursal TZ et al. Burns in southern Turkey: electrical burns remain a major problem. Journal of Burn Care and Rehabilitation, 2003, 24:309–314. Nguyen DQ et al. Infants under 1 year of age have a significant risk of burn injury. Burns, 2008 34: 873–877. Child and youth unintentional injury: 10 years in review, 1994–2003. Toronto, ON, Safe Kids Canada, 2007 (http://w w w.sick k ids.ca/SKCForPartners/custom/ NationalReportUpdatedENG.pdf, accessed 18 April 2008). National Ambulatory Care Reporting System. Canadian Institute for Health Information (http://secure.cihi. ca/cihiweb/dispPage.jsp?cw_page=services_nacrs_e, accessed 9 April 2008). 9. 2. 10. 11. 12. 3. 4. 13. 14. 5. 6. 7. 15. 94 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 114: 16. 17. 18. Papp A et al. Paediatric ICU burns in Finland 1994–2004. Burns, 2008, 34:339–344. Sharma PN et al. Paediatric burns in Kuwait: incidence, causes and mortality. Burns, 2006, 32:104–111. Palmieri RL et al. Pediatric soup scald burn injury: etiology and prevention. Journal of Burn Care and Research, 2008, 29:114–118. Ndiritu S, Ngumi ZW, Ngaim O. Burns: the epidemiological pattern, risk and safety awareness at Kenyatta National Hospital, Nairobi. East African Medical Journal, 2006, 83:455–460. Yongqiang F et al. Epidemiology of hospitalized burn patients in Shandong Province, 2001–2005. Journal of Burn Care and Research, 2007, 28:468–473. Hijar-Medina MC et al. Accidentes en el hogar en niños menores de 10 años: causas y consecuencias [Home accidents in children less than 10 years of age: causes and consequences]. Salud Pública de México, 1992, 34:615– 625. Gali BM, Madziga AG, Naaya HU. Epidemiology of childhood burns in Maiduguri, north-eastern Nigeria. Nigerian Journal of Medicine, 2004, 13:144–147. Rossi LA et al. Childhood burn injuries: circumstances of occurrences and their prevention in Ribeirão Preto, Brazil. Burns, 1998, 24:416–419. Vilasco B, Bondurand A. Burns in Abidjan, Côte d’Ivoire. Burns, 1995, 21:291–296. Gupta M, Gupta OK, Goil P. Paediatric burns in Jaipur, India: an epidemiological study. Burns, 1992, 18:63–67. Lari AR et al. Epidemiology of childhood burns in Fars province, Iran. Journal of Burn Care and Rehabilitation, 2002, 23:39–45. Hyder AA et al. Review on childhood burn injuries in Sub Saharan Africa: a forgotten public health challenge. African Safety Promotion: A Journal of Injury and Violence Prevention, 2004, 2:43–49. Adamo C et al. Epidemiological data on burn injuries in Angola: a retrospective study of 7230 patients. Burns, 1995, 21:536–538. Mashreky SR et al. Epidemiology of childhood burn: yield of largest community based injury survey in Bangladesh. Burns, 2008 34: 856–862. Bawa Bhalla S, Kale SR, Mohan D. Burn properties of fabrics and garments worn in India. Accident Analysis and Prevention, 2000, 32:407–420. Hemeda M, Maher A, Mabrouk A. Epidemiology of burns admitted to Ain Shams University Burns Unit, Cairo, Egypt. Burns, 2003, 29:353–358. Ghosh A, Bharat R. Domestic burns prevention and first aid awareness in and around Jamshedpur, India: strategies and impact. Burns, 2000, 26:605–608. Gupta RK, Srivastava AK. Study of fatal burn cases in Kanpur (India). Forensic Science International, 1988, 37:81–89. 34. McCullough JE, Henderson AK, Kaufman JD. Occupational burns in Washington State, 1989–1993. Journal of Occupational and Environmental Medicine, 1998, 40:1083–1089. Baggs J, Curwick C, Silverstein B. Work-related burns in Washington State, 1994 to 1998. Journal of Occupational and Environmental Medicine, 2002, 44:692–699. Arshi S et al. Prevention oriented epidemiologic study of accidental burns in rural areas of Ardabil, Iran. Burns, 2006, 32:366–371. Mohammadi R et al. Unintentional home-related injuries in the Islamic Republic of Iran: findings from the first year of a national programme. Public Health, 2005, 119:919–924. Forjuoh SN, Guyer B, Smith GS. Childhood burns in Ghana: Epidemiological characteristics and home-based treatment. Burns, 1995, 21:24–28. Kalayi GD, Muhammad I. Clothing burns in Zaria. Burns, 1994, 20:356–359. Argirova M, Hadzhiyski O. Treatment of palm burns in children. Annals of Burns and Fire Disasters, 2005, 18:190– 193. Electrical injuries. The Merck Manuals Online Medical Library, 2005 (http://www.merck.com/mmpe/sec21/ ch316/ch316b.html?qt=electrical%20burns&alt=sh, accessed 17 April 2008). Gore DC et al. Assessment of adverse events in the demise of pediatric burn patients. Journal of Trauma, 2007, 63:814–818. Esselman PC. Burn rehabilitation: an overview. Archives of Physical and Medical Rehabilitation, 2007, 88(Suppl. 2):S3–S6. Smith JS, Smith KR, Rainey SL. The psychology of burn care. Journal of Trauma Nursing, 2006, 13:105–106. Spurr ED, Shakespeare PG. Incidence of hypertrophic scarring in burn-injured children. Burns, 1990, 16:179– 181. Taylor SC. Epidemiology of skin diseases in people of color. Cutis, 2003, 71:271–275. Clark A. Psychosocial aspects of facial disfigurement: problems, management and the role of a lay-led organization. Psychology, Health and Medicine, 1999, 4:127–142. Mathangi Ramakrishnan K et al. Paediatric rehabilitation in a developing country, India, in relation to aetiology, consequences and outcome in a group of 459 burnt children. Pediatric Rehabilitation¸ 2004, 7:145–149. Gilboa D. Long-term psychosocial adjustment after burn injuries. Burns, 2001, 27:335–341. Rizzone LP et al. Posttraumatic stress disorder in mothers of children and adolescents with burns. Journal of Burn Care and Rehabilitation, 1994, 15:158–163. Kent L, King H, Cochrane R. Maternal and child psychological sequelae in pediatric burn injuries. Burns, 2000, 26:317–322. WORLD REPORT ON CHILD INJURY PREVENTION 95 35. 19. 36. 37. 20. 38. 21. 39. 40. 22. 41. 23. 24. 25. 26. 42. 43. 44. 45. 27. 28. 46. 47. 29. 30. 48. 31. 49. 50. 32. 33. 51.
Slide 115: 52. Doctor ME. Burn camps and community aspects of burn care. Journal of Burn Care and Rehabilitation, 1992, 13:68–76. Mancuso MG et al. Impact on the family: psychosocial adjustment of siblings of children who survive serious burns. Journal of Burn Care and Research, 2003, 24:2. Siritongtaworn P, Peunchompoo N. Economic problem of referred trauma cases in Siriraj Hospital. Journal of the Medical Association of Thailand, 2006, 89:1621–1629. Griffiths HR et al. The cost of a hot drink scald. Burns, 2006, 32:372–374. Forjuoh SN. The mechanisms, intensity of treatment, and outcomes of hospitalized burns: issues for prevention. Journal of Burn Care and Rehabilitation, 1998, 19:456– 460. Joseph KE et al. Parental correlates of unintentional burn injuries in infancy and childhood burns. Burns, 2002, 28:455–463. Han RK, Ungar WJ, Macarthur C. Cost-effectiveness analysis of a proposed public health legislative/educational strategy to reduce tap water scald injuries in children. Injury Prevention, 2007, 13:248–253. Burd A, Yuen C. A global study of hospitalized pediatric burn patients. Burns, 2005, 31:432–438. Runyan CW. Using the Haddon matrix: introducing the third dimension. Injury Prevention, 1998, 4:302–307. Chung ECH et al. Burn injuries in China: a one year survey at the United Christian Hospital. Hong Kong Practice, 1996, 18:631–636. Ying SY, Ho WS. Playing with fi re: a significant cause of burn injury in children. Burns, 2001, 27:39–41. Chan KYO et al. A review of burns patients admitted to the burns unit of hospital universiti Kebangsaan Malaysia. Medical Journal of Malaysia, 2002, 57:418–425. Zhu ZX, Yang H, Meng FZ. The epidemiology of childhood burns in Jiamusi, China. Burns, 1988, 14:394–396. Chen G et al. Incidence and pattern of burn injuries among children with disabilities. Journal of Trauma, 2007, 62:682–686. Spitz MC. Injuries and death as a consequence of seizures in people with epilepsy. Epilepsia, 1998, 39:904–907. Dempsey MP, Orr DJ. Are paediatric burns more common in asylum seekers? An analysis of paediatric burn admissions. Burns, 2006, 32:242–245. Carlsson A et al. Burn injuries in small children: a population-based study in Sweden. Journal of Clinical Nursing, 2006, 15:129–134. Soori H, Naghavi M. Childhood deaths from unintentional injuries in rural areas of Iran. Injury Prevention, 1998, 4:222–224. Kane JM, Nazarian EB, Connolly H. Hydrocarbon inhalation injury. eMedicine, 2006 (http://www.emedicine. com/PED/topic2790.htm, accessed 10 April 2008). 71. Warda L, Tenenbein M, Moffat MEK. House fire prevention update (Part 1): a review of risk factors for fatal and nonfatal house fires. Injury Prevention, 1999, 5:145–150. Hippisley-Cox J et al. Cross sectional survey of socioeconomic variations in severity and mechanism of childhood injuries in Trent 1992–7. British Medical Journal, 2002, 324:1132–1134. Reimers A, Laflamme L. Neighbourhood socio-economic composition and injury risks. Acta Paediatrica, 2005, 94:1488–1494. Poulos R et al. Area socioeconomic status and childhood injury morbidity in New South Wales, Australia. Injury Prevention, 2007, 13:322–327. Delgado J et al. Risk factors for burns in children: crowding, poverty, and poor maternal education. Injury Prevention, 2002, 8:38–41. Daisy S et al. Socioeconomic and cultural influence in the causation of burns in the urban children of Bangladesh. Journal of Burn Care and Rehabilitation, 2001, 22:269–273. Forjuoh SN et al. Risk factors for childhood burns: a case-control study of Ghanaian children. Journal of Epidemiology and Community Health, 1995, 49:189–193. Werneck GL, Reichenheim ME. Paediatric burns and associated risk factors in Rio de Janeiro, Brazil. Burns, 1997, 23:478–83. Katcher ML. Tap water scald prevention: it’s time for a worldwide effort. Injury Prevention, 1998, 4:167–168. Munro S-A, van Niekerk A, Seedat M. Childhood unintentional injuries: the perceived impact of the environment, lack of supervision and child characteristics. Child: Care, Health and Development, 2006, 32:269–279. Vassilia K, Eleni P, Dimitrios T. Firework-related childhood injuries in Greece: a national problem. Burns, 2004, 30:151–153. Mohan D, Varghese M. Fireworks cast a shadow on India’s festival of lights. World Health Forum, 1990, 11:323–326. Abdulwadud O, Ozanne-Smith J. Injuries associated with fireworks in Victoria: an epidemiological review. Injury Prevention, 1998, 4:272–275. Witsaman RJ, Comstock RD, Smith GA. Pediatric fireworks-related injuries in the United States, 1990–2003. Pediatrics, 2006, 118:296–303. Roesler JS, Day H. Sparklers, smoke bombs, and snakes, oh my! Effect of legislation on fireworks-related injuries in Minnesota, 1999–2005. Minnesota Medical Journal, 2007, 90:46–47. Van Niekerk A et al. Caregiver experiences, contextualisations and understandings of the burn injury to their child: accounts from low-income settings in South Africa. Child: Care, Health and Development, 2007, 33:236–245. Seedat M et al. The application of still photography in marshalling data for community-based initiatives. African Journal of Psychology, 2006, 2:303–314. 53. 72. 54. 73. 55. 56. 74. 75. 57. 76. 58. 77. 59. 60. 61. 78. 79. 80. 62. 63. 81. 64. 65. 82. 83. 66. 67. 84. 85. 68. 86. 69. 70. 87. 96 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 116: 88. Kellet P, Tipple AG. The home as workplace: a study of income-generating activities within the domestic setting. Environment and Urbanization, 2000, 12:203–213. Godwin Y, Hudson DA, Bloch CE. Shack fires: a consequence of urban migration. Burns, 1996, 23:151– 153. Zwi KJ et al. Patterns of injury in children and adolescents presenting to a South African township health centre. Injury Prevention, 1995, 1:26–30. Van Rijn OJ et al. Aetiology of burn injuries among children aged 0–4 years: results of a case-control study. Burns, 1991, 17:213–219. Forjuoh SN. Burns in low- and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns, 2006, 32:529–537. Petridou E et al. Risk factors for childhood burn injuries: a case-control study from Greece. Burns, 1998, 24:123– 128. Davies JWL. The problem of burns in India. Burns, 1990, 16(Suppl. 1):S1–S24. Cheng JCY et al. An analysis of 1704 burn injuries in Hong Kong children. Burns, 1990, 16:182–184. Van Niekerk A, Rode H, Laflamme L. Incidence and patterns of childhood burn injuries in the Western Cape, South Africa. Burns, 2004, 30:341–347. El-Badawy A, Mabrouk AR. Epidemiology of child burns in the burn unit of Ain Shams University in Cairo, Egypt. Burns, 1998, 24:728–732. LeBlank JC et al. Home safety measures and the risk of unintentional injury among young children: a multicentre case-control study. Canadian Medical Association Journal, 2006, 175:883–887. Koupil J et al. Special features of burn injuries in elderly patients. Acta Chirurgiae Plasticae, 2001, 43:57–60. installation and fire safety (SAIFE) program. Journal of Burn Care and Rehabilitation, 2005, 26:434–439. 105. Working to prevent and control injury in the United States: fact book for the year 2000. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2000. 106. Home fire protection: residential fire sprinkler systems. Emmitsburg, MD, Federal Emergency Management Agency, United States Fire Administration, 2004 (https:// www.usfa.dhs.gov/downloads/pdf/publications/fa-43. pdf, accessed 1 June 2008). 107. Fires and burns fact sheet. Brisbane, Kidsafe Australia ( ht t p://w w w. g t p.c om . au / k id s a fe qld /i ne w s f i le s/ inews.25847.1.pdf, accessed 16 June 2008). 108. Children’s sleepwear regulations. Washington, DC, United States Consumer Product Safety Commission, 2001. 109. Lyons R et al. Modification of the home environment for the reduction of injuries. Cochrane Database Systematic Reviews, 2003, 4:CD003600:1–33. 110. MacArthur C. Evaluation of Safe Kids Week 2001: prevention of scald and burn injuries in young children. Injury Prevention, 2003, 9:112–116. 111. Feldman KW et al. Tap water scald burns in children. Injury Prevention, 1997, 4:238–242. 112. Rivara CF. Hot water scald burns in children. Pediatrics, 1998, 102:256–258. 113. Ytterstad B, Sogaard AJ. The Harstad injury prevention study: prevention of burns in small children by a community-based intervention. Burns, 1995, 21:259–266. 114. Waller AE, Clarke JA, Langley JD. An evaluation of a program to reduce home hot tap water temperatures. Australian Journal of Public Health, 1993, 17:116–123. 115. Smith L, Smith C, Ray D. Lighters and matches: an assessment of risk associated with household ownership and use. Washington, DC, United States Consumer Product Safety Commission, 1991. 116. Smith LE, Greene MA, Singh HA. Study of the effectiveness of the US safety standard for child-resistant cigarette lighters. Injury Prevention¸ 2002, 8:192–196. 117. EU requires cigarette lighters to be child-resistant. EUROPA Press Releases, 14 March 2007 (http://europa.eu/rapid/ pressReleasesAction.do?reference=IP/07/325, accessed 1 June 2008). 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. Bruce N et al. Prevention of burns among children in wood fuel using homes in rural Guatemala (Poster presentation). 16th Annual Conference of the International Society for Environmental Epidemiology, New York, NY, 1–4 August 2004 (http://ehs.sph.berkeley.edu/heh/guat/pubs/ Burns%20poster%20ISEE%202004%20v230704.pdf, accessed 17 April 2008). 101. Madubansi M, Schackleton CM. Changes in fuelwood use and selection following electrification in the Bushbuckridge lowveld, South Africa. Journal of Environmental Management, 2007, 83:416–426. 102. Runyan CW et al. Risk factors for fatal residential fires. New England Journal of Medicine, 1992, 327:859–863. 103. DiGuiseppi C, Higgins JPR. Systematic review of controlled trials of interventions to promote smoke alarms. Archives of Diseases in Children, 2000, 82:341–348. 104. Ballesteros MF, Jackson ML, Martin MW. Working towards the elimination of residential fire deaths: The Center for Disease Control and Prevention’s smoke alarm 118. Edwin AF, Cubison TC, Pape SA. The impact of recent legislation on paediatric fireworks injuries in the Newcastle upon Tyne region. Burns, 2008, May 26 [epub ahead of print]. 119. Kendrick D et al. “Risk Watch”: cluster randomized controlled trial evaluating an injury prevention program. Injury Prevention, 2007, 13:93–99. 120. Warda LJ, Ballesteros MF. Interventions to prevent residential fire injury. In: Doll L et al., eds. Handbook of injury and violence prevention. Atlanta, GA, Springer, 2007:97–115. WORLD REPORT ON CHILD INJURY PREVENTION 97
Slide 117: 121. Gielen AC et al. A randomized trial of enhanced anticipatory guidance for injury prevention. Archives of Pediatric and Adolescent Medicine, 2001, 155:42–49. 122. Gielen AC et al. The effects of improved access to safety counseling, products and home visits on parents’ safety practices. Archives of Pediatric and Adolescent Medicine, 2002, 156:33–40. 123. Gosselin RA, Kuppers G. Open versus closed management of burn wounds in a low-income developing country. Burns, 2008 (in press). 124. Herndon DN. Total burn care (2nd ed.). Philadelphia, PA, Harcourt, 2002. 125. Thomas J, Rode H. A practical guide to paediatric burns. Cape Town, SAMA Health and Medical Publishing Group, 2006. 126. Albertyn R, Bickler S, Rode H. Paediatric burn in injuries in Sub Sahara Africa: an overview. Burns, 2006, 32:605– 612. 127. Davies JWL. Prompt cooling of burned areas: a review of benefits and the effector mechanisms. Burns, 1982, 9:1–6. 128. Nguyen NL et al. The importance of immediate cooling: a case series of childhood burns in Vietnam. Burns, 2002, 28:173–176. 129. Sheridan RL et al. Current expectations for survival in pediatric burns. Archives of Pediatric and Adolescent Medicine, 2000, 154:245–249. 130. Resources of optimal care of the injured patient. Chicago, IL, American College of Surgeons, Committee on Trauma, 1999. 131. Cooper DJ et al. Quality assessment of the management of road traffic fatalities at a level I trauma center compared with other hospitals in Victoria, Australia. Journal of Trauma, 1998, 45:772–799. 132. Sheridan RL et al. Early burn center transfer shortens the length of hospitalization and reduces complications in children with serious burn injuries. Journal of Burn Care and Rehabilitation, 1999, 20:347–50. 133. Organization and delivery of burn care. Practice Guidelines of the American Burn Association, 2001 (http://www. ameriburn.org/PracticeGuidelines2001.pdf, accessed 15 April 2008). 134. Forjuoh SN, Li G. A review of successful transport and home injury interventions to guide developing countries. Social Science and Medicine, 1996, 43:1551–1560. 135. Yuan J et al. Assessment of cooling on an acute scald burn injury in a porcine model. Journal of Burn Care Research, 2007, 28:514–520. 136. McLoughlin E, MacGuire A. The causes, cost and prevention of childhood burn injuries. American Journal of Diseases of Children, 1990, 166:677–683. 137. Norton R et al. Unintentional injuries. In: Jamison DT et al., eds. Disease control priorities in developing countries (2nd ed.). New York, NY, Oxford University Press and World Bank, 2006:737–753 (http://www.dcp2.org/pubs/ DCP/39/, accessed 14 February 2008). 138. Turner C et al. Community-based interventions for the prevention of burns and scalds in children. Cochrane Database Systematic Reviews, 2004, 3:CD004335. 139. Kenrick D, Mulvaney C, Watson M. Does targeting injury prevention towards families in disadvantaged areas reduce inequalities in safety practice? Health Education Research, 2008 (http://her.oxfordjournals.org/cgi/content/full/ cym083, accessed 14 August 2008). 98 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 118: WORLD REPORT ON CHILD INJURY PREVENTION 99
Slide 119: © C. Khasnabis Sohel, a boy of 14 years, was the main breadwinner in his family of four. He lived in the village of Krishnapur, in Narsingdi district in Bangladesh. At the age of 7 years, Sohel lost his father, Fazlur, who had slipped in the bathroom and suffered a severe head injury. S O H E L’ S S T O RY The father left behind a small plot of land and a poor dwelling. The mother, Jharna, a 38-year-old widow, did household work for neighbours to earn a minute income. As a result of their circumstances, Sohel dropped out of school when he was in the seventh grade, and began to cultivate their small piece of land. He grew rice and other crops, which mostly went for their own consumption. Sohel and his friends used to go to the river to fish, to earn a bit of extra money for their daily living. It was the rainy season, in July 2004. One afternoon Sohel went out to the river to fish with his two friends. After failing for two hours to catch anything, they returned despondently to the village. There was an old mosque there, on which the villagers had started some renovation work. Keen to see what had been done and inquisitive by nature, Sohel climbed onto the roof of the mosque. No construction workers or anyone else were around at the time. Sohel’s friends wouldn’t follow him and pleaded with him not to climb. Sohel ignored them and walked around the roof, moving towards the edge. The roof, littered with construction materials, was very wet. Suddenly Sohel stumbled over some materials, lost control and fell from the roof. His head, which was badly injured, bled profusely, his right hand was broken and he lost consciousness. Some nearby people, alerted by the cries of his friends, took him to the nearest health centre, 15 kilometres from the village. So severe were his injuries that the paramedic could not help him. Within half an hour, he was dead. Sohel’s tragic case is not unique in Bangladesh. The Bangladesh Health and Injury Survey showed that each year more than a thousand children under 18 years of age die in the country as a result of unintentional falls. Each year five thousand children are injured from rooftop falls alone. Over 5% of these become permanently disabled while the others suffer from varying degrees of illness. More than half the childhood injuries are among 10–14-year-olds, with more boys than girls suffering (1). To stop more children like Sohel needlessly dying from what are preventable injuries, action must be taken now. FALLS
