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1.  The Importance of Poisoning vs. Road Traffic Injuries as a Cause of Death in Rural Sri Lanka 
PLoS ONE  2007;2(7):e599.
Background
Road traffic crashes are considered by the WHO to be the most important global cause of death from injury. However, this may not be true for large areas of rural Asia where road vehicles are uncommon. The issue is important, since emphasising the importance of road traffic crashes risks switching resources to urban areas, away from already underfunded rural regions. In this study, we compared the importance of road traffic crashes with other forms of injury in a poor rural region of South Asia.
Methodology/Principal Findings
We collected data on all deaths from injury in the North Central Province of Sri Lanka (NCP; population 1,105,198 at 2001 census) over 18 months using coronial, hospital, and police data. We calculated the incidence of death from all forms of intentional and unintentional injury in the province. The annual incidence of death from injury in the province was high: 84.2 per 100,000 population. Half of the deaths were from self-harm (41.3/100,000). Poisoning (35.7/100,000)—in particular, pesticide self-poisoning (23.7/100,000)—was the most common cause of death, being 3.9-fold more common than road traffic crashes (9.1/100,000).
Conclusions/Significance
In poor rural regions of South Asia, fatal self-harm and pesticide self-poisoning in particular are significantly more important than road traffic injuries as a cause of death. It is possible that the data used by the WHO to calculate global injury estimates are biased towards urban areas with better data collection but little pesticide poisoning. More studies are required to inform a debate about the importance of different forms of injury and how avoidable deaths from any cause can be prevented. In the meantime, marked improvements in the effectiveness of therapy for pesticide poisoning, safer storage, reduced pesticide use, or reductions in pesticide toxicity are required urgently to reduce the number of deaths from self-poisoning in rural Asia.
doi:10.1371/journal.pone.0000599
PMCID: PMC1904253  PMID: 17622344
2.  The burden of disease and injury in Iran 2003 
Background
The objective of this study was to estimate the burden of disease and injury in Iran for the year 2003, using Disability-Adjusted Life Years (DALYs) at the national level and for six selected provinces.
Methods
Methods developed by the World Health Organization for National Burden of Disease (NBD) studies were applied to estimate disease and injury incidence for the calculation of Years of Life Lost due to premature mortality (YLL), Years Lived with Disability (YLD), and DALYs. The following adjustments of the NBD methodology were made in this study: a revised list with 213 disease and injury causes, development of new and more specific disease modeling templates for cancers and injuries, and adjustment for dependent comorbidity. We compared the results with World Health Organization (WHO) estimates for Eastern Mediterranean Region, sub-region B in 2002.
Results
We estimated that in the year 2003, there were 21,572 DALYs due to all diseases and injuries per 100,000 Iranian people of all ages and both sexes. From this total number of DALYs, 62% were due to disability premature deaths (YLD) and 38% were due to premature deaths (YLL); 58% were due to noncommunicable diseases, 28% – to injuries, and 14% – to communicable, maternal, perinatal, and nutritional conditions. Fifty-three percent of the total number of 14.349 million DALYs in Iran were in males, with 36.5% of the total due to intentional and unintentional injuries, 15% due to mental and behavioral disorders, and 10% due to circulatory system diseases; and 47% of DALYs were in females, with 18% of the total due to mental and behavioral disorders, 18% due to intentional and unintentional injuries, and 12% due to circulatory system diseases. The disease and injury causes leading to the highest number of DALYs in males were road traffic accidents (1.071 million), natural disasters (548 thousand), opioid use (510 thousand), and ischemic heart disease (434 thousand). The leading causes of DALYs in females were ischemic heart disease (438 thousand), major depressive disorder (420 thousand), natural disasters (419 thousand), and road traffic accidents (235 thousand). The burden of disease at the province level showed marked variability. DALY estimates by Iran's NBD study were higher than those for EMR-B by WHO.
Conclusion
The health and disease profile in Iran has made the transition from the dominance of communicable diseases to that of noncommunicable diseases and road traffic injuries. NBD results are to be used in health program planning, research, and resource allocation and generation policies and practices.
doi:10.1186/1478-7954-7-9
PMCID: PMC2711041  PMID: 19527516
3.  Epidemiology of traffic injuries and motor vehicles utilization in the Capital of Iran: A population based study 
BMC Public Health  2011;11:488.
Background
Road traffic injuries are a serious public health problem worldwide. The incidence rate of fatal road traffic injuries is 26.4 per 100000 in the Eastern Mediterranean Region. Road traffic injuries are a major public health problem in Iran. Different routine sources are available for road traffic injuries in Iran, but they present several limitations.
This study aimed to determine the epidemiology of road traffic injuries in greater Tehran, using a population-based approach which is less prone to under-estimation compared to service-based data.
Methods
In the year 2008, 2488 households were randomly selected for a face to face interview. Trained interviewers referred to the selected households to collect the subjects' demographic information, as well as their motor vehicle utilization and traffic injuries during the year prior to data collection. All interviews were recorded using a digital voice recorder and reviewed by a quality control team the day after the interview. The Student's t-test and ANOVA were used to analyze continuous variables. Chi-square test -including a test for trend for ordinal data- was used to analyze categorical variables. Ninety-five percent confidence interval was calculated for point estimates of incidences using Poisson or binomial distribution assumptions accordingly.
Results
There were 119 traffic injury cases including 3 deaths (33 per 100 000) in the survey sample (n = 9100). The annual incidence of all traffic injuries for 1000 population was 13.1 (95% CI: 10.8 - 15.6), and that of fatal traffic injuries was 33.0 per 100 000 population (95% CI: 6.80 - 96.32). The annual incidence of collision traffic injury for 1000 motorcycles was 95.
Conclusion
This population-based study demonstrates that the morbidity rate of RTIs is about ten times higher than the national figures reported by other available sources; and this can serve as an important warning to countries like Iran to prioritize this issue in their public health activities. To ensure more safety on our roads, we need to establish an injury surveillance system, and a more accurate national data capture system on RTIs.
doi:10.1186/1471-2458-11-488
PMCID: PMC3141457  PMID: 21693056
4.  Road Trauma in Teenage Male Youth with Childhood Disruptive Behavior Disorders: A Population Based Analysis 
PLoS Medicine  2010;7(11):e1000369.
Donald Redelmeier and colleagues conducted a population-based case-control study of 16-19-year-old males hospitalized for road trauma or appendicitis and showed that disruptive behavior disorders explained a significant amount of road trauma in this group.
Background
Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder).
Methods and Findings
We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio  =  1.37, 95% confidence interval 1.22–1.54, p<0.001). The risk was evident over a range of settings and after adjustment for measured confounders (odds ratio 1.38, 95% confidence interval 1.21–1.56, p<0.001). The risk explained about one-in-20 crashes, was apparent years before the event, extended to those who died, and persisted among those involved as pedestrians.
Conclusions
Disruptive behavior disorders explain a significant amount of road trauma in teenage male youth. Programs addressing such disorders should be considered to prevent injuries.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In the latest World Health Organization (WHO) global burden of disease list, road traffic crashes are currently ranked eighth but are predicted to take fourth place by 2030 (by which time, road traffic deaths are likely to increase by more than 80% in developing countries and to decrease by nearly 30% in industrialized countries.) Every year, road traffic crashes kill an estimated 1.2 million people world-wide and injure or disable a further 20–60 million. Furthermore, the economic consequences of road traffic crashes account for about 2% of the gross national product of the entire global economy.
90% of road traffic deaths occur in developing countries where pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) are the most vulnerable. In industrialized countries, teenage male drivers are the single most risky demographic group, with an incidence of road traffic crashes of twice that of the population average. Also, male teenagers are sometimes a hazard to other road users and contribute to more fatalities in older pedestrians than older drivers. Furthermore, teenage male drivers involved in serious crashes can have ongoing health care needs but are often resistant to standard road safety advice.
Why Was This Study Done?
Previous studies have suggested that disruptive behavior disorders might contribute to the risk of road traffic crashes in male teenagers but methodological problems with these studies make these results unclear. Given the importance of this topic, authorities have called for more research into the full range of behavioral disorders and relevant populations. This study attempted to avoid the methodological problems of previous studies and to rigorously assess whether disruptive behavior disorders predispose male teenagers to road traffic crashes.
What Did the Researchers Do and Find?
