Unintentional injuries in developing countries: the epidemiology of a neglected problem.

Epidemiologic Reviews Copyright © 1991 by The Johns Hopkins University School of Hygiene and Public Health All rights reserved

Vol. 13, 1991 Printed in U.S.A.

Unintentional Injuries in Developing Countries: The Epidemiology of a Neglected Problem

Gordon S. Smith and Peter Barss

Many developing countries are experiencing what Omran described as the epidemiologic transition, where "the Old World epidemics of infection are progressively replaced by degenerative diseases, diseases due to stress, and man-made diseases...." (1, p. 4). Among those conditions assuming increasing importance are injuries. In many industrialized countries, injuries are the leading cause of death during the first half of the human life span (2). In many less developed countries, injuries are rapidly becoming one of the leading causes of death and disability, despite the recent spread of acquired immunodeficiency syndrome and the resurgence of malaria (3-7). In Mexico, from 1950 to 1980, mortality rates declined dramatically for several infectious diseases and increased greatly for ischemic heart disease, diabetes, and injuries Received for publication January 18, 1989, and in final form June 10, 1991. From the Injury Prevention Center, The Johns Hopkins University School of Hygiene and Public Health, 624 N. Broadway, Baltimore, MD 21205. (Reprint requests to Dr. Gordon S. Smith at this address.) This paper is based in part on a position paper prepared for Risks Old and New: A Global Consultation on Health, held at the Carter Center, Emory University, Atlanta, Georgia, on April 27 to May 1, 1986. Support for the initial work on this paper was provided by the Carter Center. The subsequent revision was supported in part by a consultancy with the World Bank Adult Health Project and by grant R49/CCR302486-01 from the Division of Injury Epidemiology and Control, Center for Environmental Health and Injury Control, Centers for Disease Control. Dr. Barss was supported during the revision by a fellowship from the Medical Research Council of Canada. The authors are grateful for the assistance of The Johns Hopkins Injury Prevention Center. The authors also wish to thank Susan Baker, Garen Wintemute, Richard Feachem, Carlos Dora, Lawrence Berger, Philip Graitcer, Sally Stansfield, and Dinesh Mohan for their valuable comments; Katy Benjamin for editorial assistance; Laura Higgins and Joanne Burgess for preparation of the manuscript; and the staff of the Welch Medical Library for their valuable assistance in a difficult search for appropriate references.

caused by motor vehicles (figure 1). From the period 1955 to 1980, deaths caused by infectious diseases (gastroenteritis, influenza/pneumonia, and childhood diseases) declined from 43 percent of deaths to only 17 percent (6). During that same time period, deaths caused by unintentional injuries rose from 4 percent of all deaths to 11 percent, almost entirely as the result of an increase in fatalities resulting from motor vehicle crashes. However, the relative importance of injuries not caused by motor vehicles increased during this time as well, as rates of other competing causes of mortality declined. Similarly, Selya (8) described this epidemiologic transition in Taiwan, where from 1960 to 1977, as the status of the country moved from developing to developed, unintentional injuries rose from the seventh to the third leading cause of death, and the annual injury mortality rate increased from 39 to 57 per 100,000 population. In Thailand, another country in rapid economic transition, injuries resulting from drowning and motor vehicles are a major cause of premature mortality (9); in 1983, unintentional injuries were the leading cause of death, with a rate of 35.4 deaths per 100,000 population (10). Deaths resulting from injuries incurred in motor vehicle crashes were responsible for more years of potential life lost than tuberculosis and malaria combined. Similar data from Latin America and Shanghai County, China, revealed injuries to be the leading cause of death for people between the ages of 1 and 44 years (11, 12). Although injuries and many chronic diseases are gaining increasing importance in developing countries, this is not necessarily due to large increases in age-specific injury risks, but rather, in many countries, to an

228

Unintentional Injuries in Developing Countries

MALARIA \

100

ALL UNINTENTIONAL INJURIES

Q> S O TS

or

6 0 - -WH00PING\ COUGH

\

2 40 o

/ •

20--

1950 1955 I960

i

"a

15-

1 h

A.

20 4O

/ NON-MOTOR VEHICLE UNINTENTIONAL INJURIES n

1965 1970 1975 1980 Year

25

a:

229

ISCHAEMIC HEART DISEASES/*'

A*' MOTOR VEHICLE INJURIES

10-

o 5-4-

FIGURE 1. Changes in mortality rates per 100,000 inhabitants for deaths from unintentional injuries and the other main causes of death in Mexico that showed either a significant increase or decline between 1950 and 1980. (Adapted from Frenk J, Bobadilla JL, Sepulveda J, et al. Health transition in middle-income countries: new challenges for health care. Health Policy and Planning 1989;4:29-39, by permission of Oxford University Press; and from personal communication, Frenk J, 1991.)

overall decline in mortality rates and to the increasing proportion of adults who are at the highest risk for injuries (13). It is estimated that the adult population (age, 15-60 years) in developing countries has grown

overall at a rate of 2.6 percent annually from 1970 to 1985, while the general population has only increased by 2.3 percent (14). A recent study examined longitudinal data on adult mortality from the 1950s and 1960s to

230

Smith and Barss

the present for Singapore and four developing countries, (Chile, Costa Rica, Cuba, and Sri Lanka). It found that injury rates among adults 15 to 60 years of age had changed little during this time, despite major declines in other causes of death (14, 15). The study used the 45Q15, which is the percentage of persons alive at the age of 15 years who die before the age of 60, to measure the burden of adult mortality (15). The 45Q15 declined considerably in four of the five countries from the 1950s and 1960s to the mid-1980s, while in Cuba there was little change. In most of these countries, this decline was due to decreases in both communicable and noncommunicable diseases. However, little change or even some increase was seen in the rate of injuries, especially motor vehicle injuries. These data and the study from Mexico mentioned earlier (figure 1) suggest that in some countries, injury rates, with the exception of motor vehicle injuries, have remained relatively constant, while most diseases have decreased in importance. However, no data are available from the least developed countries, especially those in Africa. In addition, new hazards, such as poisoning from pesticides, may be introduced with new agricultural practices, and sometimes go undetected (16). In developed countries, the causes and means of prevention of injuries have not been intensively investigated, as they have for chronic and infectious diseases. Recently, however, epidemiologic studies have begun to identify, according to age, sex, and other risk factors, specific groups at high risk for particular injuries. Combined with analyses of common factors related to injury, especially environmental ones, this research has led to the prevention of many deaths and disabilities (17-24). Unfortunately, much less is known about the incidence and causes of injuries in developing countries, or about the groups at high risk for injury in those countries. As the population continues to age, injuries will become increasingly important, especially since injury rates and case fatality rates for injuries are higher in the elderly (25, 26). The cost of treating injuries also imposes a considerable burden on the health system

in both developed and developing countries (17-29). The costs of providing effective treatment and rehabilitation services can only increase as the population ages, unless some of the proven prevention strategies that have already been evolved (17-24) can be applied in developing countries. This paper will review the epidemiology of unintentional injuries that occur at home and in everyday life in developing countries. Unintentional injuries are defined on the basis of the International Classification of Diseases, Ninth Revision (ICD-9), external cause codes E800-E949 (30). These include drowning; falls; burns; poisonings; injuries related to bicycles, land or marine animals, and insects; and lacerations and other injuries from cutting tools such as the machete or small farm machines. Traditionally, these were called "accidents," but the term "unintentional injuries" is now preferred by injury researchers because the term "accident" implies fatalism or acts of God, namely, phenomena that cannot be studied or prevented (17-20). Those injuries purposefully inflicted by self (suicide) or others (assault, homicide) are known as "intentional injuries." Detailed discussion of their epidemiology is excluded in this paper, since such injuries usually have different causes and risk factors. Intent, however, is sometimes difficult to determine for injuries such as drowning, burns, and poisoning, which are sometimes suicidal or homicidal (5, 31, 32). In addition, some prevention strategies can reduce both intentional and unintentional injuries; examples include the reduction of carbon monoxide in household gas in Britain (33, 34) and the control of handguns. The injury groupings used in this review are based on the major causes of death in the ICD-9 and do not separately describe injuries from activities such as sports and occupation, which will be included under the discussions of specific injuries. Motor vehicles have been recognized as a major cause of death in many developing countries and have been the subject of a number of excellent reviews (35-45); the reader is referred to these for details on injuries resulting from motor vehicle crashes. The importance of other unintentional injuries has been largely


overlooked, and will be the focus of this paper. However, some data for injuries from motor vehicle crashes will be presented, as they relate to the overall injury problem or are necessary to understand injury trends over time. For the purposes of this paper, developing countries are defined as those countries with an annual per capita gross national product of less than US$2,500, based on 1986 figures from the World Bank (46). This figure represents a reasonable cut-off point between countries with resources and hazards similar to those of wealthy countries and countries with few resources where people are often exposed to chemicals, machines, and other hazards, but are afforded little or none of the protection offered in more developed countries. Some developing countries have few resources (per capita gross national product less than US$450), while others are rapidly becoming industrialized. The material in this paper is based upon an extensive review of the world literature on injuries indexed in three computer databases (Medlars, Biosis, and Excerpta Medica) for the developing countries of Africa, the Middle East, Asia, Oceania, South and Central America, and the Caribbean, for the period from 1966 through 1990. Although more than 2,500 reference titles and abstracts were reviewed, particular emphasis was given to the few epidemiologic studies that focus on the risk factors for and causes of injuries. INJURY MORTALITY

Most developing countries have poorly developed health information systems that often have little or no data regarding the incidence of diseases or the causes of death (47-48). For example, Mohan (4) estimated that only one third of deaths resulting from injuries were reported in the official statistics of the Indian Government. Sometimes only deaths that occur in hospital and for which a death certificate is completed are recorded, although the majority of deaths occur close to home and go unreported. Even for countries that do report statistics to the World Health Organization, data are only reported

231

using the basic tabulations list, which only provides a breakdown of the data into the major injury categories (30, 49). Data are presented in this paper mainly for those countries with a population greater than 1 million. Of these, only two countries in Asia (Sri Lanka and Thailand) and two on the African continent (Egypt and the small island of Mauritius), reported injury data to the World Health Organization during the 10-year period ending in 1987 (table 1) (49). No data are available for the poorest countries in sub-Saharan Africa. For the Americas (the Caribbean and Central and South America), however, better health data capable of forming the basis for more extensive analysis are available (11). Health impact of injury mortality

Among those countries for which statistics are available, the reported mortality rates associated with all injuries (intentional and unintentional) vary much more widely than the rates for unintentional injuries alone, owing to the wide variation by country in the rates of intentional injuries (table 1). The causes of intentional injury include suicide, homicide, and acts of war, the relative importance of each of which varies by country. One of the highest suicide rates was reported for males in Sri Lanka (48 per 100,000); the highest rate, for homicide and acts of war, occurred in El Salvador (163 per 100,000). Mortality rates for unintentional injuries, however, also varied considerably, from a high of 96 per 100,000 population for Mexican males to 28 per 100,000 population for Guatemalan males. Mortality rates for unintentional injuries among females are usually about one half to one third of those for males, ranging from 28 per 100,000 population in Uruguay to 8 per 100,000 population in Guatemala. The male-to-female rate ratio for mortality from all injuries varies greatly by country. The highest was 6.8 in El Salvador, where there was a 10.6 rate ratio for suicide, homicide, and other violence, which was almost entirely the result of high homicide rates among males. The lowest male-to-female rate ratio of 1.9 was seen in Cuba (where

232

Smith and Barss

TABLE 1.

