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Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (>145 000 lives saved) and instituting and improving trauma teams (>115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (>200 000 excess deaths to >200 000 lives saved per year). For clinical interventions, damage control resuscitation (>60 000 lives saved per year) and institution of interventional radiology (>50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Work-related injuries (WRIs) are recognized as a leading cause of admission to the national trauma center of Qatar. A retrospective analysis of trauma registry data and electronic medical records was conducted on a cohort of all WRI patients who were admitted to the Hamad Trauma Center (HTC), in Doha, Qatar, between 2011 and 2017. A total of 3757 WRI patients were treated at the HTC over the 7-year study period. The overall cost for treatment was 124,671,431 USD (18 million USD per year), with a median cost of 19,071 USD. There was a strong positive correlation between the overall cost and hospital-stay cost (r 2 = 0.949, p = 0.00001) and between the overall cost and procedure cost (r 2 = 0.852, p = 0.00001). Motor vehicle crash (MVC) victims who wore seatbelts had significantly lower injury severity, hospital stay and median total costs. A comparison of patients by quartiles of the costs incurred showed that the proportions of MVC victims, pedestrian injuries and mortality were significantly higher in the fourth quartile when compared to other quartiles ( p < 0.05). These findings suggest that investments in the primary prevention of work-related injuries from falls and MVCs, through proven interventions, should be priorities for occupational safety and health in Qatar.

Introduction: There is currently no defined method for assessing injury severity using population-based data, which limits our understanding of the burden of non-fatal injuries and community-based approaches for primary prevention of injuries. This study describes a systematic approach, Population-based Injury Severity Assessment (PISA) index, for assessing injury severity at the population level., Methods: Based on the WHO International Classification of Functionality conceptual model on health and disability, eight indicators for assessing injury severity were defined. The eight indicators assessed anatomical, physiological, postinjury immobility, hospitalisation, surgical treatment, disability, duration of assisted living and days lost from work or school. Using a large population-based survey conducted in 2013 including 1.16 million individuals from seven subdistricts of rural Bangladesh, information on the eight indicators were derived for all non-fatal injury events, and these were summarised into a single injury severity index using a principal component analysis (PCA). Principal component loadings derived from the PCA were used to predict the severity (low, moderate, high) of non-fatal injuries, and were applied to the fatal injury data to assess the criterion validity of the index. The determinants of non-fatal injury severity were determined using ordered logistic regression., Results: There were 119 703 non-fatal injuries and 14% were classified as high severity based on the PISA index. The PISA index accurately predicted 82% of all fatal injuries as highly severe. Non-fatal injuries of high severity were frequent with unintentional poisoning (57%) and violence (35%). Injuries of high severity were commoner among males (OR 1.16, 95% CI 1.12 to 1.21), adults 65 years and older (OR 1.30, 95% CI 1.23 to 1.36), lower socioeconomic status and intentional injuries. Education was associated with reduced odds of high severe injuries., Conclusion: The PISA index provides a valid and systematic approach for assessing injury severity at the population level, and is relevant for improving the characterisation of the burden and epidemiology of injuries in non-health facility-based settings. Additional testing of the PISA index is needed to further establish its validity and reliability., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Unintentional injury is the leading cause of death among children aged 10-19 years and over 95% of injury deaths occur in low- and middle-income countries (LMICs). As patterns of injury in the pediatric population may differ from those in adults, risks specific to children in LMICs need to be identified for effective injury prevention and treatment. This study explores patterns of pediatric injury epidemiology and cost in Yaoundé, Cameroon to inform injury prevention and resource allocation., Methods: Pediatric (age < 20 years) trauma patient data were collected at the emergency department (ED) of Central Hospital of Yaoundé (CHY) from April through October 2009. Univariate, bivariate, and multivariate analyses were used to explore injury patterns and relationships between variables. Regression analyses were conducted to identify predictors of receiving surgical care., Results: Children comprised 19% (544) of trauma cases. About 54% suffered road traffic injuries (RTIs), which mostly affected the limbs and pelvis (37.3%). Half the RTI victims were pedestrians. Transportation to CHY was primarily by taxi or bus (69.4%) and a preponderance (71.1%) of the severely and profoundly injured patients used this method of transport. Major or minor surgical intervention was necessary for 17.9% and 20.8% of patients, respectively. Patients with an estimated injury severity score ≥ 9 (33.2%) were more likely to need surgery (p < 0.01). The median ED cost of pediatric trauma care was USD12.71 [IQR 12.71, 23.30]., Conclusions: Injury is an important child health problem that requires adequate attention and funding. Policies, surgical capacity building, and health systems strengthening efforts are necessary to address the high burden of pediatric injuries in Cameroon. Pediatric injury prevention efforts in Cameroon should target pedestrian RTIs, falls, and burns and consider school-based interventions.

Introduction: About 54% of deaths in low- and middle-income countries (LMICs) are attributable to lack of prehospital care. The single largest contributor to the disability-adjusted life years due to poor prehospital care is injury. Despite having disproportionately high injury burdens, most LMIC trauma systems have little prehospital organization. An understanding of existing prehospital care patterns in LMICs is warranted as a precursor to strengthening prehospital systems., Methods: In this retrospective pilot study, we collected demographic and injury characteristics, therapeutic itinerary, and transport data of patients that were captured by the trauma registry at the Central Hospital of Yaoundé (CHY) from April 15, 2009 to October 15, 2009. Bivariate and multivariate regression analyses were used to explore relationships between care-seeking behavior, method of transport, and predictor variables., Results: The mean age was 30.2 years (95% CI [29.7, 30.7]) and 73% were male. Therapeutic itinerary was available for 97.5% of patients (N = 2855). Nearly 18.7% of patients sought care elsewhere before CHY and 82% of such visits were at district hospitals or health clinics. Moderately (OR 1.336, p = 0.009) and severely (OR 1.605, p = 0.007) injured patients were more likely to seek care elsewhere before CHY and were less likely to be discharged home after their emergency ward visit as opposed to being admitted to the hospital for further treatment (OR 0.462, p < 0.001). Commercial vehicles provided most prehospital transport (65%), while police or ambulance transported few injured patients (7%)., Conclusions: Possible areas for prehospital trauma care strengthening include training lay commercial vehicle drivers in trauma care and formalizing triage, referral, and communication protocols for prehospital care to optimize timely transfer and care while minimizing secondary injury to patients.