The researchers conducted a 7-year population-based case-control study in Ontario, Canada of consecutive male teenagers aged between 16 and 19 years who were admitted to a hospital due to a road traffic crash, including those who were pedestrians. For the controls, the researchers used consecutive males in the same age range who were admitted to the same hospitals during the same time interval for acute appendicitis (which is common and generally unrelated to traumatic injury). For each participant in the study, the authors used universal health care databases in Canada's single-payer health care system to identify relevant psychiatric diagnoses (attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder) during the decade before admission.
During the study period, 3,421 male teenagers were admitted to hospital as the result of a road traffic crash and 3,812 male teenagers were admitted to hospital for appendicitis. A history of disruptive behavior disorders was significantly more frequent among male teenagers admitted for road traffic crashes than controls (767 of 3,421 versus 664 of 3,812) giving an odds ratio 1.37. This higher risk was still present after the researchers adjusted for possible confounding factors (such as age, social status, and home location) and accounted for about one-in-20 road traffic crashes, including male teenagers who had died and those involved as pedestrians.
What Do These Findings Mean?
The results of this study suggest that disruptive behavior disorders explain a significant amount of road traffic crashes experienced in male teenagers. Overall, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder are associated with about a one-third increase in the risk of a road traffic crash (which is similar to the relative risk among individuals treated for epilepsy.) As in previous studies in this area, some methodological problems may affect the interpretation of these findings. As this study did not document who was “at fault,” an alternative interpretation might be that behavioral disorders impair a teenager's ability to avoid a mishap initiated by someone else. Most importantly, the observed increase in risk as pedestrians indicates that male teenagers who abstain from driving do not escape the danger of road traffic crashes.
The researchers stress that any increased risk of road traffic crashes associated with disruptive behavior disorders in male teenagers does not justify withholding a driver's license, especially as many such disorders can be effectively treated or, indeed, because it does not address the issue of the increased risk for those teenagers who were pedestrians. Instead, they suggest that disruptive behavior disorders could be considered as contributors to road traffic crashes—analogous to seizure disorders and some other medical diseases. Therefore, greater attention by primary care physicians, psychiatrists, and community health workers might be helpful since interventions can perhaps reduce the risk including medical treatments and avoidance of distractions.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000369.
The World Health Organization has information on road traffic crashes
The US National Institutes of Health has information about behavior disorders in children as well as UK-based Kids Development
The Ontarion Ministry of Transportation has information on annual roadway collisions in Ontario
doi:10.1371/journal.pmed.1000369
PMCID: PMC2981585  PMID: 21125017
5.  Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy 
Background
Despite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality.
Aim
To estimate the epidemiology of the injury seen in patients presenting to the government hospital in Kampala, the capital city of Uganda.
Methods
A secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005.
Results
From 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance.
Conclusions
Road traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development.
doi:10.1007/s12245-010-0200-1
PMCID: PMC2926872  PMID: 21031040
Road traffic; Injuries; Developing country; Trauma; Uganda
6.  Diet and Physical Activity for the Prevention of Noncommunicable Diseases in Low- and Middle-Income Countries: A Systematic Policy Review 
PLoS Medicine  2013;10(6):e1001465.
Carl Lachat and colleagues evaluate policies in low- and middle-income countries addressing salt and fat consumption, fruit and vegetable intake, and physical activity, key risk factors for non-communicable diseases.
Please see later in the article for the Editors' Summary
Background
Diet-related noncommunicable diseases (NCDs) are increasing rapidly in low- and middle-income countries (LMICs) and constitute a leading cause of mortality. Although a call for global action has been resonating for years, the progress in national policy development in LMICs has not been assessed. This review of strategies to prevent NCDs in LMICs provides a benchmark against which policy response can be tracked over time.
Methods and Findings
We reviewed how government policies in LMICs outline actions that address salt consumption, fat consumption, fruit and vegetable intake, or physical activity. A structured content analysis of national nutrition, NCDs, and health policies published between 1 January 2004 and 1 January 2013 by 140 LMIC members of the World Health Organization (WHO) was carried out. We assessed availability of policies in 83% (116/140) of the countries. NCD strategies were found in 47% (54/116) of LMICs reviewed, but only a minority proposed actions to promote healthier diets and physical activity. The coverage of policies that specifically targeted at least one of the risk factors reviewed was lower in Africa, Europe, the Americas, and the Eastern Mediterranean compared to the other two World Health Organization regions, South-East Asia and Western Pacific. Of the countries reviewed, only 12% (14/116) proposed a policy that addressed all four risk factors, and 25% (29/116) addressed only one of the risk factors reviewed. Strategies targeting the private sector were less frequently encountered than strategies targeting the general public or policy makers.
Conclusions
This review indicates the disconnection between the burden of NCDs and national policy responses in LMICs. Policy makers urgently need to develop comprehensive and multi-stakeholder policies to improve dietary quality and physical activity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Noncommunicable diseases (NCDs)—chronic medical conditions including cardiovascular diseases (heart disease and stroke), diabetes, cancer, and chronic respiratory diseases (chronic obstructive pulmonary disease and asthma)—are responsible for two-thirds of the world's deaths. Nearly 80% of NCD deaths, close to 30 million per year, occur in low- and middle-income countries (LMICs), where they are also rising most rapidly. Diet and lifestyle (including smoking, lack of exercise, and harmful alcohol consumption) influence a person's risk of developing an NCD and of dying from it. Because they can be modified, these risk factors have been at the center of strategies to combat NCDs. In 2004, the World Health Organization (WHO) adopted the Global Strategy on Diet, Physical Activity and Health. For diet, it recommended that individuals achieve energy balance and a healthy weight; limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids; increase consumption of fruits, vegetables, legumes, whole grains, and nuts; limit the intake of free sugars; and limit salt consumption from all sources and ensure that salt is iodized. For physical activity, it recommended at least 30 minutes of regular, moderate-intensity physical activity on most days throughout a person's life.
Why Was This Study Done?
By signing onto the Global Strategy in 2004, WHO member countries agreed to implement it with high priority. A first step of implementation is usually the development of local policies. Consequently, one of the four objectives of the WHO Global Strategy is “to encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity.” Along the same lines, in 2011 the United Nations held a high-level meeting in which the need to accelerate the policy response to the NCD epidemic was emphasized. This study was done to assess the existing national policies on NCD prevention in LMICs. Specifically, the researchers examined how well those policies matched the WHO recommendations for intake of salt, fat, and fruits and vegetables, as well as the recommendations for physical activity.
What Did the Researchers Do and Find?
The researchers searched the Internet (including websites of relevant ministries and departments) for all publicly available national policies related to diet, nutrition, NCDs, and health from all 140 WHO member countries classified as LMICs by the World Bank in 2011. For countries for which the search did not turn up policies, the researchers sent e-mail requests to the relevant national authorities, to the regional WHO offices, and to personal contacts. All documents dated from 1 January 2004 to 1 January 2013 that included national objectives and guidelines for action regarding diet, physical exercise, NCD prevention, or a combination of the three, were analyzed in detail.
Most of the policies obtained were not easy to find and access. For 24 countries, particularly in the Eastern Mediterranean, the researchers eventually gave up, unable to establish whether relevant national policies existed. Of the remaining 116 countries, 29 countries had no relevant policies, and another 30 had policies that failed to mention specifically any of the diet-related risk factors included in the analysis. Fifty-four of the 116 countries had NCD policies that addressed at least one of the risk factors. Thirty-six national policy documents contained strategies to increase fruit and vegetable intake, 20 addressed dietary fat consumption, 23 aimed to limit salt intake, and 35 had specific actions to promote physical activity. Only 14 countries, including Jamaica, the Philippines, Iran, and Mongolia, had policies that addressed all four risk factors. The policies of 27 countries mentioned only one of the four risk factors.
Policies primarily targeted consumers and government agencies and failed to address the roles of the business community or civil society. Consistent with this, most were missing plans, mechanisms, and incentives to drive collaborations between the different stakeholders.
What Do These Findings Mean?
More than eight years after the WHO Global Strategy was agreed upon, only a minority of the LMICs included in this analysis have comprehensive policies in place. Developing policies and making them widely accessible is a likely early step toward specific implementation and actions to prevent NCDs. These results therefore suggest that not enough emphasis is placed on NCD prevention in these countries through actions that have been proven to reduce known risk factors. That said, the more important question is what countries are actually doing to combat NCDs, something not directly addressed by this analysis.