Reported crude injury mortality rates, by sex and country* All injuries Countryt

Africa Mauritius

Motor vehicle

All M

Intentional injuries^

Unintentional injuries

F

M

F

1986 Per capita GNP

Other

M

F

M

F

M

F

Year

66

34

43

21

16

3

27

18

23

13

1,200

1987

118 107

46 29

49 52

17 17

10 21

2 6

38 31

15 11

69 55

29 12

400 810

1983 1981

62

32

21

20

4

2

17

18

41

12

760

1979

Americas El Salvador Mexico Chile Ecuador Cuba Guatemala Uruguay Panama Argentina Costa Rica Paraguay Peru

245 131 113 97 97 86 80 76 70 64 59 46

36 29 32 29 50 16 33 21 26 17 22 15

65 96 40 73

19 25 16 24

21 30 11 27

7 8 2 8

44 66 29 46

12 17 14 16

180 35 73 24

17 4 16 5

820 1,973 1,320 1,160

28 62 53 45 48 41 37

8 28 17 19 13 18 11

2 14 26 13 20 15 10

1 5 7 4 5 6 3

26 48 27 32 28 25 27

7 22 10 15 8 12 8

58 18 23 25 16 18 9

8 5 4 7 4 4 4

§ 930 1,900 2,330 2,350 1,480 1,000 1,090

1983 1983 1986 1986 1986 1984 1986 1986 1985 1986 1986 1983

United States Sweden Kuwait

93 80 45

34 40 14

56 43 42

24 25 11

28 15 28

11

28 28 14

13 20 5

37 38 3

10 15 3

17,980 13,160 13,890

1986 1986 1987

Southeast Asia Sri Lanka Thailand Eastern Mediterranean Egypt

6 6

* Per 100,000 population. Occasional discrepancies in totals and subtotals reflect rounding error. Data obtained from the World Health Organization, World Health Statistics Annual, 1982-1988. M, males; F, females; GNP, gross national product. t Countries with populations greater than 1 million and a per capita gross national product for 1986 of less than US$2,500. The United States, Sweden, and Kuwait are included for comparison. t Includes suicide, homicide, and other violence. § Not available.

more detailed data were not available), Mauritius, and Egypt. Egypt was the only country where female mortality rates for unintentional injuries from causes other than motor vehicles exceeded those for males; this was due to the high rate of burns among women (see table 5). For deaths from injuries caused by motor vehicles, the maleto-female rate ratios varied from 5.5 in Chile to a low of 2 in Egypt and Guatemala. Mortality rates for unintentional injuries from other causes show less variation. For most countries, mortality rates associated with unintentional injuries are strikingly similar to those in developed nations such as the United States and Sweden and to those of Kuwait, a country that for the 30

years preceding the recent Gulf war had experienced rapid rises in per capita gross national product. The data in table 1 are presented as crude rates. When available, injury mortality rates age-adjusted to the standard world population (49) do not in most cases differ substantially from the crude rates shown. When compared with other causes of death, unintentional injuries represent from 3 to 11 percent of all causes of death, depending on the country (49); Mexico has the highest proportional mortality from injuries. However, while death rates provide an indication of the relative magnitude of the problem, the measure of premature mortality—years of potential life lost before the age


of 65—has been advocated as a better indicator of the impact of injuries on society, since it takes into account the fact that injuries affect younger age groups more than many other leading causes of death (9, 50, 51). Unintentional injuries, including those caused by motor vehicles, are the leading cause of years of potential life lost per 100,000 population in most countries of the Americas with populations greater than 1 million (table 2). In Ecuador, Uruguay, Peru, and Paraguay, they are second only to enteritis/diarrhea, malignant neoplasms, influenza/pneumonia, and enteritis/diarrhea, respectively. In Guatemala, unintentional injuries are exceeded by enteritis/diarrhea, homicide/war, and influenza/pneumonia as causes of years of potential life lost. Despite the burden of infectious disease in many countries, most have higher rates of years of potential life lost from injuries than the United States or Canada, the two most developed countries in the Americas. Fatality rates for unintentional injuries vary considerably by age and sex and among countries. However, the peak in rates for teenagers and young adults seen in the United States, largely the result of motor vehicle crashes (2, 18, 21), is not seen in most developing countries (49) because of restricted access to private vehicles. Mortality rates for unintentional injuries from causes other than motor vehicles are shown in table 3 by age and sex for selected countries. As age increases beyond about 44 years, injury mortality rates increase; the high rates in the elderly reflect high case fatality rates, especially from falls (25, 26). The lowest rates are usually seen between the ages of 5 and 14 years, while rates for males in the most productive years (35-44 years) range from 5.3 times higher in Mexico to only 1.2 times higher in Egypt. The rates for females show only slight differences between these two age groups, except in Mauritius, where the rates vary widely, owing to small numbers. Motor vehicle crashes are the largest single cause of death from unintentional injuries in most developing countries for which data

233

are available; however, this may not be the case in rural areas, where reporting is poor. Death rates for motor vehicle crashes are often up to five times higher in males than in females (table 1) and range from 30 per 100,000 males in Mexico for 1983 to a low of 2 per 100,000 males in Guatemala for 1984. Deaths resulting from motor vehicle injuries, as a proportion of all deaths from unintentional injuries in developing countries, range from 7 percent in Guatemalan males to 49 percent in Panamanian males; as a percentage of all deaths from injuries, including intentional injuries, they range from 2 to 34 percent in the same countries. In comparison, deaths from motor vehicle crashes comprise 50 percent of all deaths from unintentional injuries among males in the United States and only 35 percent of deaths among males in Sweden. In Kuwait, a country that had developed very rapidly from oil profits and is no longer considered a developing country, 65 percent of all deaths from unintentional injuries among males in 1987 were caused by motor vehicles. Comparison of injury mortality rates per 100,000 population may not be the best measure of risk, since exposures vary widely by country. A better method for comparison would be to use injuries per 100 million vehicle miles traveled (52). However, such data are only available for a select number of developed countries. Another measure of exposure, the number of deaths per 10,000 registered vehicles, is available for many countries (37). The fatality rates per 10,000 vehicles are much greater in developing countries, and the differences between the rates for developing and developed countries are much greater than the differences between population-based rates. For example, in 1978 the fatality rate per 10,000 vehicles in Nigeria was 240, more than 70 times higher than that in the United States (37). Very high rates were also found in Ethiopia, Malawi, Lesotho, and Swaziland. Many other developing countries such as Kenya, Niger, and Liberia had fatality rates of from 60 to 70 per 10,000 vehicles. In contrast, the

234

Smith and Barss

TABLE 2. Potential years of life lost in the Americas before the age of 65 years from the leading causes, by country* Injuries Countryt

South America Colombia Ecuador Chile Argentina Uruguay Peru Paraguay Central America Guatemala El Salvador

All ijnintentionalf

1,506 1,913 1,636 1,100 753 920 895

Nicaragua Honduras Panama Costa Rica

2,723 2,341 1,280 1,655 1,192 694

North America Mexico

2,234

Caribbean Cuba Dominican Republic Canada United States

CiijpjHp OUIvlUv

Chronic diseases

972

175

3,560 1,314 877

524

482

307 932 581

659 925 945

383

395

387 486 443 230 276

389 576

441

393

1,622

514

596

844

464

271

481 672

745 769

894 993

379

133 159

532

336 270

Infectious diseases

Homicide, Heart Malignant Enteritis/ Influenza/ war, etc. disease neoplasms diarrhea pneumonia

259

531 1,920

1,013 228 162

891 923

1,257 525

4,387 626 1,041 1,252 206

2,838

639

303

346

Total PYLL§

Per capita

Year

UlNr ||

7,991 12,657 5,091 5,629 4,314 7,460 7,400

1,139 1981 1,160 1980 1,320 1983 2,350 1981 1,900 1984 1,090 1982 1,000 1984

23,659 9,922 8,513 9,010 4,059 3,297

930 1981 820 1984 790 1977 740 1981 2,330 1984 1,480 1983

7,594

1,973 1982

4,077

1983

5,711

710 1981

3,210 14,120 1984 3,918 17,980 1983

* Per 100,000 population, individuals aged 1 to 64 years. Only causes among the five leading causes of potential years of life lost for a country were included; a few leading causes were in categories not included in the table. Data taken from the Pan American Health Organization, Health Conditions in the Americas 1981-1984, Vol. I, Washington, DC: Pan American Health Organization, 1986 (Scientific publication no. 500). t Countries with populations greater than 1 million and a per capita gross national product for 1986 of less than US $2,500. Canada and the United States are included for comparison. t Including injuries resulting from motor vehicle incidents. § PYLL, potential years of life lost. II Annual per capita gross national product (GNP) in 1986.

United States had only 3.3 fatalities per 10,000 vehicles in 1978. Motor vehicle fatality rates by vehicle and population, and per mile traveled, have declined dramatically in the United States during the last 35 years. However, the rates in many developing countries have increased. For example, from 1960 to 1983, the mortality rate for unintentional motor vehicle injuries in Sri Lanka increased from 3 to 11 per 100,000 males, while the rates for unintentional injuries not related to motor vehicles changed little (30). Similarly, in Mauritius, while fatality rates for motor vehicle injuries increased from 15 per 100,000 males during the period from 1965 to 1969 to 32

per 100,000 in 1976, the rates for other unintentional injuries only increased from 27 to 30 per 100,000 males. While motor vehicle injury mortality rates vary widely among countries, there is also great variation in the importance of the various types of motor vehicle injuries. The distribution of all motor vehicle fatalities by class of road user (i.e., pedestrian, cyclist, motorcyclist, driver, passenger) varies considerably depending on local road use and conditions in various countries (37). In Ethiopia for example, where there are few vehicles, 84 percent of those killed in motor vehicle crashes were pedestrians and only 13 percent were the occupants of motor vehi-


235

TABLE 3. Age- and sex-specific mortality rates for unintentional injuries from causes other than motor vehicles for selected countries, 1979-1986* Deaths per 100,000 of age group (years) per year Country

Year

Egypt

1979

Mauritius

1986

Thailand

1981

Mexico

1982

Costa Rica

1984

El Salvador

1984

Argentina

1982

Sweden

1984

United States

1984

Sexf

75

All ages

15 11 42 57 9 11

11 11

19 27 20 24 36 10 92 15 28 5 50 8 31 7

19 19 42 24 39 9 120 16 27 7 61 6 32 6

13 14 37 22 38 10 127 18 39 6 66 8 39 7

16 12 61 16 46 14 135 22 48 2 58 13 39 9

17 16 65 13 38 11 145 31 52 5 106 16 47 13

24 20 75 58 40 13 180 53 80 22 130 47 56 27

36 37 170 66 59 27 348 212 274 276 254 167 140 140

17 17 32 20 30 11 80 20 30 9 43 11 37 16

6 1 22 4

13 3 26 5

23 3 24 5

28 5 27 8

37 9 32 11

44 20 47 21

169 157 145 100

28 19 28 13

M F M F M F M F M F M F M F

48 39 22 8 29 16 87 68

25 20 13 16 22 16 30 21 20 10 9 8 30 18

M F M F

4 7 20 17

5 2 17 11

10 5 14 10 24 10 9 3 13 6 13 5 3 1 9 3

* Per 100,000 population per year; injuries classified E800-E809 and E820-E949 by the International Classification of Diseases, Ninth Revision. Data taken from the World Health Organization, World Health Statistics Annual, 1985-1988, and from the Pan American Health Organization, Health Conditions in the Americas, 1981-1984, Vol. 1, Washington, DC: Pan American Health Organization, 1986 (Scientific publication no. 500).

t M, male; F, female.

cles. In Indonesia, on the other hand, only 20 percent of those killed in motor vehicle crashes were pedestrians, and a higher proportion, 34 percent, were riding motorcycles or motor scooters. Few cyclists are killed in most countries, although in Guyana and West Malaysia, cyclists comprise 13 percent of all those killed in road incidents. Even in countries with higher incomes, the risk groups for motor vehicle fatality vary, with pedestrians being at highest risk in Hong Kong, where they comprise 70 percent of those killed; in the United States, in comparison, only 16 percent of those killed are pedestrians, and 72 percent are drivers or passengers. In Kuwait, few deaths occurred among cyclists (2 percent) or motorcyclists (2 percent), most involving pedestrians (55 percent) and vehicle occupants (41 percent). While motor vehicle crashes are the largest single cause of death from unintentional injury in many countries, mortality rates for other injuries remain high and often appear to have changed little with time, despite the

fact that many are thought to be preventable (2, 3, 17-24, 33, 34, 53). The epidemiology of specific injuries that do not involve motor vehicles will be discussed separately in the sections to follow. Local population-based studies

The data presented thus far are derived from available statistical reports, which do not generally include information for the poorest countries, owing to their lack of reliable health information systems. A review of the published literature revealed only a few population-based studies that could be used to calculate the impact of injuries in poor countries. One was done by Gordon et al. (54) three decades ago in India, others at the Matlab Demographic Surveillance Unit in Bangladesh (55-57), and another in Egypt (58). The study by Gordon et al. (54) reported an annual rate of death from unintentional injury of 63 per 100,000 population in 11

236

Smith and Barss

rural villages in northern India in 1959. While the size of the study was extremely small (12,022 people), and only 23 deaths occurred, they represented all deaths from injury that occurred during the 3-year study period. The injury mortality rate of males was 1.6 times that of females, despite the fact that more females than males sustained nonfatal injuries, and mortality rates were highest in young children and adults over 65 years of age. Injury rates by age and sex were not published for all age groups. The following were the causes of fatal injury found in the study: burns (22 percent), injuries from animals (22 percent), drowning (13 percent), poisoning (9 percent), falls (9 percent), suffocation (4 percent), and lack of infant care (9 percent). Complications from secondary infection caused 13 percent of all the injuryrelated deaths. None of the deaths were caused by motor vehicles. There were no factories and no electricity in the area, which reflected the situation in many isolated rural villages at the time. By comparison, the 1959 World Health Statistics Annual reported mortality rates per 100,000 population for unintentional injuries from causes other than motor vehicle crashes of 33 for the United States, 58 for Egypt, and 56 for Burma, with most of the tropical countries reporting rates exceeding those for the United States (49). Rates have since declined in both the United States and Egypt (table 1).