Slide 120: CHAPTER 5 – FALLS Chapter 5 Falls Introduction Falling is a normal part of the way a child develops – learning to walk, climb, run, jump and explore the physical environment. Fortunately, most falls are of little consequence and most children fall many times in their lives without incurring damage, other than a few cuts and bruises. All the same, some falls are beyond both the resilience of the human body and the capacity of the contact surface to absorb the energy transferred. Falls are thus an important cause of childhood injuries, including those resulting in permanent disability or death. Falls of this degree of seriousness are not randomly distributed, either globally or within single countries. To understand why this should be one needs to examine the built environment and the social conditions in which children live. This chapter focuses on the main ideas underlying the prevention of unintentional falls in childhood, using a public health approach. The extent and characteristics of the problem are first identified and after that the types of exposure that are linked to a risk of injury. Intervention strategies to prevent such injuries and their disabling consequences are examined for their effectiveness and cost-effectiveness. Finally, consideration is given as to how the most promising strategies can be successfully implemented on a wider scale. Falls have been defined and recorded in several ways. This chapter adopts the World Health Organization’s definition, according to which falls are “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (2). In the WHO database of injuries, fall-related deaths and non-fatal injuries exclude those due to assault and intentional self-harm. Injuries and deaths resulting from falls from animals, burning buildings and vehicles, as well as falls into water and machinery, are also not coded as falls. Instead, they are recorded, respectively, as injuries due to animals, fire, transport, submersion and machinery. An expert group convened by the National Institute of Child Health and Human Development defined falls as an external cause or type of exposure, the impact of which is “to come down by force of gravity suddenly; to tumble, topple, and forcibly lose balance” (3). The group listed the main factors relating to falls in childhood. These included: – social and demographic factors, such as the child’s age, gender, ethnicity and socioeconomic status; – the physical development of the child; – activity taking place before the fall – such as running, walking or climbing; – the location of the fall; – the height from which the fall occurs; – characteristics of the surfaces with which contact is made – such as texture, smoothness and deformability. All this information, if available, taken together with information on risk factors, can provide valuable clues as to how and why fall-related injuries occur, and greatly help efforts to prevent them. Epidemiology of falls According to the WHO Global Burden of Disease project for 2004, an estimated 424 000 people of all ages died from falls worldwide. Although the majority of fallrelated deaths were among adults, they ranked as the twelft h leading cause of death among 5 to 9-year-olds and 15 to 19-year-olds (see Table 1.1 in Chapter 1). Morbidity from falls is much more common and represents a significant burden on health-care facilities around the world. Among children under 15 years, non-fatal falls were the 13th leading cause of disability-adjusted life years (DALYs) lost. In most countries, falls are the most common type of childhood injury seen in emergency departments, accounting for between 25% and 52% of assessments (4, 5). The published literature on the incidence and patterns of fall-related injuries among children relates largely to high-income countries, where just 10% of the world’s children live. In many of these countries, deaths from all types of injury are estimated to have dropped by over 50% over the past three decades (6, 7). A systematic review of the literature from mainly low-income and middle-income countries in Africa, Asia and Central and South America on the incidence of unintentional childhood falls resulting in death or needing medical care, found the following. In Africa, the median incidence of falls among children and youth aged less than 22 years was 41 per 100 000 population (8). In Central and South America, the rate varied from 1378 to 2700 per 100 000 population aged less than 20 years (9, 10). In Asia, the median incidence was 170 per 100 000 population aged less than 18 years (43% of all injuries). The highest rate on the Asian continent was recorded in the United Arab Emirates with an incidence of some 1923 per 100 000 population (11–14). WORLD REPORT ON CHILD INJURY PREVENTION 101
Slide 121: The UNICEF–TASC surveys have also found falls to be a leading cause of morbidity and disability in children, resulting in high social and economic costs (15). The studies reviewed suggest a substantial variability in the incidence of falls between regions – and sometimes within regions. In the absence of a common methodology and standard definition, however, data from different studies and settings cannot be compared directly and are potentially misleading. Less than a fift h of the studies documented deaths due to falls, only 12% used standardized or formal definitions for falls, and none provided reliable data on the severity of injuries or consequent disability resulting. levels are so much higher in some places, it is also possible that some misclassification of data has occurred. Child abuse, for instance, is sometimes wrongly classified in the category of falls (16, 17). Age In high-income countries, the average fall mortality rates, by age, are similar over the first 20 years of life. However, in low-income and middle-income countries, infants less than one year of age have very high rates (see Figure 5.2). FIGURE 5.2 Fatal fall-related injury rates per 100 000 children by age and country income level, World, 2004 6 Rate per 100 000 population Mortality In 2004, nearly 47 000 children and youth under the age of 20 years died as a result of a fall. Fall-related mortality data compiled by WHO reveal important differences between regions, and between countries within regions (see Figure 5.1). High-income countries in the Americas, Europe and Western Pacific regions had average mortality rates of between 0.2 and 1.0 per 100 000 children aged less than 20 years. However, low-income and middle-income countries in the same regions reported rates up to three times higher. Low-income and middle-income countries in South-East Asia and the Eastern Mediterranean regions had the highest average rates – of 2.7 per 100 000 and 2.9 per 100 000, respectively. While it is quite possible that the FIGURE 5.1 HIC 4 LMIC 2 0 Under 1 1–4 5–9 10–14 Age (years) 15–19 under 20 HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. Fatal fall-related injury rates per 100 000 children a by WHO region and country income level, 2004 2+ 0.5–1.9 <0.5 No data Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific LMIC 1.5 a HIC 0.2 LMIC 0.7 LMIC 2.7 HIC 0.3 LMIC 1.0 HIC 2.2 LMIC 2.9 HIC 0.4 LMIC 2.2 These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. 102 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 122: Community surveys conducted in Asia highlight the high incidence of fall deaths in the region. In Bangladesh, the overall fall mortality rate for the 0–17-year age group was 2.8 per 100 000 (1), and falls were the second leading cause of death through injury among infants aged less than one year (24.7 per 100 000 population). In Viet Nam, falls were the sixth leading cause of childhood death (4.7 per 100 000 aged 0–17 years) (18). In Jiangxi province in China, falls were the fourth leading cause of death (3.1 per 100 000 aged 0–17 years). Higher rates were reported in rural areas than in urban areas (19). Falls are still an important cause of death in children in high-income countries, even though the incidence rates are considerably less than in low-income and middle-income countries. Falls are the fourth leading cause of trauma deaths in childhood in the United States (20) and the sixth leading external cause of death among Australian children aged 0–14 years (21). Gender Boys are overrepresented in fall mortality statistics (see Table 5.1), with the male-to-female ratio varying from 1.2:1 (in low-income and middle-income countries in South-East Asia) to 12:1 (in high-income countries in the Eastern Mediterranean region). countries (20, 23–28). Falls were also cited as the leading cause of injury among 13–15-year-olds in the Global School Health Survey, covering 26 countries (see Statistical Annex, Table A.3). Most published studies of non-fatal injury in low-income and middle-income countries are hospital-based and may fail to capture data on children who are unable to access medical care (29, 30). Community-based studies suggest that there are many more significant fall-related injuries than just those seen at health-care facilities (14, 31). The Asian community surveys recorded injury events that were serious enough to warrant seeking medical attention or that resulted in school days missed. Injuries not meeting these criteria were deemed insignificant in terms of health-care costs and social costs (29, 31). In the injury survey in Jiangxi province, China (19), for every one death due to a fall, there were 4 cases of permanent disability, 13 cases requiring hospitalization for 10 or more days, 24 cases requiring hospitalization for between 1 and 9 days, and 690 cases where care was sought or where at least 1 day of work or school was missed (see Figure 5.3). The survey highlighted the substantial cost of non-fatal injuries due to falls and the small proportion of cases seen in hospital settings – cases which, taken together, must contribute considerably to the overall cost of falls. FIGURE 5.3 Type of fall Based on data from the Global Burden of Disease project, which includes the fourth ICD coding digit from 70 mainly middle-income and high-income Member States, 66% of fatal falls among children occurred from a height, while 8% resulted from falls on the same level. Unfortunately, the relevant information was unavailable for a quarter of the reported falls (22). Inury pyramid for falls among children 0–17 years, Jiangxi province, China Death (1) Permanent disability (4) Hospitalization (10+ days) (13) Hospitalization (1–9 days) (24) Missed work or school or sought treatment (690) Source: Reference 19. Morbidity Extent of the problem Global statistics on non-fatal injury are not readily available, though the incidence of non-fatal falls is clearly much higher than that of fatal cases. Data that are available indicate that falls are a leading, if not in fact the most common, type of injury resulting in hospitalization or emergency room attendance in most high-income TABLE 5.1 Fatal fall injury rates per 100 000 childrena by sex, country income level and WHO region, 2004 Africa LMIC Boys Girls a Americas HIC 0.3 0.1 LMIC 1.0 0.4 South-East Asia LMIC 3.0 2.4 HIC 0.5 0.2 Europe LMIC 1.3 0.6 Eastern Mediterranean HIC 4.0 0.3 LMIC 3.5 2.3 Western Pacific HIC 0.5 0.3 LMIC 2.5 1.9 1.8 1.1 These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low- and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. WORLD REPORT ON CHILD INJURY PREVENTION 103
Slide 123: Similar patterns of injury were observed in Uganda, where there were higher rates of falls among children in rural than in urban areas (32). Data from various countries in Latin America and from Pakistan also reveal that falls are a common cause of non-fatal injury among children (9, 33–36). Globally, 50% of the total number of DALYs lost due to falls occur in children less than 15 years of age. However, the burden of childhood falls is largely explained by the morbidity and disabilities that may persist for life. The skewed distribution of this burden geographically and the relative scarcity of statistics on non-fatal injury events make it more difficult to describe and address the problem of childhood falls. BOX 5.1 Falls from trees in Mozambique In 2006, an injury and violence survey was conducted in Mozambique. The study covered 179 households from the urban district of Matola and 162 from the rural district of Boane, both areas in the southernmost part of the country. Falls were the leading cause (31.7%) of injury in Boane district, while they accounted for 23.8% of injuries in Matola district, surpassed only by road traffic injuries, accounting for 34.7% of all injuries. Twenty-eight per cent of all the falls involved children and adolescents under the age of 20 years. Many of the falls were from trees, a common occurrence in developing countries. In one of the most rural parts of Boane district, a widowed mother with seven children is in tears as she tells the story of her eldest son, José. José broke his leg after falling from a coconut tree while collecting fruit for the family’s breakfast. Now aged 17 years, he is permanently disabled. One of his legs had to be amputated because he did not receive immediate care. His mother recalls that neighbours tried to help soon after the fall, but that it took many hours to get him to the nearest health-care facility. On arrival there it was apparent that the fracture was compound and the facility lacked the necessary equipment to handle his case. He was consequently referred to Maputo Central Hospital, a further three hours’ drive away. It was 17 hours before José was seen by an orthopaedic surgeon. José’s mother has now lost her primary breadwinner. She reflects on their experience, saying “these are the realities of the day-to-day life we have to deal with in Mozambique.” José’s case is not an isolated one. Data from the emergency department surveillance system in Maputo Central Hospital show that falls account for 40% of those presenting to the emergency department, with children under 18 years of age making up almost two thirds of these cases. Seventy-five per cent of the serious fall injuries among children are the result of their falling from trees, usually around the home. Severity of falls The severity of a fall-related injury is determined by the anatomy of the human body and the impact force to which the body is subjected – in the absence of any special protection on the body or impact-absorbing materials in the landing or contact surfaces (37–41). The impact force itself depends, among other things, on the height from which the fall occurs. These relationships are well described in high-income countries in relation to falls from playground equipment (42–46) and from windows and roofs (47–49). The proportions of injuries due to falls, as well as the patterns of injury from falls generally, can differ considerably in developing countries from those in developed countries (50). For instance, a recent study conducted in four lowincome and middle-income countries found that falls were the leading cause of unintentional injury among children under the age of 12 years. The types of injuries sustained were largely cuts and scrapes, fractures of the upper and lower extremities and contusions. In half of all cases, the children were left with some form of disability – in 41% of cases with a temporary disability of less than six weeks (see Statistical Annex, Table C.1). Generally, the greater the height from which a child falls, the more severe the injury (51). The Jiangxi survey found that about 18% of falls were from heights of five metres or more and two thirds involved heights of between one and five metres (19). The Jiangxi and Beijing surveys (19, 52) revealed that as children grew older, an increasing proportion of falls were from greater heights – such as trees and rooftops, frequently, in the case of adolescents. A Nigerian study, on the other hand, found that only 25% of falls in childhood leading to hospitalization were from heights, the remainder occurring at ground level (53). Injuries from falls from heights of more than two storeys typically involve falls from windows, balconies and roofs (41, 51). Falls from stairs and trees are also common, as are falls into ditches, wells, shafts and other holes in the ground (19). Trees are particularly hazardous, especially in some tropical countries where children are employed to harvest high tree crops (50) (see Box 5.1). 104 WORLD REPORT ON CHILD INJURY PREVENTION © WHO
Slide 124: In the United States, many of the fall fatalities among children involve falls from poor-quality housing in lowincome urban areas, typically from the second floor or higher (51). Falls from greater heights tend to occur more in the summer months. This is presumably because windows – the usual site for falls of pre-school-age children – are more likely to be open at that time of year, and older children are more likely to be outdoors playing on fi re escapes, roofs and balconies (47–49). A case–control study from New Zealand has shown that the risk of injury in a fall from playground equipment increases dramatically for heights of over 1.5 metres (54). After adjusting for various factors such as the child’s age and weight and the presence of impact absorbing surfaces, children falling from over 1.5 metres were found to have four times the risk of injury compared to those falling from below that height. The risk of injury rose with increasing fall height, with children who fell from over 2.25 metres having 13 times the risk of injury compared to those who fell from 0.75 metres or below. The extent to which falls from low heights result in lifethreatening injuries, especially head injuries, has generated considerable controversy, largely in relation to suspected child abuse (55–57). What evidence there is on this does tend to point in the direction of possible abuse. Reported fatalities following short or minor falls are more common in situations where there are no unrelated witnesses who can confirm the history of events (55–57). When making clinical decisions, therefore, the height of a fall should not be the only criterion used to determine the threat to life that a particular injury poses (58). Consequences of falls Falls are the leading cause of traumatic brain injury, especially in young children, with a significant risk of longterm consequences (20, 59–61). In the United States, about one third of the 1.4 million people suffering traumatic brain injuries are children aged 0 to 14 years, who have disproportionately high rates of falls compared with other age groups (62). A Canadian study noted that 36% of infants aged less than one year presenting to an emergency department following a fall had significant head injuries, and that falls were responsible for 90% of all head injuries seen in the emergency department (20). Falls are also the most common cause of fatal and serious head injuries among children in France and the United Kingdom (63–65). While the incidence of spinal-cord injuries following a fall is generally low, most spinal-cord injuries, resulting in quadriplegia or paraplegia, are attributed to falls (66–68). A case study from Nigeria describes the lifelong disability resulting from such injuries, often the result of falls from tall palm trees (69). Children tend to use their arms to protect their heads when falling from a height. Limb fractures, particularly of the forearm, are therefore the most common type of fall-related injury in children beyond the age of infancy (37, 70–73). An analysis in Australia of children falling from playground equipment showed that fractures accounted for 85% of playground injuries (74). There have been suggestions that the incidence of upper limb fractures has increased in recent years, while that of serious head injuries has declined. This claim needs to be investigated further in relation to safety standards in playgrounds (75, 76). Even after incurring open or complex fractures, children in low-income countries can make a good recovery if they receive proper care (77). All the same, permanent disfigurement and functional impairment from such fractures are frequently seen in poorer settings (5, 9, 78, 79). Growth-plate fractures are particularly liable to result in permanent disability (79). Abdominal and chest injuries are uncommon in falls from one or two storeys, but more frequent in falls from greater heights (47, 72, 80). The UNICEF–TASC survey in Jiangxi province, China, found that falls were the leading cause of permanent disability in young people aged 0–17 years, primarily due to the long-term consequences of brain and cervical spine injury. Such disability was estimated to be 3.5 times more frequent in boys than in girls (19). A study in Nicaragua also found that falls were the leading cause of permanent disability in young people less than 15 years of age (33). In Thailand (81) and Viet Nam (18), falls accounted for 1% and 4% of the total burden of permanent disability, respectively. Permanent disability in these surveys referred to the loss of a physical sense – such as sight or hearing – loss of mobility or loss of the ability to speak. However, emotional, psychological and cognitive longterm consequences were not included because of the difficulty in measuring them (19). As a result, the overall amount of permanent disability is likely to be considerably greater than the survey estimates suggest. Cost of fall-related injury In Canada, annual injuries from childhood falls were estimated in 1995 to cost 630 million Canadian dollars (82). Implementing strategies known to be effective is expected to result in a 20% reduction in the incidence of falls among children aged 0–9 years, 1500 fewer hospitalizations, 13 000 fewer non-hospitalized injuries, 54 fewer injuries leading to permanent disability and net savings of over C$ 126 million (US$ 120 million) every year (82). In the United States, falls account for the largest share of the cost of deaths and injuries in children under 15 years of age – more than a quarter of all childhood unintentional injury-related costs, and costing almost US$ 95 billion in 2004 (83). For children aged 0–19 years, hospital data from 36 states suggest that the total expenditure for a case of acute care following a fall was second only to that of road traffic injury (84). WORLD REPORT ON CHILD INJURY PREVENTION 105
