Uncovering the Neglected Field of Injury Epidemiology

Injury Epidemiolog

y

An epidemic of neglect?

•

Published first injury paper in 1970 (child seat

restraint use)

•

subsequently published over 100 peer reviewed

papers on injury prevention

•

all studies employ epidemiologic methods

•

Founding editor of “Injury Prevention” (BMJ

Specialty journal)

•

Co- Founder of Canadian Hospitals Injury

Reporting and Prevention Program (surveillance)

Injury defined

•

The word injury, as defined by Baker et al: ‘‘Injury is the

transfer of one of the forms of physical energy

(mechanical, chemical, thermal, etc.) in amounts or at

rates that exceed the threshold of human tolerance.’’ It

may also result from lack of essential energy such as

oxygen (for example, drowning) or heat (for example,

hypothermia).7"

•

In Haddon’s paper, "On the escape of tigers” he expounds

on the notion of uncontrolled energy transfer as the key

element in what constitutes an injury.

Injury: a glossary of terms, In J Epidemiology, Hagel and Pless

Objectives

•

To help you understand the current status of

injury epidemiology (IE)

•

To explore why it’s so neglected (especially in

Canada)

•

To encourage you to become involved in this

field

1.

Not old enough

2.

Not big enough

3.

Not scholarly enough

4.

Not taught enough

5.

Not costly enough

6.

Not unified enough

7.

Not Canadian enough

Another for good measure

•

injuries = accidents = bad luck

•

hence, not preventable

•

so why bother?

Injury epidemiology & injury

prevention (IP)

•

Overlapping (most IE bears on IP & vice-

versa)

Injury

epidemiology

Injury

prevention

Neglected?

Robertson:

•

“For almost two-thirds of the 20th Century, injury deaths were listed in

mortality statistics but largely ignored by researchers in

epidemiology

and public health. Near the end of the century,

despite a growing body

of knowledge

…. important discussions of the future direction of

epidemiological research made no mention of injury.

•

A conference in 2005 on the future of Public Health included one brief

mention of injury,

but more was said about Elvis impersonators…

•

The WHO

publication “A Safer Future” (2007) emphasizes safety from

diseases (but) has 

no

 section on injury ….

•

Almost every category of injury fatality is

much larger in LICs than in HICs

•

Difference overall is 51 vs 89 per 100,000

•

Largest difference is ‘war’ injuries

•

Next largest are ‘traffic’ and ‘drowning’

Death rate by mechanism and economic status

Rate per 100,000 per year

Mock et al., Lancet 2004; 363

In 1985, a National Research Council/Institute of Medicine committee

published  

Injury in America: A Continuing Public Health Problem

. The

conclusion: 

 Injuries kill more Americans aged 1-34 than all diseases

combined; (thus) they

are the leading cause of deaths up to the age of

44.

•

In 1986, a Division of Injury Epidemiology and Control was created in

CDC's Center for Environmental Health

•

In 1987, DIE started

funding

specialized Injury Control Research

Centers (ICRC)

•

In 1992, the Division + new program for acute care, rehabilitation, and

prevention of injury-related disabilities became CDC’s 

National Center

for Injury Prevention and Control

•

To prevent violence and injuries and reduce

their consequences (by)

–

Identifying and monitoring the problem

–

Conducting research to guide decision making

–

Empowering states through funding and technical

assistance

•

e.g., WISQARS™ (Web-based Injury Statistics Query

and Reporting System) - an interactive, online

database covering fatal and nonfatal injury, violent

death, and cost based on several trusted sources

WISQARS

•

Link to website

Injury Control vs Injury Prevention

The difference is subtle but important when politics, policy

making, and resources are being considered.

•

Injury 

prevention

 is largely a matter of 

primary and

secondary 

prevention, especially secondary.