In the Matlab study in Bangladesh (table 4), the causes of death were determined from mortality interviews (verbal autopsies) with relatives (55). Verbal autopsies provide a structured approach for obtaining information on the cause of or conditions associated with death (59-61). The published data from Matlab list several causes of death, but unintentional injuries are only divided into drowning and all other unintentional injuries. Unintentional injury mortality rates were highest in the population between 1 and 4 years of age, because of the high rate of drowning in this age group. A more recent study of deaths from injury among women in the same population found that 12 percent of deaths among women aged 15 to 44

years were the result of injuries (19 percent among women aged 15 to 24 years), of which 58 percent were unintentional, 37 percent were suicide, and 4 percent were homicide (56). A follow-up study found that when complications of medical and surgical care (technically considered injuries by the ICD9) were included, injuries were responsible for 18 percent of all deaths among women of reproductive age; complications of induced abortions accounted for 63 of 207 deaths from injury (30 percent) (57). The leading causes of unintentional injuries were drowning (35 percent), burns (27 percent), and snakebite (20 percent). Epileptic seizures were responsible for 33 percent of unintentional injuries. Another population-based study in a rural area of Egypt (58) investigated all causes of death among married women of reproductive age (15-49 years). Injuries were the third leading cause of death, and accounted for 14 percent of all deaths in this population group. The injury mortality rate for married women of reproductive age was 29 per 100,000 population. This study also evaluated the standard vital registration system for married women of childbearing age and compared it with mortality histories obtained from relatives (verbal autopsies) (61), Reporting of deaths from injuries ("trauma") was validated through detailed interviews with relatives and record review, and was found to be considerably more reliable than reporting of death from other causes; of 237 deaths reported as injuries, 93 percent were reported correctly, whereas only 53 percent agreement was found for all causes of death. A total of 293 deaths were identified by either system, and 220 of these (75 percent) were classified as injuries by both systems. In addition, for those injuries for which a specific cause was identified, there was 74 percent agreement between the two systems. A recent verbal autopsy study in a remote area of the highlands of Papua New Guinea found that injuries ranked fourth as a cause of death among the study population of 25,000 subsistence cultivators (7). However, provincial and national health reporting sys-


TABLE 4.

237

Mortality rates for injuries and all causes by sex and age, Matlab, Bangladesh, 1978-1981* All ages

Drowning Other unintentional Suicide Homicide All injuries All causes Injuries as a percentage of all causes

Deaths per 100,000 of age group (years) per yeart

Males

Females

Total

65

47 7 4 2 60 1,269

33 4 2 2 41 1,385

40 6 3 2 51 1,327

78 4 0 11 93 11,244

215 9 0 0 224 2,194

25 3 1 1 30 256

4 2 6 2 14 249

7 13 7 4 31 1,488

12 30 0 4 46 7,237

4.7

3.0

3.8

0.8

10.2

11.7

5.6

2.1

0.6

* Per 100,000 population per year. Adapted from Zimicki S, Nahar L, Sarder AM, et al. Source Book of Cause-Specific Mortality Rates 1975-1981, Demographic Surveillance System—Matlab. Vol. 13. Dhaka, Bangladesh: International Center for Diarmoeal Disease Research, 1985:63:26-61. t Rates for both sexes.

tems did not list injuries among the top 10 causes of death. Among persons in the study population aged 15 to 44 years, injuries were the leading cause of death, with a mortality rate per 100,000 population of 105 for males and 79 for females. Among the 359 deaths studied, the leading causes were homicide (27 percent), suicide (19 percent), drowning (17 percent), burns and fire (10 percent), falls and falling objects (10 percent), motor vehicles (6 percent), and poisoning (4 percent). Deaths resulting from unintentional injuries comprised 59 percent of all injuryrelated deaths for males and only 42 percent for females. Compared with other countries, agestandardized mortality rates for all injuries among males in the highlands of Papua New Guinea were 1.9 times those for the United States and Bangladesh, 1.4 times those for rural China, and comparable to those reported for Sri Lanka and Thailand. Rates among females were 3.2 times those for the United States, 2.4 times those for Bangladesh, and more than double those for Sri Lanka and Thailand. With regard to other diseases, it is well known that even in countries with a welldeveloped vital registration system, there is considerable difficulty in establishing causeof-death data, especially among the elderly (25, 26, 62-71). Deaths from injury are, however, coded by the external cause, which is based upon observations of the circumstances of the death. This information is

likely to be reported if a reliable informant is available. The high level of agreement between the two reporting methods for cause-of-death noted in the study in Egypt suggests that it is possible to obtain reliable cause-of-death data for injuries in developing countries, even when the extent of medical certification and the accuracy of diagnosis for other health conditions is low. In some countries, poisoning, suicide, homicide, and some other conditions may be over- or under-reported as a result of cultural influences or beliefs or when compensation is involved (7). INJURY MORBIDITY

In addition to causing premature death, injuries are a significant cause of temporary disability or time lost from normal activities, including work and subsistence farming, and are also a significant cause of permanent crippling (4). As is the case for information on mortality from injuries, morbidity data are often inaccurate and unrepresentative. Morbidity data, especially population-based information, are frequently unavailable. Simply defining what constitutes an injury can be difficult, and is often determined by cultural and other factors. It is difficult to compare rates between countries, even if the same definition is used for the type, cause, and severity of injury, because of restricted access to care and differing reporting systems. In addition, other conditions such as back pain may or may not be reported as

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injuries, depending on whether they are recognized as the result of specific trauma. In the report by Gordon et al. (54) cited earlier, nonfatal injuries were studied in a population of 4,377 people in four villages in northern India followed up for 1 year in 1959 (54). The rate of injury (defined as causing disruption of normal activity) was determined to be 116 per 1,000 population per year; 4 percent of these injuries resulted in permanent disability or crippling (a rate of 5 per 1,000 per year). Comparable rates in the United States are about 270 per 1,000, but valid comparisons are difficult because of different interpretations of definitions of what constitutes an injury (72). Injury rates showed considerable variation by age and sex, with the highest male rates occurring between birth and the age of 14 years, and the highest female rates between the ages of 25 and 44 years. The majority (43 percent) occurred in the home; 28 percent occurred in public places, and 23 percent at work; only 6 percent were vehicular, reflecting the lack of mechanized transport in the villages. The leading cause of injury in this population was cutting and piercing by instruments such as knives and axes, followed by cutting and piercing by objects such as glass, sharp sticks, etc. No data were reported on the type of treatment provided for these injuries. In a more recent study from another Indian agricultural area, motor vehicle-related injuries comprised 15 percent and agricultural injuries 32 percent of all serious injuries (73). The most serious disabling injuries were caused mainly by mechanized equipment such as threshers, tillers, tractors, and fodder-cutters that lacked protective guards. Another study in four sample urban areas in Brazil, Chile, Cuba, and Venezuela found that between birth and the age of 19 years, falls were the most common cause of injury (40-52 percent) and that motor vehicles, while a major cause of mortality, were only responsible for 5 to 24 percent of nonfatal injuries (74, 75). Among all the children identified as injured in the community component of the study, 60 percent in Chile did not go to the hospital, while 50 percent in Venezuela and 38 percent in Cuba did not,

which demonstrates the problems of comparing injury rates, especially rates based on hospital data. Calculation of incidence rates for hospital visits was difficult, owing to the difficulties in estimating the catchment population served. The community component of the study found incidence rates of injury of 303 per 1,000 population in two cities in Chile, and 220 per 1,000 in Caracas, Venezuela. No breakdown by age was provided. There are few studies documenting the effect of the long-term disability from injuries. In Nepal, one study estimated that 3 percent of the population was disabled; 25 percent of these disabilities had been caused by injuries, of which one fifth were the result of burns (27). Based on a national survey, Mohan (76) estimated that the prevalence of traumatic amputations in India was 24 per 100,000 rural males and 20 per 100,000 urban males. The annual incidence was greater than 1.4 per 100,000 rural males and 1.2 per 100,000 urban males. Many of the amputees were teenagers or young adults; rates among females were much lower. The most important causes of traumatic amputations were road crashes in urban areas, and railways and agricultural machines in rural areas. Data on the costs of injuries are also scarce, although long-term disability from injuries results in considerable burden to the individual as well as to other members of the family (4, 76). One study in a semirural area of northeastern Brazil assessed the direct and indirect costs of various categories of illness (28). Direct costs are the cost of treatment and other expenditures. Indirect costs represent estimates of lost productivity. Injuries accounted for only 12 percent of all direct costs; however, they accounted for 28 percent of indirect costs. Because of their impact on both long-term disability and on the most productive members of society, injuries accounted for 26 percent of total costs, direct and indirect. There is a need for careful studies, similar to the cost of injury study conducted in the United States (29), to document more fully the economic impact of injuries on developing societies. The lack of good morbidity data for inju-


ries is not unique to developing countries (17, 21, 77, 78). As a consequence of inadequate population-based data, much of the information on injuries is derived from hospital admissions, which provide a measure of severe, nonfatal injuries. Hospital data are based upon clinical records, and often include only nature-of-injury data (N codes) (30). Such data suggest that the number of patients with serious trauma has increased over time in some hospitals, such as the University Hospital in Kingston, Jamaica, where admissions for major trauma increased from about 100 cases per year in the 1950s to almost 600 a year in the 1970s. The increase was largely the result of an increase in motor vehicle injuries; however, no mention was made of changes in the population during this period (79). The usefulness of hospital data as a reflection of disease patterns in the community depends upon a number of factors. The area served by a hospital is difficult to define and may change over time. If most patients die before reaching the hospital, as is often the case with drowning victims, it may be erroneously assumed that the cause of death, such as drowning, is not a serious public health problem in the community. Hospital statistics may also be misleading as a record of overall patterns of serious nonfatal injury in the community. In many less developed countries, injured persons may not seek hospital care if the general public does not have free access to facilities, if public confidence in the health system is low, or if the primary care and referral system for transferring injured patients to hospital is poor. Referral patterns to hospital for different age groups and sexes may differ; for example, male children may be brought to hospital for serious illness more often than females (80). Hospitals in isolated areas with a defined catchment population may be more useful for sampling purposes than those in areas where patients have a choice of multiple institutions. In spite of these limitations, hospital data are usually readily available and can be a useful guide to whether particular injuries are a problem in an area. In fact, most of

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the available literature on injuries in developing countries is based upon hospital data, particularly the information on specific types of injuries. The injuries that are most likely to reach hospitals include motor vehicle injuries, burns, falls, poisonings, bicycle injuries, and wounds, including those from cutting tools. Some patients with injuries caused by animal bites may reach hospitals, although in some countries it is believed that a majority of snakebite victims do not seek medical care because of traditional beliefs and superstitions, and because of the remoteness of many villages (81). Rural health centers are another potential source of injury data, but the information is subject to the same limitations as hospital data. In some developing countries, police reports may be the only source of data for motor vehicle injuries and intentional injuries, particularly for nonfatal cases. However, if data are based on police reports, serious under-registration will occur for incidents where there was a disincentive to involve police. Police records generally are only useful for reporting motor vehicle injuries, although considerable underreporting of these exists even in developed countries (82-84).