In richer countries, NCDs have for decades been the leading cause of sickness and death, and the fact that public health strategies need to emphasize NCD prevention is now widely recognized. LMICs not only have more limited resources, they also continue to carry a large burden from infectious diseases. It is therefore not surprising that shifting resources towards NCD prevention is a difficult process, even if the human cost of these diseases is massive and increasing. That only about 3% of global health aid is aimed at NCD prevention does not help the situation.
The authors argue that one step toward improving the situation is better sharing of best practices and what works and what doesn't in policy development. They suggest that an open-access repository like one that exists for Europe could improve the situation. They offer to organize, host, and curate such a resource under the auspices of WHO, starting with the policies retrieved for this study, and they invite submission of additional policies and updates.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001465.
This study is further discussed in a PLOS Medicine Perspective by Stuckler and Basu
The WHO website on diet and physical activity contains links to various documents, including a diet and physical activity implementation toolbox that contains links to the 2004 Global Strategy document and a Framework to Monitor and Evaluate Implementation
There is a 2011 WHO primer on NCDs entitled Prioritizing a Preventable Epidemic
A recent PLOS Medicine editorial and call for papers addressing the global disparities in the burden from NCDs
A PLOS Blogs post entitled Politics and Global HealthAre We Missing the Obvious? and associated comments discuss the state of the fight against NCDs in early 2013
The NCD Alliance was founded by the Union for International Cancer Control, the International Diabetes Federation, the World Heart Federation, and the International Union Against Tuberculosis and Lung Disease; its mission is to combat the NCD epidemic by putting health at the center of all policies
The WHO European Database on Nutrition, Obesity and Physical Activity (NOPA) contains national and subnational surveillance data, policy documents, actions to implement policy, and examples of good practice in programs and interventions for the WHO European member states
doi:10.1371/journal.pmed.1001465
PMCID: PMC3679005  PMID: 23776415
7.  BMI and Risk of Serious Upper Body Injury Following Motor Vehicle Crashes: Concordance of Real-World and Computer-Simulated Observations 
PLoS Medicine  2010;7(3):e1000250.
Shankuan Zhu and colleagues use computer crash simulations, as well as real-world data, to evaluate whether driver obesity is associated with greater risk of body injury in motor vehicle crashes.
Background
Men tend to have more upper body mass and fat than women, a physical characteristic that may predispose them to severe motor vehicle crash (MVC) injuries, particularly in certain body regions. This study examined MVC-related regional body injury and its association with the presence of driver obesity using both real-world data and computer crash simulation.
Methods and Findings
Real-world data were from the 2001 to 2005 National Automotive Sampling System Crashworthiness Data System. A total of 10,941 drivers who were aged 18 years or older involved in frontal collision crashes were eligible for the study. Sex-specific logistic regression models were developed to analyze the associations between MVC injury and the presence of driver obesity. In order to confirm the findings from real-world data, computer models of obese subjects were constructed and crash simulations were performed. According to real-world data, obese men had a substantially higher risk of injury, especially serious injury, to the upper body regions including head, face, thorax, and spine than normal weight men (all p<0.05). A U-shaped relation was found between body mass index (BMI) and serious injury in the abdominal region for both men and women (p<0.05 for both BMI and BMI2). In the high-BMI range, men were more likely to be seriously injured than were women for all body regions except the extremities and abdominal region (all p<0.05 for interaction between BMI and sex). The findings from the computer simulation were generally consistent with the real-world results in the present study.
Conclusions
Obese men endured a much higher risk of injury to upper body regions during MVCs. This higher risk may be attributed to differences in body shape, fat distribution, and center of gravity between obese and normal-weight subjects, and between men and women.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Worldwide, accidents involving motor vehicles kill 1.2 million people and injure as many as 50 million people every year. Collisions between motor vehicles, between vehicles and stationary objects, or between vehicles and pedestrians are responsible for one in 50 deaths and are the 11th leading cause of death globally. Many factors contribute to the risk of motor traffic accidents and the likelihood of subsequent injury or death. These risk factors include vehicle design, vehicle speeds, road design, driver impairment through, for example, alcohol use, and other driver characteristics such as age. Faced with an ever-increasing death toll on their roads, many countries have introduced lower speed limits, mandatory seat belt use, and greater penalties for drunk driving to reduce the carnage. Road design and traffic management initiatives have also been introduced to try to reduce the incidence of road traffic accidents and cars now include many features that provide protection in crashes for their occupants such as airbags and crumple zones.
Why Was This Study Done?
Although these measures have reduced the number of crashes and casualties, a better understanding of the risk factors associated with motor vehicle crashes is needed to deal with this important public-health problem. Another major public-health problem is obesity—having excess body fat. Obesity increases the risk of heart disease and diabetes but also contributes to the severity of motor vehicle crash injuries. Men with a high body mass index (an individual's weight in kilograms divided by height in meters squared; a BMI of 30 or more indicates obesity) have a higher risk of death after a motor vehicle accident than men with a normal BMI (18.5–24.9). This association between death and obesity is not seen in women, however, possibly because men and women accumulate fat on different parts of their body and the resultant difference in body shape could affect how male and female bodies move during traffic collisions and how much protection existing car safety features afford them. In this study, therefore, the researchers investigated how driver obesity affects the risk of serious injuries in different parts of the body following real and simulated motor vehicle crashes in men and women.
What Did the Researchers Do and Find?
The researchers extracted data about injuries and BMIs for nearly 11,000 adult men and women who were involved in a frontal motor vehicle collision between 2001 and 2005 from the Crashworthiness Data System of the US National Automotive Sampling System. They then used detailed statistical methods to look for associations between specific injuries and driver obesity. The researchers also constructed computer models of obese drivers and subjected these models to simulated crashes. Their analysis of the real-world data showed that obese men had a substantially higher risk of injury to the upper body (the head, face, chest, and spine) than men with a normal weight. Serious injury in the abdominal region was most likely at low and high BMIs for both men and women. Finally, obese men were more likely to be seriously injured than obese women for all body regions except the extremities and the abdominal region. The researchers' computer simulations confirmed many of these real-world findings.
What Do These Findings Mean?
These findings suggest that obese men have a higher risk of injury, particularly to their upper body, from motor vehicle crashes than men with a normal body weight or than obese women. The researchers suggest that this higher risk may be attributed to differences in body shape, fat distribution, and center of gravity between obese and normal weight individuals and between men and women. These findings, although limited by missing data, suggest that motor vehicle safety features should be adjusted to take into account the ongoing obesity epidemic. Currently, two-thirds of people in the US are overweight or obese, yet a crash test dummy with a normal BMI is still used during the design of car cabins. Finally, although more studies are needed to understand the biomechanical responses of the human body during vehicle collisions, the findings in this study could aid the identification of groups of people at particularly high risk of injury or death on the roads who could then be helped to reduce their risk.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000250.
Wikipedia has a page on traffic collision (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The World Health Organization has information about road traffic injuries as a public-health problem; its World report on road traffic injury prevention is available in several languages
The US Centers for Disease Control and Prevention provides detailed information about overweight and obesity (in several languages)
MedlinePlus provides links to further resources about obesity (in English and Spanish)
The US National Automotive Sampling System Crashworthiness Data System contains detailed data on thousands of US motor vehicle crashes
doi:10.1371/journal.pmed.1000250
PMCID: PMC2846859  PMID: 20361024
8.  Evaluation of Chest and Abdominal Injuries in Trauma Patients Hospitalized in the Surgery Ward of Poursina Teaching Hospital, Guilan, Iran 
Archives of Trauma Research  2013;1(4):161-165.
Background
Trauma, especially chest and abdominal trauma are increasing due to the growing number of vehicles on the roads, which leads to an increased incidence of road accidents. Urbanization, industrialization and additional problems are the other associated factors which accelerate this phenomenon. A better understanding of the etiology and pattern of such injuries can help to improve the management and ultimate the outcomes of these patients.
Objectives
This study aimed to evaluate the patients with chest and abdominal trauma hospitalized in the surgery ward of Poursina teaching hospital, Guilan, Iran.
Patients and Methods
In this cross-sectional study, the data of all chest and abdominal trauma patients hospitalized in the surgery ward of Poursina teaching hospital were collected from March 2011 to March 2012. Information about age, gender, injured areas, type of injury (penetrating or blunt), etiology of the injury, accident location (urban or rural) and patients' discharge outcomes were collected by a questionnaire.