•

Injury 

control

 also involves 

tertiary

 prevention—

preventing tragic outcomes (death, disability, etc.) after an

injury has occurred

•

Injury control includes prehospital care—ambulances and

emergency medical services —and emergency or casualty

care and rehabilitation

•

Some tension because most preventive resources are

consumed by the hospital sector  leaving little for

traditional public health initiatives

Injury Control Research Centers

(ICRCs)

•

conduct research in all three core phases of

injury control (prevention, acute care, and

rehabilitation)

•

also for training & public information

•

most ICRC research is interdisciplinary

(epidemiology, biostatistics, public health,

medicine, engineering, law, behavioral and

social sciences, biomechanics)

Current 11 ICRCs

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Columbia University

•

Johns Hopkins School of Public Health

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University of Iowa

•

University of Michigan

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Mount Sinai School of Medicine

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The Research Institute at Nationwide Children's Hospital

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University of North Carolina at Chapel Hill

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University of Pennsylvania

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University of Rochester Medical Center

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West Virginia University

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Emory University

Does it matter?

•

That the US has a National Center and

Canada does not?

•

The data are inconclusive (partly because

some Canadian data are not up-to-date)

US vs Canada

US = 40.4 unintentional/100,000

Note

: total US rate higher

and increases 35.7 to

40.4/100,000 over same

time period

My hypotheses

Not 5 but 7

•

1937, Godfrey ES. Role of the Health Department in the

Prevention of Accidents, Am J Public Health Nations Health. (?

first peer-reviewed)

•

1938, Holcomb RL. Alcohol in relation to traffic accidents, JAMA

•

1949, Gordon JE. The epidemiology of accidents. Am J Public

Health

•

1952, De Havens H. The site, frequency and dangerousness of

injury sustained in 800 survivors of light plane accidents. Crash

Injury Research, Cornell University

•

1964 Haddon, Suchman, 

Accident Research: Methods and Approaches

,

Association for Crippled Children

•

1980, Haddon Matrix introduced a conceptual basis for

prevention, Hazard Prevention

•

1980, Haddon W. Advances in the epidemiology of injuries as a

basis for public health policy, Public Health Reports

Historical landmarks

•

1980 -  advances in injury epidemiology voted by

Epidemiology Section of APHA as 1 of 10 landmark

achievements in US epidemiology

•

1992 - US National Center for Injury Prevention and

Control became independent program of CDC

•

1995 - first academic IP journal (Injury Prevention)

•

1999 - reductions in MV and occupational injury mortality

judged 2 of 10 great US public health achievements of 20

th

century

•

2000 -  WHO established Dept. of Injury and Violence

Prevention

•

2000 – E Mackenzie publishes “Epi of injuries’ in Epid Rev

•

2014 - first academic IE journal (Injury Epidemiology)

Sue Baker – Pioneer (Hopkins*

)

•

Pilot

•

Artist

•

Epidemiologist

•

Great teacher

•

Good friend

*Johns Hopkins Center for Injury

Research & Policy

Sue Baker – pilot

I asked her when and why. Her reply -

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(Started) in 1986, when I was 56, which was old for a

student pilot and stopped about 8 or 10 years ago.

•

I  took it up  because I wanted to do research on

aviation crashes, and needed to understand what is

required of pilots.

•

Getting my license opened a lot of doors – e.g., pilots

lectured in the course I started on aviation safety –

and some airlines allowed me to fly jump-seat on the

flight deck, right behind the captain, on any flight

where I was a ticketed passenger. (Also gave her more

data about pilot behaviour)

2. Not big enough?

Consider death rates

Canada 2005

Causes of death, Canada, 2011

ages 15 to 24 & 25 to 34 years

Causes of death, Canada, 2011

Global problem

•

WHO ‘Global Burden of Disease’  -- injuries

are Increasingly 

the

 major problem in ‘third

world’ countries (LICs), especially MV

crashes, and they are rising rapidly.

•

If present trends continue, road traffic

injuries are predicted to be the third-leading

contributor to the global burden of disease

and injury by 2020.