RISK FACTORS COMMON TO MANY INJURIES

Risk factors for injuries may vary greatly from one country to another, and the risk groups may not be the same in each country. For example, a comparison of pedestrian deaths from injury in two urban areas— Baltimore, Maryland, United States, and Rio de Janeiro, Brazil—found marked differences in the ages of the people killed (85). The pedestrian death rate in Rio de Janeiro was about four times that in Baltimore. In Baltimore, 72 percent of those killed were either less than 10 years old, older than 65, or had blood alcohol concentrations greater than 100 mg/dl, while in Rio de Janeiro, only 28 percent of pedestrian fatalities were in these risk groups. While these findings may not be generalizable to all situations,

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they illustrate the differences that often exist between risk factors in developed and developing countries, even for the same injury. Age and sex are important risk factors for many injuries and will vary within specific injury categories. In most developed countries, the highest rates of serious injury occur among the elderly, particularly women (2). The published data from the World Health Organization in table 3, the study by Gordon et al. (54) in India, and the recent study by Barss (7), support the concept that injury mortality rates among the elderly are also higher in developing countries. However, the literature reviewed does not specifically identify the elderly as being at increased risk of injury or death from injury in developing countries. Little data by age and sex are available, particularly for specific injuries in the least developed countries. An increased risk may have been overlooked, since the elderly represent only about 4 percent of the population on average in developing countries, compared with 11 percent in developed countries (86). Another possible reason may be that there is less loss of bone strength with increasing age in developing countries, and that serious injuries, such as fractures of the hip, are therefore uncommon (87). The increasing fatality rates seen among the elderly for unintentional injuries from causes other than motor vehicles, especially in developing countries at higher levels of development, suggest patterns similar to those of the United States, where falls are the leading cause of death (2). Alcohol is a risk factor for many types of injuries, especially the more severe and fatal injuries (18, 88-90). For motor vehicle injuries, a dose-response relationship has been shown, with high blood alcohol concentration more common in victims of the most severe injuries (90). The importance of alcohol and other drugs in relation to injuries has been described for motor vehicle injuries in developing countries (37, 91-96). For example, Wyatt (92) found that in Papua New Guinea, 42 percent of all those who died of injuries sustained in a motor vehicle crash had a blood alcohol concentration greater

than 80 mg/dl. However, no studies were found documenting the role of alcohol in other injuries, despite its known involvement in developed countries (89). Alcohol abuse is known, nevertheless, to be a problem in many developing countries, and its use is often widely underestimated (92, 95, 97, 98). In cultures in which alcohol consumption is high, it is likely to have effects similar to those in developed countries. The role of other drugs in the risk of injury in developing countries is unknown. In Nigeria, the kola nut has been suggested as a risk factor for road traffic injuries, although no data are available to support this claim (99, 100). Other risk factors, such as poverty, residence in rural areas, and race, have all been shown to be major factors in injury risk in industrialized countries (2, 12), but only one study was found that specifically examined these risk factors in developing countries. This study of children and adolescents (age, birth-19 years) in four cities in Brazil, Chile, Cuba, and Venezuela found that young children in Venezuela (age, 1-4 years) were five times more likely to be injured at home than were children in older age groups (75). In Brazil, children of parents with a low educational level (primary or less) experienced a threefold increase in the risk of injury. Poverty has been suggested as a risk factor for injury in a number of studies, but little published evidence for this is available at this time from developing countries. One study, which used the educational level of the head of the household as a proxy for socioeconomic status, found that in Brazil, children in a household whose head had only a primary education were 2.9 times more likely to sustain a home injury than children in other households, but were 2.5 times less likely to sustain a motor vehicle injury when compared with children in better educated households (75). Another study suggested that in developing countries, poor workers do not have the option of leaving hazardous jobs, because of economic necessity, but data were not provided to support this claim (101). The process of development may ere-


ate new hazards or simply replace old hazards with new, making examinations of trends over time using grouped data difficult. A study by Wintemute found no support for the theory that injury mortality is a "disease of development" (102, p. 540) and found no relationship between per capita gross national product and injury mortality rates reported to the World Health Organization for 46 developing and industrialized countries. It was noted, however, that the highest injury rates were reported from developing or transitional countries. A major problem with this study was that data from the poorest countries were not available. In addition, per capita gross national product may not be the best measure of the level of development, especially in rural areas. Physical factors may also influence injury risk. A study of taxi drivers in Lagos, Nigeria, found that one third had serious deficiencies of visual acuity and that only 10 percent were aware of the need for corrective lenses (103). Compulsory vision tests for drivers have all but eliminated this problem in many countries. Vitamin A deficiency may also increase the risk of injury at night, but this has not been documented. Epilepsy has been shown to be a risk factor for burns (57, 104, 105) and drowning (106). SPECIFIC INJURIES Drowning

Drowning accounts for the loss of many young lives in most countries around the globe, and generally ranks second only to motor vehicle trauma as a cause of death from injury in children and young adults (107). One study comparing rates of unintentional injuries in children in different regions of the world found drowning to be the leading cause of death from injury among boys aged 1 to 4 years in Latin America, Asia, and Oceania (107). In Asia, drowning was responsible for 48 percent of male and 44 percent of female deaths by unintentional injury. In some deltaic areas, such as Bangladesh, drowning death rates in young children, especially toddlers, exceed those

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for many of the leading infectious diseases (55). In China, drowning is the third leading cause of death from injury (108). Accurate information on drowning is difficult to obtain, since most victims never reach a hospital, and the event may therefore never be recorded. Data are not available for many countries with less developed mortality reporting systems. However, a number of individual reports are available, including some from countries that have recently undergone demographic transition. In Brazil, the rate of death by drowning reported for 1979 was highest among children aged 10 to 14 years—6 per 100,000— and represented the second most common external cause of childhood death after motor vehicle injuries (109). A 1976 report from the Indian government lists drowning as the leading cause of "accidental loss of life," accounting for 23 percent of deaths from injury, with an annual rate of 4 per 100,000 population (110). Drowning was noted as one of the three most common methods of suicide in India. In Shanghai County, China, where injuries are now the leading cause of death among the population aged 1 to 44 years, drowning accounted for 30 percent of all deaths from injury (12). The overall drowning rate was 13 per 100,000 in 1980; 6 percent of these deaths occurred in children less than 14 years old. In Bangkok, Thailand, drowning was among the leading fatal injuries in kindergarten and primary school students in analyses of over 10,000 injuries (111, 112). In Thailand, drowning represented 60 percent of all injury fatalities in males and females aged 14 years in 1971 (107). In Singapore, the death rate from drowning is reported to be 2 per 100,000 for males and 0.4 per 100,000 for females, with most drownings occurring in the 15- to 24-year-old age group and related to falls into open bodies of water (113,114). In Taiwan, drowning was responsible for 17 percent of deaths from injury in males, and 18 percent in females, with rates of 10 per 100,000 population for both males and females in 1977 (8). In Hong Kong, drowmng accounted for 18 percent of all

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injuries in 1977, and 51 percent of deaths from injury in children aged 1-4 years (115). Drowning was also a major cause of death from injury for the population aged 5 to 34 years. Little is known about the specific circumstances of drowning in developing countries. In developed countries, the domestic swimming pool is the leading site of drownings and near drownings (41 percent) in children from birth to the age of 15 years (116-118); in many developing countries, unfenced ponds and wells are found in vast numbers of villages, and appear to be a significant environmental hazard for toddlers (54, 119). However, few specific details are known. Risk factors for drowning are poorly understood. In developed countries, several risk factors have been suggested for drownings involving young children, including large family size (120) and reliance on supervision by older siblings (121); such practices are common in developing countries. Bathtubs are a particular hazard, especially in infants in low socioeconomic groups (121), the elderly, the intoxicated, and persons with seizure disorders (122). Older children more often fall into rivers and irrigation ditches (2). However, the importance of these factors in developing countries is unknown. Even the specific sites of drowning have been poorly described, although the frequency of involvement of each will depend on the local environment; for example, in Singapore, 45 percent of cases occur in the sea, and rates are highest at the ages of 9 and 10 years (113,114). Epilepsy has been found to be a risk factor for drowning in developed countries (106, 123). While no articles could be found documenting this risk in developing countries, the higher prevalence of untreated epilepsy suggests this is likely to be a significant problem. The combination of alcohol consumption and proximity to water is particularly hazardous, especially for young males (124126). Alcohol consumption is involved in from 18 to 77 percent of all adult drownings in industrialized countries (89), but few data are available from developing countries. In

countries with large tourist industries, tourists who swim after consuming alcohol may be at significant risk of drowning. A study in Barbados found that 37 percent of visitors who were victims of near drowning had clinical evidence of alcohol intoxication recorded in medical records (124). However, no blood alcohol testing was conducted to confirm the clinical observations. Alcohol testing should be an integral part of any future studies of drowning. As a general principle of injury prevention, "passive" protection through modification of the hazardous environment is usually more effective than "active" protection, which requires constant vigilance and action on the part of an individual (24, 127). Studies from Australia, Hawaii, and New Zealand, where the most important environmental drowning hazard for young children is the domestic pool, show that legislation mandating adequate fencing, together with self-closing, self-locking gates, can prevent most drowning deaths among toddlers (128— 130). One study found swimming pool drowning rates among children in Honolulu to be only one tenth the rate in Brisbane, despite similar patterns of swimming pool ownership and use (128). While it is obviously impossible to fence off every body of open water in a developing country, it may be feasible to enclose small ponds, wells, and drainage canals in residential areas, since toddlers are at highest risk from sources close to homes. In developing countries, the housing of poor people is often located on swampland, marshes, or flood plains with many drainage canals and open sewers that present drowning hazards. Dramatic evidence for this was provided by the heavy floods during the recent cyclone in Bangladesh. In developed countries, persons from lower socioeconomic groups appear to be at increased risk of drowning; it was suggested in Australia that such children are less likely to know how to swim (131). The drowning rate for black males is more than twice that for whites in the state of Maryland (132). It has been suggested that swimming and water


safety instruction may reduce drowning (133), although others have suggested that more detailed studies of the value of swimming instruction are needed, since the ability to swim could potentially increase exposure to hazardous situations (24). In addition, swimming instruction is not recommended for children under the age of 3 years, the age group at highest risk (134). Efforts to train the public in basic resuscitation are worthwhile, however, since survival after drowning is often possible if resuscitation is begun immediately at the time of rescue (135). Training in even rudimentary resuscitation skills is largely nonexistent in developing countries. In developing countries, careful community surveys are needed to establish baseline data on and determine the main causes of drowning. Analyses are needed of the environments in which drowning commonly occurs, of high risk groups in the population by age and sex, and of other causal factors such as alcohol. In addition, drowning patterns differ in various regions of the world, and what is appropriate prevention for one country or district may not be suitable for another. Until such information is available, it is unlikely that governments will be able to develop effective public health programs to prevent drowning. Such studies could be completed inexpensively as a part of population or demographic surveys done for other purposes. Carefully done surveys showing whether enclosure of such common hazards as village ponds and wells can lower drowning rates for toddlers would be useful. Burns and fires

Burns and fires are a leading cause of death from injury in many countries. Females have been identified as being at particularly high risk for burns, which occur most often in the kitchen or result from the ignition of loose clothing. The rates for selected countries for which data are available are shown in table 5. Rates are generally highest among the very young, women of reproductive age, and the very old. The data

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on women aged 15 to 49 years in Menoufia, Egypt, are from a study of 1,691 deaths of married women of reproductive age conducted by Saleh et al. (136). This study involved in-depth follow-up and found that burns accounted for 9 percent of all deaths surveyed. In the report by Gordon et al. (54), burns were found to be the leading cause of death (1.4 per 100,000 population) in the rural Indian villages studied. Burns are the fourth leading cause of deaths from injury within the home in Singapore (137). A study of government employees' families in Allahabad, India, found burns to be the second largest cause of any injury in the home, occurring more than four times as often in women (138). It is estimated by Gupta (139) that in India, more than 10,000 deaths occur annually from burns, and that over 1 million people suffer annually from moderate to severe burns. These figures from India correspond to a burn mortality rate of 1.4 per 100,000 population, and are probably a gross undercount for all deaths from burns and fire, because many people who die in house fires die before they reach hospital. Comparable figures for deaths per 100,000 population in the United States are 2.8 for all burns and fires, 2.1 for house fires, and 0.1 for scalds (2). Most of the literature on burns in developing countries is based on hospitalized cases, which would miss many deaths from house fires. However, burns are a major cause of injury mortality, even among hospitalized patients. A study of three burn centers in Madras, Bombay, and Delhi, India, found that burns caused from 15 to 45 percent of all deaths in persons hospitalized for trauma, with a case fatality rate of 23 to 35 percent (140). In a hospital in Zimbabwe, burn victims comprised 8 percent of trauma admissions, but 16 percent of trauma deaths (141). Ignition of clothing has been identified as a major cause of mortality on the Indian subcontinent, especially in women wearing long, flammable saris, which can easily ignite during cooking (142, 143). A study in Pakistan found 31 percent of patients hospitalized for burns to be victims of clothing

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TABLE 5.