Results
In total, 211 patients with a mean age of 34.1 ± 1.68 years was entered into the study. The most common cause of trauma was traffic accidents (51.7%). Among patients with chest trauma, 45 cases (35.4%) had penetrating injuries and 82 cases (64.6%) blunt lesions. The prevalence of chest injuries was 35.5% and rib fractures 26.5%. In chest injuries, the prevalence of hemothorax was 65.3%, pneumothorax 2.7%, lung contusion 4% and emphysema 1.3%, respectively. There were 24 cases (27.9%) with abdominal trauma which had penetrating lesions and 62 cases (72.1%) with blunt lesions. The most common lesions in patients with penetrating abdominal injuries were spleen (24.2%) and liver (12.1%) lesions. The outcomes of the patients were as follow: 95.7% recovery and 4.3% death. The majority of deaths were observed among road traffic victims (77.7%).
Conclusions
Considering the fact that road-related accidents are quite predictable and controllable; therefore, the quality promotion of traumatic patients' care, and the road safety should be noted as problems associated with public health.
doi:10.5812/atr.7672
PMCID: PMC3876503  PMID: 24396771
Abdomen; Chest; Traffic Accident; Wounds and Injuries
9.  An epidemiological study on pattern of thoraco-abdominal injuries sustained in fatal road traffic accidents of Bangalore: Autopsy-based study 
Background:
The statistical profile reflects a global estimate of 5.1 million deaths in 2000, which was due to injuries that accounted for 10% of deaths due to all causes. Out of this, a quarter of injury-related deaths occurred in the South-East Asian region. Road Traffic Accident (RTA) is one among the top 5 causes of morbidity and mortality in South-East Asian countries. Most common cause of blunt abdominal trauma in India is road traffic accident followed by pedestrian accidents, abdominal blows, and fall from heights. Aims: To analyze the epidemiology and pattern of fatal thoraco-abdominal injuries in road traffic accidents.
Materials and Methods:
An autopsy-based cross-sectional study conducted. A purposive sampling technique was applied to select the study sample of 100 post-mortems of road traffic accident between November 2008 and May 2010 subjected to medico-legal autopsy at the department of Forensic Medicine, KIMS Hospital Bangalore.
Results:
The majority of the victims were aged 21 to 40 years, 50 (50.0%), most of the victims were male 92 (92.0%); and male/female ratio was 11.5:1. Commonest offending agents in heavy motor vehicles were 54 (54.0%). Bony cage sustained injuries were observed in 71; out of this, fractures of ribs were observed in 45 (63.3%) victims, clavicle in 14 (19.7%), sternum was 6 (8.4%), and vertebrae 6 (8.4%) of fatal road traffic accidents. Internal thoracic injuries were observed in 26 cases. Among internal thoracic injuries, lungs were the most commonly involved organ 24 (92.3%) followed by the heart 2 (7.6%). Lung sustained more lacerations 19 (79.1%) than contusions 5 (20.8%). Internal abdominal injuries were observed in 49 cases. In road traffic accidents, the most commonly injured abdominal organs were solid organs such as liver 16 (32.6%) followed by spleen 9 (18.3%).
Conclusions:
Majority of the times in road traffic accidents, young and productive males were injured or lost their life. This study may help the planners to take safety measures, to implement strict traffic rules, to risk stratification in the susceptible population to educate the people, and the study of nature of offending agent in RTA can help the authorities to plan better availability of health care on roads.
doi:10.4103/0974-2700.130882
PMCID: PMC4013727  PMID: 24812457
Abdominal injuries; Bangalore; road traffic accidents; thoracic injuries
10.  Burden of transportation injuries among children and adolescents of Fars province: analysis of Iran’s 20-year trends 
Epidemiology and Health  2014;36:e2014032.
OBJECTIVES:
Transportation injuries are among the top ten causes of burden of disease in all age groups worldwide. The burden of transportation injuries among children and adolescents in Iran is higher than the world average and that of other developing countries. The aims of this study were to investigate the burden of transportation injuries in children and adolescents in the province of Fars in Iran from 2009 to 2013, and to report the burden of these kinds of injuries in children and adolescents in Iran from 1990 to 2010.
METHODS:
The number of deaths due to transportation injuries and the location of fatal injuries in the province of Fars in Iran from 2009 to 2013 were analyzed using data from the Fars Forensic Medicine Organization. The 20-year trend in the burden of transportation injuries in Iran was analyzed using data from the Institute for Health Metrics and Evaluation.
RESULTS:
Similarly to the long-term trend in Iran, the burden of transportation injuries among the male population of Fars province was generally higher than in females. Most fatal accident injuries occurred on roads (males: n=4151, 61.51%; females: n=1182, 65.95%) and in urban areas (males: n=1994, 29.54%; females: n=473, 26.40%).
CONCLUSIONS:
Considering that children and adolescents are high risk groups for transportation injuries, adopting an effective comprehensive multi-sectoral approach, including enacting and enforcing appropriate laws and regulations, developing general knowledge, and facilitating the availability of Personal protective equipment, could be helpful for reducing the burden of these injuries.
doi:10.4178/epih/e2014032
PMCID: PMC4300829  PMID: 25420953
Transportation injuries; Burden of diseases; Child; Adolescent
11.  Prescription Medicines and the Risk of Road Traffic Crashes: A French Registry-Based Study 
PLoS Medicine  2010;7(11):e1000366.
Using three nationwide databases in France, Ludivine Orriols, Emmanuel Lagarde, and colleagues provide evidence that prescribed medicines contribute to the risk of experiencing a road traffic crash.
Background
In recent decades, increased attention has been focused on the impact of disabilities and medicinal drug use on road safety. The aim of our study was to investigate the association between prescription medicines and the risk of road traffic crashes, and estimate the attributable fraction.
Methods and Findings
We extracted and matched data from three French nationwide databases: the national health care insurance database, police reports, and the national police database of injurious crashes. Drivers identified by their national health care number involved in an injurious crash in France, between July 2005 and May 2008, were included in the study. Medicines were grouped according to the four risk levels of the French classification system (from 0 [no risk] to 3 [high risk]). We included 72,685 drivers involved in injurious crashes. Users of level 2 (odds ratio [OR]  = 1.31 [1.24–1.40]) and level 3 (OR  = 1.25 [1.12–1.40]) prescription medicines were at higher risk of being responsible for a crash. The association remained after adjustment for the presence of a long-term chronic disease. The fraction of road traffic crashes attributable to levels 2 and 3 medications was 3.3% [2.7%–3.9%]. A within-person case-crossover analysis showed that drivers were more likely to be exposed to level 3 medications on the crash day than on a control day, 30 days earlier (OR  = 1.15 [1.05–1.27]).
Conclusion
The use of prescription medicines is associated with a substantial number of road traffic crashes in France. In light of the results, warning messages appear to be relevant for level 2 and 3 medications and questionable for level 1 medications. A follow-up study is needed to evaluate the impact of the warning labeling system on road traffic crash prevention.
Please see later in the article for the Editors' Summary
Editors' Summary
About 1.3 million people die each year on the world's road. 90% of road traffic deaths occur in developing countries, with pedestrians, cyclists, and users of two-wheel vehicles (scooters, motorbikes) the most vulnerable road users. Although the use of prescribed benzodiazepines has already been documented to be associated with road traffic accidents in industrialized countries, the effects of other medicines have not been well studied or have inconsistent results (for example opioids and antidepressant medications). In the European Union, it is mandatory for pharmaceutical companies to provide data about the effect of a medicine on ability to drive. In France, a multidisciplinary group of experts was appointed to classify all medicines into four levels of risk (from level 0, no or negligible risk, to level 3, major risk), in terms of their effect on driving performances. In 2006, the International Council on Alcohol, Drugs and Traffic Safety proposed a classification list similar to the French classification system.
Why Was This Study Done? There is a pressing need to understand the association between prescribed medicines and the risk of road traffic crashes and also to have a more accurate picture of the fraction of road traffic crashes that are attributable to the use of prescribed medicines. This large French study aimed to advance knowledge in this important area.
What Did the Researchers Do and Find? The researchers used three data sources to find the information they needed: the national health care insurance database (which covers the whole French population and includes data on reimbursed prescription medicines), police reports, and the national police database of injurious road traffic crashes. Drivers involved in road traffic crashes (identified by their national healthcare number) between July 2005 and May 2008 were included in the study. The researchers used a statistical model to conduct a responsibility analysis, which determined factors associated with each driver responsible for the road traffic crash and each driver who was not responsible (controls). In addition, the researchers compared medicine exposure during a period immediately before the crash (case period) with exposure during an earlier period (control period) for each driver involved in a crash. The researchers retrieved data on reimbursed medicines, dispensed within six months of the road traffic crash, by linking included drivers to the national health care insurance database using their national ID, gender, and date of birth and grouped all prescribed medicines according to the four risk levels of the French classification system.