Slide 125: In Australia, the annual direct health-care cost of falls in children is estimated to be over 130 million Australian dollars, of which 28 million dollars is attributable to hospital inpatient care (21). While sufficient data are not available from low-income and middle-income countries to obtain an estimate of the cost of fall-related injuries, it is clear that cost is substantial. In Lilongwe, Malawi, almost 10% of paediatric admissions were related to unintentional injuries, a third of which were as a result of fractures, generally from falls (85). An emergency department study in Turkey noted that falls accounted for 41% of injury admissions and contributed to a major part of the overall budget for paediatric trauma cases (86). The high risk of wounds becoming contaminated and of complications such as bone and joint infections, together with the scarcity of powerful antibiotics and microsurgical techniques, create significant problems for health-care services (77, 85, 87, 88). The length of paediatric hospital admissions involving osteomyelitis in a Gambian hospital, for instance, was found to be second only to that of admissions as a result of burns (88). departing from the standard International Classification of Disease codes – have provided valuable information to help develop prevention measures. Risk factors As already mentioned, the incidence and patterns of fall injuries among children depend to a great extent on contextual factors. A systematic review of the published literature on risk factors for unintentional injuries due to falls in children identified age, sex and poverty as consistent independent risk factors (4). Other major risk factors influencing the incidence and severity of fall injuries were: the height of the fall; the type of surface; the mechanism (whether dropped, falling down stairs or falling using a baby walker); and the setting (whether day care or home care). Drawing on these studies and other epidemiological findings, Table 5.2 shows the major factors influencing the incidence of unintentional childhood falls and their consequences. Limitations of data Rates of fatalities resulting from falls are relatively low. Much of the estimated global burden of falls among children stems from subsequent disability. The lack of reliable data, in much of the world, on non-fatal outcomes is therefore a significant deficiency. The mechanisms and patterns of fall-related injury among children are highly dependent on the context. Again, this information is generally not available for most low-income and middle-income countries – countries in which the burden of falls is the heaviest. In high-income countries, studies gathering data specifically related to the context and circumstances surrounding falls – and TABLE 5.2 Child-related factors Age and development Children’s developmental stages – as well as the activities and environments associated with these stages – have a bearing on the incidence and characteristics of fall-related injuries (89, 90). Research into the ways that infants and small children learn to climb stairs (91) has found complex interactions between: – their evolving motor and cognitive skills; – the physical opportunities presented to them, such as access to stairs; – their social opportunities or lack of them, such as strict supervision by caregivers. Haddon Matrix applied to the risk factors for childhood falls Phases Pre-event Factors Child Age; gender; level of activity; pre-existing disability. Agent Unsafe product or equipment; unprotected rooftop, balcony or staircase; tree. Lack of protective equipment or barriers that reduce the severity of an injury in the event of a fall. Sharp objects and others hazards that increase risk of cuts and infections. Physical environment Lack of access to safe play spaces and opportunities; lack of preventive measures such as stair gates and guard rails. Socioeconomic environment Poverty; single-parent family; family size; maternal education; awareness of fall risks among caregivers, childcare providers and educators. Event Size and physical development of child. Height of fall; type of surface Lack of awareness of potentially serious inonto which child falls; lack juries associated with falls, e.g. concussion of impact-absorbing and brain injury. surfaces. Post-event Child’s general health; disability; post-injury complications. Lack of adequate prehospital care, acute care or rehabilitation. Lack of first-aid skills; lack of access to health care; lack of resources to manage post-injury outcomes. 106 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 126: Most of the falls young children have might be considered a normal part of their development and learning experience. However, their curiosity to explore their surroundings is generally not matched by their capacity to gauge or respond to danger (5, 92). As they become older and increasingly independent, they have access to a wider range of territory and are capable of a greater range of physical activity. They also often strive to perform more challenging and daring acts – a behaviour known as “risk-taking”. In most high-income countries, children under one year of age are most likely to fall from furniture or car seats, or through being dropped. Between the ages of one and three years, children are most likely to fall from stairs or steps, baby walkers, furniture or play equipment. Older children typically fall from playground equipment or from being pushed (89, 93–95). Evidence from low-income countries is less specific. However, a population-based study from Brazil, Chile, Cuba and Venezuela noted that falls involving young children occurred most commonly at home, though with older children, institutions, such as schools, and public places were the prime locations (9, 96). A study from three paediatric hospitals in Mexico found that falls from stairways and beds accounted for a high proportion of admissions of children under 10 years of age. The factors creating particular injury risks for these children were (34, 97): a lack of protective rails on beds (30%); unprotected staircases (48%); and easy access to roofs (40%). Falls from unprotected rooftops – on which children play as well as sleep – are common in countries such as Bangladesh, India and Turkey (98, 99). playground. The study showed that mothers responded less often and were slower to intervene in instances of risky behaviour on the part of a son than they did in the case of a daughter (105). Parental practices have also been found to foster greater exploratory behaviours among boys than among girls and to impose fewer restrictions on boys than on girls. Poverty A recent systematic review of risk factors for fall-related injuries among children found a strong relationship between social class and the incidence of childhood falls (4). The complex associations between social deprivation and increased risks of childhood injury have several underlying factors (5, 106–111), including: – overcrowded housing conditions; – hazardous environments; – single-parenthood; – unemployment; – a relatively young maternal age; – a relatively low level of maternal education; – stress and mental health problems on the part of caregivers; – lack of access to health care. In some cases, poor-quality housing may be made more hazardous for falls as a result of its location. Examples of this are dwellings built on sloping sites in mountainous areas (112) and slum settlements constructed on rocky terrain (113, 114). Underlying conditions Despite the relative lack of data, there is evidence that children who are minimally mobile, but who are perceived by a caregiver as immobile on account of their disability, are at increased risk for falling from a bed or other elevated surface (92). The presence of mental disability can increase the risk of unintentional injury, including falls, by a factor of up to eight (115–117). An emergencydepartment study from Greece concluded that falls and concussion were more common among children with psychomotor or sensory disability than in children who were not disabled (118). Children in wheelchairs are particularly at risk, regardless of their cognitive ability, with falls estimated to account for 42% of the number of injuries among wheelchair users (92). Gender Males outnumber females for fall-related injuries – and indeed most types of injury – among children and young people (6, 100). This is the case in most countries, and applies to both fatal and non-fatal falls (4, 37, 53, 101, 102). The nature of childhood falls and injuries can be partly explained by patterns of child-rearing, socialization and role expectations. Risk-taking behaviour is also biologically determined. Irrespective of culture boys engage in rough play more frequently than do girls. Gender differences in the extent to which children are exposed to hazards are also common in most societies (29). Some researchers attribute proneness to injury in children to personality traits such as impulsiveness, hyperactivity, aggression and other behaviours more commonly ascribed to boys than girls (12, 103). While many psychological characteristics are indeed associated with increased risks of injury, a review of the literature suggests that the contribution of personality traits to childhood injuries is relatively small compared with that of environmental and social factors (104). Differences in the way boys and girls are socialized by their parents were highlighted in a study examining the reactions of mothers to their child’s behaviour on the Agent factors Consumer products In surveys of product safety in high-income countries, falls – generally involving infants in the first year of life – are among the most common non-fatal injuries. Such falls are associated with pushchairs (known as strollers in North America), prams, baby walkers, high chairs, changingtables, cots (excluding portable cots) and baby exercisers WORLD REPORT ON CHILD INJURY PREVENTION 107
Slide 127: (119, 120). A study from the state of Victoria, Australia, suggests that baby bouncers (also called baby exercisers) are involved in the most severe non-fatal injuries related to products, with almost one in three injuries resulting in hospital admission. After baby bouncers, high chairs and pushchairs are the products linked to the most severe injuries from falls (120, 121). A review of fall-related risk factors in the 0–6-year age group found that among children using bunk beds, the risk of a fall injury is greater for younger children, children from poorer families, children in newer beds, and children who fall onto non-carpeted floors (4, 122). Other reports suggest that while bunk beds and conventional beds may cause almost the same number of fall injuries among 5–9-year-olds, injuries from bunk bed falls are more severe than those from conventional bed falls as the fall is from a greater height (120). Many products for leisure activities – such as skateboards, in-line skates, Heelys (a popular brand of shoes that convert from sports to roller shoes), ice-skates, swing ropes and trampolines – can result in fall-related injuries, particularly limb fractures, sprains and head injuries (123–129) (see Box 5.2). The European Union’s injury database has identified children’s bicycles, roller skates and swings as the three leading consumer products implicated in home and leisure activity injuries, most of which are from falls (130). Despite the virtual absence of data on the issue, product safety is considered to be a significant problem for children in developing countries. In addition to product-related risks in occupational settings, globalization has led to the widespread use in developing countries of potentially dangerous products that are not always accompanied by the safety features or regulations generally found in developed countries. Heelys are one such case of increasing concern, as falls involving their use can result in significant head and limb fractures (124, 131, 132). BOX 5.2 Protective equipment to prevent wrist fractures Falls are a common form of sport and recreational injury in children and adolescents. Activities that are associated with “outreach” falls – where the person falls forward and lands on an outstretched arm – have a significant likelihood of resulting in upper limb injuries. Such activities include snow and ice sports (such as skiing and ice skating) and sports involving wheels (such as roller skating and skateboarding). Fractures of the ulna and radius, particularly of the distal radius, as well as severe upper limb injuries, are common outcomes of outreach fall injuries. The usual sequence of events leading to these wrist injuries is a loss of balance followed by a forward fall, with the person landing on an outstretched arm. The risk of injury is further increased by factors such as: – high speed; – hard or irregular surfaces; – other physical hazards; – risky manoeuvres, such as aerial jumps in skateboarding. There is considerable evidence that the majority of distal radial fractures associated with sporting activities, particularly those in snow and those involving wheels, could be prevented by the use of wrist guards (140). In fact, children and young people who do not wear wrist guards are up to ten times more likely to sustain severe wrist injuries than those who wear them. This is the case, irrespective of the person’s level of skill in the sport (141). Despite this, few participants wear them, with wearing rates estimated at less than 60% for in-line skaters and less than 30% for snowboarders. Wrist guards are ergonomically designed devices that protect the palm of the hand and support the wrist without compromising range of motion. They reduce wrist fractures by absorbing impact energy and by sharing the load, so that the bones in the wrist and forearm take less of the strain of the fall (142). Fears that wrist guards may exacerbate injury risk, or lead to more fractures further up the arm, are largely unfounded. Currently, there is no international standard for wrist guards and there are suggestions that not all models provide full protection. Nonetheless, the overwhelming weight of evidence is in favour of their effectiveness. The problem, as with other forms of protective equipment, is how to encourage young people to wear wrist guards. A range of approaches is needed, combining educational measures with laws and their enforcement at the sites where children and young people are likely to participate in these activities. These measures should be accompanied by the use of prominent role models seen wearing wrist guards, and advice as to their effectiveness at places where they are sold or rented out. appropriate and sufficiently thick surface materials, and adequate handrails or guardrails. Playground equipment Falls from playground equipment can lead to severe injuries and are commonly seen in hospital admission statistics in high-income countries (120, 133–135). A study from Victoria, Australia, found that falls from playground equipment accounted for 83% of emergency department admissions. Of these cases, 39% were related to falls from climbing equipment, 18% from slides and 14% from swings (120). Several studies have discovered significant associations between certain structural features of playgrounds and fall injuries (45, 54, 136–139). A New Zealand study has shown that lowering the height of equipment to 1.5 metres could reduce the risk of children having to attend emergency departments following playground falls by 45% (42). Studies from Canada (45) and Greece (138) have found high risks of injury, particularly from falls, in playgrounds lacking the proper safety standards – such as having 108 WORLD REPORT ON CHILD INJURY PREVENTION Animals Studies from several developing countries point to the increasing number of cases in recent years of children and young people presenting to hospital as a result of falling from a horse. This may be due to the growing popularity of horse riding as a recreational sport, as well as to larger numbers of children working on farms (143–145). While
Slide 128: most injuries from falls from horses are minor ones, a study from the Netherlands estimated that up to 40% of children and adolescents treated in hospital after falling from a horse still suffered a disability four years later (146). Animal racing also poses significant risks of childhood falls (147–150). Camel racing is a popular spectator sport, whose origins lie in the desert culture of West Asia and North Africa (150). Traditionally, race camels were ridden by young children from the family of the camel owner. In recent decades, though, migrant children as young as three or four years of age have performed as camel jockeys, sometimes trafficked for that purpose (150, 151). Falls are the commonest type of injury in camel racing, frequently resulting in head injuries, including fractures of the skull (148, 149). What a caregiver considers an adequate level of supervision may not be consistent with the epidemiological evidence. Economic conditions, such as poverty, unemployment and the disruption of social networks, may seriously affect the quality of supervision. In poor families, children may not only be left unsupervised, but find themselves acting as caregivers to younger siblings. Conditions in which caregivers are under stress and have conflicting demands placed on their attention are often the most hazardous. Other factors that increase children’s susceptibility to falls in poor households may include mental health problems affecting caregivers (5, 90, 160–164). Illustrating the last point, a large urban slum in Rocinha, Brazil, was the site of a study of childhood injuries (90). Falls accounted for 66% of the injuries, an unsurprising finding given the steeply sloping terrain on which the settlement was constructed, its rocky outcrops and open drains, as well as the high levels of stress exhibited by the children’s mothers. Several studies in high-income countries have suggested that day-care facilities may pose significant risks of injury (165, 166). A systematic review, though, found two studies that compared fall injuries in day care with those in home care. These studies showed that the risk of a fall injury among infants and young children in the home was twice the comparable risk in day-care settings (167, 168). Nonetheless, there exist great differences in conditions within day-care centres – as indeed there are within home care. A more sophisticated analysis is therefore called for, that goes beyond simple categorization of care arrangements into “home care” and “day care”. Environmental factors Physical environment The “built environment” is a vital resource for the healthy development of children. At the same time, it is often the source for their fall-related injuries (152). Structural hazards in the built environment stem from the presence of dangerous or inappropriate features, or from the absence of protective features. Specifically, such factors include: – a lack of building maintenance, particularly in lowincome rented housing; – design features in buildings and products that do not take account of the changing capabilities of young children – such as a lack of window guards in high-rise buildings; – poor lighting in buildings and in streets. Socioeconomic environment Inadequate adult supervision is often cited as a major contributor to childhood injuries (153, 154). The issues involved, however, are complex and cut across many of the problems facing the most vulnerable families. As described in Chapter 1, the relative developmental immaturity of children leads to their having limited ability to recognize danger and foresee the consequences of their actions if left unattended. It is therefore often regarded as axiomatic that caregivers should supervise children and know what type of injuries the children risk at different ages, so as to prevent them from incurring fall injuries (98). Parents, social workers and medical personnel are generally further agreed that pre-school-age children, in particular, should be supervised constantly to minimize the risk of injury – with any unsupervised period lasting no longer than five minutes (154). However, despite these generally agreed “facts”, an overreliance on supervision as the only or primary approach to prevent falls among children is ill-advised, for several reasons, including the following (155–161): Falls can occur even with adult supervision, as has been shown in several studies in high-income countries on injuries from baby walkers. Work environment Child labour places children of both sexes at a significant risk of falls. Th is is partly because the demands placed on the children usually exceed their ability to cope, in terms of developmental skills, strength, stamina and size (169). Agriculture is also the most common setting for non-fatal serious falls resulting in disabling head and limb injuries. Particular dangers for children working in this sector include unprotected platforms; ladders and tall trees used for reaching high-growing crops; pits, wells and unlit shaft s; and barns, silos and deep drainage ditches (50, 170). Children and adolescents on farms are an important group at risk in high-income countries. Data from Canadian and United States registries found that falls accounted for 41% of injuries among children in this setting. In addition, 61% of falls from heights occurred among children who were not working but who lived on the farms (143, 171, 172). WORLD REPORT ON CHILD INJURY PREVENTION 109