Age-specific mortality rates for death by fire among females, selected countries* Deaths per 100,000 of age group (years) per year 75

All ages

Egypt (Menoufia)f Egypt (total) Mauritius Sri Lanka Thailand Ecuador Chile Mexico Brazil Panama Costa Rica

3.1 0 4.1 1.7 8.2 4.7 2.9 2.2 10.3 2.8

11.9 6.5 1.8 1.4 9.2 5.0 2.6 2.1 0 0.9

6.1 4.1 1.5 0.2 2.0 1.1 0.7 0.7 0.8 0

22.2 23.6 14.7 2.6 0.3 2.0 0.4 0.8 0.5 0 0

16.1 14.2 13.2 2.6 0.4 1.9 0.8 1.0 0.4 0 0

16.8 9.4 2.1 1.1 0.4 1.1 1.8 1.1 0.6 0 0

15.7§ 7.1 2.8 0.7 0.4 2.7 1.4 0.9 0.8 0 0

8.1 0 0.8 0.2 2.9 1.9 1.6 0.8 2.1 0

11.8 0 2.4 0.5 9.3 5.8 2.5 0.9 0 0

30.6 11.5 9.6 4.2 4.3 19.7 11.3 3.0 0 0

12.1 7.6 2.0 0.5 3.4 2.1 1.4 1.0 0.6 0.2

1981-1983 1979 1983 1983 1981 1983 1983 1983 1980 1983 1983

Kuwait United States Sweden

11.0 2.9 0

2.3 4.1 1.6

1.2 1.2 0

0.8 0.8 0

3.2 0.8 0.7

1.3 0.9 0.3

0 1.0 0.5

0 1.6 0.1

0 2.8 1.1

0 5.9 1.7

1.9 1.6 0.6

1983 1983 1983

Countryt

Year

* Per 100,000 population per year. Data taken from the World Health Organization, World Health Statistics Annual, 1982-1988, and Saleh S, Gadalla S, Fortney JA, et al., Accidental burn deaths to Egyptian women of reproductive age, Burns 1986:12:241-5. t Countries with a per capita gross national product of less than US$2,500. Kuwait, the United States, and Sweden are included for comparison. t Data unavailable for all age groups. § Data for ages 45 to 49 years only.

ignition (142). Similar problems have been identified in Papua New Guinea involving the ignition of grass skirts, which caused 48 percent of hospitalizations for burns in one province (104). Scalds from hot liquids such as water and cooking oil are a major cause of morbidity (104, 144-148). A study of hospital admissions for burns in children (age, birth-15 years) in Nigeria found scalds from hot water or tea to be responsible for 64 percent, cooking oil for 13 percent, gas stoves or petroleum explosion for 7 percent, naked fires for 6 percent, and motorcycle exhaust for 5 percent (145). Electrical burns, which constitute a problem directly related to development and poor understanding of the hazards of electricity, were responsible for 19 percent of burn center admissions in Turkey (146). Burns often result in significant long-term medical care, considerable disfigurement, and severe disability (147, 148). Clothing ignition was once a major cause of burns in developed countries, especially among females (2). A change to more closely fitting styles of clothing, together with decreased fabric flammability, have resulted in significant decreases in deaths from clothing

ignition, which now represent only 5 percent of all burn deaths in the United States (149). Unfortunately, cotton, the most common fiber used for clothing in developing countries, is particularly flammable, although the addition of a borax rinse after washing has been shown in experiments to reduce the flammability of materials in common use (143). The application of some of these prevention strategies, particularly to women and children's clothing, could significantly reduce injuries from clothing ignition in developing countries. Open flames used for cooking and lighting are the most important source of burns in many developing countries. Portable kerosene and gas stoves were the cause of 63 percent of deaths from burns among women of reproductive age in Menoufia, Egypt (136). The control of burns at the source may be the best approach to burn prevention. Saleh et al. (136) found the placement of stoves on uneven surfaces where they could overturn, or on the floor where long skirts could catch the flames, together with refueling and maintenance problems, to be the major reasons for the high death rate from burns caused by stoves. They noted


that in Bali, where similar kerosene stoves were used, but were placed on a firm raised surface, only one of 1,214 deaths among women of reproductive age was caused by a cooking stove. Kerosene pressure stoves have also been identified as a major cause of burns in Singapore, where the ignition of leaking fuel or upsetting a stove used on the floor were identified as causingfiresin clothing and other materials (144, 150). Better design of stoves and encouraging their use on raised surfaces could help to reduce this hazard. Safer, low-pressure wick stoves are now available at about the same cost as pressure stoves (151). House fires are particularly common in areas where indoor open fires are used for cooking. The use of enclosed stoves rather than open flames in households not only can improve the safety of fires considerably, but also can save on valuable fuel by increasing heating efficiency. Such stoves can often be constructed cheaply from local materials. One study reported that introducing such stoves reduced burns by 70 percent in Nepal (27). The use of open candles and "bottle lamps" for lighting is a recognized hazard, especially since they are often unstable and can easily be overturned. Simple stabilizing holders can easily be built to prevent this (3). Cigarettes are a major cause of house fires in the United States (152), and simple modifications to cigarettes can almost eliminate this risk (153). Despite increasing smoking rates in developing countries, little is known regarding the role of cigarettes in fires. In many areas, people sleep in huts around an open fire. In this setting, children and adults are at risk of clothing ignition from rolling into the fire and of house fires. Medical complications may precipitate burns. In one area of Papua New Guinea, epilepsy is a precipitating factor in many cases of severe burns, being the second leading cause in patients hospitalized for burns (24 percent) (104). Severe burns can result if a person falls into a fire during a convulsion. Cerebral cysticercosis, one cause of epilepsy, presented as an epidemic of burns in Irian Jaya (Indonesia) subsequent to the

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introduction of taeniasis (tapeworm) into the local pig population (105). Even in Leeds, Britain, 38 percent of the patients under treatment for epilepsy were reported to have been burned during a seizure, and rates of reported burns were four times those among a similar population of diabetics (154). Better treatment of epilepsy can reduce the incidence of epileptic convulsions, and thus prevent some serious burns (155). The development of effective barriers around open fires, or the conversion to simple enclosed stoves, could also help to prevent many burns. Auchincloss and Grave (141) estimate that about 90 percent of burns necessitating hospital admission among children in Africa could be prevented by such measures, but provide no data to substantiate this claim. Fireworks, especially the so called "safer" fireworks that are held in the hand, have been identified as a major source of burns in India, (156,157). Homemade bombs were reported to cause 86 deaths during a 5-year period in Colombo, Sri Lanka (158). Regulations governing the use and design of fireworks reduced burn injuries from fireworks by 17 percent in the state of Washington (159, and J Harris, Washington State Health Department, personal communication, 1987), and states that do not restrict firework sales have fireworks-related injury rates seven times higher than those that do (160). Application of cold water to burns to reduce their severity is a simple measure that can be used whenever water is available. One published letter (161) suggests that of 68 burn victims who applied cold water immediately after being burned, only one required a skin graft; in comparison, of 36 burn victims who did not apply cold water, four required grafts. One study in India successfully promoted the use of cold water to treat fireworks burns (156). Falls

The importance and patterns of falls in a community is largely dependent on the environment and the activities and age structure of the population. Falls are a major cause of minor and severe injuries in devel-

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oped and developing countries. In the rural areas of some developing countries, where the products of tall trees are important sources of foods and income, falls from trees may be the leading cause of serious injury. Studies from rural hospitals in India, Sri Lanka, and Papua New Guinea have shown that falls from trees and tree-related injuries, such as being struck by falling coconuts, are the main cause of hospital admission for trauma, as well as of deaths from head and spinal injuries (162-167). The highest risk group is young boys, and, in some areas, young adult males. Falls from trees are the main cause of spinal cord injury in Nigeria (166, 167) and in some other developing countries such as Burma (168). Workrelated falls, such as on construction sites, are also a major problem in many countries (3, 169). In developed countries and in urban areas of developing countries, design features of homes and furnishings are often significant environmental factors in falls. In New York City, a major cause of deaths from falls among young children were the windows of tall buildings. After legislation was passed requiring landlords to install window guards, such deaths decreased greatly (170). A study from Sao Paulo, Brazil, showed that fatal falls in infants were mainly from beds, in 5to 9-year-old children from windows or into wells, and in 10- to 14-year-old children from trees or roofs (109). In Hong Kong (which still has some of the characteristics of a developing country) falls accounted for more hospital admissions than any other type of injury, with an average of 19,000 hospital discharges per year (115). This represents 32 percent of all discharges of trauma victims, with an approximate rate of 416 per 100,000 population from 1975 to 1979. Admission rates for falls were more than three times higher than the rates for injuries from motor vehicles, reflecting the many high buildings. Although it is impossible to prevent all injuries caused by falls, measures can be taken that would greatly reduce both their frequency and impact, especially in high-

risk groups. In developed countries, many deaths from falls occur in the elderly subsequent to fracture of weakened and often osteoporotic bones, such as the hip (2, 18, 171). The regular exercise that is common and necessary for most people in developing countries may be effective in preventing osteoporosis (87, 171-173). The increased incidence of hip fractures in Hong Kong over the last two decades is believed to have resulted from declining activity levels (173). Restricting small boys from climbing taller trees might be effective, although it would be better to eliminate the need to climb trees to harvest their fruit. New, shorter hybrid varieties of tropical trees, such as the palm oil, mango, and coconut palms, have been developed and are more productive than taller varieties (166). Shorter trees allow crops to be harvested from ladders or by machines. Injuries from dropping coconuts are often severe enough to kill (174), and can be prevented by planting trees away from dwellings and footpaths, preventive removal of green coconuts in pedestrian areas, wearing helmets in plantations, and planting shorter trees. Falls from rooftops, windows or into wells can be prevented by appropriate design modifications or barriers. The collapse of walls of mud houses can be prevented by better design and construction. There are many important causes of falls; the situation will vary from one country to another and from rural to urban areas. Study of the causes of falls and of high risk groups using data from hospital admissions will help in planning prevention programs. Community or health center surveys can reveal whether significant numbers of deaths are occurring in remote areas without the victim reaching hospital (162). Poisoning

Poisoning is a major problem in developing countries. For example, in Sri Lanka, there were over 1,000 deaths from pesticide poisoning reported in 1978, compared with only 572 deaths from polio, diphtheria, tetanus, and whooping cough combined, and no deaths were reported from malaria (175).


There are few studies on poisoning deaths, and most are case series based on hospital records. More recent data from Sri Lanka indicate that pesticide poisoning was the leading cause of death among young people of both sexes aged 15 to 24 years. Most of these poisonings were suicidal (176). Children are at particular risk of poisoning in developing countries. Poisoning was the leading cause (36 percent) of admission for injuries to a pediatric hospital in Tanzania (177); kerosene was the major poisoning agent. Other authors have confirmed that kerosene is the most common cause of injury in children under the age of 5 years in India and various parts of Africa (178-182). The majority of cases occur during the hottest months of the year, when a thirsty child may drink kerosene believing it to be water or soda, since it is often stored in containers such as soft-drink bottles (178). There are marked differences in both the causes of poisoning and the age distribution of poisoning victims reported for developed and developing countries. A study in South Africa of all hospital outpatient and inpatient visits for poisonings found marked differences in the pattern of poisonings of blacks and whites (183). Poisonings among whites showed the typical pattern of developed countries, with bimodal age distribution among children and adults, a predominance in females (especially in adults), a high incidence of poisoning from drugs, and more intentional than unintentional poisonings. Blacks, on the other hand, showed the typical pattern of poisoning found in most developing countries, with the majority of cases occurring in children, slightly more cases in males, and the vast majority of the poisonings (87 percent) being unintentional. The major causes were kerosene (56 percent), drugs (10 percent), carbon monoxide (8 percent), household products (6 percent), organophosphate insecticides (4 percent) and unknown substances (11 percent), many of which were believed to be traditional herbal medicines. Among blacks, there were 82 poisoning deaths reported to the coroner; causes included carbon monoxide (29 per-

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cent), organophosphate insecticides (18 percent), kerosene (10 percent), corrosives (9 percent), metals (9 percent), and herbal medicines (an estimated 16 percent). Lead poisoning is a severe but widely under-reported phenomenon in many developing countries (184). With development, poisoning from drugs and insecticides has been observed to become an increasing problem, especially among children. In India, the proportion of hospitalizations for poisoning by drugs and medicines rose from 24 percent in 1953 to 30 percent in 1976 (181). Several studies identify the problem of inadvertent poisoning through use of prescribed medications. In Afghanistan, the most common cause of unintentional poisoning was overdosage of drugs from excessive consumption of medication (185). The inappropriate use of drugs was a serious problem; 17 percent of drug poisonings were due to chlorpromazine, which was used to control vomiting in children. Chloroquine was also a significant cause of fatal poisoning in some areas. Poisonings by ingestion of chloroquine are largely confined to adult suicides; few childhood deaths are caused by chloroquine, probably because of its intense, bitter taste. In one study of 33 chloroquine deaths in Papua New Guinea, the youngest victim was 16 years of age (186). Acute methanol poisoning from the consumption of methylated spirits has been identified as a problem in Papua New Guinea (187). Large "outbreaks" have followed social gatherings where methanol is served as cheap alcohol. A recent study from the Middle East reported 25 cases of acute methanol intoxication after the introduction of a new methanol-containing eau de cologne (188). Contaminants in traditional homemade alcoholic beverages may also be a problem (189). Motor vehicle exhaust is the leading cause of carbon monoxide poisoning in the United States (2). In Seoul, South Korea, the use of coal or charcoal to heat poorly-ventilated homes resulted in 252 deaths in 1 year (no rates were reported), more than three times