Introduction: This study presents a systematic approach-assessment of child injury prevention policies (A-CHIPP)-to assess and track policies on effective child injury interventions at the national level. Results from an initial pilot test of the approach in selected countries are presented., Method: A literature review was conducted to identify conceptual models for injury policy assessment, and domains and indicators were proposed for assessing national injury policies for children aged 1-9 years. The indicators focused on current evidence-supported interventions targeting the leading external causes of child injury mortality globally, and were organised into a self-administered A-CHIPP questionnaire comprising 22 questions. The questionnaire was modified based on reviews by experts in child injury prevention. For an initial test of the approach, 13 countries from all six WHO regions were selected to examine the accuracy, usefulness and ease of understanding of the A-CHIPP questionnaire., Results: Data on the A-CHIPP questionnaire were received from nine countries. Drowning and road traffic injuries were reported as the leading causes of child injury deaths in seven of these countries. Most of the countries lacked national policies on interventions that address child injuries; supportive factors such as finance and leadership for injury prevention were also lacking. All countries rated the questionnaire highly on its relevance for assessment of injury prevention policies., Conclusion: The A-CHIPP questionnaire is useful for national assessment of child injury policies, and such an assessment could draw attention of stakeholders to policy gaps and progress in child injury prevention in all countries., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Problem: The burden of trauma and injuries in Uganda is substantial and growing. Two important gaps that need addressing are the shortage of trained people and a lack of national data on noncommunicable diseases and their risk factors in Uganda., Approach: We developed and implemented a new track within an existing master of public health programme, aimed at developing graduate-level capacity and promoting research on key national priorities for trauma and injuries. We also offered training opportunities to a wider audience and set up a high-level national injury forum to foster national dialogue on addressing the burden of trauma, injuries and disability., Local Setting: The Chronic Consequences of Trauma, Injuries and Disability in Uganda programme was implemented in 2012 at Makerere University School of Public Health in Kampala, Uganda, in conjunction with Johns Hopkins Bloomberg School of Public Health in Baltimore, United States of America., Relevant Changes: Over the years 2012 to 2017 we supported four cohorts of master's students, with a total of 14 students (9 females and 5 males; mean age 30 years). Over 1300 individuals participated in workshops and seminars of the short-term training component of the programme. The forum hosted three research symposia and two national injury forums., Lessons Learnt: Institutional support and collaborative engagement is important for developing and implementing successful capacity development programmes. Integration of training components within existing academic structures is key to sustainability. Appropriate mentorship for highly motivated and talented students is valuable for guiding students through the programme.

Background: Between 1990 and 2015, the global injury mortality declined, but in countries where the poorest billion live, injuries are becoming an increasingly prevalent cause of death. The vulnerability of this population requires immediate attention from policy makers to implement effective interventions that lessen the burden of injuries in these countries. Our aim was two-fold; first, to review all the evidence on effective interventions for the five main types of unintentional injury; and second, to estimate the potential number of lives saved by effective injury interventions among the poorest billion., Methods: For our systematic review we used references in the Disability Control Priorities third edition, and searched PubMed and the Cochrane database for papers published until Sept 10, 2016, using a comprehensive search strategy to find interventions for the five major causes of unintentional injuries: road traffic crashes, falls, drowning, burns, and poisoning. Studies were included if they presented evidence with significant effects sizes for any outcome; no inclusions or exclusions made on the basis of where the study was carried out (ie, low-income, middle-income, or high-income country). Then we used data from the Global Burden of Disease 2015 study and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved among the poorest billion by these evidence-based injury interventions. We estimated results for 84 countries where the poorest billion live., Findings: From the 513 papers identified, 47 were eligible for inclusion. We identified 11 interventions that had an effect on injury mortality. For road traffic deaths, the most successful interventions in preventing deaths are speed enforcement (>80 000 lives saved per year) and drink-driving enforcement (>60 000 lives saved per year). Interventions potentially most effective in preventing deaths from drowning are formal swimming lessons for children younger than 14 years (>25 000 lives saved per year) and the use of crèches to supervise younger children (younger than 5 years; >10 000 lives saved per year). We did not find sufficient evidence on interventions for other causes of unintentional injuries (poisoning, burns, and falls) to run similar simulations., Interpretation: Based on the little available evidence, key interventions have been identified to prevent lives lost from unintentional injuries among the poorest billion. This Article provides guidance to national authorities on evidence-based priority interventions that can reduce the burden of injuries among the most vulnerable members of the population. We also identify an important gap in knowledge on the effectiveness and the mortality impacts of injury interventions., Funding: Partly supported by the Fogarty International Center of the US National Institutes of Health (Chronic Consequences of Trauma, Injuries, Disability Across the Lifespan: Uganda; #D43TW009284)., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Heavy burden of child injuries and lack of policy response in Ethiopia call for an improved understanding of the situation and development of action plans from multiple governmental agencies and stakeholders., Methods: A consortium of international and Ethiopian researchers and stakeholders used extensive literature review and mixed analytical methods to estimate and project the burden of fatal and non-fatal child unintentional injuries in Ethiopia from 2015 to 2030. Estimates were derived for children aged 0-14 years. Data sources include a longitudinal study conducted by the Central Statistics Agency of Ethiopia and the World Bank as well as model-based estimates from World Health Organization 2017 and Global Burden of Disease 2016 project., Results: Injuries caused about 25 thousand deaths among 0-14-year olds in Ethiopia in 2015. The leading cause of fatal child unintentional injuries in Ethiopia was road-traffic injuries, followed by fire, heat and hot substances and drowning. The death rate due to injuries among 0-14 years olds was about 50 percent higher in males than females. Rural children were exposed to a greater risk of injury than their urban peers. The longitudinal survey suggests that the incidence rate of child injuries increased during the period 2011-2014. The annual mortality caused by injuries is projected to increase from 10,697 in 2015 to 11,279 in 2020 and 11,989 in 2030 among children under 5 years, an increase of 12 percentage points in 15 years. The number of deaths among 0-14-year olds will be 26,463, 27,807, and 30,364 respectively in 2015, 2020, and 2030., Conclusions: As the first multisectoral collaboration on child injuries in Ethiopia, this study identified gaps in understanding of the burden of child injuries in Ethiopia. In consultation with Ethiopian government and other stakeholders, we propose starting an injury surveillance system at health clinics and hospitals and building an intervention package based on existing platforms.