3. Not scholarly enough?

Books and Journals

But many injury epidemiology

books

Most focus on prevention

Come visit my bookshelf

Other books

•

Hemenway D.  

While We Were Sleeping: Success Stories in Injury and

Violence Prevention 

(2009)

•

Roberts I.  

The Energy Glut: Climate Change and the Politics of Fatness

(2010)

•

Li G, Baker S

.  Injury Research: Theories, Methods, and Approaches

(2012)

•

Liller K

, Injury Prevention for Children and Adolescents: Research,

Practice, and Advocacy, 

2nd Edition (2012)

•

Barss P, Smith G, Baker S, Mohan D. 

Injury Prevention: An International

Perspective: Epidemiology, Surveillance, and Policy

•

Christoffel K, Gallagher S

. Injury Prevention And Public Health: Practical

Knowledge, Skills, And Strategies

peer reviewed & respectable IFs

(for whatever that’s worth!)

Injury Epidemiology Contents

Journal

The contents give some idea of the range of

topics included in IE

•

Scope: 

magnitude, distribution, determinants, causes,

prevention, diagnosis, treatment, prognosis, and outcomes

of injuries in specific population groups, geographic regions,

and environmental settings

•

Policy: 

priority given to papers

that feature contemporary

theories, innovative methods, and novel techniques applied

to injury surveillance, risk assessment, effective

interventions, and program/policy evaluation

Table of contents

Original Article:

Using a virtual environment to study child pedestrian behaviours: a comparison of parents' expectations and

children's street crossing behaviour (22 Sep 2015)

Original Article:

Scald burns in children under 3 years: an analysis of NEISS narratives to inform a scald burn prevention program (22

Sep 2015)

Original Article:

An examination of concussion education programmes: a scoping review methodology (22 Sep 2015)

Original Article:

Defining a safe player run-off zone around rugby union playing areas (22 Sep 2015)

Original Article:

Influence of voluntary standards and design modifications on trampoline injury in Victoria, Australia (22 Sep 2015)

Original Article:

Investigating the fall-injury reducing effect of impact absorbing flooring among female nursing home residents:

initial results (22 Sep 2015)

Methodology:

Validation of ICDPIC software injury severity scores using a large regional trauma registry (22 Sep 2015)

Anniversary Archives:

Australia's 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass

shootings (22 Sep 2015)

News And Notes:

Global news highlights (22 Sep 2015)

And a few others

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J of Injury and Violence reserch

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J of Safety Research

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Safety Science

•

Transportation Research

4.Not taught enough?

(in epi departments)

Canadian responses

Email to 20+ Canadian chairs

… indicate if your department at present (or in

the last decade) offers a course on injury

epidemiology

… if you don

’

t offer one and care to elaborate

on why you don’t, please do

•

9 responses

•

None said they teach IE and none explained

why

5. Not cost enough?

Various cost of injury estimates

Cost of Injury (Canada)

•

The Cost of Injury in Canada Report

–

financial & societal burden on people, health care,

economy is rising & not sustainable

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$27 billion lost to economy

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3.5 million visits to emergency rooms

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> 60,000 disabilities

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costs more than heart and stroke

•

Loss of life equivalent to one jumbo jet crashing

every 10 days

Cost of injury (UK)

savings from prevention

If we prevented 

one

 child from being admitted

to hospital for treatment as a result of liquitab

ingestion, this would represent an average cost

saving of approximately £19,500 to the NHS

Cost of Injury (Canada)

•

From Parachute launch

•

“As Minister of Health, 

nothing

 is more

important that the health and safety of all

Canadians” (Rona Ambrose)

•

I am NOT

•

many such reports in Canada and elsewhere

•

have had little or no proven effect on policy,

programs, etc.

•

unfortunate that in this instance Parachute uses

report as fund-raiser

•

clock will not be stopped ‘if we all joined the

movement”, as Parachute suggests, unless the

power it gave was used to change government

policy, esp. a 

National Center

The flip side – too 

little

 funding

--  research, programs, etc.?