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the number from communicable diseases and more than the number of reported deaths from motor vehicle injuries (190). Many deaths still occur because of leaks in heating systems that circulate hot air laden with carbon monoxide under the floor (Baker SP, The Johns Hopkins University, personal communication, 1987). Unintentional carbon monoxide poisoning is largely restricted to developing countries in temperate climates; however, 30 percent of suicides in Singapore were committed by victims putting their heads into gas ovens (191); occupational poisonings were responsible for most other carbon monoxide deaths there (192). Poisoning from pesticides is also a particular problem in developing countries, with rates far exceeding those of developed countries (175, 176, 193-197). While the majority are the result of suicides and occupational exposures, unintentional poisoning, especially from organophosphate compounds, still represents a serious problem. One study in Nicaragua reported rates of poisoning requiring medical attention of 75 per 100,000 population and 165 per 100,000 in rural areas, and a mortality rate of 1.2 per 100,000 (198). The World Health Organization has estimated that there were over 10,000 deaths worldwide from unintentional and occupational pesticide poisonings during the 1970s, but a recent study of excess mortality in the Philippines suggests there may be an excess mortality of "many tens of thousands" from pesticide use (16). Nonfatal poisonings often go unrecognized; the study in Nicaragua showed that during peak agricultural activities, up to 40 percent of the workers at risk had significantly depressed serum cholinesterase activity, an indicator of organophosphate poisoning (198). One chemical, paraquat, has been recognized as particularly hazardous. Ingestion of more than 15 ml of paraquat is almost uniformly fatal (199). About 1,300 deaths from paraquat poisoning, many of which are suicides, are reported each year in Japan (199). However, the number of paraquat deaths in developing countries, where handling pre-

cautions are often poor, is largely unknown. Regulations mandating better labeling, addition of an emetic and "stenchant," and restricting the availability of the concentrated form of the chemical are said to have "lessened the chances" of paraquat poisoning in Papua New Guinea (197); however, no data were provided to support this assertion. There have been a number of deaths among children who have ingested paraquat stored in soft drink bottles and subsequent to the use of paraquat for the treatment of head lice in children (200-202). There have also been a number of reports of mass poisonings caused by the use of grain contaminated by pesticides and other chemicals, such as mercury (203, 204). Poisonings from various plants, including those used for food and other purposes such as herbal medicines, occur in endemic and epidemic forms in many developing countries. For example, food poisoning from acute and chronic cyanide poisoning has been documented in Africa as a result of improper preparation of cassava, a root crop widely used as a food source, especially during times of famine (205). Plants which contain pyrrolizidine alkaloids occur throughout the world and have resulted in many deaths from acute hepatotoxicity; chronic disability and death also occur as a result of hepatic venous occlusion (206). Outbreaks have resulted when cereal grains such as wheat and millet were contaminated with alkaloid-containing plants. The other main cause of such poisonings has been the use of herbal medicines, such as herbal infusions, which contain such alkaloids. The use of such medicines usually results in individual cases rather than outbreaks. However, many cases have been documented, although no rates are available because of lack of good reporting. Another source of poisoning in coastal areas is the consumption of seafood containing biotoxins. These include paralytic shellfish poisoning, ciguatera, and tetrodotoxin poisoning (207). It was reported by the World Health Organization that as of 1971, about 1,600 cases of paralytic shellfish poi-


soning had been reported, mainly from developed countries (207). The pattern changed during the last two decades, with more cases being reported from developing countries; for example, 201 cases, including four deaths from ingestion of clams, were reported from Malaysia in 1977; 171 cases were reported from Venezuela, including 10 deaths from ingestion of mussels. It is possible, indeed likely, that many cases go unreported in rural areas, but as surveillance improves, there may be an apparent increase in the number of cases. The incidence of ciguatera poisoning from the consumption of ciguatoxic fish ranges from one case per 10,000 population to from 40 to 50 cases per 10,000 in different islands of Micronesia and Polynesia, and has been estimated to be as high as 300 per 10,000 in the Virgin Islands (208). It has been suggested that there may be a relation between the observed increases in ciguatera poisoning and development projects that disrupt the marine environment; urbanization may also be a factor. In developed countries such as the United States, there has been a marked decline in poisoning deaths in recent decades, particularly among children (2). However, similar declines have not occurred in developing countries. There is an urgent need to apply proven preventive strategies, such as childproof caps and proper storage for toxic substances, to reduce poisonings in developing countries (3).

Bites, wounds, and envenomation from land and marine animals and insects

Injury from animals is an important public health problem in many developing countries. The types of injuries seen in any given area are usually a product of the prevailing environment, as well as of the habits and customs of the people. The widespread custom of keeping dogs as pets is probably the most important source of such injuries worldwide. Rabies is endemic in much of the developing world, and adequate immunization of dogs and treatment of victims of dog bite in both urban and rural areas is a

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tremendous burden and nearly impossible for many developing countries. In a survey of rural health centers in the Ivory Coast, the incidence of animal bites was 11 per 1,000 population per year, with dog bites predominating in the north of the country, and snakebites in the south (209). In Nigeria, one hospital reported that over 1 percent of outpatient department attendances involving casualties were for dog bites (210). In the Americas, the countries of Brazil, Colombia, Ecuador, El Salvador, Mexico, and Peru together accounted for 84 percent of all reported cases of rabies in the region. In Brazil, from 1970 to 1984 there was a range of 87 to 190 reported cases of rabies in humans per year, while in Mexico, the range was from 55 to 83 cases per year (11). Children from 1 to 4 years of age accounted for 11 percent of these cases and children from 5 to 14 years for 47 percent. Ninety percent of cases in humans in Latin America were caused by dogs. Many cases occurred in rural and urban areas; however, in many developing countries, rabies may be sustained by urban dog-to-dog transmission, whereas in developed countries, rabies tends to be maintained in wildlife. In a recent World Health Organization survey that attempted to document the incidence of rabies in 30 developing countries, India had the largest number of reported human cases, with 20,000 in 1979, followed by Ethiopia with 412 (211); the highest incidence of cases also occurred in India, with 29 cases per 1 million population, followed by Ethiopia with 13. The lowest reported incidence among the 30 countries surveyed was in South Africa, which had an incidence of 0.1 per 1 million population in 1979. The dramatic variations in incidence may reflect both differences in reporting and the availability of effective control measures such as vaccines and wound treatment, as well as control of the animal reservoir. Snakebites are often overlooked as an important cause of death in many countries, and have been described by one authority as "the most neglected area of tropical medicine" (81, p. 547). This is attributed to the

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fact that the majority of bites occur in rural areas remote from hospitals, and are therefore never reported in national statistics. It was estimated that almost 10,000 deaths from snakebite occur annually in Savanna, Nigeria, and about 23,000 in all West Africa. In northern Nigeria, more than 1 percent of all deaths are estimated to be caused by snakebite (212). Among the Waorani Indians in Ecuador, almost 5 percent of all deaths are said to be caused by snakebite (213). In Burma, snakebite is reported to be the seventh leading cause of death (81), and is also one of the leading causes of death from injury to women of childbearing age in Bangladesh (57). Other injuries that are less general in their distribution, but still important in many areas, include goring by animals and, in Oceania and Asia, injuries of coastal fisherman by various marine creatures. The literature includes reports of goring by cattle in India (214), by water buffalo in Cambodia (215), and by pigs in Melanesia (216), but no estimates of the incidence of these injuries are available. Although the shark is commonly thought to represent a particular hazard in developing countries, reports of shark attacks in the medical literature are rare. Injuries inflicted by needlefish (217, 218) and stingrays (219) are probably more common and can result in death, visceral injury, and severe disability. Most villagers attacked by crocodiles disappear without a trace, and their deaths are never reported. Bites and stings from insects are well recognized as entry points for tropical diseases, and their role as foci for initiating various skin infections such as cellulitis, tropical ulcers, pyoderma, and more severe ensuing infections has been suggested, but needs substantiation (220). Scorpion stings are said to be more important than snakebites in large areas of the world, such as Mexico, Trinidad, North Africa, and parts of Brazil (221). A 1979 study in southern Libya found an incidence of 900 scorpion stings and at least seven deaths per 100,000 population. Deaths occurred mainly in small children under the age of 2 years (221). In Mexico,

there are 1,000 to 2,000 deaths from scorpion stings per year, with an incidence of mortality ranging from 3 to 84 per 100,000 population per year in various states. The toxic effects of wasp and other hymenoptera stings are recognized (222), but the incidence of such events or of fatal allergic reactions to other insect bites or stings is unknown. Many developing countries need assistance with the development of effective public health programs to deal with dog bites and rabies prevention. Legislation and enforcement are needed to cope with excessive numbers of domestic and stray dogs, and to require immunization of all dogs. Assistance with purchase, storage, and possibly manufacture of modern rabies vaccine and immunoglobulin is needed. It has been suggested that in many populations, the most cost-effective approach may be to concentrate on human vaccination after exposure, with or without passive immunization, but that in some situations, elimination of the reservoir by canine vaccination could be considered (211). To implement programs effectively, education campaigns directed at the general public are necessary. In many communities, simple descriptive epidemiologic studies are needed to define the extent of the problem, so that public support for programs can be generated. Better knowledge of the incidence of serious injuries caused by such animals as cattle and pigs, and of the age and sex groups at risk, may help in prevention. Blunting or capping of horns, use of different breeds, and restricting young boys from working as herders could help prevent injuries from cattle; however, all such countermeasures need to be evaluated. Pig hunters who carry only one spear or use an inadequate number of dogs appear to be at increased risk of severe injury from pig goring (216). Ecologic study of how snakebites occur and how food storage and the local habitat could be altered to discourage snakes from residing in and around domestic areas may lead to a means of preventing snakebites. Improved, rodent-proof storage facilities may help both in controlling rodents and


snakes and in reducing food wastage. Clearing the edges of paths in grassy areas and the use of lights at night might also reduce the incidence of snakebite, but further study is needed. Adequate supplies of effective antivenins at rural centers, staff trained to use them, and education of the rural public to seek help would be effective in reducing deaths, but the costs may be prohibitive for many countries. A variety of other methods for treating snakebite, including electric shock, have been suggested but have been shown to be ineffective (81, 223). Better knowledge of the ecology of various marine creatures may help prevent some injuries. Prompt recognition of the potentially serious nature of injuries, such as those resulting from needlefish and stingrays, and resuscitation and rapid transfer for basic surgical treatment may help to reduce mortality and disability. Immersion of the injured limb in hot water detoxifies many marine toxins (81). Shark attacks at large public swimming beaches near tropical cities have been greatly reduced by the use of hanging nets, the vibration of which attracts sharks, which then become entangled and suffocate (224). While the ecologic impact of such nets may need further study, they are only used locally at popular beaches. Training of lifeguards in resuscitation and hemostasis has also saved a number of persons attacked by sharks in South Africa (224). Cutting tools, other sharp objects, and machinery

Cutting tools such as the machete, smaller knives, and the axe are prized possessions in most tropical villages today. Indeed, they are so much more effective than the formerly used stone tools that their introduction to many remote areas has rapidly accelerated the pace of deforestation and environmental degradation. The machete, also known as the panga or bush knife, is inexpensive and ubiquitous. While the great utility of this simple device is undeniable, severe and often disabling injuries result from its use both as a multipurpose tool (Barss, unpublished

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data) and as an offensive weapon (225). Cutting and piercing instruments, such as knives, hand tools, etc., were the leading cause of nonfatal injury in Punjab, India, causing 22 percent of all injuries, with a rate of 26 per 1,000 persons per year (54). An additional 17 percent of all injuries were caused by sharp objects such as sheet metal or sticks, giving an overall rate of 44 injuries per 1,000 per year caused by lacerations and stabbings. The corresponding rate of attendance for cutting and piercing injuries at emergency rooms in northeastern Ohio was 28 per 1,000 (226). Of 86 soft tissue injuries reported at Mulago teaching hospital in Kampala, Uganda, 48 resulted from assault, 54 percent of which were caused by the machete (225). The resulting lacerations are frequently deep, severing multiple tendons, nerves, vessels and even bone, especially in injuries affecting the palm of the hand. Such injuries often receive inadequate surgical treatment, or none at all, frequently resulting in permanent disability. Other modes of injury include running or falling onto unsheathed knives, which can result in deep thoracic and abdominal wounds. When the machete is used as a digging tool, the hand can slip down onto the blade because of the absence of a safety guard between handle and blade (Barss, unpublished data). Small children are often left alone playing with sharp pointed knives, spears, or sticks. Penetrating wounds of the eye or hand may result in blindness or disability. Chopping wood, an everyday activity in many villages, is the most important cause of severe eye injury in many developing countries, as was shown in Malawi, where 25 percent of the eye injuries were caused by chopping wood (227). Sharp sticks fly up into the eye, sometimes as a result of improper positioning of the sticks, or perhaps because of a blunt or inadequate tool. The mechanization of agriculture and industry can present new problems in developing countries, because adequate safeguards often do not accompany the new technology. A recent study of agricultural injuries in India found that while hand tools