Background: Injury rates in low- and middle-income countries are among the greatest in the world, with >90% of unintentional injury occurring in low- or middle-income countries. The risk of death from injuries is 6 times more in low- and middle-income countries than in high-income countries. This increased rate of injury is partly due to the lack of availability and access to timely and appropriate medical care for injured individuals. Kenya, like most low- and middle-income countries, has seen a 5-fold increase in injury fatalities throughout the past 4 decades, in large part related to the absence of a coordinated, integrated system of trauma care., Methods: We aimed to assess the trauma-care system in Kenya and to develop and implement a plan to improve it. A trauma system profile was performed to understand the landscape for the care of the injured patient in Kenya. This process helped identify key gaps in care ranging from prehospital to hospital-based care., Results: In response to this observation, a 9-point plan to improve trauma care in Kenya was developed and implemented in close collaboration with local stakeholders. The 9-point plan was centered on engagement of the stakeholders, generation of key data to guide and improve services, capacity development for prehospital and hospital care, and strengthening policy and legislation., Conclusion: There is an urgent need for coordinated strategies to provide appropriate and timely medical care to injured individuals in low- or middle-income countries to decrease the burden of injuries and related fatalities. Our work in Kenya shows that such an integrated system of trauma care could be achieved through a step-by-step integrated and multifaceted approach that emphasizes engagement of local stakeholders and evidence-based approaches to ensure effectiveness, efficiency, and sustainability of system-wide improvements. This plan and lessons learned in its development and implementation could be adaptable to other similar settings to improve the care of the injured patient in low- or middle-income countries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes., Methods: An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes., Results: A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity., Conclusion: The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Road traffic injury surveillance systems are a cornerstone of organized efforts at injury control. Although high-income countries rely on established trauma registries and police databases, in low- and middle-income countries, the data source that provides the best collection of road traffic injury events in specific low- and middle-income country contexts without mature surveillance systems is unclear. The objective of this study was to compare the information available on road traffic injuries in 3 data sources used for surveillance in the sub-Saharan African country of Cameroon, providing potential insight on data sources for road traffic injury surveillance in low- and middle-income countries. We assessed the number of events captured and the information available in Yaoundé, Cameroon, from 3 separate sources of data on road traffic injuries: trauma registry, police records, and newspapers., Methods: Data were collected from a single-hospital trauma registry, police records, and the 6 most widely circulated newspapers in Yaoundé during a 6-month period in 2009. The number of road traffic injury events, mortality, and other variables included commonly in injury surveillance systems were recorded. We compared these sources using descriptive analysis., Results: Hospital, police, and newspaper sources recorded 1,686, 273, and 480 road traffic injuries, respectively. The trauma registry provided the most complete data for the majority of variables explored; however, the newspaper data source captured 2, mass casualty, train crash events unrecorded in the other sources. Police data provided the most complete information on first responders to the scene, missing in only 7%., Conclusion: Investing in the hospital-based trauma registry may yield the best surveillance for road traffic injuries in some low- and middle-income countries, such as Yaoundé, Cameroon; however, police and newspaper reports may serve as alternative data sources when specific information is needed., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Many Arab countries have undergone the epidemiologic transition of diseases with increasing economic development and a proportionately decreasing prevalence of communicable diseases. With this transition, injuries have emerged as a major cause of mortality and morbidity in the Gulf Cooperation Council countries in addition to diseases of affluence. Injuries are the number one cause of years of life lost and disability-adjusted life-years in the Sultanate of Oman. The burden of injuries, which affects mostly young Omani males, has a unique geographic distribution that is in contrast to the trauma care capabilities of the country. The concentration of health care resources in the northern part of the country makes it difficult for the majority of Omanis who live elsewhere to access high-quality and time-sensitive care. A broader multisectorial national injury prevention strategy should be evidence based and must strengthen human resources, service delivery, and information systems to improve care of the injured and loss of life. This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Road traffic injuries kill more people in India than in any other country in the world, and these numbers are rising with increasing population density and motorization. Official statistics regarding road traffic injuries are likely subject to underreporting. This study presents results of a surveillance program based at a public tertiary hospital in Hyderabad, India., Methods: All consenting patients who presented to the casualty ward after a road traffic injury over a 9-month period were enrolled. Interviews were performed and data abstracted from clinical records by trained research assistants. Data included demographics, injury characteristics, risk factors, safety behaviors, and outcomes., Results: A total of 5,298 patients were enrolled; their mean age was 32.4 years (standard deviation 13.8) and 87.3% were men; 58.2% of patients were injured while riding a motorcycle or scooter, 22.5% were pedestrians, and 9.2% used motorized rickshaws. The most frequent collision type was skid or rollover (40.9%). Male victims were younger than female victims and were overrepresented among motorized 2-wheeler users. Patients were most frequently injured from 1600 to 2400. A total of 27.3% of patients were admitted. Hospital mortality was 5.3%, and 48.2% of deaths were among motorized 2-wheeler users., Conclusion: This is one of the few prospective, hospital-based studies of road traffic injury epidemiology in India. The patient population in this study was similar to prior hospital-based studies. When compared to government surveillance systems, this study showed motorized 2-wheeler users to be more frequently represented among the overall population and among fatalities. Further research should be done to develop interventions to decrease mortality associated with 2-wheeled vehicles in India., (Copyright © 2017. Published by Elsevier Inc.)

Background: Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low- and middle-income countries where more than 90% of injury-related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low- and middle-income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital-based trauma registries., Methods: From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes., Results: A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries., Conclusion: Hospital-based trauma registries can be important sources of data to study the epidemiology of injuries in low- and middle-income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality-of-care improvement programs., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Pediatric injuries are associated with significant morbidity and mortality, especially in low- and middle-income countries. Data to characterize the cause and risk factors associated with childhood injuries in low- and middle-income countries are very scarce. The aim of this study is to describe the cause of pediatric injuries and their possible changes between 2007 and 2011 using hospital-based data in Cape Town, South Africa., Methods: Data from injured children <13 years of age who presented to the Red Cross War Memorial Children's Hospital's emergency department in 2007 and 2011 were captured in Childsafe South Africa's trauma surveillance system. Poisson regression was used to assess changes in rates of injury between 2007 and 2011 in terms of demographics, geographic location of injury, type of injury mechanism, injury severity, and anatomic region of the sustained injury., Results: In total, 14,915 injured children with 15,414 injuries presented to Red Cross War Memorial Children's Hospital in 2007 and 2011. The mean age was 5.01 ± 3.5 years and 60.3% were male. Common mechanisms of injury included falls (n = 6,036; 40%), road traffic injuries (n = 1,939; 13%), burns (n = 1,885; 12.6%), and assault (n = 640; 4.3%). Comparing 2011 to 2007, the incidence of road traffic injuries has decreased by 7% (P < .05) while burn injuries increased 11% (P < .05). Seventy-three percent (73%) of injuries that presented to Red Cross War Memorial Children's Hospital occurred in the Cape Flats area of Cape Town, where many informal settlements exist., Conclusion: These epidemiologic findings suggest that while road traffic injuries decreased and burn injuries increased at Red Cross War Memorial Children's Hospital, there is a need for data that are population-based and not hospital based. If we could describe injuries accurately within the pediatric population of a city such as Cape Town, we could in turn use this data to strengthen the need for targeted interventions to address risk factors for pediatric injuries. Despite this, hospital-based data remain a powerful tool to study injuries in low and middle-income countries., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Low- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya., Methods: This study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations., Results: A total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866-0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852-0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736-0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures., Conclusions: This multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Adolescence is a distinct period of rapid and dramatic biological, cognitive, psychological, and social development. The burden of injuries among young people (aged 10-24) is both substantial and maldistributed across regions and levels of economic development., Objectives: Our objective was to compare sociodemographic correlates of injury cause, intentionality, and mortality between Kenya and Oman, 2 countries with different levels of economic development and position in the demographic and epidemiologic transitions., Methods: Data on 566 patients in Oman and 5859 in Kenya between 10 and 24 years old were extracted from 2 separate multicenter trauma registries. Multivariable log binomial and Poisson regressions were used to evaluate social and demographic factors associated with injury cause, intentionality, and mortality. Literature on adolescent development was used to parameterize variables, and Akaike information criteria were used in the final model selections., Findings: The trauma registry data indicated a substantial burden of adolescent and young adult injury in both Oman and Kenya, particularly among males. The data indicated significant differences between countries (P < .001) in age category, gender distributions, level of education, occupation, cause of injury, and place where injury occurred. Consistent with other literature, road traffic injuries emerged as the most common type of injury as well as the most severe and fatal, with interpersonal violence also resulting in severe injury across contexts. Both road traffic injuries and interpersonal violence were more common among older adolescents and young adults. Education and being in school were protective against injury, after controlling for gender, age category, occupation, and country., Conclusions: A rising burden of injuries among young people has been documented in every region of the world, irrespective on income status or level of development. Cost-effective injury control measures targeting this age group exist, including involvement in educational, vocational, and other prosocial activities; environmental alterations; and road safety measures., (Copyright © 2017 Icahn School of Medicine at Mount Sinai. Published by Elsevier Inc. All rights reserved.)