•

No industrial support, no advertisers, no

pharmas, few commercial applications

•

No major charities or ‘victim groups’

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Few advocacy groups e.g., CSC, Parachute

OF TOTAL $1 BILLION BUDGET,

POSSIBLY$900,000 FOR INJURY

RESEARCH (3 PROJECTS)

Reviewed CIHR funding decisions 

2014

CIHR funding, 2014

Investigator initiated $732m    priority-driven $254m

•

ebola, cancer, HIV vaccine, vaccines, neuroinflammation,

critical care trials, rare diseases nutrition biomarkers,

knowledge translation, adverse reactions,, aging, cancer

prevention, mental health, longitudinal cohorts,, breast

cancer, blood supply, genetics,  aboriginal, bioethics, aging,

ALS, drug safety, epigenetic, gastroenterology, IBD,

•

applied public health chairs, Canada research chairs, new

investigator priority, Canada excellence research chairs,

Injury related

•

safe active school travel 199k, booster seat and helmet

laws 199k, suicide prevention 500k

6. Not unified enough?

Too many components to “injury”

Field 

is

 diverse

•

Unintentional: 

burns, drowning, falls, traffic,

sports, recreation

•

Intentional

: violence, suicide

•

Other IE

: methods, models, surveillance

•

diversity means no lobbying, no parent

groups, no charities & no (political) pressure

•

it means less money for research,

implementation of research findings via

programs, policies, legislation, regulation

•

but is this less unified than ‘cancer’?

7. Not Canadian enough

Eh?

•

if the Americans do it (have a National Center) why

should we bother?

•

not just a Harper (Tory) view because successive

governments have rejected the idea

•

excuse is that ‘health is a provincial matter’ but we

have had all sorts of ‘

national strategies

’ e.g., breast

cancer, mental health, aboriginal, pharmacare, e-

records, AIDs,

•

and at least one National Center – the Canadian

Center for Occupational Health and Safety

No National Center

After 30 years of pressing the issue we are no closer to having a

National Center comparable to what exists in CDC and light

years away from comparable funding for research. Nor do we

have anything that remotely resembles the Swedish model that

appears to have been so successful.  Instead,  one Health

Canada publication gives these examples of success: the Back

to Sleep campaign, a statement about the need to combine

education with other tactics and with the onus placed on not-

for-profit organizations. The section on “legislation, products

and standards” refers to the importance of product standards

and regulations and playground standards are the shining

example. However, compliance with these standards is

voluntary. The same mixed message emerges from the other

example given – the importance of legislation – using bicycle

helmets as an example while noting that many provinces refuse

to pass such laws.

•

examples of (failed) advocacy (mine & others)

–

many meetings with Deputy Ministers and some

with Ministers

–

many letters to the editor (journals, newspapers,

etc.)

–

many keynote presentations

–

many editorials and some op-eds

the need for a Canadian equivalent of National

Center for Injury Control consistently rejected

Semantic Scholar

•

Found in recent issue of “The Scientist”

•

a search engine described as ‘A Literature Database

with Smarts’ launched Nov 2 by Allen Institute for

Artificial Intelligence

•

uses machine reading  to extract meaning and impact

from scientific papers

•

aims to help researchers find most relevant papers

•

helps users make sense of papers, how often

reference has been cited? which papers are of

highest quality? who else Is working on this problem?

Semantic scholar results ‘injury

epidemiology’

•

Found 51 papers in 2015

•

They ranged from ‘fall detection’ to

‘environmental determinants in Canadian

North’ to ‘Lushan Earthquake’

•

Interesting alternative to Google Scholar (GS)

•

But ‘no cigar’ --- too many missed

•

GS came up with 35,400 in 2015

Moral remains: Why is IE so neglected?

Thank you

Time for questions, or -

better still - suggestions