During the study period, 72,685 drivers involved in injurious road traffic crashes were included. The researchers found that drivers who had been prescribed level 2 and level 3 medicines were at higher risk (odds ratio 1.31 and OR 1.25, respectively) of being responsible for the road traffic crash, an association that remained after the researchers adjusted for the presence of chronic diseases. Furthermore, the researchers found that the fraction of road traffic crashes attributable to the use of (prescriptions for) level 2 and 3 medicines was 3.3% and that drivers were more likely to be exposed to level 3 medicines on the day of the road traffic crash than on a control day.
What Do These Findings Mean? This study provides strong evidence for the contribution of medicines to the risk of experiencing a road traffic crash. The French drug risk classification scheme seems accurate for medicines classified as levels 2 and 3 of risk for road traffic crashes. The effect on driving abilities of level 2 medicines depends both on the pharmacodynamics of the drug and on individual susceptibility, whereas for level 3 medicines, the pharmacodynamic effect seems to be predominant. The effects of level 1 medicines seem to be so dependent on individual susceptibility that effects on driving abilities are rare, which raises questions about the relevance of the labels for these medicines. However, some limitations with the study methodology might affect the interpretation of these findings. For example, the researchers used dispensing dates for medications as a surrogate for ingestion and were not able to check for noncompliance.
However, this study provides some of the strongest evidence to date of the need for health care workers to provide patients with proper information on the potential effect of any medicine that they are prescribed (or take) on their driving abilities.
Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000366.The World Health Organization (WHO) provides information on road traffic accidentsTwo Web sites provide information for drivers about drugs that could affect their ability to driveThe US National Institute on Drug Abuse of the National Institutes of Health has an information sheet on drugged driving
doi:10.1371/journal.pmed.1000366
PMCID: PMC2981588  PMID: 21125020
12.  Incidence and pattern of injuries among residents of a rural area in South-Western Nigeria: a community-based study 
BMC Public Health  2007;7:246.
Background
Despite the high incidence of infectious diseases in developing countries, injuries still contribute significantly to the health burden. There are few reports of rural, community-based injury surveys in Nigeria. This study describes the incidence and pattern of injuries among the residents of a rural area in South-Western Nigeria.
Methods
It was a community based cross-sectional study. Two of six census areas were randomly selected and all households in the two areas visited. Information on the sociodemographic characteristics, individual injury events and outcomes was obtained with a questionnaire. Data were analyzed using SPSS version 11.
Results
Information was obtained on the 1,766 persons in 395 households. Fifty-nine injuries were recorded by 54 people, giving an injury incidence of 100 per 1,000 per year (95% CI = 91.4–106.9). Injury incidence among <30 years was 81.6 per 1,000 per year (95% CI = 62.3–83.1); and 126 per 1,000 per year (95% CI = 98.2–137.4) for those ≥ 30 years (p = 0.013). Injury incidence for females was 46 per 1,000 per year; and 159 per 1,000 per year (p = 0.000) for males. A significantly higher proportion of males (5%) sustained injury compared to females (2%) (p = 0.043). Falls and traffic injures, 15 (25%) each, were the leading causes of injury; followed by cuts/stabs 12 (21%), and blunt injuries, 9 (15%). Traffic injuries were the leading cause of injuries in all age groups except among the 5–14 years where falls were the leading cause of injury. In thirty-four (58%) of those injuries, treatment was at a hospital/health centre; while in two (3%), treatment was by untrained traditional practitioners. Thirty-nine (66%) of the injuries were fully recovered from, and 19 (32%) resulted in disability. There were 2 fatalities in the 5-year period, one (2%) within the study period.
Conclusion
Injuries were common in Igbo-Ora, though resultant disability and fatality were low. Males and those aged ≥ 30 years had significantly higher proportions of the injured. Falls and traffic injuries were the most commonly reported injuries. Appropriate interventions to reduce the occurrences of injuries should be instituted by the local authorities. There is also need to educate the community members on how to prevent injuries.
doi:10.1186/1471-2458-7-246
PMCID: PMC2169237  PMID: 17875213
13.  Pattern, Severity and Circumtances of Injuries Sustained in Road Traffic Accidents: A Tertiary Care Hospital-Based Study 
Introduction:
Expansion in road network, motorization, and urbanization in the country has been accompanied by a rise in road accidents leading to road traffic injuries (RTIs). Today RTIs are one of the leading causes of deaths, disabilities, and hospitalizations with severe socioeconomic costs across the world.
Objectives:
The following study analyses the:
Age and sex distribution of injured in road traffic accidents (RTAs).Circumstances leading to RTA.Pattern and severity of injuries sustained in RTAs cases.
Design:
Retrospective record-based study.
Materials and Methods:
The aim of this study was to audit retrospectively the circumstances, severity, and pattern of injury sustained by vehicle occupants presenting to the Saraswathi Institute of Medical Sciences (SIMS) hospital Hapur, for a period of one year. Data were collected using the case sheets of 347 patients from the medical records section of hospital and analyzed using SPSS computer software version 16.0. Results are interpreted in terms of percentage, mean, chi-square, and z-test.
Results:
The pattern and severity of injuries sustained by 347 vehicle occupants admitted to the emergency department of SIMS, Hapur were retrospectively documented. Male victims 258 (74.35%) were more commonly involved than females 89 (25.65%) and majority of victims 141 (40.63%) were in age group of 20-30 years. Urban victims 222 (64.00%) outnumbered rural. The most frequently injured body regions were the extremities 499 (53.54%), followed by maxillofacial180(19.31%).. Out of total 802 external injuries, the most common type of injury was lacerations 307 (38.28%), abrasions 306 (38.15%)and followed by bruises 154 (19.20%). Multiple external injuries were more common on upper limb 216 (26.93%), lower limbs 210 (26.18%) and face 170 (21.20%), while crush injuries were more predominently seen in both the limbs. While laceration were common on face 120 (38.83%). Injuries to the chest 19 (2.36%), abdomen13 (1.61%), and spine 11 (1.36%) were seen in roughy equal proprotion of victims. The bones on right side 55 (55.55%) were more commonly fractured which is statistically significant. Skull injuries were mostly found on frontal 77 (47.53%), followed by parietal bone 33 (20.37%), mostly on right side. Conclusion: RTAs constitute a major public health problem in our setting. Urgent preventive measures targeting at reducing the occurrence of RTAs are necessary to reduce the morbidity and mortality resulting from these injuries.
doi:10.4103/0970-0218.126353
PMCID: PMC3968579  PMID: 24696537
Injury pattern; road traffic accidents road traffic injuries; victims
14.  The burden of injuries in Iranian children in 2005 
Background
Child injury is recognized as a global health problem. Injuries caused the highest burden of disease among the total population of Iran in 2003. We aimed to estimate the morbidity, mortality, and disease burden caused by child injuries in the 0- to 14-year-old population of Iran in 2005.
Methods
We estimated average age- and sex-specific mortality rates for different types of child injuries from 2001 to 2006 using Iran's death registration data. Incidence rates for nonfatal outcomes of child injuries in 2005 were estimated through a time- and place-limited sample hospital registry study for injuries. We used the World Health Organization's methods for estimation of years of life lost due to premature mortality and years lived with disability in 2005.
Results
Injuries were the most important cause of death in children ages 1 to 14, with 35, 33.4, 24.9, and 22.9 deaths per 100,000 in the 0-14, 1-4, 5-9, and 10-14 age groups respectively. Road transport injuries were responsible for the highest death rate per 100,000 population among all types of injuries in children, with 15.5 for ages 0-14, 16.1 for ages 1-4, 16.3 for ages 5-9, and 13.1 for ages 10-14. Incidence rates of injuries leading to hospitalization were 459, 530, and 439 per 100,000 in the 0-14, 1-4, and 5-14 age groups respectively. Incidence rates of injuries leading to outpatient care were 1,812, 2,390, and 1,650 per 100,000 in the same age groups respectively. Among injury types, falls and burns had the highest hospitalization and outpatient care incidence rates.