Background: 90% of the global burden of injuries is borne by low-income and middle-income countries (LMICs). However, details of the injury burden in LMICs are less clear because of the scarcity of data and population-based studies. The Saving of Lives from Drowning project, implemented in rural Bangladesh, did a census on 1·2 million people to fill this gap. This Article describes the epidemiology of fatal and non-fatal injuries from the study., Methods: In this study, we used data from the baseline census conducted as part of the Saving of Lives from Drowning (SoLiD) project. The census was implemented in 51 unions from seven purposively sampled rural subdistricts of Bangladesh between June and November, 2013. Sociodemographic, injury mortality, and morbidity information were collected for the whole population in the study area. We analysed the data for descriptive measures of fatal and non-fatal injury outcomes. Age and gender distribution, socioeconomic characteristics, and injury characteristics such as external cause, intent, location, and body part affected were reported for all injury outcomes., Findings: The census covered a population of 1 169 593 from 270 387 households and 451 villages. The overall injury mortality rate was 38 deaths per 100 000 population per year, and 104 703 people sustained major non-fatal injuries over a 6-month recall period. Drowning was the leading external cause of injury death for all ages, and falls caused the most number of non-fatal injuries. Fatal injury rates were highest in children aged 1-4 years. Non-fatal injury rates were also highest in children aged 1-4 years and those aged 65 years and older. Males had more fatal and non-fatal injuries than females across all external causes except for burns. Suicide was the leading cause of injury deaths in individuals aged 15-24 years, and more than 50% of the suicides occurred in females. The home environment was the most common location for most injuries., Interpretation: The burden of fatal and non-fatal injuries in rural Bangladesh is substantial, accounting for 44 050 deaths and 21 million people suffering major events annually. Targeted approaches addressing drowning in children (especially those aged 1-4 years), falls among the elderly, and suicide among young female adults are urgently needed to reduce injury deaths and morbidity in Bangladesh., Funding: Bloomberg Philanthropies., (Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Non-fatal injuries have a significant impact on disability, productivity, and economic cost, and first-aid can play an important role in improving non-fatal injury outcomes. Data collected from a census conducted as part of a drowning prevention project in Bangladesh was used to quantify the impact of first-aid provided by trained and untrained providers on non-fatal injuries. The census covered approximately 1.2 million people from 7 sub-districts of Bangladesh. Around 10% individuals reported an injury event in the six-month recall period. The most common injuries were falls (39%) and cuts injuries (23.4%). Overall, 81.7% of those with non-fatal injuries received first aid from a provider of whom 79.9% were non-medically trained. Individuals who received first-aid from a medically trained provider had more severe injuries and were 1.28 times more likely to show improvement or recover compared to those who received first-aid from an untrained provider. In Bangladesh, first-aid for non-fatal injuries are primarily provided by untrained providers. Given the large number of untrained providers and the known benefits of first aid to overcome morbidities associated with non-fatal injuries, public health interventions should be designed and implemented to train and improve skills of untrained providers., Competing Interests: The authors declare no conflict of interest. The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the decision to publish the results.

This study provides a comprehensive review of the care-seeking patterns and direct economic burden of injuries from the victims' perspective in rural Bangladesh using a 2013 household survey covering 1.17 million people. Descriptive statistics and bivariate analyses were used to derive rates and test the association between variables. An analytic model was used to estimate total injury out-of-pocket (OOP) payments and a multivariate probit regression model assessed the relationship between financial distress and injury type. Results show non-fatal injuries occur to 1 in 5 people in our sample per year. With average household size of 4.5 in Bangladesh--every household has an injury every year. Most non-fatally injured patients sought healthcare from drug sellers. Less than half of fatal injuries sought healthcare and half of those with care were hospitalized. Average OOP payments varied significantly (range: $8-$830) by injury type and outcome (fatal vs. non-fatal). Total injury OOP expenditure was $$355,795 and $5000 for non-fatal and fatal injuries, respectively, per 100,000 people. The majority of household heads with injuries reported financial distress. This study can inform injury prevention advocates on disparities in healthcare usage, OOP costs and financial distress. Reallocation of resources to the most at risk populations can accelerate reduction of preventable injuries and prevent injury related catastrophic payments and impoverishment.

Background: Trauma registries (TRs) play a vital role in the assessment of trauma care, but are often underutilized in countries with a high burden of injuries., Objectives: We investigated whether information and communications technology (ICT) such as mobile health (mHealth) could enable the design of a tablet-based application for healthcare professionals. This would be used to inform trauma care and acquire surveillance data for injury control and prevention in Oman. This paper focuses on documenting the implementation process in a healthcare setting., Methods: The study was conducted using an ICT implementation framework consisting of multistep assessment, development and pilot testing of an electronic tablet-based TR. The pilot study was conducted at two large hospitals in Oman, followed by detailed evaluation of the process, system and impact of implementation., Results: The registry was designed to provide comprehensive information on each trauma case from the location of injury until hospital discharge, with variables organized to cover 11 domains of demographic and clinical information. The pilot study demonstrated that the registry was user friendly and reliable, and the implementation framework was useful in planning for the Omani hospital setting. Data collection by trained and dedicated nurses proved to be more feasible, efficient and reliable than real-time data entry by care providers., Conclusions: The initial results show the promising potential of a user-friendly, comprehensive electronic TR through the use of mHealth tools. The pilot test in two hospitals indicates that the registry can be used to create a multicenter trauma database.

Introduction: Injury is a significant and increasingly common cause of morbidity and mortality in sub-Saharan Africa; however, the social and economic factors underlying these trends are not well understood. We evaluated the relationship between socioeconomic status (SES) and trauma outcomes using a prospective registry of patients presenting to the largest trauma hospital in Yaoundé, Cameroon., Methods: Trauma patients (n=2855) presenting to the emergency ward at Central Hospital, Yaoundé between April 15 and October 15, 2009 were surveyed regarding demographic and socioeconomic background, nature and severity of injuries, treatment, and disposition. A wealth score was estimated for each patient, corresponding to an SES index constructed using principle components analysis of the urban Cameroonian Demographic and Health Survey. Logistic regression was used to evaluate the effects of SES on care-seeking behaviour, injury severity, and treatment outcome., Main Outcome Measures: SES wealth score, care-seeking prior to visiting hospital, injury severity, treatment outcome., Results: Patients aged 1-89 presented with road traffic injuries (59.83%), falls (7.76%), and penetrating trauma (6.16%), and had higher SES than the broader urban Cameroonian population. Within the Yaoundé sample, being in the lowest SES quintile was associated with an increased likelihood of having sought care elsewhere before presenting to the hospital (aOR=3.28, p<0.001), after controlling for background and injury characteristics. Patients in the lowest SES quintile were also more likely to present with moderate/severe injuries (aOR=4.93, p<0.001), and were more likely to be transferred to the operating room., Conclusions: Patients presenting to this trauma centre were wealthier than the broader community, suggesting the possibility of barriers to accessing care. Poorer patients were more likely to have severe injuries and more likely to need surgery, but were less likely to seek care from a major trauma centre immediately. Substantial differences in SES between the sample visiting the hospital and the broader community suggest a need for community-based sampling approaches in future trauma research., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Road traffic crashes have been an increasing threat to the wellbeing of road users worldwide; an unacceptably high number of people die or become disabled from them. While high-income countries have successfully implemented effective interventions to help reduce the burden of road traffic injuries (RTIs) in their countries, low- and middle-income countries (LMICs) have not yet achieved similar results. Both scientific research and capacity development have proven to be useful for preventing RTIs in high-income countries. In 1999, a group of leading researchers from different countries decided to join efforts to help promote research on RTIs and develop the capacity of professionals from LMICs. This translated into the creation of the Road Traffic Injuries Research Network (RTIRN) - a partnership of over 1,100 road safety professionals from 114 countries collaborating to facilitate reductions in the burden of RTIs in LMICs by identifying and promoting effective, evidenced-based interventions and supporting research capacity building in road safety research in LMICs. This article presents the work that RTIRN has done over more than a decade, including production of a dozen scientific papers, support of nearly 100 researchers, training of nearly 1,000 people and 35 scholarships granted to researchers from LMICs to attend world conferences, as well as lessons learnt and future challenges to maximize its work.

