Validating and Applying a Novel Method of Assessing Trauma Burden in a Resource Poor Setting

Introduction: Trauma, particularly Road Traffic Injury (RTI), is a leading cause of global death. African RTI mortality is among the highest in the world, at 28.3 deaths per 100,000 population. However, this burden of injury may be underestimated for the African region as only 7% of cause of death information is obtained from population based vital registration systems. The Verbal Autopsy (VA) method has been extensively used to assess maternal and child deaths in resource poor settings by analyzing the deceased's symptoms and circumstances as reported by family members. Here we present the validation and application of a VA tool to assess trauma burden in Lilongwe, Malawi, an urban sub Saharan African setting. Methods: A modified World Health Organization (WHO) VA tool was administered at the Kamuzu Central Hospital (KCH) morgue in Lilongwe, Malawi to family members of inpatient deceased. Two physicians assigned cause of death as 'trauma' or 'non-trauma' as well as a simplified ICD-10 code based on the Verbal Autopsy questionnaire. These assignments were compared to the 'gold standard' of physician review of hospital records using a kappa statistic. The validated tool was then applied to deceased from the community who were "brought in dead" (BID) to the morgue. Results: The VA method had near perfect agreement with the hospital record in determining "trauma" versus "non-trauma" while there was moderate agreement when comparing types of death e.g cardiovascular disease versus infectious disease. When applied to the BID population, it showed a significantly higher percentage of RTI deaths in BID versus in-hospital deceased while the total trauma burden was similar in BID versus in-hospital deaths. Conclusion: This VA tool can accurately ascertain trauma-related mortality with almost perfect agreement. It provides information on the high burden of road traffic injury death that is not captured by hospital based trauma registries and reaffirms the great need for primary prevention and early care for the injured. To allocate resources for secondary trauma mortality prevention, VA of BID community deaths illustrates that pre-hospital care must be improved in addition to continuing efforts at improving in-hospital care.Master of Public Healt

Head injury triage in a sub Saharan African urban population

AbstractBackgroundInjuries are the ninth leading cause of death in the world and disproportionately affect low- and middle-income countries. Head injury is the leading cause of trauma death. This study examines the epidemiology and outcomes of traumatic head injury presenting to a tertiary hospital in Malawi, in order to determine effective triage in a resource limited setting.MethodsThe study was conducted at Kamuzu Central Hospital (KCH) in Lilongwe Malawi during a three-month period. Vital signs and Glasgow Coma Score (GCS) were prospectively collected for all patients that presented to the casualty department secondary to head injury. All head injury admissions were followed until death or discharge.ResultsDuring the three-month study period, 4411 patients presented to KCH secondary to trauma and 841 (19%) had a head injury. A multivariate logistic regression model revealed that GCS and heart rate changes correlated strongly with mortality. There is a four-fold increase in the odds of mortality in moderate versus mild head injury based on GCS.ConclusionIn a resource limited setting, basic trauma tools such as GCS and heart rate can effectively triage head injury patients, who comprise the most critically ill trauma patients. Improvements in head injury outcome require multifaceted efforts including the development of a trauma system to improve pre-hospital care

Under-Reporting of Road Traffic Mortality in Developing Countries: Application of a Capture-Recapture Statistical Model to Refine Mortality Estimates

Road traffic injuries are a major cause of preventable death in sub-Saharan Africa. Accurate epidemiologic data are scarce and under-reporting from primary data sources is common. Our objectives were to estimate the incidence of road traffic deaths in Malawi using capture-recapture statistical analysis and determine what future efforts will best improve upon this estimate. Our capture-recapture model combined primary data from both police and hospital-based registries over a one year period (July 2008 to June 2009). The mortality incidences from the primary data sources were 0.075 and 0.051 deaths/1000 person-years, respectively. Using capture-recapture analysis, the combined incidence of road traffic deaths ranged 0.192–0.209 deaths/1000 person-years. Additionally, police data were more likely to include victims who were male, drivers or pedestrians, and victims from incidents with greater than one vehicle involved. We concluded that capture-recapture analysis is a good tool to estimate the incidence of road traffic deaths, and that capture-recapture analysis overcomes limitations of incomplete data sources. The World Health Organization estimated incidence of road traffic deaths for Malawi utilizing a binomial regression model and survey data and found a similar estimate despite strikingly different methods, suggesting both approaches are valid. Further research should seek to improve capture-recapture data through utilization of more than two data sources and improving accuracy of matches by minimizing missing data, application of geographic information systems, and use of names and civil registration numbers if available