Burdens and trends

Injury/trauma from all causes kills 5.8 million per year globally, accounting for 10% of the world’s deaths. This is 32% more than the number of deaths from malaria, tuberculosis and HIV/AIDS combined . This statistic includes unintentional injuries (road traffic injuries, falls, fires, poisoning and drowning), as well as intentional injuries from war, interpersonal violence and self-inflicted injuries.

Throughout the world, injury is a leading cause of death and disability for all age groups except persons greater than 60 years old, and is one of the top three causes of death for persons between 5 and 44 years . For high-income countries, road traffic injuries, self-inflicted injuries and interpersonal violence are the three leading causes of death among people 15–29 years old. These data on leading causes of death by age globally can be seen in Fig. 1 .

Leading causes of death, for all ages. Taken from the Global injury report from the World Health Organization “Global Burden of Disease 2004 Update”.

All injuries cannot be prevented and, as a result, improvements in trauma care are needed, especially in low- and middle-income countries. It is estimated that 2 million of the 5.8 million people that die annually from trauma could be saved with improvements in trauma care. Ninety percent of the deaths that occur as a result of trauma are in low- and middle-income countries. This is not only due to a lack of prevention, but also due to a lack of timely and quality trauma care, as persons with life threatening, but salvageable, injuries are six times more likely to die in a low-income setting (36%) versus high-income setting (6%) .

Road traffic injuries are the leading cause of injury-related deaths worldwide with 1.2 million people dying annually in road traffic accidents (3250 per day), and 20–50 million wounded . Traffic accidents were the ninth leading cause of death in 2004, and are projected by the World Health Organization to be the fifth leading cause of death by 2030. Currently, road traffic injuries are the leading cause of death among 15–29-year-olds; 75% of these deaths occur in men . This is an economically viable group of the population and, as a result, injuries and deaths in this group have enormous indirect costs as well.

Death from injury disproportionately affects those from lower-income countries. More than 90% of the deaths from road traffic injuries occur in low- and middle-income countries; however, these countries only own 48% of the vehicles ( Fig. 2 ). The injury trends in high-income countries have improved, with the injury rates decreasing since the 1970s. In low-income countries, the injury rates have continued to increase since that time . The countries with the highest injury rates in the world are China, India, Nigeria, USA, Pakistan, Indonesia, Russian Federation, Brazil, Ethiopia and Egypt. The lowest rates in the world are in Netherlands, Sweden and the UK, where there are only between 3.4 and 5.4 deaths per 100,000 per year . Rates of non-fatal extremity injuries are also much higher in low- and middle-income countries with combined rates from falls and road traffic crashes being two to five times higher (1000–2600/100,000 year ⁻¹ ) than high-income countries where (500/100,000 year ⁻¹ ) . Forty-six percent of those who die due to road traffic injuries are ‘vulnerable road users’. A vulnerable road user is a road user who does not have a protective shell around them, and includes pedestrians, cyclists, two or three wheelers, as well as persons using overcrowded and unsafe public transportation. There is also tremendous regional variation in the percentage of deaths in vulnerable road users. In low-income countries of South East Asia, over 80% of those who are killed are vulnerable road users, while in the high-income countries of the Americas it is 22%. The needs of vulnerable road users need to be taken into account during the planning of land use and road construction .

Road traffic deaths by level of income as compared to vehicle ownership by level of income. Taken from World Health Organization, Global Status Report on Road Safety 2009.

If the disparities between high- and low-income countries were eliminated, with the fatality rates from serious injury in low- and middle-income countries being brought down to the rates in high-income countries, over 2 million lives could be saved per year. If the rates are decreased by 8%, 400,000 lives could be saved each year .

In addition to the loss of human life, the global financial costs of road traffic injuries are significant, costing more 518 billion US dollars per year, more than 1–3% of the gross domestic product .

Key developments in research, prevention and management

The Global Status Report on Road Safety, which is a survey to assess the status of road injury prevention, and to help countries identify key priorities, began in 2007. Data have now been received from 178 countries and areas (98% of world’s population) . Michael Bloomberg, in 2007, began a pilot programme in Vietnam and Mexico which was very successful in both countries. In Vietnam, there was an increase in motorcycle helmet usage from 43% to 94%, resulting in a 20% reduction in head injury fatalities. In Mexico, enforcement of drunk-driving laws reduced road traffic injuries in the city of Leon by greater than 20% .