Unintentional injuries are a leading cause of deaths for children of all ages. Globally, they accounted for 15.4% of 2.6 million deaths recorded among children aged 1 to 14 years in 2013. The 12 highest burden countries in the world by absolute death count and mortality are low- and middle-income countries (LMIC) except for Russia and Equatorial Guinea. These countries accounted for 58% of the 406,442 unintentional injury deaths among 1 to 14 year olds in 2013. Globalization drives inequalities in the distribution of economic gains, risks, and opportunities for preventing child unintentional injuries between high-income countries and LMIC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Considering the high burden of injuries, the Health Authority-Abu Dhabi developed a draft electronic and paper-based injury and poisoning notification system (IPNS) to generate better data on the nature and severity of injuries. The pilot testing and evaluation of IPNS was conducted with the specific objectives to (1) identify the characteristics of injury cases, (2) explore potential risk factors, (3) illustrate the nature and type of data, and (4) the working mechanism of data collection. Data were collected from selected hospitals on patient demographics, injury information and clinical assessment. Descriptive, bivariate and multivariate analyses were conducted. Of 4226 injury cases, nearly three-fourths were male, majority were non-UAE nationals, and the mean age was 21.9. Multivariate findings suggested that compared to UAE nationals, non-UAE nationals were 27% more likely to experience fatal, severe or moderate injuries (p = 0.01). Individuals with health insurance were 31% less likely to suffer a fatal, severe or moderate injury compared to those having no health insurance (p < 0.001). This is the first systematically standardised collection of injury data across three facilities in Abu Dhabi, and provides initial information on characteristics and injury risk factors that will help identify the need for evidence-based intervention for injury prevention and control.

Introduction: Each year in India, road traffic crashes lead to more than 200,000 deaths and the country has seen an unprecedented rate of roadway fatalities in recent years. At the same time, alcohol consumption per capita among Indians is rising. Despite these increasing trends of road traffic injuries (RTIs) and alcohol use, alcohol is not routinely assessed as a risk factor for RTIs. This study aims to examine the involvement of alcohol among emergency department patients presenting with RTIs in the Indian city of Hyderabad., Patients and Methods: As part of a prospective study, data were collected from 3366 patients (88.0% male) presenting with RTIs at an emergency department in Hyderabad, India, from September 2013 to February 2014. Logistic regression models were used to assess individual-level and road traffic crash characteristics associated with suspected or reported alcohol consumption six hours prior to the RTI., Results: Alcohol was suspected or reported among 17.9% of the patients with RTIs. Adjusting for confounders, males experienced 9.8 times greater odds of alcohol-related RTIs than females. Compared to 15-24 year-olds, the odds of alcohol consumption was 1.4 times greater among 25-34 year-olds and 1.7 times greater among 35-44 year-olds, adjusting for confounding factors. Patients who were passengers in vehicles other than motorized two-wheelers had 90% reduced odds of an alcohol-related RTI than motorized two-wheeler drivers. Drivers of non-two-wheelers, passengers on two-wheelers, and pedestrians did not have significantly different odds of an alcohol-related RTI compared to two-wheeler drivers. Nighttime crashes were associated with nearly a threefold increase in the odds of alcohol consumption., Conclusions: Given that alcohol was suspected or reported in more than one in six injured ED patients with RTIs, it is clear that alcohol is a serious risk factor for RTIs; this evidence can guide prevention efforts. These findings suggest that evidence-based interventions to reduce drink-driving, such as random breath testing (where law enforcement officials stop drivers on the road to test them for alcohol use), could be more widespread in India. Future studies should assess the effectiveness of greater implementation and enforcement of policies to decrease alcohol's availability to reduce RTIs., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Occupational injuries are the second leading cause of trauma admission in Qatar. Given the wide diversity of the country's migrant worker populations at risk, this study aimed to analyse and describe the epidemiology of these injuries based on the workers nationality residing in Qatar., Methods: A retrospective analysis of trauma registry data on occupational-related injuries was conducted. The analysis included all patients [aged ≥18 years] admitted to the Level I Hamad Trauma Center, from January 1, 2010 to December 31, 2013., Results: Out of 6555 trauma admissions, 2015 (30.7%) patients had occupational injury. The admitted Case Fatality Rate (CFR) was 4.3 per 100 occupational injury related trauma admissions. Overall non-fatal occupational injury rate was 37.34 per 100,000 workers, whereas fatal injury rate was 1.58 per 100,000 workers. Most of the workers experiencing occupational injuries were from Nepal (28%), India (20%) and Bangladesh (9%). Fatal occupational injuries were predominately among Indians (20%), Nepalese (19%), and Filipinos/Bangladeshis (both 8%). Filipinos had the highest admitted CFR at 8.2 deaths per 100 trauma admissions with the next highest being Indians and Indonesians (4.2 per 100 trauma admissions). During the study period, the incidence of severe occupational injuries decreased despite a simultaneous increase in the worker population within Qatar. Almost one in four occupational injuries was a major trauma (ISS≥16). Nepalese and Indian workers represented 29% and 18% of all major trauma cases., Conclusions: Non-fatal occupational injuries appear to follow a pattern distinct from fatal ones. High-risk worker populations as defined by those with high admitted CFRs, experiencing the most severe or fatal injuries, must be the focus of targeted risk factor analysis and occupational safety interventions., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Injury is a leading cause of death and disability in low- and middle-income countries. Kenya has a particularly high burden of injuries, accounting for 88.4 deaths per 100,000 population. Despite recent attempts to prioritize injury prevention in Kenya, trauma care systems have not been assessed. We assessed perceptions of formal and informal district-level trauma systems through 25 qualitative semi-structured interviews and 16 focus group discussions with Ministry of Health officials, district hospital administrators, health care providers, police, and community members. We used the principles of theoretical analysis to identify common themes of prehospital and hospital trauma care. We found prehospital care relied primarily on "good Samaritans" and police. We described hospital care in terms of human resources, infrastructure, and definitive care. The interviewers repeatedly emphasized the lack of hospital infrastructure. We showed the need to develop prehospital care systems and strengthen hospital trauma care services., (© The Author(s) 2015.)