Conclusions
Injuries, particularly road transport injuries, were the most important health problem of children in Iran in 2003 and 2005. Strong social policy is needed to ensure child survival.
doi:10.1186/1478-7954-8-5
PMCID: PMC2853502  PMID: 20356350
15.  Molecular assessment of atpase6 mutations associated with artemisinin resistance among unexposed and exposed Plasmodium falciparum clinical isolates to artemisinin-based combination therapy 
Malaria Journal  2012;11:373.
Background
Artemisinin-based combination therapy (ACT) is the mainstay of global efforts for treatment of Plasmodium falciparum malaria, but decline in its efficacy is the most important obstacle towards malaria control and elimination. Therefore, the present molecular analysis provides information on putative mutations associated with artemisinin resistance in P. falciparum clinical population unexposed and exposed to artesunate 4 years after adoption of ACT as the first-line anti-malarial therapy in Iran.
Methods
In this study, blood samples (n = 226) were collected from uncomplicated P. falciparum-infected patients from different health centers of Chabahar district in Sistan and Baluchistan province in the south-eastern part of Iran, during 2003 to 2010. All collected isolates were analysed for putative candidate mutations (TTA) L263E (GAA), (GAA) E431K (AAA), (GCA) A623E (GAA) and (AGT) S769N (AAT) of pfatpase6 gene using nested PCR/RFLP, followed by sequencing. Furthermore, the gene copy number was assessed by real-time quantitative PCR (RT-qPCR) in the presence of SYBR green.
Results
Neither the pfatpase6 L263E nor the A623E mutation was detected among all examined isolates. The E431K mutation was found in 23% of the analysed samples unexposed to ACT; however, it was detected in 17.8% (34/191) of P. falciparum isolates exposed to artesunate after 2007. High frequency of this single nucleotide polymorphisms (SNP) (overall 18.6%) among both examined groups (X2 test, P>0.05) indicated that this SNP should be considered as an unrelated mutation to artemisinin resistance. In contrast, S769N mutation was not detected in unexposed isolates; however, it was found in 2.6% (5/191), four years after introduction of ACT in this malaria setting. Also, detected SNPs were not significantly frequent in both unexposed and exposed examined isolates (X2 test, P> 0.05). Investigation in the copy number of pfatpase6 gene revealed a similar number of copy (n = 1) as in an isolate sensitive to artemisinin.
Conclusion
Taken together, the results suggest, in particular, that pfatpase6 S769N gene needs more consideration for its possible association with artesunate resistance among P. falciparum isolates.
doi:10.1186/1475-2875-11-373
PMCID: PMC3552969  PMID: 23140394
16.  Pre-hospital care time intervals among victims of road traffic injuries in Iran. A cross-sectional study 
BMC Public Health  2010;10:406.
Background
Road traffic injuries (RTIs) are a major public health problem, requiring concerted efforts both for their prevention and a reduction of their consequences. Timely arrival of the Emergency Medical Service (EMS) at the crash scene followed by speedy victim transportation by trained personnel may reduce the RTIs' consequences. The first 60 minutes after injury occurrence - referred to as the "golden hour"- are vital for the saving of lives. The present study was designed to estimate the average of various time intervals occurring during the pre-hospital care process and to examine the differences between these time intervals as regards RTIs on urban and interurban roads.
Method
A retrospective cross-sectional study was designed and various time intervals in relation to pre-hospital care of RTIs identified in the ambulance dispatch centre in Urmia, Iran from 20 March 2005 to 20 March 2007. All cases which resulted in ambulance dispatches were reviewed and those that had complete data on time intervals were analyzed.
Results
In total, the cases of 2027 RTI victims were analysed. Of these, 61.5 % of the subjects were injured in city areas. The mean response time for city locations was 5.0 minutes, compared with 10.6 minutes for interurban road locations. The mean on-scene time on the interurban roads was longer than on city roads (9.2 vs. 6.1 minutes, p < 0.001). Mean transport times from the scene to the hospital were also significantly longer for interurban incidents (17.1 vs. 6.3 minutes, p < 0.001). The mean of total pre-hospital time was 37.2 (+/-17.2) minutes with a median of 32.0. Overall, 72.5% of the response interval time was less than eight minutes.
Conclusion
The response, transport and total time intervals among EMS responding to RTI incidents were longer for interurban roads, compared to the city areas. More research should take place on needs-to and access-for EMS on city and interurban roads. The notification interval seems to be a hidden part of the post-crash events and indirectly affects the "golden hour" for victim management and it needs to be measured through the establishment of the surveillance systems.
doi:10.1186/1471-2458-10-406
PMCID: PMC2918553  PMID: 20618970
17.  The Role of Malaria Microscopy Training and Refresher Training Courses in Malaria Control Program in Iran during 2001 – 2011 
Iranian Journal of Parasitology  2012;7(4):104-109.
Background
Malaria is still one of the most important infectious diseases in the world. The disease also is a public health problem in south and southeast of Iran. This study programmed to show the correlation between regular malaria microscopy training and refresher training courses and control of malaria in Iran.
Methods
Three types of training courses were conducted in this programme including; five – day, ten – day and bimonthly training courses. Each of the training courses contained theoretical and practical sections and training impact was evaluated by practical examination and multiple-choice quizzes through pre and post tests.
Results
Distribution pattern of the participants in the training and refresher training courses showed that the most participants were from Sistan & Baluchistan and Hormozgan provinces where malaria is endemic and most cases of the infection come out from these malarious areas. A total of 695 identified individuals were participated in the training courses. A significant conversely correlation was found between conducting malaria microscopy training courses and annual malaria cases in Iran.
Conclusion
Conducting a suitable programme for malaria microscopy training and refresher training plays an important role in the control of malaria in endemic areas. Obviously, the decrease of malaria cases in Iran has been achieved due to some activities that malaria diagnosis training was one of them.
PMCID: PMC3537468  PMID: 23323099
Training courses; Malaria; Control; Iran
18.  The road most travelled: the geographic distribution of road traffic injuries in England 
Background
Both road safety campaigns and epidemiological research into social differences in road traffic injury risk often assume that road traffic injuries occur close to home. While previous work has examined distance from home to site of collision for child pedestrians in local areas, less is known about the geographic distribution of road traffic injuries from other modes. This study explores the distribution of the distance between home residence and collision site (crash distance) by mode of transport, geographic area, and social characteristics in England.
Methods
Using 10 years of road casualty data collected by the police, we examined the distribution of crash distance by age, sex, injury severity, area deprivation, urban/rural status, year, day of week, and, in London only, ethnic group.
Results
54% of pedestrians, 39% of cyclists, 17% of powered two-wheeler riders and 16% of car occupants were injured within 1 km of home. 82% of pedestrians, 83% of cyclists, 54% of powered two-wheeler and 53% of car occupants were injured within 5 km of home. We found some social and geographic differences in crash distance: for all transport modes injuries tended to occur closer to home in more deprived or urban areas; younger and older pedestrians and cyclists were also injured closer to home. Crash distance appears to have increased over time for pedestrian, cyclist and car occupant injuries, but has decreased over time for powered two-wheeler injuries.
Conclusions
Injuries from all travel modes tend to occur quite close to home, supporting assumptions made in epidemiological and road safety education literature. However, the trend for increasing crash distance and the social differences identified may have methodological implications for future epidemiological studies on social differences in injury risk.
doi:10.1186/1476-072X-12-30
PMCID: PMC3680192  PMID: 23738624
Accidents; Wounds and injuries; Social differences
19.  Measuring the Population Burden of Injuries—Implications for Global and National Estimates: A Multi-centre Prospective UK Longitudinal Study 
PLoS Medicine  2011;8(12):e1001140.
Ronan Lyons and colleagues compared the population burden of injuries using different approaches from the UK Burden of Injury and Global Burden of Disease studies and find that the absolute UK burden of injury is higher than previously estimated.
Background
Current methods of measuring the population burden of injuries rely on many assumptions and limited data available to the global burden of diseases (GBD) studies. The aim of this study was to compare the population burden of injuries using different approaches from the UK Burden of Injury (UKBOI) and GBD studies.