Slide 129: Studies from various low-income countries suggest that falls are a common cause of serious injury for children working in the construction industry, with significant risks posed by open building sites (173– 175). Engineering measures Identifying, replacing or modifying unsafe products has been a leading strategy to prevent injuries from falls in many high-income countries. Major reductions in the incidence of childhood fall injuries have been achieved by removing or redesigning nursery furniture (see Box 5.3), playground equipment, sports and recreational equipment, and other items such as shopping carts and wheelchairs (180, 181). In some instances, a complete ban on a product has ensued. In other cases, there has been substantial modification of the original design – such as the introduction of a new braking mechanism for baby walkers (182). To be effective, such measures generally require continuous enforcement (180, 182, 183). In some cases, sufficient evidence has accumulated from other situations for devices to be recommended to protect against fall-related injuries. Thus, despite a lack of intervention studies relating to horse riding, helmets are now recommended to reduce the risk of serious head injuries among young riders (144). All the same, studies from Australia, Canada, New Zealand and the United States suggest that rates of wearing helmets remain relatively low in these countries (184–186). Helmets and wrist guards are also strongly recommended for children engaging in ice skating, in-line skating and roller skating (126). Lack of treatment and rehabilitation Community-based surveys in low-income and middleincome countries show that a significant proportion of children, including those with moderate to severe fallrelated injuries, do not receive medical care. The reasons for this include: the distance to the hospital; prohibitive transport costs; and a lack of awareness on the part of the caregiver of the need for early attention (9, 19, 33, 66, 176). The Jiangxi Injury Survey reported that many children sustaining fall injuries were either alone or with another child at the time of the injury – rather than with a caregiver. The survey also found that adult caregivers were generally unaware of basic fi rst-aid procedures and did not know how to reach high-quality medical care (19). A Nigerian study noted that it was relatives or neighbours who managed most childhood injuries, and that less than 1% of injuries were seen by a health-care professional (177). The risks of late recognition of intracranial haemorrhage, inadequate care of the airway, poor management of transfer between facilities, and inadequate acute trauma and rehabilitation care can profoundly influence the probabilities of survival and disability (34, 176, 178, 179). Rates of pre-hospital deaths are greater in places with less developed emergency medical services and longer periods of transfer to hospital (178). A study from the Islamic Republic of Iran found that 40% of fatalities following childhood falls occurred in pre-hospital settings, while 30% occurred in emergency departments and 30% in hospitals (66). Environmental measures Modifying the environment to make it more “childfriendly” is a passive intervention approach that benefits people of all ages. Major changes in the design and maintenance of playgrounds have substantially reduced the number of playground injuries in many high-income countries (180). Such modifications included laying rubber or bark ground surfacing of sufficient depth, and making equipment, such as slides, safer in terms of height and structure. A community-based programme in the United States has demonstrated how modifying buildings can achieve substantial reductions in fall-related injuries among children. The “Children Can’t Fly” programme (49) (see Box 5.4), combining individual counselling and a mass media campaign with the free distribution and installation of window guards, has proved effective in cutting the incidence of falls from high-rise buildings in low-income areas. How this strategy might be transferred to other settings depends on the structure of dwellings, the resources available and other factors. However, the use of window guards in many parts of Africa and other developing regions (187) suggests that this approach might be useful, if implemented along with other measures, such as the enforcement of building regulations. Interventions The prevention of fall-related injuries among children is of paramount importance worldwide, given the large amount of resulting morbidity, the high costs of health care and the significant risk of death, particularly from head injuries. The measures employed must strike a careful balance between, on the one hand, promoting the healthy development of children – allowing them to play, explore and be physically active – and, on the other hand, recognizing the vulnerability of children living in environments designed primarily for adults. The Child safety good practice guide (180) is one of several national or regional policy documents describing practical approaches for preventing fall-related injuries among children. The following section considers the most promising such interventions in a global context. 110 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 130: BOX 5.3 Product safety and falls from nursery furniture Many countries have found injuries associated with nursery furniture to be an important issue in children under the age of five years. In the first year of a child’s life, these injuries may represent almost 20% of injuries treated in hospital (188). The introduction of injury surveillance systems and detailed systematic analyses of deaths in young children led, in the last two decades of the twentieth century, to a greater awareness in developed countries of injuries related to nursery furniture, including cots, baby walkers, high chairs, prams, pushchairs, baby bouncers and changing-tables (121). While the overwhelming majority of non-fatal, hospital-treated injuries associated with nursery furniture are due to falls, the types of injury involving nursery furniture leading to deaths are more varied. Such injuries include suffocation and strangulation, as well as asphyxiation following a fall – for example, following the tipping over of a pram. In 2002, the International Standardization Organization published guidelines for protecting children against injury from products (including buildings and installations), processes and services (189). These guidelines were aimed at those involved in setting or revising standards, as well as at designers, architects, manufacturers, service providers, communicators and policy-makers. Several countries have established standards – usually voluntary but sometimes mandatory – for the most frequently-used nursery products. These product-specific standards are known as “vertical standards”. Mandatory vertical standards have been introduced in developed countries on a country-by-country basis, where voluntary measures have failed. The European Union has a Product Safety Directive that clearly sets out who is responsible for product safety at each stage – from design through manufacture, to importation, wholesale and retail of products. Standards can also be based on the hazards, rather than the products, and these are known as “horizontal standards”. Australia, for instance, is in the process of introducing horizontal standards, following a review of the product safety system and the way in which standards were made. Developing countries need now to adopt the best practices in product safety. Several developing countries already manufacture products for export, and follow safety standards set in the high-income countries importing the products. A horizontal approach to safety standards is often the most effective way to ensure safety for a wide range of existing, new and redesigned products. Laws and regulations Laws can be powerful tools to reinforce the use of existing technology and influence behaviour. In New York City, following the passage of legislation requiring landlords to install window guards, a large decrease was observed in the number of fatal falls of young children from high-rise buildings (41). Since the introduction of both mandatory and voluntary standards for baby walkers in Canada and the United States, the tipping over of these items and structural failures in them appear to have become uncommon (51, 190). Often, the potential effectiveness of promising regulatory approaches remains unclear. For example, the effectiveness of regulatory and enforcement procedures in day-care centres is still uncertain, largely because of methodological shortcomings in the evaluative studies conducted to date (139). Even where the effectiveness of laws or regulations is clearly established, a lack of adequate enforcement may mean that a measure is not widely implemented. Despite the recognized benefits, for instance, of adopting standards for playgrounds, less than 5% of playgrounds surveyed in an Australian study were found to comply with the recommended guidelines on the depth of surface material (191). Educational approaches Educational and awareness-raising campaigns – particularly those conducted in isolation – have been criticized in several quarters (5, 105, 189). These criticisms have centred on the relative lack of evidence that these campaigns reduce injuries, the difficulty in changing human behaviour, and human weaknesses – such as inattention and the ability to be distracted – that undermine the potential effectiveness of “active” interventions. Critics have also pointed to the disproportionate burden of injury among poorer social groups, and the limited effect of health messages aimed at these groups. Nevertheless, educating the parents of young children about falls is often regarded as an affordable and feasible intervention measure. An attraction of this strategy is the relative ease with which programmes can be updated with new information – such as new guidance on baby walkers (189, 192–194). An intensive community-wide programme in the United States to educate the general public and health-care workers about the dangers of WORLD REPORT ON CHILD INJURY PREVENTION 111 © WHO
Slide 131: BOX 5.4 Children Can’t Fly “Children Can’t Fly” was a programme developed by the New York City Department of Health in the early 1970s, to counter the high rates of death and injury among children following falls from windows. The programme involved persuading the city’s health board to amend the laws, so that all landlords were required to provide window guards in high-rise apartments in which young children lived. This was the first such law of its kind in the United States. The programme contained three components. A voluntary reporting system. All falls among children under 15 years had to be reported by hospital emergency rooms and the police. Home visits were made by nurses in the public health system to the household where the fall had occurred. Education. Parents were counselled on a one-to-one basis on how to prevent falls. A mass media campaign was conducted on radio and television and in the press, informing people of the risks of children falling from windows. This was accompanied by a community education programme, involving the dissemination of printed material. Equipment. Easily-installable window guards were provided free of charge, where required, to families with young children living in areas of high risk. As a result of the programme, a significant reduction in the incidence of falls was recorded, particularly in the city’s Bronx district, where the number of reported falls declined by 50%. Many other cities around the world have since followed New York City’s lead. In addition to the lives saved, this intervention has been shown to be cost-effective in terms of savings in hospitalizations, rehabilitation and the costs of maintaining injured or permanently disabled children. Source: reference 49. infant walkers resulted in a 28% decline in the number of children presenting to emergency departments with injuries from falling down stairs related to the use of these walkers (195). Educational campaigns, though, are generally regarded to be more beneficial when combined with other strategies, such as legislation or environmental modification. Such combined approaches often make the interventions easier to transfer to other settings, or indeed to implement in the original setting (196). A review in 2007 showed that education on safety in the home (with or without the provision of safety equipment) resulted in a 26% increase in the proportion of households with fitted stair gates. However, there was a lack of evidence that these interventions actually reduced injury rates (197). A more targeted study published in 2008 has now shown some modest reductions in fall rates (198). In settings where the technology and resources exist, there is increasing interest in employing electronic communication to deliver safety messages, in the hope that such an approach will overcome the problems encountered by traditional methods of communication. One example was an early-childhood safety education programme delivered through a stall containing computers in a busy emergency department. This emergency department served a poor community with high levels of illiteracy. A randomized control trial suggested that the programme was successful in increasing knowledge and several types of safety behaviour. Its impact, however, on reducing injury rates is not as yet clear (199). An interesting finding was the observation that the benefits from more resourceintensive recommendations – such as to install child safety seats – depended on family income. As demonstrated in both developed and developing countries (200, 201), unless financial barriers and the particular situations of poor populations are addressed, “effective” interventions may increase, rather than decrease, disparities in the burden of injury, with the most vulnerable children being the least likely to benefit. Combining strategies Many intervention strategies combine several of the measures outlined above. Home visitation programmes Supportive home visitation programmes during early childhood have been used for a wide range of purposes. These include improvement of the home environment, family support and the prevention of behavioural problems in the children. A Cochrane review and other more recent studies have shown that home visits – including measures directed at poorer families – are effective in improving home safety and in reducing the risk of injury (202–206) and may result in modest reductions in injury rates (198, 202). More robust evaluation, though, 112 WORLD REPORT ON CHILD INJURY PREVENTION © T. Toroyan WHO
Slide 132: is required in this area. The visits appear to be most effective when the information provided is targeted, age-appropriate and combined with the provision and installation of safety equipment (204–207). Community interventions The use of multiple strategies repeated in different forms and contexts is a powerful means to foster a culture of safety (208). The prevention of falls is commonly included among the goals of community-based programmes for reducing childhood injury (209). Measures found to be particularly effective in this context include the installation of window guards in high-rise buildings, making playgrounds safer and removing baby walkers. In the “Children Can’t Fly” programme in New York, important components were surveillance and follow-up, media campaigns and community education – as well as the provision to families with young children of free, easily-installable window guards (49). Some programmes in developing countries have adopted the WHO Safe Communities model which includes safety audits of stairs and balcony rails, and campaigning for environmental improvements and safe recreational areas. However, good evaluations of the effectiveness of these programmes, particularly with regard to their impact on the incidence of childhood fall injuries, are still not available. Adapting interventions There is little evaluative evidence on interventions that can reduce the rate of falls and their consequences in developing countries (210). Many measures that have proved successful in reducing the incidence of fall injuries in developed countries are limited with regard to their feasibility and acceptability in developing countries. Nevertheless, the experience of intervention strategies in developed countries can suggest suitable programmes in poorer settings. There now exists a range of promising strategies to reduce the incidence of childhood falls in lowincome and middle-income countries. A recent overview of programmes in developed countries to prevent injuries from falls found that – other than general recommendations about greater supervision of children, interventions to reduce the height of playground equipment and appropriate ground surfacing in playgrounds – only one proven intervention was defi nitely transferable to developing countries (210). Th is was the “Children Can’t Fly” programme already mentioned, that was effective in reducing falls from high-rise buildings in a low-income community in New York City. While the materials used and the context may differ, more widespread use in developing countries of barriers (such as the window guards in the “Children Can’t Fly” programme) and safety equipment is likely not only to be effective but also affordable, feasible and sustainable. Specifically, it is reasonable to assume that reinforced construction and protective barriers around the periphery of roofs, as well as railings on stairs, can reduce the risk of falls among children. Furthermore, such measures can be strengthened by introducing and enforcing housing standards and building regulations (105, 189). As already noted, the most effective interventions to prevent injuries related to falls from playground equipment have focused on the use of impact-absorbing materials, height restrictions on equipment and the overall design of playgrounds. While the materials may vary, the same principles apply in all countries. A study in a township in Johannesburg, South Africa, found that creating safer and improved recreational spaces and play areas for children was of prime importance for preventing injury, as well as violence, to children (211). The effectiveness of home visitation programmes in early childhood in reducing the risk of falls and other injuries holds particular promise for low-income and middle-income countries. Many studies undertaken in high-income countries have focused on vulnerable families and used non-professional visitors (202). An exploratory study in Jordan of childhood injuries, including those from falls, has highlighted the promising nature of risk inventories prepared by health visitors (162). Several studies from developing countries have considered the potential benefits of mass media and pamphlet campaigns (97). Others have examined home safety and injury prevention information targeted variously at parents, health-care workers, law enforcement officers, municipal officials, construction workers and policy-makers (106, 162, 212–214). Features of some of these promising programmes include: – the inclusion of public safety messages that correspond to children’s cognitive and developmental stages and to their settings (97, 213); – the combination of education with specific environmental modifications to achieve greater safety (90, 211); – the use of culturally appropriate modes of communication (97, 211); – the formulation of messages that are relevant to the conditions of poor or marginalized communities (90, 211). As already noted, research has so far failed to provide convincing evidence that educational and awarenessraising campaigns, in isolation, are effective in reducing the incidence of childhood fall injuries. It is possible that this reflects inadequate data and limitations in the design of evaluations (197). On the other hand, the lack of evidence may be a result of the fact that changes in knowledge and attitudes do not necessarily create corresponding changes in injury rates. The Injury Prevention Project Safety WORLD REPORT ON CHILD INJURY PREVENTION 113