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were the most frequent cause of injuries, the majority of serious injuries were caused by a few types of crude powered machines, which were used as fodder cutters or for crushing sugar cane (228-232). These machines had no protective guards. In small industries, the primitive machinery used to power equipment, such as unprotected drive belts, has been reported to cause many injuries (233). One survey in Brazil of press machines for stamping metal found that none of 290 machines in 10 plants had safety devices to prevent amputations (234). Redesign of the machete to provide a simple guard to prevent the hand from slipping onto the blade might be effective in preventing some injuries, as could the mandatory use of a sheath when carrying such knives. Use of proper eye protection, such as glasses while chopping wood, can prevent eye injuries, but is difficult to implement in rural villages. Instructing village people about the potential hazards of cutting tools and safe handling procedures may be effective, although the effectiveness of such educational efforts has not been evaluated in developing countries. Even in developed countries, such educational efforts have been difficult to evaluate and are probably most effective in occupational settings, where there is a more structured environment (18, 24). The most effective prevention strategies will be those that involve the installation of safety guards on hazardous equipment or other changes in design to reduce injury (3, 5). Simple guards have been developed to reduce injuries caused by agricultural machines in rural Indian villages, and are easy to use (230232). Further study to develop and evaluate suitable prevention methods is needed. Since data are scarce, a population-based study, in collaboration with surgical staff, of disability resulting from injury by cutting tools and machinery, would help to define the extent of the problem. Bicycle injuries

Throughout most of Asia and Africa, bicycles and rickshaws are a major mode of

transport. Considering the great importance of the bicycle in many developing countries and its importance as a cause of serious injury in developed countries (2), it was surprising to find that little was reported in the literature concerning bicycle injuries in these areas. We are unsure whether the lack of reports on bicycle injuries in the literature reflects that they are infrequent or simply seldom reported. It could reflect a relative lack of involvement of bicyclists in collisions with motor vehicles, or be an indication of less injury-prone age groups—namely, adults—using bicycles; more data are needed. One article described fatalities by road user class in a variety of developing countries; the extent of involvement by cyclists ranged from 1 to 13 percent of all road fatalities, and in most countries was less than 10 percent. However, in Guyana and western Malaysia, 13 percent of traffic victims were cyclists (37). Waller (18) reported that bicycle injuries are a problem at night on unlit rural roads, where injured cyclists are often not discovered until daybreak. The use of bicycles to transport cargo is also mentioned as a hazard, but no documentary evidence was available to support this. In the United States in 1981, about 90 percent of the nearly 1,000 deaths from bicycle incidents involved collisions with motor vehicles (2); two thirds of these occurred in individuals under the age of 20 years; and an estimated 554,000 people were hospitalized (235). It is likely that bicycle injuries are a common but unrecognized problem in developing countries. There is some evidence that bicyclerelated injuries in developing countries may be of a somewhat different nature from those in industrialized countries. Two related reports of bicycle injuries from Sangli, Maharashtra, India, showed that amputation of the right toe was the most common injury related to bicycles, and occurred in children who were riding as passengers on the rear carrier (236, 237). There is apparently a law prohibiting the transportation of children on the rear carrier, but it is not well enforced. The big toe was supported near the chain,


and frequently became entrapped where there was no protective guard. About 9 percent of bicycle injuries were fractures, mainly of the clavicle or tibia and related to falls; other crushing fractures of the toes were caused by catching the foot in the spokes. There were no head injuries in these two series comprising 217 patients, which may indicate either that those who sustained a head injury did not survive to reach the hospital, or that other injuries are more common. Poorly built and badly maintained bicycles used over rough, narrow trails in remote areas are also likely to be a cause of injuries, but further studies are needed. In developed countries, it is estimated that five out of six deaths from bicycle incidents are caused by head and neck injuries, and that these victims sustain few other major injuries or none. If the situation in developing countries is similar, effective bicycle helmets could considerably reduce deaths among bicyclists (238, 239). Efforts to increase the visibility of bicycles, such as reflective tape and bright colors, may also reduce the risk of collision (18). Better separation of bicycle traffic from motorized vehicles by the use of separate lanes or paths could greatly reduce the cyclist's risk of being hit by traffic. Further studies of the epidemiology of bicycle injuries in both rural and urban areas of developing countries are needed to define high-risk groups, causes, and types of injuries, to assist policy makers to determine what preventive measures are necessary. Eye injuries

The eye is particularly vulnerable to injury, and therefore will be considered separately, since minor injuries can result in permanent disability if they are inadequately treated. In developed countries, eye injuries are a major cause of blindness, ranging from 4 percent in Japan to 35 percent in Finland (240). The extent to which this reflects differences in reporting or in risk factors is unknown. In addition, a clear distinction must be made between binocular blindness,

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which renders a person functionally blind, and monocular blindness, which is much less debilitating. Most eye injuries only affect one eye (241). While similar data are not available for developing countries, the large number of clinical articles on eye injuries suggests that they are a significant problem. A hospital study in one state in Nigeria found that trauma was responsible for 8 percent of permanent blindness (242). In Malawi, as discussed earlier, domestic activities such as chopping firewood cause the most (25 percent) eye injuries (227). Other common causes are thorns, sharp objects such as knives, needles, arrows, and chips from grinding activities, and chemical irritants used in the occupational setting. Corneal ulceration from the venom of spitting cobras occurred in some countries (243). Primary prevention to avert eye injuries includes wearing appropriate eye protection such as glasses or goggles in hazardous situations, and the presence of appropriate guards on machinery likely to cause injury to the eye. Safe practices in handling hot and caustic substances are also essential. A review by Adala (244) found that in developing countries, treatment is often delayed, resulting in extensive infection and loss of sight. More than 80 percent of injuries occur in rural areas where treatment is usually unavailable. What begins as a minor injury can often result in permanent blindness if not properly treated. A study in Nigeria found that only 20 percent of patients with eye injuries were seen at hospital within 1 week of the injury (245). Many had tried traditional remedies and only sought advice when these treatments failed to resolve their symptoms. Disasters

In the Americas from 1980 to 1985, 36,000 persons died from natural disasters, over 6.5 million people were affected, and economic losses of several billion dollars were sustained (11). The two major sources of injuries were the 1985 Mexico City earthquake, which resulted in 10,000 deaths and

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30,000 injuries, and the 1985 volcanic eruption in Columbia, which resulted in 23,080 deaths and 4,420 injuries. The true burden of nonfatal injuries is difficult to determine because of the ambiguity in the published data. Each disaster usually captures worldwide attention and causes widespread devastation. However, viewed over a span of time, natural disasters are not a major cause of injury mortality in most developing countries, but can cause considerable losses in certain individual countries (246). Injury patterns depend on the type of disaster and the part of the world affected. Earthquakes cause many deaths and large numbers of severe injuries requiring extensive care (247). Earlier studies of large earthquakes suggested a ratio of injuries to deaths of approximately 3:1, and that such ratios may be a useful guide to predict the number of injured persons requiring medical care (248, 249). However, a more comprehensive analysis by Alexander (250) found that this ratio only applied to a limited number of earthquakes. In the recent earthquake in Armenia, an estimated 25,000 people were killed and 31,000 injured (251). The large number of deaths was the result of the poor construction of the buildings (252). High winds cause few deaths and moderate numbers of severe injuries. Tidal waves and flash floods cause many deaths and few injuries, whereas normal floods generally result in relatively few deaths or injuries (247). Certain areas, such as the Bangladesh delta, have been subject to regular massive floods after cyclones, resulting in very high fatality rates (246). A newly recognized hazard, the volcanic release of massive quantities of carbon dioxide, asphyxiated more than 1,700 persons near Lake Nyos in the Cameroons (253-255). Obvious preventive strategies, such as not rebuilding in areas subject to frequent natural disasters, are often not implemented because of land shortages and the fact that such land is often very fertile. Technologic disasters such as the release of poisonous gas at the Bhopal chemical plant in India are becoming increasingly common (256, 257). The Bhopal incident

resulted in nearly 3,000 deaths, while between 50,000 and 200,000 persons required medical attention (101, 256). Another 1,700 were expected to die from late effects. In Mexico, a single explosion from 5 million liters of butane gas resulted in 400 deaths, 1,000 people unaccounted for, and 5,000 injured (11). Nuclear mishaps such as the Chernobyl explosion in the USSR in 1986 have the potential for massive immediate and delayed casualties (253). Although "body counts" for many disasters may be available from news reports and other sources, very few epidemiologic studies have been conducted to examine risk factors for injury (258). The value of good epidemiologic information was demonstrated by a study of the 1985 cyclone in Bangladesh (246). On one island with no cyclone shelters, the study group lost 40 percent of its family members, while at another island that had cyclone shelters, only 3 percent of the study group lost family members. Similar studies of earthquakes and tornadoes have led to useful suggestions for preventing loss of life from disasters (259, 260). Disaster planning and preparedness can reduce the overall impact of disasters, but often basic planning is not done, even in countries at high risk (247, 253). There is a need for more studies of the epidemiology of injuries after disasters (256-258). Examples of such research include studies to determine risk factors for death caused by building collapse, injury patterns in relation to building design, factors responsible for survival, the most appropriate means of rescue and emergency preparedness, and a variety of other factors that could help in planning appropriate interventions either to prevent injury in a natural disaster or to develop means to mitigate its effects. The low fatality rates seen in recent disasters in the United States (hurricanes Gilbert and Hugo in 1988 and 1989, and the Loma Prieta, California, earthquake in 1989) were in part the result of the application of previous research findings (253). The application of such findings in developing countries with scarce resources will be a challenge.


Emergency medical services

In most developed countries, the adverse effects of many injuries are minimized by rapid treatment of the injury. It is generally believed that decreasing the time from injury to emergency treatment and providing definitive care for severely injured persons decreases the risk of death (261-263). This was the rationale behind the formation of the Mobile Army Surgical Hospital units in Korea, and later led to the development of emergency medical care systems in most developed countries. A study of trauma in the Afghan guerilla war found that few patients with serious injuries survived the long trip to the nearest hospital (264). Many severe injuries in developing countries occur in remote areas far from adequate surgical care. However, relatively simple emergency care systems that rely on welltrained primary health care workers, together with radio network linkages between rural health centers and district or provincial hospitals, and intermittent chartered use of local vehicles and/or aircraft, can improve the quality of trauma care, even in remote rural areas (265-267). Such links also do a great deal to bolster public confidence in rural health services, as well as to increase the morale and competence of isolated health care workers. Hospital physicians can advise rural staff about the resuscitation and initial management of injured patients, and help decide on the necessity for and urgency of transfer. In areas where road links are absent or poor, the construction of health centers and hospitals near suitable airstrips can allow evacuation by aircraft, which can usually be chartered far more cheaply than helicopters. Many countries will perhaps feel that such emergency systems are beyond the capacities of their limited health care budgets; however, by utilizing intermittent charters only when needed, costs can be kept surprisingly low. A study of 92 emergency flights in a remote province of Papua New Guinea from 1979 to 1981 determined the annual cost of such a service for all medical, surgical, and

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obstetric conditions to be US$0.20 per capita, with a cost per life saved of US$450. The use of such a system also helped to draw attention to the most serious problems, so that appropriate preventive activities could be planned (265). A study in Trinidad and Tobago found that the death-to-injury ratio for motor vehicle trauma was at least double that in a North American population of similar size (268). The author recommended that advanced trauma life support programs be established in third world countries, but only if the system could be evaluated to document its impact. However, a more important priority is probably the development of better basic first aid at the household and primary health care levels, including simple treatments to control hemorrhage and to prevent infection. Treatment and rehabilitation

The study by Gordon et al. in 1959 (54) found an incidence of permanently disabling or crippling injuries of 5 per 1,000 population in four rural Indian villages and that 4 percent of all injuries caused permanently disabling or crippling injuries. He also found that three of 23 deaths from injury (13 percent) were the result of infections subsequent to the injury. Adequate treatment of injuries could have reduced many of these complications. More recent studies by Mohan and colleagues (4, 73, 76) confirm that adequate treatment and rehabilitation services are lacking in parts of India. Even when they are available, villagers often prefer local healers, whose methods of treatment can often prolong healing time or lead to permanent disability (232). The inadequate or often complete absence of treatment of many injuries in developing countries greatly contributes to the total impact they have on society. If left untreated, what begins as a relatively minor injury can result in death or severe disability. Careful attention to the prevention and treatment of small injuries such as insect bites and scratches can prevent the development of more severe sepsis. Many tropical ulcers are

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thought to start as a minor skin wound (220); if left untreated for prolonged periods, they can result in the development of squamous cell carcinomas, which can require limb amputation if suitable initial treatment facilities are not available (220, 269). Other examples of inadequate initial treatment leading to unnecessary disability include failure to remove a foreign body from the eye promptly, causing infection and subsequent loss of vision; application of ointments to burns and other harmful local remedies that can cause infection, contractures, disfigurement, and functional losses; and improper setting of a fractured limb, resulting in loss of limb function because of malunion. In many developing countries, fatality rates for hospitalized burn patients are high. Modern treatment can greatly reduce both mortality rates and disability (270), even in developing countries (271), and early and effective rehabilitation can also reduce disability (272). Simple standardized treatment regimes for all injuries can greatly improve the quality of care available, even in poor countries (273). Adequate treatment and rehabilitation of the seriously injured person is an important component of injury prevention that is often overlooked as a major prevention strategy (4, 17, 273-275). Unfortunately, the maldistribution of health facilities and personnel is still a serious problem in many developing countries. In some areas, such as in India, the situation has actually worsened in recent years (276). Even within rural areas of India, the ratio of hospital beds to the population ranges between 3 and 131 per 100,000 population. Planners and politicians need to take both population distribution and remoteness from other facilities into account when planning the organization and regionalization of health services. Centralization and specialization of accident and emergency services in urban areas, at the expense of smaller facilities in rural areas, is generally favored by powerful hospital-based specialists and some planners. This policy, however, has at least been called into question by a recent study suggesting that rural areas of the