Context: Currently, little is known about rates of death by cause and country among US travellers. Understanding the risk by cause and country is imperative to risk communication and the development of risk reduction strategies., Methods: Publicly available data on non-natural deaths of US citizens abroad were gathered from January 2003 to December 2009 from the US Department of State's Department Bureau of Consular Affairs. Traveller information was gathered from the US Department of Commerce Office of Travel and Tourism for the same time period. Rates of death were calculated by dividing the number of non-natural deaths of US citizens abroad by the number of US outbound visits for each country., Results: A total of 5417 non-natural death events were retrieved between 2003 and 2009 from the US State Department. Intentionally caused death rates ranged from 21.44 per 1 000 000 visits in the Philippines to 0 per 1 000 000 visits in several countries; the majority of countries had fewer than five intentionally caused deaths per 1 000 000 visits. Rates of road traffic crashes were higher than rates of intentionally caused deaths in almost every instance. Thailand had the highest rate of deaths due to road traffic crashes (16.49 per 1 000 000), followed by Vietnam, Morocco and South Africa (15.12 per 1 000 000, 11.96 per 1 000 000 and 10.90 per 1 000 000, respectively). Motorcycle deaths account for most of the heightened risk observed in Thailand and Vietnam., Conclusions: The leading cause of non-natural deaths in US travellers abroad was road crashes, which exceeds intentional injury as the leading cause of non-natural deaths in almost every country where US citizens travel. Southeast Asia had the highest unintentional injury death rates for US citizens abroad due to the high rates of deaths from motorcycle crashes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Introduction: This article aims to describe the National Injury Surveillance System (NISS) in China from its establishment in 2006 to the methods used and some key findings from 2006 to 2011., Methods: From 2003 to 2005, based upon specific injury case definitions, a pilot study was conducted to explore the feasibility of a National Injury Surveillance System (NISS) in China. The NISS formally started operations in January 2006, and 126 hospitals from 43 sample points (23 rural, 20 urban) were selected to participate. Doctors and nurses in participating hospitals were trained to administer standardised data collection forms. Chinese Center for Disease Control and Prevention is in charge of analysing data and releasing findings., Results: From 2006 to 2011, the annual recorded injury cases increased from 340,000 to 630,000, the majority being male (65%) and over 80% aged 15-64 years. Falls (32%), road traffic injuries (23%) and blunt injuries (19%) were the most common causes. More than 70% of cases were of minor severity, and over 75% of cases were discharged after treatment in the emergency department., Conclusions: The NISS is the first hospital-based national system in China, therefore considered an important source of injury data. It has the potential to describe injury morbidity in China and to be utilised to develop national technical and policy documents., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Drowning is a heavy burden on the health systems of many countries, including Pakistan. To date, no effective large-scale surveillance has been in place to estimate rates of drowning and near-drowning in Pakistan. The Pakistan National Emergency Department Surveillance (Pak-NEDS) study aimed to fill this gap., Methods: Patients who presented with a complaint of "near-drowning" were analyzed to explore patterns of true near-drowning (unintentional) and intentional injuries that led to the "near-drowning" complaint. Bivariate analysis was done to establish patterns among patients treated in emergency departments, including socio-demographic information, injury-related information, accompanying injuries, and emergency department resource utilization., Results: A total of 133 patients (0.2% of all injury patients) with "near-drowning" as presenting complaints were recorded by the Pak-NEDS system. True near-drowning (50.0%) and intentional injuries that led to "near-drowning" complaints (50.0%) differed in nature of injuries. The highest proportion of true near-drowning incidents occurred among patients aged between 25-44 years (47.5%), and among males (77.5%). True near-drowning patients usually had other accompanying complaints, such as lower limb injury (40.0%). Very few patients were transported by ambulance (5.0%), and triage was done for 15% of patients. Eleven (27.5%) true near-drowning patients received cardiopulmonary resuscitation., Conclusion: There was major under-reporting of drowning and near-drowning cases in the surveillance study. The etiology of near-drowning cases should be further studied. Patients who experienced non-fatal drownings were more commonly sent for medical care due to other accompanying conditions, rather than near-drowning event itself. There is also need for recognizing true near-drowning incidents. The results of this study provide information on data source selection, site location, emergency care standardization, and multi-sector collaboration for future drowning prevention studies.

To address the growing burden of violence and injuries, especially in low- and middle-income countries, in 2007 the World Health Organization launched MENTOR-VIP, a global violence and injury prevention (VIP)-mentoring programme. The programme aims to develop human resource capacity through 12-month mentoring arrangements between individual VIP experts (mentors) and less-experienced injury practitioners (mentees). In this paper, we review the first five years of the programme (2007-2011) using a systems analysis and SWOT (Strengths, Weaknesses, Opportunities and Threats) frameworks, discuss programme findings and make recommendations. A well-defined programme with clear instructions, successful matching of mentorship pairs with similar interests and language, a formal accord agreement, institutional support and effective communication were identified as programme strengths. Overambitious projects, lack of funds and difficulties with communications were identified as programme weaknesses. Mentorship projects that require institutional permissions or resources could be potential threats to the success of mentorship. The study resulted in the four following recommendations to strengthen the programme: (1) institute additional steps in selection and matching mentor-mentee pair; (2) train mentors on e-mentoring; (3) conduct special orientation for mentees to the programme; and (4) maintain effective and open communication throughout the programme.

Background: We aimed to analyse the frequency and patterns of fall-related injuries presenting to the emergency departments (EDs) across Pakistan., Methods: Pakistan National Emergency Departments surveillance system collected data from November 2010 to March 2011 on a 24/7 basis using a standardized tool in seven major EDs (five public and two private hospitals) in six major cities of Pakistan. For all patients presenting with fall-related injuries, we analysed data by intent with focus on unintentional falls. Simple frequencies were run for basic patient demographics, mechanism of falls, outcomes of fall injuries, mode of arrival to ED, investigations, and procedures with outcomes., Results: There were 3335 fall-related injuries. In cases where intent was available, two-thirds (n = 1186, 65.3%) of fall injuries were unintentional. Among unintentional fall patients presenting to EDs, the majority (76.9%) were males and between 15-44 years of age (69%). The majority of the unintentional falls (n = 671, 56.6%) were due to slipping, followed by fall from height (n = 338, 28.5%). About two-thirds (n = 675, 66.6%) of fall injuries involved extremities, followed by head/neck (n = 257, 25.4%) and face (n = 99, 9.8%). Most of the patients were discharged from the hospital (n = 1059, 89.3%). There were 17 (1.3%) deaths among unintentional fall cases., Conclusion: Falls are an important cause of injury-related visits to EDs in Pakistan. Most of the fall injury patients were men and in a productive age group. Fall injuries pose a burden on the healthcare system, especially emergency services, and future studies should therefore focus on safety measures at home and in workplaces to reduce this burden.

Introduction: In low- and middle-income countries, injuries are a leading cause of mortality in children. Much work has been done in the context of unintentional injuries but there is limited knowledge about intentional injuries among children. The objective of this paper was to understand the characteristics of children with intentional injuries presenting to emergency departments in Pakistan., Methods: The data was from the Pakistan National Emergency Departments Surveillance (Pak-NEDS), conducted from November 2010 to March 2011 in seven major emergency departments of Pakistan. Data on 30,937 children under 18 years of age was collected. This paper reports frequency of intentional injuries and compares patient demographics, nature of injury, and discharge outcome for two categories of intentional injuries: assault and self-inflicted injuries., Results: Intentional injuries presenting to the emergency departments (EDs) accounted for 8.2% (2551/30,937) amongst all other causes for under 18 years. The boy to girl ratio was 1:0.35. Intentional injuries included assault (n = 1679, 65.8%) and self-inflicted injuries (n = 872, 34.2%). Soft tissue injuries were most commonly seen in assault injuries in boys and girls but fractures were more common in self-inflicted injuries in both genders., Conclusion: Intentional injury is one of the reasons for seeking emergency treatment amongst children and a contributor to morbidity in EDs of Pakistan. Moreover, such injuries may be underestimated due to lack of reporting and investigative resources. Early identification may be the first step leading to prevention.