Slide 133: Survey (TIPP-SS) of the American Academy of Pediatrics is a widely used educational programme in the United States that seeks to assess changes in behaviour. A recent study of TIPP-SS suggests that rather than behaviour, it is knowledge and attitudes that the survey actually measures (215). Before countries start to invest scarce resources, it is therefore important that educational campaigns that appear feasible are carefully evaluated for their ability to significantly reduce the rate of injuries. Conclusions and recommendations Falls are the most common cause in many countries of injury-related hospital stays and emergency department visits involving children. Limb fractures and head injuries are common and traumatic brain injuries are most likely to result in lifelong disability. The predisposing factors and the types of fall vary considerably across different settings. Developing countries have a disproportionately high rate of fall-related injuries among children, and efforts to prevent these injuries are hampered by the lack of evaluative evidence of interventions that have been tried in these countries. Furthermore, although it is clear that the health-care sector has a pivotal role to play in preventing childhood injury, injury prevention in many countries often does not figure among the priorities for health. Table 5.3 summarizes the main approaches to addressing childhood falls. The most effective strategies, in all countries, are those that combine proven or promising measures. Involving a range of sectors It is always necessary to consider the broader social determinants that affect the incidence of childhood falls. Given the different settings and types of childhood fall, it is not surprising that prevention efforts cut across a range of sectors. For falls involving work in the agricultural sector, for example, groups involved in prevention include governmental and commercial bodies in that sector, landowners, farmers, manufacturers of equipment, occupational health workers, labour unions and community groups. Efforts to prevent falls in the home bring in municipal authorities, architects, builders, town planners, furniture designers, product manufacturers, health-care services, social services and nongovernmental organizations. Children can incur injuries as a result of one or more of a range of factors relating to their caregivers. Such factors include poverty, ignorance, lack of control over the environment, fatigue, depression and malevolence. Agencies that might address some of these factors include those dealing with mental health and criminal justice, social service agencies, and community and nongovernmental organizations. TABLE 5.3 Recommendations From the discussion in this chapter, a number of recommendations stand out, including the following. Countries should, where possible, develop and promote locally manufactured, cheap and effective measures to protect against childhood falls – such as window guards, roof railings and stair gates. Where building regulations exist, home modifications – such as the installation of window guards – should be incorporated into the regulations and enforced. Local authorities should address structural hazards in the built environment that pose fall risks for children, such as open drains and wells. Key strategies to prevent falls among children Insufficient evidence Ineffective Promising Strategy Effective Harmful Implementing multifaceted community programmes such as “Children Can’t Fly” Redesigning nursery furniture and other products Establishing playground standards for the depth of appropriate surface material, height of equipment and maintenance Legislating for window guards Using stair gates and guard rails Conducting supportive home visitation and education for at-risk families Holding mass media campaigns directed at parents, health workers Providing appropriate paediatric acute care Raising awareness through educational campaigns Implementing housing and building codes Covering wells and ditches and removing hazards 114 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 134: Local authorities should ensure that children have access to safe playgrounds and recreational spaces – thereby encouraging physical activity while at the same time reducing the risk of fall-related injury. Parental supervision is an important aspect of prevention, particularly when combined with other interventions. Acute care and rehabilitation should be available and devised appropriately for children, so as to minimize the long-term consequences of falls and prevent longterm disability. Community-based injury surveys that extend beyond assessments at health-care facilities are needed to obtain epidemiological data on fall injuries in lowincome and middle-income countries. Data on the characteristics of injuries and the associated risk factors are of special importance. This research should help identify, for a given setting, the five leading causes and types of childhood fall injuries and point to the most cost-effective prevention strategies. Large-scale evaluation studies of interventions for reducing the incidence of childhood fall injuries and their consequences urgently need to be undertaken in low-income and middle-income countries. 9. Bangdiwala SI et al. The incidence of injuries in young people: I. Methodology and results of a collaborative study in Brazil, Chile, Cuba and Venezuela. International Journal of Epidemiology, 1990, 19:115–124. Del Ciampo LA et al. Incidence of childhood accidents determined in a study of home surveys. Annals of Tropical Paediatrics, 2001, 21:239–243. Savitsky B et al. Variability in pediatric injury patterns by age and ethnic groups in Israel. Ethnicity and Health, 2007, 12:129–139. Bener A, Hyder AA, Schenk E. Trends in childhood injury mortality in a developing country: United Arab Emirates. Accident and Emergency Nursing, 2007, 15:228–233. Evbuomwan I. Paediatric trauma admissions in the Sakaka Central Hospital, Al-Jouf Province, Saudi Arabia. Saudi Medical Journal, 1994, 15:435–437. Bener A et al. A retrospective descriptive study of pediatric trauma in a desert country. Indian Pediatrics, 1997, 34:1111–1114. Linnan M et al. Child mortality and injury in Asia: survey results and evidence. Florence, UNICEF Innocenti Research Centre, 2007 (http://www.unicef-irc.org/ publications/pdf/iwp_2007_06.pdf, accessed 21 January 2008). Overpeck MD, McLoughlin E. Did that injury happen on purpose? Does intent really matter? Injury Prevention, 1999, 5:11–12. Cheng TL et al. A new paradigm of injury intentionality. Injury Prevention, 1999, 5:59–61. Linnan MJ et al. Vietnam multicentre injury survey. Hanoi, Hanoi School of Public Health, 2003. Jiangxi injury survey: child injury report. Jiangxi, Jiangxi Center for Disease Control, The Alliance for Safe Children, UNICEF–China, Jiangxi Provincial Health Bureau, Chinese Field Epidemiology Training Program, 2006. Pickett W et al. Injuries experienced by infant children: a population-based epidemiological analysis. Pediatrics, 2003, 111:e365–370. Steenkamp M, Cripps R. Child injuries due to falls (Injury Research and Statistics Series, No. 7). Adelaide, Australian Institute of Health and Welfare, 2001. WHO mortality database: tables. Geneva, World Health Organization (http://www.who.int/healthinfo/morttables/ en/index.html, accessed 21 April 2008). Pickett W, Hartling L, Brison RJ. A population-based study of hospitalized injuries in Kingston, Ontario, identified via the Canadian Hospitals Injury Reporting and Prevention Program. Chronic Diseases in Canada, 1997, 18:61–69. Agran PF et al. Rates of pediatric injuries by 3-month intervals for children 0 to 3 years of age. Pediatrics, 2003, 111:e683–692. Lam LT, Ross FI, Cass DT. Children at play: the death and injury pattern in New South Wales, Australia, July WORLD REPORT ON CHILD INJURY PREVENTION 115 10. 11. 12. 13. 14. 15. 16. References 1. Rahman A et al. Bangladesh health and injury survey report on children. Dhaka, Institute of Child and Mother Health, 2005. Falls. Geneva, World Health Organization, Violence and Injury Prevention and Disability Department (http:// www.who.int/violence_injury_prevention/other_injury/ falls/en/index.html, accessed 20 March 2008). Christoffel KK et al. Standard definitions for childhood injury research: excerpts of a conference report. Pediatrics, 1992, 89:1027–1034. Khambalia A et al. Risk factors for unintentional injuries due to falls in children aged 0–6 years: a systematic review. Injury Prevention, 2006, 12:378–385. Bartlett SN. The problem of children’s injuries in lowincome countries: a review. Health Policy and Planning, 2002, 17:1–13. Morrison A, Stone DH. Unintentional childhood injury mortality in Europe 1984–93: a report from the EURORISC Working Group. Injury Prevention, 1999, 5:171–176. A league table of child deaths by injury in rich countries (Innocenti Report Card No. 2). Florence, UNICEF Innocenti Research Centre, 2001 (http://www.unicef-icdc. org/publications/pdf/repcard2e.pdf, accessed 22 January 2008). Hyder AA et al. Falls among children in the developing world: a gap in child health burden estimations? Acta Paediatrica, 2007, 96:1394–1398. 17. 18. 19. 2. 3. 20. 4. 21. 5. 22. 6. 23. 7. 24. 8. 25.
Slide 135: 1990–June 1994. Journal of Paediatric Child Health, 1999, 35:572–577. 26. Warrington SA, Wright CM, ALSPAC Study Team. Accidents and resulting injuries in premobile infants. Archives of Disease in Childhood, 2001, 85:104–107. Potoka DA, Schall LC, Ford HR. Improved functional outcome for severely injured children treated at pediatric trauma centers. Journal of Trauma, 2001, 51:824–834. Mo F et al. Adolescent injuries in Canada: findings from the Canadian community health survey, 2000– 2001. International Journal of Injury Control and Safety Promotion, 2006, 13:235–244. Linnan M, Peterson P. Child injury in Asia: time for action. Bangkok, The Alliance for Safe Children (TASC) and UNICEF East Asia and Pacific Regional Office, 2004 (http://www.unicef.org/eapro/Child_injury_issue_paper. pdf, accessed 20 March 2008). El-Chemaly SY et al. Hospital admissions after paediatric trauma in a developing country: from falls to landmines. International Journal of Injury Control and Safety Promotion, 2007, 14:131–134. Linnan M et al. Child mortality and injury in Asia: an overview. Florence, UNICEF, Innocenti Research Centre, 2007 (http://www.unicef-irc.org/publications/pdf/ iwp_2007_04.pdf, accessed 21 January 2008). (Innocenti Working Paper 2007-04, Special Series on Child Injury No. 1). Kobusingye O, Guwatudde D, Lett R. Injury patterns in rural and urban Uganda. Injury Prevention, 2001, 7:46– 50. Tercero F et al. The epidemiology of moderate and severe injuries in a Nicaraguan community: a household-based survey. Public Health, 2006, 120:106–114. Hijar-Medina MC et al. Accidentes en el hogar en niños menores de 10 años: causas y consecuencias [Home accidents in children less than 10 years of age: causes and consequences]. Salud Pública de México, 1992, 34:615– 625. Fatmi Z et al. Incidence, patterns and severity of reported unintentional injuries in Pakistan for persons five years and older: results of the National Health Survey of Pakistan 1990–94. BMC Public Health, 2007, 7:152. Bachani A et al. The burden of falls in Pakistan: the results of the 1st National Injury Survey. Baltimore, MD, Johns Hopkins University, 2007. Garrettson LK, Gallagher SS. Falls in children and youth. Pediatric Clinics of North America, 1985, 32:153–162. Mosenthal AC et al. Falls: epidemiology and strategies for prevention. Journal of Trauma: Injury, Infection, and Critical Care, 1995, 38:753–756. Buckman RF, Buckman PD. Vertical deceleration trauma: principles of management. Surgical Clinics of North America, 1991, 71:331–344. 40. Warner KG, Demling RH. The pathophysiology of freefall injury. Annals of Emergency Medicine, 1986, 15:1088– 1093. Barlow B et al. Ten years of experience with falls from a height in children. Journal of Pediatric Surgery, 1983, 18:509–511. Chalmers DJ et al. Height and surfacing as risk factors for injury in falls from playground equipment: a case-control study. Injury Prevention, 1996, 2:98–104. Macarthur C et al. Risk factors for severe injuries associated with falls from playground equipment. Accident Analysis and Prevention, 2000, 32:377–382. Mott A et al. Safety of surfaces and equipment for children in playgrounds. The Lancet, 1997, 349:1874–1876. Mowat DL et al. A case-control study of risk factors for playground injuries among children in Kingston and area. Injury Prevention, 1998, 4:39–43. Bertocci GE et al. Influence of fall height and impact surface on biomechanics of feet-fi rst free falls in children. Injury, 2004, 35:417–424. Sieben RL, Leavitt JD, French JH. Falls as childhood accidents: an increasing urban risk. Pediatrics, 1971, 47:886–892. Bergner L, Mayer S, Harris D. Falls from heights: a childhood epidemic in an urban area. American Journal of Public Health, 1971, 61:90–96. Spiegel CN, Lindaman FC. Children can’t fly: a program to prevent childhood morbidity and mortality from window falls. American Journal of Public Health, 1977, 67:1143–1147. Barss P et al. Injury prevention: an international perspective. Epidemiology, surveillance and policy. London, Oxford University Press, 1998. American Academy of Paediatrics. Falls from heights: windows, roofs and balconies. Pediatrics, 2001, 107:1188– 1191. Beijing injury survey: child injury report. Beijing, Chinese Field Epidemiology Training Program, The Alliance for Safe Children, UNICEF–China, 2003. Adesunkanmi AR, Oseni SA, Badru OS. Severity and outcome of falls in children. West African Journal of Medicine, 1999, 18:281–285. Chalmers DJ, Langley JD. Epidemiology of playground equipment injuries resulting in hospitalization. Journal of Paediatrics and Child Health, 1990, 26:329–334. Reiber GD. Fatal falls in childhood. How far must children fall to sustain fatal head injury? Report of cases and review of the literature. American Journal of Forensic Medicine and Pathology, 1993, 14:201–207. Chadwick DL et al. Deaths from falls in children: how far is fatal? Journal of Trauma: Injury, Infection, and Critical Care, 1991, 31:1353–1355. 41. 27. 42. 28. 43. 29. 44. 45. 30. 46. 31. 47. 48. 32. 49. 33. 50. 34. 51. 52. 35. 53. 36. 54. 37. 38. 55. 39. 56. 116 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 136: 57. Williams RA. Injuries in infants and small children resulting from witnessed and corroborated free falls. Journal of Trauma, 1991, 31:1350–1352. Goodacre S et al. Can the distance fallen predict serious injury after a fall from a height? Journal of Trauma: Injury, Infection, and Critical Care, 1999, 46:1055–1058. Abdullah J et al. Persistence of cognitive deficits following paediatric head injury without professional rehabilitation in rural East Coast Malaysia. Asian Journal of Surgery, 2005, 28:163–167. Hyder AA et al. The impact of traumatic brain injuries: a global perspective. Neurorehabilitation, 2007, 22:341. Ong L et al. Outcome of closed head injury in Malaysian children: neurocognitive and behavioural sequelae. Journal of Paediatrics and Child Health, 1998, 34:363– 368. Langlois JA, Rutland-Brown W, Thomas KE. Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. Atlanta, GA, Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2006. Williamson LM, Morrison A, Stone DH. Trends in head injury mortality among 0–14 year olds in Scotland (1986– 95). Journal of Epidemiology and Community Health, 2002, 56:285–288. Brookes M et al. Head injuries in accident and emergency departments. How different are children from adults? Journal of Epidemiology and Community Health, 1990, 44:147–151. Tiret L et al. The epidemiology of head trauma in Aquitaine (France), 1986: a community-based study of hospital admissions and deaths. International Journal of Epidemiology, 1990, 19:133–140. Zargar M, Khaji A, Karbakhsh M. Injuries caused by falls from trees in Tehran, Islamic Republic of Iran. Eastern Mediterranean Health Journal, 2005,11:235–239. Al-Jadid MS, Al-Asmari AK, Al-Moutaery KR. Quality of life in males with spinal cord injury in Saudi Arabia. Saudi Medical Journal, 2004, 25:1979–1985. Cirak B et al. Spinal injuries in children. Journal of Pediatric Surgery, 2004, 39:607–612. Okonkwo CA. Spinal cord injuries in Enugu, Nigeria: preventable accidents. Paraplegia, 1988, 26:12–18. Kopjar B, Wickizer TM. Fractures among children: incidence and impact on daily activities. Injury Prevention, 1998, 4:194–197. Rennie L et al. The epidemiology of fractures in children. Injury, 2007, 38:913–922. Smith MD, Burrington JD, Woolf AD. Injuries in children sustained in free falls: an analysis of 66 cases. Journal of Trauma: Injury, Infection, and Critical Care, 1975, 15:987– 991. 73. Hansoti B, Beattie T. Can the height of a fall predict long bone fracture in children under 24 months? European Journal of Emergency Medicine, 2005, 12:285–286. Helps YLM, Pointer SC. Child injury due to falls from playground equipment, Australia 2002–04. Canberra, Australian Institute of Health and Welfare, 2006. Ball DJ. Trends in fall injuries associated with children’s outdoor climbing frames. International Journal of Injury Control and Safety Promotion, 2007, 14:49–53. Mitchell R et al. Falls from playground equipment: will the new Australian playground safety standard make a difference and how will we tell? Health Promotion Journal of Australia, 2007, 18:98–104. Bach O et al. Disability can be avoided after open fractures in Africa: results from Malawi. Injury, 2004, 35:846–851. Mock CN. Injury in the developing world. Western Journal of Medicine, 2001, 175:372–374. Dhillon KS, Sengupta S, Singh BJ. Delayed management of fracture of the lateral humeral condyle in children. Acta Orthopaedica Scandinavica, 1988, 59:419–424. Musemeche CA et al. Pediatric falls from heights. Journal of Trauma: Injury, Infection, and Critical Care, 1991, 31:1347–1349. Thailand injury survey: Child injury report. Bangkok, Institute for Health Research, Chulalongkorn University, The Alliance for Safe Children, UNICEF–Thailand, 2004. The economic burden of unintentional injury in Canada. Toronto, ON, Smartrisk; Emergency Health Services Branch, Ministry of Health, Ontario, 1998. Falls fact sheet. Washington, DC, National SAFE KIDS Campaign, 2004 (http://www.usa.safekids.org/tier3_ cd.cfm?folder_id=540&content_item_id=1050, accessed 20 March 2008). Pressley JC et al. National injury-related hospitalizations in children: public versus private expenditures across preventable injury mechanisms. Journal of Trauma: Injury, Infection, and Critical Care, 2007, 63(Suppl):S10–S19. Simmons D. Accidents in Malawi. Archives of Disease in Childhood, 1985, 60:64–66. Gurses D et al. Cost factors in pediatric trauma. Canadian Journal of Surgery, 2003, 46:441–445. Bickler SW, Rode H. Surgical services for children in developing countries. Bulletin of the World Health Organization, 2002, 80:829–835. Bickler SW, Sanno-Duanda B. Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia. Bulletin of the World Health Organization, 2000, 78:1330–1336. Flavin MP et al. Stages of development and injury patterns in the early years: a population-based analysis. BMC Public Health, 2006, 6:187. Towner E et al. Accidental falls: fatalities and injuries: an examination of the data sources and review of the literature WORLD REPORT ON CHILD INJURY PREVENTION 117 58. 74. 59. 75. 76. 60. 61. 77. 78. 79. 62. 80. 63. 81. 64. 82. 65. 83. 66. 84. 67. 85. 86. 87. 68. 69. 70. 88. 71. 72. 89. 90.