United Kingdom without accident and emergency departments had higher mortality from road traffic accidents than did areas with such facilities (277). Strategically distributed primary care facilities and staff, with the capability to provide basic first aid and resuscitation with intravenous fluids, can generally stabilize many injured patients, including burn victims, for up to 24 hours until transport to a suitable hospital can be arranged. Until effective primary prevention becomes a reality, such secondary prevention will remain an important priority for reducing mortality and morbidity from injuries. FUTURE NEEDS

The establishment of a well-developed theoretical and practical framework for the science of injury prevention has led to a replacement of the concept of injuries as random events, or accidents, with that of the "etiologic definition" of injury events as a health problem (278). Schelp (279) has proposed a model for community injury prevention in a rural municipality of Sweden that may be applicable to developing countries. It incorporates the following eight steps: epidemiologic mapping, selection of risk groups and environments, formation of intersectorial working and reference groups, joint planning of action programs to prevent injuries, implementation of action programs, evaluation of action programs, modification of action programs, and transfer of experience to other areas in the district. It is beyond the scope of this paper to discuss all of these steps; more complete discussion of prevention programs can be found elsewhere (5, 18, 19, 21, 22, 24). It is apparent that the first steps, by necessity, specify an epidemiologic basis for prevention. The initial role of epidemiology is in the identification of the hazard (most significant injuries), the circumstances (causes), and risk factors. This information is often used by other disciplines, such as engineering, to develop appropriate prevention strategies. One of the challenges for injury epidemiology is not just


to identify a single cause, which usually is not possible, but to set priorities among causal factors. The top priority is to target those causal factors that are most amenable to intervention, since the resources available for injury control are usually scarce. Much basic descriptive injury epidemiology has been done in developed countries, and increasing attention is being directed towards more analytic studies and the evaluation of interventions (17, 280). However, for most developing countries, even basic descriptive epidemiology, including hazard identification or recognition of the magnitude of the problem, is not available. Central to the development of basic hazard identification is the need for good quality data on the causes of injuries and their distribution in the community. Adequate epidemiologic surveillance for injuries is also an essential component of the evaluation of prevention programs. The type of data needed will depend on the level at which activities are being conducted. At a national or global level, adequate and consistent detail in categorizing unintentional injuries into useful groups such as drowning, falls, burns, etc., is needed, rather than simply lumping injuries into one group. This facilitates prioritization of specific injuries for more detailed study and action. At a local level, a more detailed study of causes of injury, high risk groups, and hazardous environments should be possible. The usefulness of data from hospitals and health centers would be greatly improved by insisting upon external cause coding (Ecoding) for all injury cases in hospital discharge records, where such records exist. For injuries that are usually rapidly fatal and seldom result in hospitalization, simple community surveys of representative sample villages, perhaps as part of other surveys or a census, may determine whether a serious public health problem exists in a district. Many health and demographic surveys are conducted in developing countries; the inclusion of simple questions on injuries in these surveys could provide invaluable and

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reliable information upon which to base a prevention program. The identification and coding of information on most diseases does not depend on external cause coding; the identification and coding of information on injuries does, and the information necessary for this could be obtained in developing countries. No medical tests or examinations are required to determine an accurate cause of death. Information on the cause of injury is usually provided by nonmedical people who witnessed the injury. Even in developed countries, witnesses simply describe the circumstances to the physician or medical examiner, who certifies the cause of death as an injury (e.g., a fall from a building). Thus, good information is potentially obtainable, regardless of the level of a country's development. However, accurate recording of circumstances is necessary for reliable external cause coding (71). Of all causes of death reported, injuries could be the most reliable, and it has therefore been suggested that cause of death reporting for injuries could be used as a standard against which to compare reporting for other causes (58). There is, however, a need for prospective, population-based studies to compare the accuracy and efficiency of various methods of reporting deaths from injury. Other approaches to collecting injury data include the use of short questionnaire surveys of rural health center networks, since permanent staff in an area often will be aware of many deaths from injury in their own local area for a retrospective period of a few years. This approach was useful in Papua New Guinea (162). A hospital study had shown that falls from trees were a serious source of morbidity in a rural province; a subsequent health center survey showed that such falls were also a significant source of unreported mortality. In many rural areas of developing countries, death certificates are not completed for many deaths that occur suddenly at home; thus, epidemiologic reporting based upon this source alone may greatly underestimate the extent of the problem or miss it completely. This situation requires an organized

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system of lay reporting of vital events (59), followed up, if possible, by structured mortality interviews of relatives of deceased individuals to obtain the information necessary to define the causes of mortality. Such interviews, called "verbal autopsies," have been used to collect data on causes of death and conditions associated with such deaths in the Matlab area in Bangladesh, by the Medical Research Council in the Gambia, by the Office de la Recherche Scientifique et Technique Outre-Mer (ORSTOM) in Senegal, by the Papua New Guinea Institute of Medical Research in the Tari Basin, and by others (61). It is somewhat costly, requires regular epidemiologic supervision, and is probably only feasible for selected areas of a country on a research basis; however, simple questions regarding how the injury occurred can easily be added to existing studies, such as large-scale demographic surveys. Such questions can provide valuable information for external cause coding of deaths. In addition, it should be possible to obtain this information in even the simplest of villagebased vital registration systems. The development of simple but reliable systems to collect injury data can provide the epidemiologic basis for planning and evaluating prevention efforts at the local, provincial, or country level. CONCLUSION

While the traditional problems of infectious disease, malnutrition, and environmental sanitation are still the major causes of death in many developing countries, marked decreases in these conditions (with the recent exceptions of acquired immunodeficiency syndrome and malaria) are reflected in the rapidly declining infant and childhood mortality rates in many areas (281). Chronic diseases and injuries have emerged as major causes of death and disability (5-9, 13, 15). Injuries, in particular, will become increasingly important, especially because in rushing towards development, governments often fail to adopt or enforce many of the safety standards and

legislation that already are having a significant effect in reducing the impact of injuries in developed countries. The importance of injuries as a cause of death globally has been increasingly recognized. The World Health Organization now has a special office to coordinate its global injury epidemiology and prevention program. Recent reviews of currently available injury prevention strategies in the United States estimated that many serious injuries and deaths could be prevented simply by applying what was already known about their prevention (19, 21, 22). Similar, if not greater, reductions could be expected in developing countries, once specific hazards were recognized, were they to adapt and apply many of the effective strategies already being used in developed countries. However, the study and prevention of injuries in remote villages might require methods different from those needed in crowded urban centers or countries at higher levels of development. The etiologies of many chronic diseases are still unknown; however, for most infectious diseases and for many injuries, the "causative agents" and "vectors" or causative environments are known, and the relative risks are often large. Smith observed that for many tropical diseases, interventions are usually quite obvious, and as a consequence, epidemiologic studies of tropical diseases "usually involve some kind of intervention or comparison of interventions" (282, p. 160). Similarly, for injuries, once the hazards have been identified, the interventions are often quite obvious. The first major task is to identify particularly hazardous environments and groups at high risk, so that specific interventions can be developed for specific target groups. However, such investigations are limited by the lack of trained epidemiologists necessary to conduct them and to evaluate appropriate intervention strategies. The impact on the family of permanently crippling injuries and deaths of parents or other "breadwinners" is likely to have serious consequences in developing countries,


given their almost universal lack of welfare systems. In fast-growing urban areas, large extended families are often financially dependent on one or two working members of the household (283). In rural areas, the loss of a farmer may adversely affect food supplies. However, present development and aid projects tend to emphasize infectious diseases and child survival (281). Even in children, injuries represent a significant health burden. For example, in Bangladesh, injuries are the third leading cause of death in children under the age of 5 years, surpassed only by diarrhea and dysentery (55). Injuries usually affect persons at the most productive time of their lives, just when society is beginning to reap the benefits of its earlier investments in the care and education of the individual. As discussed earlier, injuries accounted for 26 percent of all the direct and indirect costs of illness in one rural area of Brazil (28). There is thus a need to develop further studies to document the impact of injuries and disability, not only on the individual, but also on the family and society. Injuries are no longer considered accidents or acts of God, and can be subjected to epidemiologic study like that conducted for other health conditions (20). The epidemiology of specific unintentional injuries varies widely from one country to the next. Even within countries, there are wide variations in types and rates of injury, owing to such factors as urban or rural location. In most areas, injuries incurred in motor vehicle crashes are the leading cause of death from injury, with rates per 100,000 population being similar to those found in developed countries, even though the number of vehicles is much lower. Per vehicle, rates are often 20 to 70 times the rates for Western Europe and North America. Even within the category of motor vehicle injuries, however, the importance of various types of road user (e.g., occupant, motorcyclist, or pedestrian) varies widely. In many developing countries, rates of motor vehicle injuries appear to be increasing, and in some they have stabilized at high levels; in developed countries, rates

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are falling as a result of a variety of effective highway safety programs. Rates for other unintentional injuries appear to have remained fairly constant over time. Rates of unintentional injury from causes other than motor vehicles, when considered in the aggregate, appear relatively similar across countries. However, the importance of specific injuries varies widely from country to country, and even from one area to the next. For example, in some areas, drowning is a major problem, and in others it is rare. These wide variations in injury problems highlight the need to develop simple but effective surveillance tools, rather than assume that problems are similar from one country or area to the other. However, simply relying on surveillance methods used in developed countries may be inadequate and inappropriate (48, 284). Adaptation of existing methods or creation of new methods, guided by an awareness of local environmental and cultural conditions, is necessary. The key to establishing effective prevention programs is a good understanding of the basic epidemiology of injuries within the particular country or local environment. Many developed countries have recognized the need to develop coordinated injury prevention programs based on sound epidemiologic principles (17-19, 23, 86, 279). However, few developing countries or outside funding agencies have recognized the importance of the impact of injuries in the developing world. Two World Bank policy and planning projects did recently identify injuries as one of the priority areas for future prevention efforts (281, 283, 285). It is essential that adequate funds be made available, both for more applied research and surveillance, in order to identify the characteristics of local hazards, and for more indepth research, to identify specific, modifiable risk factors unique to the local culture and environment. Adequate evaluation of intervention programs is also essential to monitor progress and to determine the most cost-effective interventions. Unless countries and international donor agencies provide greater assistance for injury research

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and prevention programs, injuries will increasingly become a major cause of morbidity and mortality in the developing world.

18. 19.

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Road Traffic and Other Unintentional Injuries Among Travelers to Developing Countries.

Pregnancy-Related Pelvic Pain: A Neglected Field in Developing Countries.

Epidemiology of Unintentional Child Injuries in the Makwanpur District of Nepal: A Household Survey.

Tropical diseases and the poor: Neglected tropical diseases are a public health problem for developing and developed countries alike.

Epidemiology of acute respiratory infections in children of developing countries.

[Epidemiology of Streptococcus pyogenes infections in developing countries].

Descriptive epidemiology of unintentional residential fire injuries in King County, WA, 1984 and 1985.

Caring for patients with rabies in developing countries - the neglected importance of palliative care.

More on a neglected problem.

The emigration of doctors: a problem for the developing and the developed countries. Part II.

Epidemic diarrhea of the newborn, a nosocomial problem in developing countries.

Firewood, smoke and respiratory diseases in developing countries-The neglected role of outdoor cooking.

Noncommunicable diseases among urban refugees and asylum-seekers in developing countries: a neglected health care need.

Emigration of doctors: a problem for the developing and the developed countries. Part I.

Outside Europe. Is poliomyelitis a serious problem in developing countries?--the Danfa experience.

Impact of high ambient temperature on unintentional injuries in high-income countries: a narrative systematic literature review.

Descriptive Epidemiology of Unintentional Burn Injuries Admitted to a Tertiary-Level Government Hospital in Nepal: Gender-Specific Patterns.

[Acute pain in surgery: the significance of a neglected problem].

Clustering of disability caused by unintentional injury among 15- to 60-year-old: a challenge in rapidly developing countries.

Geriatrics and Gerontology: Neglected Areas of Research in Most Developing Countries.

Are Salmonella-Induced Gastroenteritis Neglected in Developing Countries? Feedback from Microbiological Investigations in N'Djamena Hospitals, Chad.

Is poliomyelitis a serious problem in developing countries?--lameness in Ghanaian schools.

Overweight and obesity epidemic in developing countries: a problem with diet, physical activity, or socioeconomic status?

Dehydration among lactating mothers in the Amazon: A neglected problem.