Unintentional injuries are estimated to claim the lives of more than 875,000 children each year; millions more live with long-term consequences and permanent disabilities. The epidemiology of injuries has become clearer in the past decade. NGOs need to work in concert with each other to address the global burden of injuries by sharing information. Several NGOs have heeded this call, and the field has seen the emergence of global organizations aimed at highlighting the burden of injuries and streamlining injury prevention activities worldwide. Safe Kids Worldwide Inc. (SKWW) is a global network in 16 countries whose mission is to address the burden of injuries in children under 15 by harnessing the potential of local NGOs. An organizational assessment was conducted of SKWW which included structured organizational assessment, functional organizational mapping and contextual analysis that allowed for an in-depth examination of the strengths and challenges of SKWW's injury prevention approach. Over one year, primary and secondary data were collected and analyzed from headquarters and individual country offices. SKWW appears to be an effective model and has experienced a strong momentum and growth over the last two decades. Global NGOs that address the burden of injuries should start by defining a clear and universal strategic goal, build on local successes, maximize their strengths, and create avenues for stronger country engagement., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Road traffic injuries (RTIs) are a major cause of death and disability worldwide. In Cameroon, like the rest of sub-Saharan Africa, more data on RTI patterns and outcomes are needed to improve treatment and prevention. This study analyses RTIs seen in the emergency room of the busiest trauma centre in Yaoundé, Cameroon., Methods: A prospective injury surveillance study was conducted in the emergency room of the Central Hospital of Yaoundé from April 15 to October 15, 2009. RTI patterns and relationships among demographic variables, road collision characteristics, injury severity, and outcomes were identified., Results: A total of 1686 RTI victims were enrolled. The mean age was 31 years, and 73% were male. Eighty-eight percent of road collisions occurred on paved roads. The most common user categories were 'pedestrian' (34%) and 'motorcyclist' (29%). Pedestrians were more likely to be female (p<0.001), while motorcyclists were more likely to be male (p<0.001). Injuries most commonly involved the pelvis and extremities (43%). Motorcyclists were more likely than other road users to have serious injuries (RR=1.45; 95% CI: 1.25, 1.68). RTI victims of lower economic status were more likely to die than those of higher economic status., Discussion: Vulnerable road users represent the majority of RTI victims in this surveillance study. The burden of RTI on hospitals in Cameroon is high and likely to increase. Data on RTI victims who present to trauma centres in low- and middle-income countries are essential to improving treatment and prevention., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

We review current literature and data on the burden of injury and violence in the Eastern Mediterranean Region (EMR) of the World Health Organization (WHO), with a special focus on the health, economic and social burden they impose on individuals, families and society. Injury-associated mortality and disability is on the rise in EMR, especially among economically productive adults, young males and vulnerable road users. In particular, road traffic injuries, the leading cause of injuries, account for 27% of the total injury and violence mortality in EMR according to WHO. Violence including suicide, homicide and war-related injury has also been increasing over the past two decades for both females and males. There is need for greater interest and efforts in slowing and ultimately halting the trend through interventions, legislative actions, and research that examine the special needs and challenges in the Region.

Introduction: Injury rates in sub-Saharan Africa are among the highest in the world, but prospective, registry-based reports from Cameroon are limited. We aimed to create a prospective trauma registry to expand the data elements collected on injury at a busy tertiary center in Yaoundé Cameroon., Methods: Details of the injury context, presentation, care, cost, and disposition from the emergency department (ED) were gathered over a 6-month period, by trained research assistants using a structured questionnaire. Bivariate and multivariate models were built to explore variable relationships and outcomes., Results: There were 2,855 injured patients in 6 months, comprising almost half of all ED visits. Mean age was 30 years; 73 % were male. Injury mechanism was road traffic injury in 59 %, fall in 7 %, penetrating trauma in 6 %, and animal bites in 4 %. Of these, 1,974 (69 %) were discharged home, 517 (18 %) taken to the operating room, and 14 (1 %) to the intensive care unit. The body areas most severely injured were pelvis and extremity in 43 %, head in 30 %, chest in 4 %, and abdomen in 3 %. The estimated injury severity score (eISS) was <9 in 60 %, 9-24 in 35 %, and >25 in 2 %. Mortality was 0.7 %. In the multivariate analysis, independent predictors of mortality were eISS ≥9 and Glasgow Coma Score ≤12. Road traffic injury was an independent predictor for the need to have surgery. Trauma registry results were presented to the Ministry of Health in Cameroon, prompting the formation of a National Injury Committee., Conclusions: Injuries comprise a significant proportion of ED visits and utilization of surgical services in Yaoundé. A prospective approach allows for more extensive information. Thorough data from a prospective trauma registry can be used successfully to advocate for policy towards prevention and treatment of injuries.

Introduction: Injuries are a significant cause of mortality and morbidity, of which more than 90% occur in low- and middle-income countries (LMICs). Given the extent of this burden being confronted by LMICs, there is need to place injury prevention at the forefront of public health initiatives and to understand the costs associated with injury. The aim of this article is to describe the extent to which injury-related costing studies have been conducted in LMICs., Methods: A review of literature was performed to explore costing data available for injury and/or trauma care in LMICs. Study quality was described using recommendations from the Community Guide's quality assessment tool for economic evaluations., Results: The review identified 68 studies, of which 13 were full economic evaluations. Cost of injury varied widely with mean costs ranging from US$14 to US$17 400. In terms of injury-prevention interventions, cost per disability adjusted life year averted for injury-prevention interventions ranged from US$10.90 for speed bump installation to US$17 000 for drunk driving and breath testing campaigns in Africa. The studies varied in quality, ranging from very good to unsatisfactory., Discussion: There is a lack of injury-related economic evidence from LMICs. Current costing research has considerable variability in the costs and cost descriptions of injury and associated prevention interventions. The generalizability of these studies is limited. Yet the economic burden of injury is high, suggesting significant potential for cost savings through injury prevention. A standardized approach to economic evaluation of injury in LMICs is needed to further prioritize investing in injury prevention., (Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine © The Author 2013; all rights reserved.)

Background: In the developed world, multiple injury severity scores have been used for trauma patient evaluation and study. However, few studies have supported the effectiveness of different trauma scoring methods in the developing world. The Kampala Trauma Score (KTS) was developed for use in resource-limited settings and has been shown to be a robust predictor of death. This study evaluates the ability of KTS to predict the mortality of trauma patients compared to other trauma scoring systems., Methods: Data were collected on injured patients presenting to Central Hospital of Yaoundé, Cameroon from April 15 to October 15, 2009. The KTS, Injury Severity Score, Revised Trauma Score, Glasgow Coma Scale, and Trauma Injury Severity Score were calculated for each patient. Scores were evaluated as predictors of mortality using logistic regression models. Areas under receiver operating characteristic (ROC) curves were compared., Results: Altogether, 2855 patients were evaluated with a mortality rate of 6 per 1000. Each score analyzed was a statistically significant predictor of mortality. The area under the ROC for KTS as a predictor of mortality was 0.7748 (95% CI 0.6285-0.9212). There were no statistically significant pairwise differences between ROC areas of KTS and other scores. Similar results were found when the analysis was limited to severe injuries., Conclusions: This comparison of KTS to other trauma scores supports the adoption of KTS for injury surveillance and triage in resource-limited settings. We show that the KTS is as effective as other scoring systems for predicting patient mortality.

Objectives: We aimed to analyze the epidemiology of childhood unintentional injuries presenting to hospitals in 5 select sites in low- and middle-income countries (LMICs) (Bangladesh, Colombia, Egypt, Malaysia, and Pakistan)., Methods: We collected standardized data from children ages 0 to 12 years at participating emergency departments (EDs) in 2007. Statistical analyses were conducted to compare the characteristics of these injuries and to explore the determinants of injury outcomes., Results: Among 2686 injured children, falls (50.4%) and road traffic injuries (16.4%) were the most common, affecting boys more often (64.7%). Home injuries were more common among younger children (average 5.41 vs 7.06 years) and girls (38.2% vs 31.7%). Following an ED visit, 24% of injured children were admitted to the hospital, and 6 died. Injury outcomes were associated with risk factors, such as age and sex, to varying extents., Conclusions: Standardized ED surveillance revealed unintentional injuries are a threat to child health. The majority of events took place inside the home, challenging traditional concepts of children's safety and underscoring the need for intensified context-appropriate injury prevention.