Methods and Findings
The UKBOI was a prospective cohort of 1,517 injured individuals that collected patient-reported outcomes. Extrapolated outcome data were combined with multiple sources of morbidity and mortality data to derive population metrics of the burden of injury in the UK. Participants were injured patients recruited from hospitals in four UK cities and towns: Swansea, Nottingham, Bristol, and Guildford, between September 2005 and April 2007. Patient-reported changes in quality of life using the EQ-5D at baseline, 1, 4, and 12 months after injury provided disability weights used to calculate the years lived with disability (YLDs) component of disability adjusted life years (DALYs). DALYs were calculated for the UK and extrapolated to global estimates using both UKBOI and GBD disability weights. Estimated numbers (and rates per 100,000) for UK population extrapolations were 750,999 (1,240) for hospital admissions, 7,982,947 (13,339) for emergency department (ED) attendances, and 22,185 (36.8) for injury-related deaths in 2005. Nonadmitted ED-treated injuries accounted for 67% of YLDs. Estimates for UK DALYs amounted to 1,771,486 (82% due to YLDs), compared with 669,822 (52% due to YLDs) using the GBD approach. Extrapolating patient-derived disability weights to GBD estimates would increase injury-related DALYs 2.6-fold.
Conclusions
The use of disability weights derived from patient experiences combined with additional morbidity data on ED-treated patients and inpatients suggests that the absolute burden of injury is higher than previously estimated. These findings have substantial implications for improving measurement of the national and global burden of injury.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Injuries—resulting from traffic collisions, drowning, poisoning, falls or burns, and violence from assault, self-inflicted violence, or acts of war—kill more than 5 million people worldwide every year and cause harm to millions more. Injuries account for at least 9% of global mortality and are a threat to health in every country of the world. Furthermore, for every death-related injury, dozens of injured people are admitted to hospitals, hundreds visit emergency rooms, and thousands go to see their doctors by appointment. A large proportion of people surviving their injuries will be left with temporary or permanent disabilities.
The Global Burden of Diseases, Injuries and Risk Factors (GBD) Studies are instrumental in quantifying the burden of injuries placed on society and are essential for the public health response, priority setting, and policy development. Central to the GBD methodology is the concept of Disability Adjusted Life years (DALYs), and a combination of premature mortality, referred to as years of life lost and years lived with disability. However, rather than evidence and measurements, the GBD Study used panel studies and expert opinion to estimate weights and durations of disability. Therefore, although the GBD has been a major development, it may have underestimated the population burden.
Why Was This Study Done?
Accurate measurement of the burden of injuries is essential to ensure adequate policy responses to prevention and treatment. In this study, the researchers aimed to overcome the limitations of previous studies and for the first time, measured the population burden of injuries in the UK using a combination of disability and morbidity metrics, including years of life lost, and years lived with disabilities.
What Did the Researchers Do and Find?
The researchers recruited patients aged over 5 years with a wide range of injuries (including fractures and dislocations, lacerations, bruises and abrasions, sprains, burns and scalds, and head, eye, thorax, and abdominal injuries) from hospitals in four English cities—Swansea, Nottingham, Bristol, and Guildford—between September 2005 and April 2007. The researchers collected data on injury-related mortality, hospital admissions, and attendances to emergency rooms. They also invited patients (or their proxy, if participants were young children) to complete a self-administered questionnaire at recruitment and at 1, 4, and 12 months postinjury to allow data collection on injury characteristics, use of health and social services, time off work, and recovery from injury, in addition to sociodemographic and economic and occupational characteristics. The researchers also used standardized tools to measure health-related quality of life and work problems. Then, the researchers used these patient-reported changes to calculate DALYs for the UK and then extrapolated these results to calculate global estimates.
In the four study sites, a total of 1,517 injured people (median age of 37.4 years and 53.9% male) participated in the study. The researchers found that the vast majority of injuries were unintentional and that the home was the most frequent location of injury. Using the data and information collected from the questionnaires, the researchers extrapolated their results and found that in 2005, there were an estimated 750,999 injury-related hospital admissions, 7,982,947 emergency room attendances, and 22,185 injury-related deaths, translating to a rate per 100,000 of 1,240, 13,339, and 36.8, respectively. The researchers estimated UK DALYs related to injury to be 1,771,486 compared with 669,822 using the GBD approach. Furthermore, the researchers found that extrapolating patient-derived disability weights to GBD estimates would increase injury-related DALYs 2.6-fold.
What Do These Findings Mean?
The findings of this study suggest that, when using data and information derived from patient experiences, combined with additional morbidity data on patients treated in emergency rooms and those, admitted to hospital, the absolute burden of injury is higher than previously estimated. While this study was carried out in the UK the principal findings are relevant to other countries. However, measurement of the population burden of injuries requires access to high quality data, which may be difficult in less affluent countries, and these data rely on access to health facilities, which is often restricted in resource-limited settings. Despite these concerns, these findings have substantial implications for improving measurements of the national and global burden of injury.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001140.
The World Health Organization website provides detailed information about injuries and also details the work of the Global Burden of Disease Study
The Global Burden of Injury's website is a portal to websites run by groups conducting ongoing research into the measurement of global injury metrics
doi:10.1371/journal.pmed.1001140
PMCID: PMC3232198  PMID: 22162954
20.  Demographic Profiles of Adult Trauma During a 5 Year Period (2007-2011) in Kashan, IR Iran 
Archives of Trauma Research  2012;1(2):63-66.
Background
Trauma, in addition to mortality and disability experienced by an individual, imposes direct and indirect economic and social costs on a community. Traditionally, trauma is a disease of young and middle age adults, an age group which is known to be the most dynamic and economically productive of the community. Increasing our knowledge concerning the etiology and patterns of trauma seems to be the most profitable and accessible way to prevent injuries of this nature.
Objectives
This study was designed to evaluate the epidemiology of adult trauma in Kashan, Iran.
Patients and Methods
The current study used a retrospective cross-sectional approach, enrolling all trauma adults (20 - 60 y) admitted to the Shahid Beheshti Hospital, Kashan, between 2007 and 2011. Age, gender, place of residence, work status, educational level, urban/rural location of the accident, method of transportation to hospital, injured body areas of the victims and therapeutic interventions, were extracted from the data registry and analyzed through descriptive statistics using SPSS software.
Results
A total of 22 564 patients were included in this study. Mean age of the victims was 33.18 ± 10.90 years and the male/female ratio was 4:1. Most of the victims were manual workers (61%), and they had completed primary and junior high school level education (49.4%), they were also more likely to be residents of urban areas (88.6%). Regarding the place of injury, most accidents occurred on city streets (43.8%). Approximately 40% of the total victims were transferred to the hospital by emergency medical services (EMS). During the study period, 260 deaths were recorded and among these, 76% were related to traffic accidents.
Conclusions
Regarding the high prevalence of trauma found in manual workers with low educational levels and motorbike users, the establishment of an integrated program aimed at improving public knowledge on the use of safety and protective measures in work environments should be implemented. The use of safety protective equipment by cyclists, motorbikers and car passengers should also be enforced.
doi:10.5812/atr.6770
PMCID: PMC3876531  PMID: 24396745
Adult; Epidemiology; Wound and Injury
21.  Trauma center accessibility for road traffic injuries in Hanoi, Vietnam 
Background
Rapid economic growth in Vietnam over the last decade has led to an increased frequency of road traffic injury (RTI), which now represents one of the leading causes of death in the nation. Various efforts toward injury prevention have not produced a significant decline in the incidence of RTIs. Our study sought to describe the geographic distribution of RTIs in Hanoi, Vietnam and to evaluate the accessibility of trauma centers to those injured in the city.
Methods
We performed a cross-sectional study using Hanoi city police reports from 2006 to describe the epidemiology of RTIs occurring in Hanoi city. Additionally, we identified geographic patterns and determined the direct distance from injury sites to trauma centers by applying geographical information system (GIS) software. Factors associated with the accessibility of trauma centers were evaluated by multivariate regression analysis.
Results
We mapped 1,271 RTIs in Hanoi city. About 40% of RTIs occurred among people 20-29 years of age. Additionally, 63% of RTIs were motorcycle-associated incidents. Two peak times of injury occurrence were observed: 12 am-4 pm and 8 pm-0 am. "Hot spots" of road traffic injuries/fatalities were identified in the city area and on main highways using Kernel density estimation. Interestingly, RTIs occurring along the two north-south main roads were not within easy access of trauma centers. Further, fatal cases, gender and injury mechanism were significantly associated with the distance between injury location and trauma centers.