On 18 November 2009, Bloomberg Philanthropies committed 125 million dollars to improve road safety in 10 countries. The countries included in this project are Brazil, Cambodia, China, Egypt, India, Kenya, Mexico, Russian Federation, Turkey and Vietnam. This effort is being led by Dr. Adnan Hyder at John’s Hopkins University. Their focus will be on reducing drinking and driving, increasing the usage of seat belt, appropriate child restraints and motorcycle helmets. They also will work to enhance frontline and professional training for pre-hospital and hospital trauma care, and help propose, pass and implement effective road safety laws, regulations and policies .

Recently, the first Global Ministerial Conference on Road Safety occurred in the Russian Federation in November of 2009. This meeting was well attended by more than 70 ministers of transport, health and interior, along with 1400 of the world’s leading road safety experts from 150 countries. They drafted the ‘Moscow Declaration’ which invited the United Nations General Assembly to declare the next decade ‘A Decade of Action for Road Safety’, and encourages further implementation of the recommendations of the World Report on Road Traffic Injury Prevention.

During the past decade, there have been many improvements in trauma care in low-income countries, as a result of focussed projects.

In Ghana, there was support for in-service training courses for more than 200 emergency medical technicians. In Uganda, they provided first aid training to first responders who included police officers, bus and taxi drivers, and community leaders, who also were able to learn basic first aid skills .

Rio de Janeiro held a Global Forum on Trauma Care in October of 2009. Participating in this forum were 100 trauma care leaders from 39 countries. The objective of the forum was to agree on a set of priority and goals, develop an agenda for action, agree on key messages and a consensus statement and begin creating tools for advocacy .

Quality improvement programmes were implemented in Thailand, at Khon Kaen Hospital. This hospital was selected, because a trauma registry indicated a high rate of preventable deaths. To address this, problems within the system were identified, and corrective action was then taken which included improving communication with radios, stationing fully trained surgeons in the emergency rooms during peak periods, improving orientation on trauma care for new junior doctors and improving reporting of injuries and fatalities. As a result of this quality improvement programme, overall mortality decreased from 6.6% to 4.4% in this hospital .

Improvements in pre-hospital care were made in Ghana. In Ghana, there is no national emergency response/ambulance service, and the most severely injured are usually transported to the hospital by truck, taxi or bus drivers. Between 1998 and 2000, 335 commercial drivers in Ghana participated in a first aid programme at a cost of US $4 per driver. In this course, they were taught basic first aid and rescue for road injuries consisting of control of external haemorrhage and airway protection. These commercial drivers were able to consistently apply these skills, and 61% of the drivers provided first aid within 10 months of taking the course, and improved the care of the patients these drivers were transporting as compared to untrained drivers .

Punjab, Pakistan, launched the first trained and equipped emergency rescue medical service in December 2004. This emergency rescue service consisted of a rigorous training programme for the responders, and provided emergency vehicles. As a result of training emergency responders, and providing emergency response vehicles, there have been improvements in responses to emergencies in this region.

The Essential Trauma Care Project by the International Association for Trauma Surgery and Intensive Care and World Health Organization developed a series of resource tables for essential trauma care that detailed the human and physical resources that should be in place to assure optimal care of the injured patient at a range of health-care facilities throughout the world. This was developed for everything from rural outposts to tertiary care centres. Essential resources are the lowest common denominator of pre-hospital interventions at little cost, affordable even in countries that have a total budget of 3–4 US dollars per person, per year for health care. Desired resources are the next level, for countries with more resources, at an additional cost. Resources ‘possibly required’ are listed for countries that have additional money for health care. There also is a list of irrelevant resources, which do not need to be purchased. These resources are determined for 14 categories which include (1) airway management, (2) breathing, (3) circulation, (4) management of head injury, (5) management of neck injury, (6) chest injury, (7) abdominal injury, (8) extremity injury, (9) spinal injury, (10) burns and wounds, (11) rehabilitation, (12) pain control and medications, (13) diagnosis and monitoring and (14) safety for health-care personnel. There also are recommendations for transport based on income level of the country .