Slide 137: on preventive strategies. London, Department of Trade and Industry, 1999. 91. Berger SE, Theuring C, Adolph KE. How and when infants learn to climb stairs. Infant Behavior and Development, 2007, 30:36–49. Matheny AP. Accidental injuries. In: Routh D, ed. Handbook of pediatric psychology. New York, NY, Guilford Press, 1988. Needleman RD. Growth and development. In: Behrman RE et al., eds. Nelson Textbook of Pediatrics, 17th ed. Philadelphia, PA, Saunders, 2003:23–66. Ozanne-Smith J et al. Community based injury prevention evaluation report: Shire of Bulla Safe Living Program. Canberra, Monash University Accident Research Centre, 1994 (Report No. 6). Schelp L, Ekman R, Fahl I. School accidents during a three school-year period in a Swedish municipality. Public Health, 1991, 105:113–120. Bangdiwala SI, Anzola-Perez E. The incidence of injuries in young people: log-linear multivariable models for risk factors in a collaborative study in Brazil, Chile, Cuba and Venezuela. International Journal of Epidemiology, 1990, 19:125–132. Hijar-Medina MC et al. Factores de riesgo de accidentes en el hogar en niños. Estudio de casos y controles [The risk factors for home accidents in children. A case-control study]. Boletín Médico del Hospital Infantil de México, 1993, 50:463–474. Mohan D. Childhood injuries in India: extent of the problem and strategies for control. Indian Journal of Pediatrics, 1986, 53:607–615. Yagmur Y et al. Falls from flat-roofed houses: a surgical experience of 1643 patients. Injury, 2004, 35:425–428. 106. Reading R et al. Accidents to preschool children: comparing family and neighbourhood risk factors. Social Science and Medicine, 1999, 48:321–330. 107. Engstrom K, Diderichsen F, Laflamme L. Socioeconomic differences in injury risks in childhood and adolescence: a nation-wide study of intentional and unintentional injuries in Sweden. Injury Prevention, 2002, 8:137–142. 108. Faelker T, Pickett W, Brison RJ. Socioeconomic differences in childhood injury: a population based epidemiologic study in Ontario, Canada. Injury Prevention, 2000, 6:203– 208. 109. Pensola TH, Valkonen T. Mortality differences by parental social class from childhood to adulthood. Journal of Epidemiology and Community Health, 2000, 54:525–529. 110. Thanh NX et al. Does the “Injury poverty trap” exist? A longitudinal study from Bavi, Vietnam. Health Policy, 2006, 78:249–257. 111. Shenassa ED, Stubbendick A, Brown MJ. Social disparities in housing and related pediatric injury: a multilevel study. American Journal of Public Health, 2004, 94:633–639. 112. Thanh NX et al. Does poverty lead to non-fatal unintentional injuries in rural Vietnam? International Journal of Injury Control and Safety Promotion, 2005, 12:31–37. 113. Reichenheim ME, Harpham T. Child accidents and associated risk factors in a Brazilian squatter settlement. Health Policy and Planning, 1989, 4:162–167. 114. Rizvi N et al. Distribution and circumstances of injuries in squatter settlements in Karachi, Pakistan. Accident Analysis and Prevention, 2006, 38:526–531. 115. Dunne RG, Asher KN, Rivara FP. Injuries in young people with developmental disabilities: comparative investigation from the 1988 National Health Interview Survey. Mental Retardation, 1993, 31:83–88. 116. Sherrard J, Tonge BJ, Ozanne-Smith J. Injury in young people with intellectual disability: descriptive epidemiology. Injury Prevention, 2001, 7:56–61. 117. Gallagher SS et al. The incidence of injuries among 87,000 Massachusetts children and adolescents: results of the 1980–81 Statewide Childhood Injury Prevention Program Surveillance System. American Journal of Public Health, 1984, 74:1340–1347. 92. 93. 94. 95. 96. 97. 98. 99. 100. Krug EG, Sharma GK, Lozano R. The global burden of injuries. American Journal of Public Health, 2000, 90:523– 526. 101. Rivara FP et al. Population-based study of fall injuries in children and adolescents resulting in hospitalization or death. Pediatrics, 1993, 92:61–63. 102. Roudsari BS, Shadman M, Ghodsi M. Childhood trauma fatality and resource allocation in injury control programs in a developing country. BMC Public Health, 2006, 6:117. 103. Iltus S. Parental ideologies in the home safety management of one to four year old children. New York, NY, Graduate School and University Center of the City University of New York, 1994. 104. Wazana A. Are there injury-prone children? A critical review of the literature. Canadian Journal of Psychiatry, 1997, 42:602–610. 105. Morrongiello BA, Dawber T. Mothers’ responses to sons and daughters engaging in injury-risk behaviors on a playground: implications for sex differences in injury rates. Journal of Experimental Child Psychology, 2000, 76:89–103. 118 WORLD REPORT ON CHILD INJURY PREVENTION 118. Petridou E et al. Injuries among disabled children: a study from Greece. Injury Prevention, 2003, 9:226–230. 119. Ozanne-Smith J, Heffernan CJ. Child injuries associated with nursery furniture. Melbourne, Monash University Accident Research Centre, 1990:16. 120. Watson W, Ozanne-Smith J, Lough J. Consumer product related injury to children. Melbourne, Monash University Accident Research Centre, 2000. 121. Watson W et al. Injuries associated with nursery furniture and bunk beds. Melbourne, Monash University Accident Research Centre, 1997.
Slide 138: 122. Selbst SM, Baker MD, Shames M. Bunk bed injuries. American Journal of Diseases of Children, 1990, 144:721– 723. 123. Edwards DJ. Tarzan swings: a dangerous new epidemic. British Journal of Sports Medicine, 1991, 25:168–169. 124. Vioreanu M et al. Heelys and street gliders injuries: a new type of pediatric injury. Pediatrics, 2007, 119:e1294–1298. 125. Brudvik C. Injuries caused by small wheel devices. Prevention Science, 2006, 7:313–320. 126. Knox CL, Comstock RD. Video analysis of falls experienced by paediatric iceskaters and roller/inline skaters. British Journal of Sports Medicine, 2006, 40:268–271. 127. Knox CL et al. Differences in the risk associated with head injury for pediatric ice skaters, roller skaters, and in-line skaters. Pediatrics, 2006, 118:549–554. 128. Linakis JG et al. Emergency department visits for pediatric trampoline-related injuries: an update. Academic Emergency Medicine, 2007, 14:539–544. 129. Black GB, Amadeo R. Orthopedic injuries associated with backyard trampoline use in children. Canadian Journal of Surgery, 2003, 46:199–201. 130. Zimmerman N, Bauer R. Injuries in the European Union: statistics summary 2002–2004. Vienna, European Association for Injury Prevention and Safety Promotion (EuroSafe), 2006. 131. Oh D. Heelys injuries in children. Singapore Medical Journal, 2006, 47:375. 132. Lenehan B et al. Heely injuries: a new epidemic warranting a government health warning! Injury, 2007, 38:923–925. 133. Mott A et al. Patterns of injuries to children on public playgrounds. Archives of Disease in Childhood, 1994, 71:328–330. 134. Injury hospitalisations in Victoria 1991–92. A report focusing on the injuries of children and youth. Melbourne, Victorian Government Department of Health and Community Services, 1995. 135. Norton C, Nixon J, Sibert JR. Playground injuries to children. Archives of Disease in Childhood, 2004, 89:103– 108. 136. Briss PA et al. Injuries from falls on playgrounds: effects of day care center regulation and enforcement. Archives of Pediatrics and Adolescent Medicine, 1995, 149:906–911. 137. Laforest S et al. Surface characteristics, equipment height, and the occurrence and severity of playground injuries. Injury Prevention, 2001, 7:35–40. 138. Petridou E et al. Injuries in public and private playgrounds: the relative contribution of structural, equipment and human factors. Acta Paediatrica, 2002, 91:691–697. 139. Sherker S et al. Out on a limb: risk factors for arm fracture in playground equipment falls. Injury Prevention, 2005, 11:120–124. 140. Lyons RA et al. Children’s fractures: a population based study. Injury Prevention, 1999, 5:129–132. 141. Scheiber RA et al. Risk factors for injuries from in-line skating and the effectiveness of safety gear. New England Journal of Medicine, 1996, 335:1630–1635. 142. Kim KJ et al. Shock attenuation of various protective devices for prevention of fall-related injuries of the forearm/hand complex. American Journal of Sports Medicine, 2006, 34:637–643. 143. Hendricks KJ et al. Injuries to youth living on U.S. farms in 2001 with comparison to 1998. Journal of Agromedicine, 2005, 10:19–26. 144. Jagodzinski T, DeMuri GP. Horse-related injuries in children: a review. Wisconsin Medical Journal, 2005, 104:50–54. 145. Smith GA et al. Pediatric farm-related injuries: a series of 96 hospitalized patients. Clinical Pediatrics, 2004, 43:335– 342. 146. Dekker R et al. Long-term outcome of equestrian injuries in children. Disability and Rehabilitation, 2004, 26:91– 96. 147. Ugboko VI et al. Facial injuries caused by animals in northern Nigeria. British Journal of Oral and Maxillofacial Surgery, 2002, 40:433–437. 148. Nawaz A et al. Camel-related injuries in the pediatric age group. Journal of Pediatric Surgery, 2005, 40:1248–1251. 149. Bener A et al. Camel racing injuries among children. Clinical Journal of Sport Medicine, 2005, 15:290–293. 150. Caine D, Caine C. Child camel jockeys: a present-day tragedy involving children and sport. Clinical Journal of Sport Medicine, 2005, 15:287–289. 151. Khalaf S. Camel racing in the Gulf: notes on the evolution of a traditional sport. Anthropos, 1999, 94:85–105. 152. Cummins SK, Jackson RJ. The built environment and children’s health. Pediatric Clinics of North America, 2001, 48:1241–1252. 153. Garbarino J. Preventing childhood injury: developmental and mental health issues. American Journal of Orthopsychiatry, 1988, 58:25–45. 154. Peterson L, Ewigman B, Kivlahan C. Judgments regarding appropriate child supervision to prevent injury: the role of environmental risk and child age. Child Development, 1993, 64:934–950. 155. Rieder MJ, Schwartz C, Newman J. Patterns of walker use and walker injury. Pediatrics, 1986, 78:488–493. 156. Coats TJ, Allen M. Baby walker related injuries: a continuing problem. Archives of Emergency Medicine, 1991, 8:52–55. 157. Partington MD, Swanson JA, Meyer FB. Head injury and the use of baby walkers: a continuing problem. Annals of Emergency Medicine, 1991, 20:652–654. 158. Chen X et al. Frequency of caregiver supervision of young children during play. International Journal of Injury Control and Safety Promotion, 2007, 14:122–124. WORLD REPORT ON CHILD INJURY PREVENTION 119
Slide 139: 159. Munro SA, van Niekerk A, Seedat M. Childhood unintentional injuries: the perceived impact of the environment, lack of supervision and child characteristics. Child: Care, Health and Development, 2006, 32:269–279. 160. Mull DS et al. Injury in children of low-income Mexican, Mexican American, and non-Hispanic white mothers in the USA: a focused ethnography. Social Science and Medicine, 2001, 52:1081–1091. 161. Thompstone G, Chen J, Emmons K. The participation of children and young people in emergencies: a guide for relief agencies based largely on experiences in the Asian tsunami response. Bangkok, UNICEF East Asia and Pacific Regional Office, 2007 (http://www.unicef.org/eapro/ the_participation_of_children_and_young_people_in_ emergencies.pdf, accessed 21 March 2008). 162. Janson S et al. Accident risks for suburban preschool Jordanian children. Journal of Tropical Pediatrics, 1994, 40:88–93. 163. Drachler M et al. Effect of the home environment on unintentional domestic injuries and related health care attendance in infants. Acta Paediatrica, 2007, 96:1169– 1173. 164. Howe LD, Huttly SRA, Abramsky T. Risk factors for injuries in young children in four developing countries: the Young Lives Study. Tropical Medicine and International Health, 2006, 11:1557–1566. 165. Landman PF, Landman GB. Accidental injuries in children in day-care centers. American Journal of Diseases of Children, 1987, 141:292–293. 166. Wasserman RC et al. Injury hazards in home day care. Journal of Pediatrics, 1989, 114:591–593. 167. Kopjar B, Wickizer T. How safe are day care centers? Day care versus home injuries among children in Norway. Pediatrics, 1996, 97:43–47. 168. Rivara FP et al. Risk of injury to children less than 5 years of age in day care versus home care settings. Pediatrics, 1989, 84:1011–1016. 169. Richter ED, Jacobs J. Work injuries and exposures in children and young adults: review and recommendations for action. American Journal of Industrial Medicine, 1991, 19:747–769. 170. Tackling hazardous child labour in agriculture: guidance on policy and practice. User guide. Geneva, International Labour Organization, 2006 (http://tinyurl.com/24lfar, accessed 21 March 2008). 171. Pickett W et al. Pediatric farm injuries involving nonworking children injured by a farm work hazard: five priorities for primary prevention. Injury Prevention, 2005, 11:6–11. 172. Pickett W et al. Pediatric fall injuries in agricultural settings: a new look at a common injury control problem. Journal of Occupational and Environmental Medicine, 2007, 49:461–468. 120 WORLD REPORT ON CHILD INJURY PREVENTION 173. Noe R et al. Occupational injuries identified by an emergency department based injury surveillance system in Nicaragua. Injury Prevention, 2004, 10:227–232. 174. Thepaksorn P et al. Occupational accidents and injuries in Thailand. International Journal of Occupational and Environmental Health, 2007, 13:290–294. 175. Xia ZL et al. Fatal occupational injuries in a new development area in the People’s Republic of China. Journal of Occupational and Environmental Medicine, 2000, 42:917–922. 176. Mock CN, Denno D, Adzotor E. Paediatric trauma in the rural developing world: low cost measures to improve outcome. Injury, 1993, 24:291–296. 177. Edet EE. Agent and nature of childhood injury and initial care provided at the community level in Ibadan, Nigeria. Central African Journal of Medicine, 1996, 42:347–349. 178. Mock CN et al. Trauma mortality patterns in three nations at different economic levels: implications for global trauma system development. Journal of Trauma: Injury, Infection, and Critical Care, 1998, 44:804–814. 179. Weston PM. Care of the injured in the Third World: what can we learn? Injury, 1987, 18:297–303. 180. MacKay M et al. Child safety good practice guide: good investments in unintentional child injury prevention and safety promotion. Amsterdam, European Child Safety Alliance (EuroSafe), 2006. 181. American Academy of Pediatrics, Committee on Injury Violence and Poison Prevention. Shopping cart-related injuries to children. Pediatrics, 2006, 118:825–827. 182. Nursery products report. Washington, DC, United States Consumer Product Safety Commission, 2000 (http:// www.cpsc.gov/library/nursry00.pdf, accessed 21 March 2008). 183. Sherker S, Short A, Ozanne-Smith J. The in situ performance of playground surfacing: implications for maintenance and injury prevention. International Journal of Injury Control and Safety Promotion, 2005, 12:63–66. 184. Johns E, Farrant G, Civil I. Animal-related injury in an urban New Zealand population. Injury, 2004, 35:1234– 1238. 185. Holland AJ et al. Horse-related injuries in children. Medical Journal of Australia, 2001, 175:609–612. 186. Ball CG et al. Equestrian injuries: incidence, injury patterns, and risk factors for 10 years of major traumatic injuries. American Journal of Surgery, 2007, 193:636–640. 187. Forjuoh SN, Li G. A review of successful transport and home injury interventions to guide developing countries. Social Science and Medicine, 1996, 43:1551–1560. 188. Ozanne-Smith J. Child injury by developmental stage. Australian Journal of Early Childhood, 1992, 17:39–48. 189. Safety aspects: guidelines for child safety. Geneva, International Standardization Organization, 2002 (ISO/ IEC Guide No. 50).