Among 1-19-year olds, unintentional injuries accounted for 12% of 5.1 million global deaths from injuries in 2010. Despite this high burden, childhood injuries have not received much attention in global health. This paper describes the major causes of deaths from childhood unintentional injuries and provides a review of interventions for reducing this burden. About 627,741 deaths were due to unintentional injuries in 2010 among 1-19-year olds. The proportionate mortality increased with age-from 12.6% among 1-4-year olds to 28.8% among 15-19-year olds. Deaths from Western sub-Saharan Africa and South Asia accounted for more than 50% of all deaths. Rates in these regions are 68.0 and 36.4 per 100 000 population, respectively, compared to 6.4 in Western Europe. Road traffic injuries (RTI) are the commonest cause of death, followed by deaths from drowning, burns and falls. Male children are more predisposed to unintentional injuries except for burns which occur more frequently among females in low and middle income countries (LMICs). Effective solutions exist--including barriers for preventing drowning; safer stoves for burns; child restraint systems for RTI--but the effectiveness of these measures need to be rigorously tested in LMICs. The general lack of a coordinated global response to the burden of childhood unintentional injuries is of concern. The global community must create stronger coalitions and national or local plans for action. Death rates for this paper may have been underestimated, and there is need for longitudinal studies to accurately measure the impact of injuries in LMICs.

Trauma is a major cause of death and disability worldwide, of which more than 90% occur in low- and middle-income countries. Given the magnitude of this inequality, there is a need to devise and use tools to assess the capacity of facility-based trauma care. This study used two tools, hospital flowcharts and the World Health Organization's Trauma Care Checklist, to describe trauma care capacity at two hospitals in Kenya and ways in which this capacity can be strengthened. We found these hospitals had a large volume of trauma, but due to the lack of intensive care units, specialized trauma units, and axillary services, such as orthopedics and neurosurgery, the hospitals had a limited ability to provide definitive care for injured patients in critical condition. Additionally, organizational capabilities, such as trauma registries, trauma-specific training, and quality improvement programmes were lacking. The state of trauma care at district and provincial levels in Kenya demonstrates a strong case for national and global investment in clinical and systemic interventions., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: In Russia, the high Road Traffic Injuries (RTIs) rate has been attributed to two well-known risk factors - the low rates of seatbelt and child restraints use and speeding. Despite the importance of understanding both speeding and seatbelt use patterns for the purpose of direct interventions or monitoring road safety situation, no study has assessed the current status of speeding among all vehicles and seatbelt wearing rates among all vehicle occupants in Russia. We are aware that alcohol is a known risk factor for RTI in the country however the work focused on seat belts and speed. This research was conducted as part of the Bloomberg Philanthropies Global Road Safety Programme and focuses on observed speeding and seatbelt use in two Russian regions: Lipetskaya and Ivanovskaya Oblast., Methods: Data was collected through observational surveys on selected roads in the two interventions sites (Lipetskaya and Ivanovskaya Oblast) between October 2010 and March 2013. The percentage of seatbelt use by drivers and passengers and the percentage of speeding vehicles by speed limit and road types were calculated., Results: Observational studies on speeding show signs that drivers are speeding less from the first survey held in July 2011 in Lipetskaya Oblast and March 2012 in Ivanovksya Oblast. Overall the observational studies showed a consistent reduction in the proportion of vehicles exceeding the speed limit: from 54.7% (2012) to 40.1% (2013) in Ivanovskaya Oblast and from 47.0% (2011) to 26.1% (2013) in Lipetskaya Oblast. Observational studies on seatbelt use demonstrate an increase in seatbelt wearing rates from the first survey held in October 2010 in Lipetskaya Oblast and April 2011 in Ivanovskaya Oblast. The overall prevalence of seatbelt use increased from 52.4% (2010) to 73.5% (2013) amongst all occupants in Lipetskaya Oblast and from 47.5% (2011) to 88.8% (2013) in Ivanovskaya Oblast., Conclusion: Preliminary results show some promising signs that speeding and seatbelt use are moving in the right direction in both intervention sites subsequent to the various countermeasures being implemented under the Global Road Safety Programme. The study demonstrates the need for further targeted interventions to increase drivers' compliance with the speed limit and seatbelt use. However, it is too early to draw any definite conclusions or to fully attribute the effect to the interventions., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort., Methods: A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required., Results: Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality., Conclusions: Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Viet Nam is experiencing a shift in its burden of disease profile with injuries becoming more prominent. A history of high alcohol involvement in road traffic crashes despite stringent laws led to increased enforcement by police, enhanced public education messaging and targeted social marketing campaigns in Ha Nam and Ninh Binh provinces in Viet Nam. This study aims to illustrate the changes in prevalence (November 2010 to December 2011) and knowledge, attitudes and practices (KAP) around alcohol use and drink-driving for the year 2011., Methods: Breath Alcohol Concentration (BrAC) was collected through police enforcement checkpoints in the two provinces. The proportion of drivers with BrAC above the legal limit was plotted over time for both provinces. The trend in prevalence of drink-driving over time was further assessed using Poisson regression models. Prevailing KAPs were determined through surveying randomly selected road users over the age of 17 years at gas stations at quarterly intervals. Cross tabulations of key variables as well Chi-Square statistic were used to assess associations., Results: A total of 8,404 drivers were tested for BrAC levels of which less than 0.25% were female. Of 1,639 drivers displaying BrAC levels in excess of the legal limit, 87.3% were car drivers, 7.9% motorcyclists and 86% were between the ages of 25 and 44 years. KAP surveys captured 1,661 drivers over the study period. The prevalence of self-reported drink-driving increased 6 percentage points among respondents aged 27-36. Between 44% (January 2011) and 49% (December 2011) of respondents indicated awareness of a drinking and driving Blood Alcohol Concentration (BAC) or BrAC limit and only 25% of all study participants recalled being penalized for a traffic violation - none of which were for drink-driving., Conclusion: While there has been some reduction in drink-driving prevalence, inadequate or incorrect knowledge on drink-driving legislation appears to be an impediment to greater gains. Increased attention needs to be paid to enforcement activities and social marketing campaigns need to be part of a multi-faceted programme that also works on improving existing legislation, takes into consideration gender issues, and enhances visible enforcement of the laws., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Road traffic crashes in China kill in excess of 250,000 people annually, more than any other country in the world. They are the fourth leading cause of premature death in the country and are responsible for 2.4% of the burden of non-fatal health loss in the country. Interventions to curb speeding and drunk driving are being implemented in the cities of Suzhou and Dalian since late 2010. We evaluated the ongoing effect of these activities through five roadside surveys, seven rounds of observational studies, and analysis of crash statistics in the two cities. We find that thus far, the prevalence of speeding has not reduced in either city with the notable exception of one site in Dalian, where the percentage of speeding vehicles declined from nearly 70% to below 10% after an interval-based speed enforcement system was installed. The broader deployment of such speed control technologies across China and other countries should be explored. Roadside alcohol testing suggests that prevalence of drunk driving (i.e. BAC >20 mg%) declined from 6.4% to 0.5% in Suzhou and from 1.7% to 0.7% in Dalian during the monitored time period. However, the measured prevalence rates are very low and should be validated against estimates based on hospital studies. Roadside interviews suggest that the population of both cities is already highly sensitized to the risks associated with drunk driving and speeding. Crash statistics from the two cities do not show appreciable declines in injuries and fatalities as yet. However, the possibility of substantial underreporting in crash statistics sourced from traffic police poses a severe threat to monitoring progress towards road safety in Suzhou, Dalian and across China. There is an urgent need for China to invest in a reliable road traffic injury surveillance system that can provide information for describing key risk factors, evaluating the impact of safety policies, and benchmarking achievements., (Copyright © 2013 Elsevier Ltd. All rights reserved.)