Slide 140: 190. Standard consumer safety performance specification for infant walkers (ASTM F977-96). Philadelphia, PA, American Society for Testing and Materials, 1996. 191. Sherker S, Ozanne-Smith J. Are current playground safety standards adequate for preventing arm fractures? Medical Journal of Australia, 2004, 180:562–565 [Erratum appears in Medical Journal of Australia, 2004, 181:532]. 192. Al-Nouri L, Al-Isami SA. Baby walker injuries. Annals of Tropical Paediatrics, 2006, 26:67–71. 193. Kendrick D et al. Promoting child safety in primary care: a cluster randomised controlled trial to reduce baby walker use. British Journal of General Practice, 2005, 55:582– 588. 194. Kravitz H. Prevention of accidental falls in infancy by counseling mothers. Illinois Medical Journal, 1973, 144:570–573. 195. Conners GP et al. Still falling: a community-wide infant walker injury prevention initiative. Patient Education and Counselling, 2002, 46:169–173. 196. Towner E, Errington G. How can injuries in children and older people be prevented? Copenhagen, WHO Regional Office for Europe, Health Evidence Network (HEN), 2004 (http://www.euro.who.int/Document/E84938.pdf, accessed 21 March 2008). 197. Kendrick D et al. Home safety education and provision of safety equipment for injury prevention. Cochrane Database of Systematic Reviews, 2007, (1):CD005014. 198. Kendrick D, Mulvaney C, Watson M. Does targeting injury prevention towards families in disadvantaged areas reduce inequalities in safety practice? Health Education Research, 2008 (http://her.oxfordjournals.org/cgi/content/ full/cym083, accessed 14 August 2008).. 199. Gielen AC et al. Using a computer kiosk to promote child safety: results from a randomized controlled trial in an urban pediatric emergency department. Pediatrics, 2007, 120:330–339. 200. Hart JT. The Inverse Care Law. The Lancet, 1971, i:405– 412. 201. Gwatkin DR. Health inequalities and the health of the poor: what do we know? What can we do? Bulletin of the World Health Organization, 2000, 78:3–18. 202. Roberts I, Kramer MS, Suissa S. Does home visiting prevent childhood injury? A systematic review of randomised controlled trials. British Medical Journal, 1996, 312:29– 33. 203. King WJ et al. Long term effects of a home visit to prevent childhood injury: three year follow up of a randomized trial. Injury Prevention, 2005, 11:106–109. 204. Posner JC et al. A randomized, clinical trial of a home safety intervention based in an emergency department setting. Pediatrics, 2004, 113:1603–1608. 205. Clamp M, Kendrick D. A randomised controlled trial of general practitioner safety advice for families with children under 5 years. British Medical Journal, 1998, 316:1576–1579. 206. Watson M et al. Providing child safety equipment to prevent injuries: randomised controlled trial. British Medical Journal, 2005, 330:178. 207. Viscusi WK, Cavallo GO. The effect of product safety regulation on safety precautions. Risk Analysis, 1994, 14:917–930. 208. Oldenburg BF, Brodie AM. Trends and challenges in intervention research methods. In: Doll LS et al., eds. Handbook of injury and violence prevention. New York, NY, Springer, 2007:359–380. 209. McClure R et al. Community-based programmes to prevent falls in children: a systematic review. Journal of Paediatrics and Child Health, 2005, 41:465–470. 210. Norton R et al. Unintentional injuries. In: Jamison DT et al., eds. Disease control priorities in developing countries, 2nd ed. New York, NY, Oxford University Press and the World Bank, 2006. 211. Butchart A, Kruger J, Lekoba R. Perceptions of injury causes and solutions in a Johannesburg township: implications for prevention. Social Science and Medicine, 2000, 50:331–344. 212. Forjuoh SN, Gyebi-Ofosu E. Injury surveillance: should it be a concern to developing countries? Journal of Public Health Policy, 1993, 14:355–359. 213. Archibong AE, Onuba O. Fractures in children in south eastern Nigeria. Central African Journal of Medicine, 1996, 42:340–343. 214. Peltzer K. Accidents/injuries of children in surgical admissions at the University Teaching Hospital in Lusaka, Zambia: a psycho-social perspective. Central African Journal of Medicine, 1989, 35:319–322. 215. Mason M, Christoffel KK, Sinacore J. Reliability and validity of the injury prevention project home safety survey. Archives of Pediatrics and Adolescent Medicine, 2007, 161:759–765. WORLD REPORT ON CHILD INJURY PREVENTION 121
Slide 141: © Royal Children’s Hospital Foudation POISONING Harrison is the youngest of five c children in an Australian family. One day, Lisa, his mother, changed her usual morning routine. Instead o going directly to the kitchen, of checking that the cupboard doors were locked and preparing breakfast, she put on a video f for Harrison’s older sister. In that brief period, 18-month-old Harrison opened a cupboard, removed the cap from a container o dishwasher detergent and of swallowed the powder. HARRISON’S STORY Lisa heard his cry and ran to the kitchen to find him vomiting blood. An ambulance rushed Harrison to hospital where doctors were unsure if he would survive. The container Harrison had managed to open had a cap that looked like a childresistant closure. To secure this closure, the cap had to click twice. Instructions to this effect, though, were not displayed on the packaging and Lisa mistakenly thought the container was securely closed when she felt the first click. Harrison survived, but his injuries changed his life and the lives of his family. Lisa publicized his case, which was then actively taken up by the media. Harrison’s story, and the details of other small children who had sustained similar injuries, became first local and then national news. While Australian laws stipulated that all dishwasher gels and liquids with a pH value greater than 11.5 be supplied in containers with child-resistant closures, with specific warnings as to the caustic nature of the contents, powders were exempt from this regulation. The powder swallowed by Harrison was extremely alkaline – with a pH of 13.4. The manufacturer of the dishwasher detergent was contacted. Faced with the evidence, the company placed warning labels on all its containers informing consumers of the “double-click mechanism” to engage the child-resistant closure. The company then redesigned the container itself, incorporating a device to limit the flow of powder and changing the closure to a “single-click” mechanism. Unfortunately, this was only one product of many on the supermarket shelves, leaving other manufacturers’ products unchanged. Government agencies and nongovernmental organizations lobbied for a change to the law, which was eventually amended. Dishwasher powder must now be distributed in child-resistant containers with specific warning labels if the pH exceeds 11.5. Furthermore, detergents with a pH greater than 12.5 have been removed from the domestic market. In addition, the performance standard for the child-resistant closure is also under review. The aim is to ensure that if a closure appears to be child-resistant, then it must function as such. There cannot be different stages of functionality, such as the “single-click” and “double-click” stages that Lisa’s container incorporated.
Slide 142: CHAPTER 6 – POISONING Chapter 6 Poisoning Introduction “All things are poison and nothing is without poison, only the dose permits something not to be poisonous” – Paracelsus (1). The home and its surroundings can be dangerous places for children, particularly for the possibility of unintentional poisoning. Children are naturally curious, exploring in and around the home. As a result, each year millions of calls are made to poison control centres (also called poison information centres). Thousands of children are admitted to emergency departments because they have inadvertently consumed some type of household product, medicine or pesticide. Most of these “accidental” poisonings could have been prevented. This chapter focuses on cases of acute poisoning among children – predominantly unintentional ones. It covers the extent and nature of poisonings, the risk factors and the intervention measures that can be employed to prevent poisonings or to mitigate the consequences. The chapter does not deal with chronic poisoning issues related to lead, with indoor air pollution or with other effects of repeated or prolonged exposure to toxic agents. Also excluded are allergic reactions to food or poisoning stemming from infectious agents. The issue of snake bites, a major problem in some parts of the world, is addressed in the form of a box. “Poisoning” refers to an injury that results from being exposed to an exogenous substance that causes cellular injury or death. Poisons can be inhaled, ingested, injected or absorbed. Poisoning may also be acquired in utero. The exposure may be acute or chronic and the clinical presentation will vary accordingly. The factors determining the severity of poisoning and its outcome in a child are interrelated. They include: – the type of poison; – the dose; – the formulation; – the route of exposure; – the age of the child; – the presence of other poisons; – the state of nutrition of the child; – the presence of other diseases or injuries. The time interval between the exposure to poison and the appearance of clinical symptoms is an important window of opportunity. During this period, it is important to minimize absorption by removing or neutralizing the poison (in the case of ingestion), or to administer agents that prevent damage to the organs – such as the use of N-acetyl cysteine in cases of paracetamol poisoning. The longer the time interval, the greater is the chance of survival. In general, if poisons are ingested in solid doses, which have a slower onset of absorption, more time is available for interventions targeting the absorption process. For liquid poisons, on the other hand, absorption is usually too rapid to be easily prevented. Poisoning with specific agents produces clinical syndromes that are frequently recognizable. All the same, the syndromes may be easily misdiagnosed or go unrecognized in a child. For this reason, treatment may be delayed, with serious consequences. Poisoning is therefore best prevented. Understanding the pattern of poisoning is helpful for reducing the risk of unintentional poisoning, as well as for preventing intentional poisoning (2). Epidemiology of poisoning According to the WHO Global Burden of Disease project, an estimated 345 814 people of all ages died worldwide as a result of “accidental” poisoning in 2004. Although the majority of these accidental poisonings were among adults, 13% occurred among children and young people under the age of 20 years (see Statistical Annex, Table A.1). Among 15–19-year-olds, poisoning ranks as the 13th leading cause of death (see Table 1.1). A survey of 16 middle-income and high-income countries revealed that, of the different external causes of unintentional injury death among children aged between 1 and 14 years, poisonings ranked fourth in 2000–01, after road traffic crashes, fi res and drowning (3). Mortality Acute poisoning accounted for an estimated 45 000 deaths annually in children and young people under the age of 20 years (see Statistical Annex, Table A.1). The global death rate from poisonings for children younger than 20 years is 1.8 per 100 000 population. For high-income countries the rate is 0.5 per 100 000 while for low-income and middleincome countries it is four times higher, at 2.0 per 100 000. The map in Figure 6.1 shows the geographic distribution of fatal unintentional poisoning, by WHO region. Although mortality rates are generally low and do not exceed 4 per 100 000 population, Africa, the low-income and middleincome countries of Europe, and the Western Pacific region have the highest rates. In general, low-income and middle-income countries have higher poisoning death rates than high-income WORLD REPORT ON CHILD INJURY PREVENTION 123
Slide 143: countries. The one exception is in the high-income countries of the Americas, where death rates are higher than in the middle-income and low-income countries, particularly in the 15–19-year age range (see Statistical Annex, Table A.1). Reported mortality data from countries show higher rates than the estimated regional averages, but the trends are similar. For instance, in Sri Lanka, the case fatality rate from poisoning was found to be as high as 3.2% (4). In India, the reported figures for fatal poisonings ranged between 0.6% and 11.6%, while in Viet Nam the reported case fatality rate was 3.3% (5, 6). FIGURE 6.2 Fatal poisoning rates per 100 000 children by age and sex, World, 2004 6 Rate per 100 000 population Boys Girls 4 2 0 Under 1 1–4 5–9 10–14 15–19 Under 20 Age Children under the age of one year have the highest rates of fatal poisoning (see Figure 6.2), particularly those in low-income and middle-income countries. Generally, mortality rates are highest in infants and decrease with age until 14 years. After that, there is an increase again, almost everywhere, in children 15 years of age and older. In many settings, this increase may be due to substance use, or to unintentional or undetermined drug overdoses (7). In some places, the increase may be as a result of entry into the workplace, with its increased exposure to risks. Age (years) Source: WHO (2008), Global Burden of Disease: 2004 update. Gender Boys have higher rates than girls in all regions of the world except the low-income and middle-income countries of the Western Pacific region (see Table 6.1). The poisoning rate for boys in the WHO African region is 5 per 100 000 population, while for girls in the high-income countries FIGURE 6.1 Mortality rates due to poisoning per 100 000 childrena by WHO region and country income level, 2004 3+ 1.0–2.9 0.5–1.0 <0.5 No data Africa Americas South-East Asia Europe Eastern Mediterranean Western Pacific LMIC 4.0 a HIC 0.8 LMIC 0.3 LMIC 1.7 HIC 0.2 LMIC 2.0 HIC 0.7 LMIC 1.6 HIC 0.1 LMIC 1.8 These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. 124 WORLD REPORT ON CHILD INJURY PREVENTION
Slide 144: of the Eastern Mediterranean and Western Pacific regions the rate is as low as 0.1 per 100 000 population. Morbidity In contrast to data on mortality, global data on non-fatal outcomes of poisoning are not readily available. Data at country level, though, usually obtained through poison control centres, specialized surveillance systems (such as the National Poison Data System in the United States) or the general injury surveillance systems that exist in many countries, are available. Unfortunately, much of the country information is from high-income countries. Some low-income and middle-income countries, though, including South Africa and Sri Lanka, have established poison control centres and begun to conduct research on poisonings. One difficulty when comparing poisoning incidence rates between countries is the variety of classification systems used. In Sweden, the annual rate of enquiries to the poison control centre concerning non-pharmaceutical chemicals – a category that could include natural toxins, or recreational drugs – was about 1400 per 100 000 children aged between 0 and 9 years (8). In Japan, the poison centre received 31 510 enquiries in 1995 about poisoning in children under 6 years of age. The product most frequently involved was tobacco (20%). Enquiries relating to children less than 1 year old made up 35.7% of these cases (9). Data from 2006 from the American Association of Poison Control Centers showed that the most common poisonings among children were due to pharmaceutical products. Enquiries relating to children less than 6 years old made up 50.9% of cases and 2.4% of the total reported fatalities (10). In the United States in 2004, there were over 1.25 million poison exposures involving children less than 6 years of age – 425 per 100 000 children – reported to the Toxic Exposure Surveillance System (11). The substances most frequently involved were cosmetics and personal care products, cleaning substances and analgesics. Data from published hospital admissions are available for poisonings in a number of high-income countries. Comparability is a problem here again, since admission criteria differ between countries and between urban and rural settings. Child poisoning admission rates in Australia have been consistently higher in rural areas than urban areas over a number of years. This is probably due to the fact that children are more readily admitted to hospital in rural areas, as doctors in these areas may err on the side of caution and refer children to hospital even when this is unnecessary. The actual agents involved, though, vary little between urban and rural cases (12). Hospital discharge data are a better indicator of morbidity, since they include a confirmed diagnosis. A two-year study based on hospital discharges and death certificates in California, United States, showed that children aged 15–17 months had the highest overall injury rate and that poisoning was the second leading cause of injury in this group. More than two thirds of the cases involved the ingestion of medicines (13). Although poisoning death rates are highest in infants under 12 months of age, the incidence of poisoning cases – as reflected in calls to poison control centres and emergency department visits – is generally higher in other age groups (14, 15). Non-fatal poisoning, in fact, appears to be more common among children aged 1 to 4 years (9). In a recent hospital-based study in four low-income and middle-income countries, only 2% of poisonings occurred in children under 1 year of age, compared with 54% in the 1–4-year age group (16). The fatality rate among older children admitted to hospital following an accidental poisoning is generally less than 1% (4, 17). The higher mortality rate in very young infants may be explained by the greater susceptibility of the infant body to damage by toxins. Types of poison The prevalence and types of poisoning vary considerably across the world and depend on socioeconomic status and cultural practices, as well as on local industrial and agricultural activities. TABLE 6.1 Mortality rates due to poisoning per 100 000 childrena by sex, country income level and WHO region, 2004 Africa LMIC Boys Girls 4.9 3.0 1.2 0.4 Americas HIC LMIC 0.4 0.3 South- East Asia LMIC 1.7 1.6 HIC 0.3 0.2 Europe LMIC 2.4 1.7 Eastern Mediterranean HIC 1.3 0.0 LMIC 1.7 1.5 Western Pacific HIC 0.1 0.1 LMIC 1.5 2.1 a These data refer to those under 20 years of age. HIC = High-income countries; LMIC = low-income and middle-income countries. Source: WHO (2008), Global Burden of Disease: 2004 update. WORLD REPORT ON CHILD INJURY PREVENTION 125
Slide 145: Data from poison control centres and hospitals (4, 5, 18–24) indicate that the most common agents involved in developed countries – as well as in some developing countries – are: – medicines sold over the counter, such as paracetamol, cough and cold remedies, iron tablets, antihistamines and anti-inflammatory drugs; – prescription medicines, such as antidepressants, narcotics and analgesics; – recreational drugs, such as cannabis and cocaine; – household products – such as bleach, disinfectants, detergents, cleaning agents, cosmetics and vinegar; – pesticides – including insecticides, rodenticides and herbicides; – poisonous plants; – animal or insect bites. The most common agents involved in childhood poisonings in low-income and middle-income countries are hydrocarbons used for fuel and lighting, such as paraffin oil (also known in some countries as kerosene) (5, 25–31). A study conducted in Bangladesh, Colombia, Egypt and Pakistan showed that medications were responsible for 31% of poisonings in children under 12 years of age, followed by cleaning agents, which accounted for 20% (16). Older children may be employed in the informal labour sector, in extractive metal industries that involve processing with toxic chemicals, or in agriculture, where pesticides are used. Children living in poverty may scavenge in dump sites containing toxic waste. In all these cases, there is a strong likelihood of exposure to toxic substances, including lead, mercury and organophosphates (32). Other children in the family, not directly involved in these activities, may come into contact with toxins brought into the home on the clothes or shoes of their siblings. Children may also be exposed to toxins leached into water or sprayed in the air. less than 6 years old (34). This figure represented 23.8% of all poisoning reports, with analgesics accounting for almost 100 000 cases. Additionally, more than 50 000 children under the age of 5 years were treated in emergency rooms for an unintentional exposure to medicinal drugs. Prescription medicines were more commonly implicated than over-the-counter drugs (34). In England and Wales, during the period 1968–2000, medications accounted for 12.8% of unintentional poisoning deaths in children aged less than 10 years (23). Organic fuels and solvents Ingestion of hydrocarbon fuel used for cooking, heating or lighting is a common cause of childhood poisoning in low-income countries (25–29). Paraffin oil is the leading cause of childhood poisonings in many countries, where it may account for up to 16% of all paediatric poisonings, mainly in children aged between 1 and 3 years (2, 16, 30, 31, 35–38). Organic solvents (such as paint remover, glue and acetone), as well as diethylene glycol (a component of antifreeze), have also been implicated in mass unintentional poisonings of children through contaminated medicines or toiletries. In 1998, 109 children in Haiti fell ill after consuming paracetamol (known as acetaminophen in the United States) contaminated with diethylene glycol, and 85 of them died (39). In similar incidents in Bangladesh, India, Nigeria and Panama, children were poisoned as a result of poorly regulated manufacturing processes (39). In addition to the unintentional ingestion of organic fuels and solvents, intentional inhalation of volatile substances (such as “glue sniffing”) by adolescents can result in sudden cardiac death, since inhaled hydrocarbons are about 140 times more toxic than when ingested (40). Pesticides Medicines Medicinal drugs are the leading cause of non-fatal poisoning in children in middle-income and high-income countries. A hospital-based study from United Arab Emirates found that 55% of childhood poisonings were due to medicines. Analgesics, non-steroidal anti-inflammatory drugs and antihistamines were the most commonly ingested drugs in children in the 1–5-year age group (21). A study from Turkey reported that accidental ingestion of drugs was most common (57.7%) in children aged between 1 and 5 years and that the most frequent offending agent was analgesics (33). In the United States, in 2003, some 570 000 pharmaceutical exposures were reported in children 126 WORLD REPORT ON CHILD INJURY PREVENTION Children living in agricultural communities are at risk of acute pesticide poisoning. In the Central American region, in 2000, about 12% of all acute pesticide poisoning occurred in children less than 15 years of age, with an incidence rate of 5.7 per 100 000 population (41). In poor communities, where there is often little separation between work and the home, children may be exposed to pesticide residues present in work clothes, in the air from spraying and in household dust (42). In Nicaragua, children living near cotton farms have been found to suffer poisoning from organophosphates (43). Some of the factors contributing to fatal food poisonings are the inappropriate use and storage of pesticides; the handling of food, while or after working, without proper washing of hands; and the unsafe disposal or reuse of pesticide containers. An example was the food
Slide 146: contaminated with thallium, a rodent poison, that was eaten by children in the Peruvian Andes in 1999, causing 24 deaths (44). In addition to these types of indirect exposure to pesticides, there are direct exposures. A study in China found that children had been exposed directly to rodenticides used in and around the home (45). The International Labour Organization estimates that there are approximately 250 million working children between the ages of 5 and 14 years and that some 40% of these are exposed to toxic substances in the rural areas of developing countries (42). tragedy in Haiti in 2001, in which 65 children died after eating unripe ackee fruit (50); and the consumption of C. occidentalis beans, the cause of recurrent outbreaks of encephalopathy among young children in western Uttar Pradesh, India (51). Animal envenomations (poisoning from bites or stings) from snakes (see Box 6.1), scorpions and spiders are a relatively common form of child poisoning in certain areas of the world. These include parts of Asia, the Pacific and South America, and the desert areas of North Africa, West Asia and North America. Envenomations, for instance, in Saudi Arabia account for as much as 30% of all poisonings among children aged 6–12 years (22, 52, 53). Household chemicals Chemicals around the house to which children may have access contribute significantly to unintentional poisonings in childhood. In the United States in 2004, among children less than 6 years of age, there were over 120 000 exposures to household cleaning agents, such as ammonia, bleach and laundry detergents (11). While most exposures to cleaning agents result in mild poisoning, bleach, dishwasher detergents and ammonia can lead to severe tissue damage. These agents are found in most households in developed countries. Several other studies have confirmed the existence of similar household agents in childhood exposures to toxic substances (3, 21, 22, 46). Cost of poisoning-related injury Few studies have been done on the cost of poisonings, especially those affecting children or those occurring in low-income or middle-income countries. One study conducted in South Africa estimated that the direct costs alone of hospitalization due to paraffin poisoning were at least US$ 1.4 million per year (54). The average cost of treatment per patient amounted to US$ 106.50 in urban Pretoria (36) and approximately US$ 75.58 in the Cape Peninsula (55). Data from the United States confirm the South African findings that poisonings and their management are costly (56). Figures from 2000 show that, in children under 15 years of age, there were a total of 219 000 poisonings, of which 141 were fatal and 14 000 resulted in hospital stays. The lifetime cost of poisonings in children in this age group was almost US$ 400 million, with medical treatment accounting for nearly 9% of the costs. This produces a conservative estimate of US$ 1780, on average, for each case of poisoning – including medical costs, lost earnings and lost quality of life (57). Carbon monoxide In the United States, some 1600 children under 5 years of age are treated in emergency departments each year and 10 die as a result of unintentional non-fire-related exposure to carbon monoxide. This type of poisoning among children most commonly occurs from furnaces, motor vehicles, stoves, gas pipes and generators (47). In low-income countries, indoor cooking fires in homes with poor ventilation can lead to carbon monoxide being produced as a result of incomplete combustion. This in turn can result in respiratory disease in children – from long-term exposure, rather than acute toxicity (32, 33, 48). Limitations of data The epidemiology of poisoning can be studied from hospital admissions and discharge records, mortality data, emergency department records and surveillance systems, as well as from enquiries to poison control centres. Globally, though, data on the type of toxic agents that result in child poisoning and death are limited. There is substantial under-recording and under-reporting of childhood poisoning incidents. In addition, poisoning is not generally a notifiable condition, so few countries maintain records of poisonings. Even where surveillance systems exist, child poisoning cases are not necessarily reported or counted. Cases may escape detection, especially if those affected do not seek treatment in a health-care facility. Furthermore, poisoning in children may be attributed to the wrong cause if the effects are similar to those of other conditions. Even where poisoning is correctly diagnosed, the healthcare worker or caregiver may not recognize the toxic agent that is responsible. WORLD REPORT ON CHILD INJURY PREVENTION 127 Other substances Inorganic substances – including arsenic and the heavy metals lead, copper and mercury – are also responsible for some childhood poisonings. The majority of poisonings due to heavy metals and other inorganic substances are the result of chronic exposure and are therefore excluded from this discussion. In rare instances, though, acute exposure to these agents can result in poisonings. As an example, acute lead encephalopathy with an 11% rate of mortality was reported in Oman, after a lead-containing local medication was given by parents to young infants (49). Plant toxin poisoning – involving plants such as ackee, oleander, datura and cassava – is less frequently reported. Such poisoning can cause morbidity. Death from ingesting plant toxins, though, is rare. Two exceptions are the
Slide 147: BOX 6.1 Snakebites Snakebite is an eminently treatable, but neglected, injury affecting predominantly tropical developing countries. As is also the case with dog bites, recent improvements in injury coding and surveillance, including community surveys in low-income and middle-income countries, have led to an increased understanding of the issue. How great is the problem of snakebite? The annual number of cases of snakebite worldwide is about 5 million, among which there are some 100 000 to 200 000 deaths (53, 59). In addition to the deaths, there are an estimated 400 000 snakebite-related amputations each year around the world (60). Children have both higher incidence rates and suffer more severe effects than do adults, as a result of their smaller body mass (61, 62). Snakebites are concentrated in mainly rural areas and vary considerably by season, with the peak incidence seen in the rainy and harvesting seasons (63). Analysis of 2002 WHO mortality data suggests that snakebite contributes to 35% of all child deaths, globally, from venomous bites and stings, with boys about twice as likely to suffer as girls (64). Boys appear to have a higher risk, from a very early age, of more severe, upper limb bites (65). This type of injury is considerably more common in low-income and middle-income countries, largely in Asia (53, 59). Unfortunately, although the specific antidotes for snakebites – antivenoms – are organic products, there is a worldwide shortage of this pharmaceutical (59). This has a severe impact on poor rural communities, who cannot afford the refined antivenoms used in high-income countries. As a consequence, many developing countries are driven to making crude sera that are both less safe and less effective. At the same time, those most at risk of snakebite, such as rice farmers and plantation workers and their families, are frequently far from medical care. There are a number of snakebite studies in the published literature, but few report specifically on the impact on children – although fatality rates among children are generally higher (63). Furthermore, less than 10% of countries in WHO’s South-East Asia Region, an area of high snakebite incidence, report paediatric snakebite mortality data. Nonetheless, the recent community health and injury surveys in Asia show that snakebite-related injury ranks as a leading cause of childhood morbidity and mortality in this region (66). Papua New Guinea has some of the highest snakebite rates in the world, with the country’s rural central province recording an annual incidence of 561.9 cases per 100 000 population (63). Among paediatric snakebites treated at Port Moresby Hospital Intensive Care Unit, the fatality rate for 2003–2004 was 25.9%, compared to 14.5% for adults. Children also represent 36% of all snakebiterelated ventilator bed-days in an intensive care unit, in which snakebite-related paralysis accounts for 60% of the ventilator bed-days (63). Data from developed countries, on the other hand, reveal much lower snakebite-related injury and very low mortality rates. In Australia, 1512 snakebite hospitalizations were recorded between 2000 and 2002, resulting in a crude annual rate of 3.9 per 100 000 population. The highest rates – of 7.5 per 100 000 – were among boys aged 10–14 years (61). In the United States during the period 2001–2004, the estimated crude rate of snakebite presentations to emergency departments was 3.4 per 100 000 population, with an overall admission rate of 31%. The crude presentation rate was highest among children aged 10–14 years, at 5.5 per 100 000 population (62). What can be done about snakebites? Few studies have comprehensively examined this question for adults, and even fewer have looked at paediatric snakebite. The evidence is therefore somewhat anecdotal. Nevertheless, several general points can be made about why children are at particularly high risk of snakebite (67). Natural curiosity leads children to interact with animals in general, and in particular leads boys to interact with snakes. 128 WORLD REPORT ON CHILD INJURY PREVENTION © DA Warrell, Oxford University
Slide 148: In rural areas in developing countries, children are often employed on the farm, thus incurring an increased risk of making contact with snakes. Children’s small body weight means that a snakebite is likely to have a relatively great impact. Hence children, especially boys, should be specifically targeted for snakebite prevention educational initiatives. The primary avoidance of snakebite relies on minimizing children’s interaction with snakes. Approaches here include: – wearing appropriate protective clothing – such as shoes or boots – particularly at night and in rural areas; – avoiding demonizing snakes, as deliberate aggressiveness towards them is more likely to result in a snakebite; – keeping sheds and fodder storage areas clear of mice and rats, as these attract snakes; – keeping grassy areas well cut. Regarding secondary prevention, two recommendations should be made. Compartment syndrome – where excessive pressure impairs blood supply, leading to possible nerve damage and muscle death – is often associated with tourniquet use following a snakebite, and is the most common reason for amputation in children in many areas of Africa. The use of tourniquets as first aid following snakebite should therefore be discouraged, and vigilance maintained against pressure-induced cell death (68). Traditional healers, who often initially treat snakebite, should be specifically targeted so that modern principles of medical care can be incorporated into their traditional methods. This can help avoid delays before treatment can be given in a health-care facility, and thus minimize the frequent serious harm that results from late treatment of snakebite. Snakebite is a widespread and previously poorly-documented global injury problem, in which children and young people are disproportionately represented. Low-income and middle-income countries, particularly the rural areas, are the most affected. Most deaths and serious consequences from snakebites are entirely preventable by existing means, including making antivenom much more widely available. Better surveillance and reporting are necessary to assess the extent of this forgotten injury and to improve prevention strategies. Data on child poisonings are further affected by problems with coding. The use of the International Classification of Disease coding of external causes of death, for example, does not capture sufficient detail on the agent involved (58). In addition, there is frequently insufficient information on which to make a determination of intent, with the result that many poisoning cases are classified as being of undetermined intent. Accurate information regarding intent is vital for prevention strategies. Studies show that poisonings of children up to the age of 10 years tend to be unintentional, while those of adolescents tend to be intentional in terms of deliberate consumption of the agent, but not necessarily with the intent to cause injury (7). of these factors is important for the development of interventions to prevent and, where necessary, treat cases of child poisoning. Child-related factors Age Age has a strong association with poisoning as it determines the behaviour, size and physiology of the child, thus influencing types of exposure and outcome (69). Infants and small children are closer to the ground than older children and tend to put their hands and small objects into their mouths. As a result they are at increased risk of exposure to toxins found at low levels or in the soil or dust – such as rodenticides. Many studies have confi rmed that poisoning rates increase dramatically at around 2 years of age, as young children become more mobile and have increased access to toxins (16). Young children are particularly susceptible to the unintentional WORLD REPORT ON CHILD INJURY PREVENTION 129 Risk factors As with other injuries, the risk of a child being poisoned is affected by factors related to the child, the agent and the environment. These factors are interrelated and are highly dependent on the context (see Table 6.2). An understanding © D Williams, Australian Venom Research Unit
Slide 149: TABLE 6.2 Haddon Matrix applied to the risk factors for childhood poisoning Child Pre-event Age and developmental factors (such as curiosity, judgement); gender; parental supervision. Agent Ease of opening package; attractiveness of substance; inadequate labelling; poor storage. Toxicity of chemical; dose consumed; ease with which substance can be consumed (for instance, as liquid rather than solid). Chemical agent without an antidote. Physical environment Cupboards within easy reach of children; absence of locking devices on cabinets; exposure to agents. Places where child can ingest substances without being seen. Socioeconomic environment Lack of regulations and standards for toxic products and packaging; poverty; lack of awareness of toxicity and poisoning risks among caregivers. Lack of awareness by caregivers of how to react; lack of appropriate and timely decontamination by healthcare workers. No poison control centre or lack of information on how to contact centre; lack of access to emergency medical care. Event Child’s secrecy about ingestion; parent not noticing unusual behaviour. Post-event Child’s inability to communicate incident; lack of access to poison control centre. Lack of adequate prehospital care, acute care and rehabilitation. ingestion of poisons, especially liquid ones (70). The risk of poisoning among young children is exacerbated by their size and physiological development. Most substances increase in toxicity as the dose increases relative to body mass. Some toxins are eliminated by enzyme systems in the body that develop as the child grows older. In adolescents, where poisoning can be caused by alcohol misuse or the use of other recreational drugs, fatality rates are higher than in younger children (71). Gender Boys appear to be at consistently higher risk of poisoning than girls (4, 36, 72). With specific regard to poisoning from the ingestion of paraffi n, though, some studies have shown no difference between boys and girls, while others have shown a preponderance among boys (25, 28, 37). The discrepancy in these fi ndings may be explained by gender differences in socialization between different countries. In some cultures, girls are expected not to engage in outdoor activities or to adopt risk-taking behaviours (27). Poverty Socioeconomic status is strongly associated with injury and deaths from poisoning, not only between countries but also within countries (73). Studies from the United Kingdom show that the risk of dying from poisoning among children from poor backgrounds is more than three times higher than the risk for children in affluent areas (74). One study in Greece, however, showed no association between social and demographic factors and child poisonings (75). Nonetheless, socioeconomic status may well be the strongest risk factor for poisonings in children as it affects exposure, is itself associated with several other risk factors (such as physical 130 WORLD REPORT ON CHILD INJURY PREVENTION underdevelopment in children) and is linked to poor outcomes of injury. In developing countries, socioeconomic status is a strong predictor for household fuel consumption, itself linked to an increased exposure to paraffin. At the same time, poverty drives children into work that is usually poorly paid but with high risks of injury. Poor people tend to live with inadequate sanitary facilities – for washing, and sewerage and waste disposal – and limited storage space to keep harmful substances away from children. Poor dwellings are more likely to be close to areas sprayed with pesticides or to toxic dumps, or to draw their water from contaminated sources. Poverty and malnutrition can also place children at risk of poisoning by forcing them to consume unsafe but cheaply obtained foods – such as undercooked cassava or unripe ackee fruit, both of which are toxic. The ability to withstand toxic effects depends, among other factors, on the nutritional and health status of the child. Children living in poverty are generally inadequately nourished and therefore more vulnerable to poisons than their healthier counterparts. In addition, conditions of poverty frequently prevent people from accessing health care. Agent factors Characteristics of the agent The more concentrated or more potent the toxic agent, the greater the risk of severe morbidity and mortality. Chemical analyses of seven samples of paraffin from South African refineries found significant differences in their levels of toxicity (76). The nature of the substance is also important. There is a higher incidence of injury associated with liquid agents than with solid compounds (69). Households
Slide 150: with children are more likely to have liquid medications. Liquid preparations are easier to swallow than powdered preparations, such as dishwasher detergents or tablets, because they do not stick to the mucosa of the mouth. Nor do they usually produce a burning sensation (which powdered preparations do) which would limit the amount consumed. Unfortunately, powdered chemicals are now being produced with an anti-caking agent, which increases the ease of flow of the powdered chemical, but which also makes ingestion easier. The physical appearance of a toxic substance plays a large part in its attractiveness to children, while its chemical composition determines its effect. Features such as size, colour and texture may attract or deter a child from handling and ingesting a substance. Studies show that liquids rather than solids, clear liquids rather than dark coloured ones, and small solids rather than large solids have more appeal to young children and are therefore more likely to be ingested by them (77). Bright colours in solid medications may also make them more attractive to children. closure or a blister pack. Child-resistant closures make it more difficult for a child to open a container because they require a series of complex actions – such as squeezing and turning, or pushing downwards and turning. The standard for the testing of child-resistant closures adopted in most countries requires that at least 85% of children aged from 42 to 51 months must be unable to open the container within five minutes, and at least 80% must fail to open the container following a non-verbal demonstration (85). No closure, though, is perfect. In the child testing, up to 20% of children aged between 42 and 51 months may be able to overcome the child-resistant closure. Many parents are unaware that young children may indeed be able to access the contents of child-resistant packaging. Childresistant closures should therefore never take the place of good supervision (24). Environmental factors Season and climate There are significant seasonal variations in the incidence of poisoning cases for different poisoning agents. Summer is the time of greatest risk for the ingestion of paraffin, medications and organophosphates and for bites from scorpions and snakes (25, 36). Several explanations have been put forward. Children on their summer holidays are more likely to be outdoors or to be left at home unattended or in the care of an older child or elderly relative (65, 86, 87). Children may also consume more fluids because of the warmer weather. Around national or religious holidays, parents or siblings may be less alert to hazards or children may exhibit more attention-seeking behaviour (88). Although the incidence of poisoning is higher during the summer months, a few types of poisoning are more common in winter or during cold weather. These include carbon monoxide poisoning – from heating appliances – and poisoning through ingesting cough or cold medicines, as these are often considered harmless and left unattended (89). Storage and access The most obvious risk factor for ingestion of a substance is its presence in the domestic environment, within reach of the child. Dispensing substances – such as paraffin and medications – in unlabelled or incorrectly labelled containers without child-resistant closures also increases the risk of poisoning (14, 26). Paraffin oil is frequently stored in bottles or other containers meant for cold drinks, milk or fruit juice, which children associate with beverages (36, 66, 78). In some places, tablets are poured into unsealed envelopes or ziplock bags, and liquids into nondistinctive, poorly labelled containers. Children may also drink from containers, such as cups, which have previously been used for refilling heating or lighting appliances (79). White pesticide powders improperly stored close to food substances can be mistaken for flour, starch or milk, and have led to poisonings of entire families (80). Even when dangerous products are stored in distinctive containers with visual warning labels – such as images of “skull and crossbones” – young children are unlikely to recognize the significance of these signs (81). Some studies have found carelessness, overcrowding or limited space to be the cause of incorrect storage (14, 36). Research in Australia has shown that many products leading to child poisoning incidents were recently purchased or else not kept in their usual place of storage (80, 82). Medicine and bathroom cabinets, and kitchen cupboards and drawers appeared to be the safest storage places, while handbags, refrigerators, shelves and bathroom ledges were the least safe (83). Even safe packaging cannot compensate for unsafe storage. In developed countries, many products are required by law to be distributed in child-resistant packaging (84). This usually involves either a bottle with a child-resistant Socioeconomic environment Several case–control studies in low-income and middleincome countries have highlighted social and demographic risk factors in the poisoning of children. These factors include the presence of young parents, residential mobility and limited adult supervision (65, 90, 91). Although parents and caregivers may have been present at the time of the poisoning incident, studies confirm they were usually engaged in household duties or attending to personal needs. In a significant proportion of cases, poisoning occurred when a child was left in the care of another child or with a grandparent (65, 87, 91, 92). Poor living conditions, local beliefs and customs and ignorance of the dangers of chemicals are other risk factors associated with acute poisoning (14). Previous poisoning may also be a risk factor (72). WORLD REPORT ON CHILD INJURY PREVENTION 131