Conclusions
Geographical patterns of RTIs in Hanoi city differed by gender, time, and injury mechanism; such information may be useful for injury prevention. Specifically, RTIs occurring along the two north-south main roads have lower accessibility to trauma centers, thus an emergency medical service system should be established.
doi:10.1186/1752-2897-5-11
PMCID: PMC3198672  PMID: 21962210
22.  Profile of non-fatal injuries due to road traffic accidents from a industrial town in India 
Background:
India has one of the highest road traffic accident rates in the world. To lessen this burden, information on the contributing factors is necessary.
Materials and Methods:
We studied a series of cases of non-fatal road traffic accidents in two tertiary care hospitals in Pimpri, Pune, India. A total of 212 non-fatal road traffic accidents admitted over a period of one year in these two hospitals constituted the study sample. The study variables were, the gender of the accident victims, mode of accident, days of week on which the accident took place, time of day when the injury was sustained, part of the body injured, nature of injury, and self-reported reasons for the accident.
Statistical Analysis:
data were summarized using percentages. The Chi-square test for goodness of fit was applied, to see whether there was any association between the different weekdays or time of day and the accidents.
Results:
Male : female ratio was almost 5 : 1, which was statistically significant (Chi-Square for goodness of fit = 95.11, df = 1, P < 0.0001). The maximum accidents occurred on Sundays and Mondays and the least around midweek (Wednesday). This pattern was also statistically significant (Chi-square for goodness of fit = 30.09, df = 6, P < 0.001). Pedestrians were the most vulnerable group, followed by drivers and pillions of two wheelers. These categories of road users contributed to almost 80% of the cases of Road Traffic Injuries (RTIs). Accidents were more likely in the time zone of 8 pm to midnight, followed by 4 pm to 8 pm (Chi-square for goodness of fit = 89.58, df = 5, P < 0.0001). A majority of the patients sustained multiple injuries followed by injuries to the lower limbs. A majority reported impaired visibility and fatigue as the cause of accident. Almost half (46.22%) of the injured admitted to drinking alcohol on a regular basis.
Conclusion:
Wide pavements and safe zebra crossings should be provided for pedestrians, as the highest casualty in this study were pedestrians. More accidents occurred on Sundays and Mondays and in the late evenings. Extra supervision by traffic police may be considered on Sundays / Holidays and the day following. Roads should be well lit to improve visibility after sunset.
doi:10.4103/2229-5151.109409
PMCID: PMC3665126  PMID: 23724378
Non-fatal; road traffic accidents; case series
23.  Risk factors for injury mortality in rural Tanzania: a secondary data analysis 
BMJ Open  2012;2(6):e001721.
Background
Injuries rank high among the leading causes of death and disability annually, injuring over 50 million and killing over 5 million people globally. Approximately 90% of these deaths occur in developing countries.
Objectives
To estimate and identify the risk factors for injury mortality in the Rufiji Health and Demographic Surveillance System (RHDSS) in Tanzania.
Methods
Secondary data from the RHDSS covering the period 2002 and 2007 was examined. Verbal autopsy data was used to determine the causes of death based on the 10th revision of the International Classification of Diseases (ICD-10). Trend and Poisson regression tests were used to investigate the associations between risk factors and injury mortality.
Results
The overall crude injury death rate was 33.4/100 000 population. Injuries accounted for 4% of total deaths. Men were three times more likely to die from injuries compared with women (adjusted IRR (incidence risk ratios)=3.04, p=0.001, 95% CI (2.22 to 4.17)). The elderly (defined as 65+) were 2.8 times more likely to die from injuries compared with children under 15 years of age (adjusted IRR=2.83, p=0.048, 95% CI (1.01 to 7.93)). The highest frequency of deaths resulted from road traffic crashes.
Conclusions
Injury is becoming an important cause of mortality in the Rufiji district. Injury mortality varied by age and gender in this area. Most injuries are preventable, policy makers need to institute measures to address the issue.
doi:10.1136/bmjopen-2012-001721
PMCID: PMC3533022  PMID: 23166132
Accident & Emergency Medicine
24.  The Global Burden of Unintentional Injuries and an Agenda for Progress 
Epidemiologic Reviews  2010;32(1):110-120.
According to the World Health Organization, unintentional injuries were responsible for over 3.9 million deaths and over 138 million disability-adjusted life-years in 2004, with over 90% of those occurring in low- and middle-income countries (LMIC). This paper utilizes the year 2004 World Health Organization Global Burden of Disease Study estimates to illustrate the global and regional burden of unintentional injuries and injury rates, stratified by cause, region, age, and gender. The worldwide rate of unintentional injuries is 61 per 100,000 population per year. Overall, road traffic injuries make up the largest proportion of unintentional injury deaths (33%). When standardized per 100,000 population, the death rate is nearly double in LMIC versus high-income countries (65 vs. 35 per 100,000), and the rate of disability-adjusted life-years is more than triple in LMIC (2,398 vs. 774 per 100,000). This paper calls for more action around 5 core areas that need research investments and capacity development, particularly in LMIC: 1) improving injury data collection, 2) defining the epidemiology of unintentional injuries, 3) estimating the costs of injuries, 4) understanding public perceptions about injury causation, and 5) engaging with policy makers to improve injury prevention and control.
doi:10.1093/epirev/mxq009
PMCID: PMC2912603  PMID: 20570956
accidental falls; burns; developing countries; drowning; motor vehicles; poisoning; wounds and injuries
25.  Medico-Legal Findings, Legal Case Progression, and Outcomes in South African Rape Cases: Retrospective Review 
PLoS Medicine  2009;6(10):e1000164.
Rachel Jewkes and colleagues examine the processing of rape cases by South African police and courts and show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases.
Background
Health services for victims of rape are recognised as a particularly neglected area of the health sector internationally. Efforts to strengthen these services need to be guided by clinical research. Expert medical evidence is widely used in rape cases, but its contribution to the progress of legal cases is unclear. Only three studies have found an association between documented bodily injuries and convictions in rape cases. This article aims to describe the processing of rape cases by South African police and courts, and the association between documented injuries and DNA and case progression through the criminal justice system.
Methods and Findings
We analysed a provincially representative sample of 2,068 attempted and completed rape cases reported to 70 randomly selected Gauteng province police stations in 2003. Data sheets were completed from the police dockets and available medical examination forms were copied. 1,547 cases of rape had medical examinations and available forms and were analysed, which was at least 85% of the proportion of the sample having a medical examination. We present logistic regression models of the association between whether a trial started and whether the accused was found guilty and the medico-legal findings for adult and child rapes. Half the suspects were arrested (n = 771), 14% (209) of cases went to trial, and in 3% (31) of adults and 7% (44) of children there was a conviction. A report on DNA was available in 1.4% (22) of cases, but the presence or absence of injuries were documented in all cases. Documented injuries were not associated with arrest, but they were associated with children's cases (but not adult's) going to trial (adjusted odds ratio [AOR] for having genital and nongenital injuries 5.83, 95% confidence interval [CI] 1.87–18.13, p = 0.003). In adult cases a conviction was more likely if there were documented injuries, whether nongenital injuries alone AOR 6.25 (95% CI 1.14–34.3, p = 0.036), ano-genital injuries alone (AOR 7.00, 95% CI 1.44–33.9, p = 0.017), or both nongenital and ano-genital injuries (AOR 12.34, 95% CI 2.87–53.0, p = 0.001). DNA was not associated with case outcome.
Conclusions
This is the first study, to our knowledge, to show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases in a developing country. Its findings are of particular importance because they show the value of good basic medical practices in documentation of injuries, rather than more expensive DNA evidence, in assisting courts in rape cases. Health care providers need training to provide high quality health care responses after rape, but we have shown that the core elements of the medico-legal response require very little technology. As such they should be replicable in low- and middle-income country settings. Our findings raise important questions about the value of evidence that requires the use of forensic laboratories at a population level in countries like South Africa that have substantial inefficiencies in their police services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Sexual violence has significant short- and long-term mental and physical health consequences for the victim. Estimates of how common rape is vary within and between countries. The World Health Organization (WHO) estimates that between 1% and 12% of women aged 15 or over have experienced sexual violence by a nonpartner. It has also been used as a weapon of war.
The WHO recognises that rape may be committed by a spouse, partner, or acquaintance as well as a stranger, that men can be victims as well as perpetrators, and that coercion need not be physical. It advocates preventing sexual violence through better support for victims, legal and policy changes, educational programmes, and campaigns to change attitudes, and better health care services and training for health care workers.
Health services for victims of rape have two important roles: to assist the victim and to gather evidence for the police and courts. Nonetheless, health services for victims of rape are often poor. Over the last decade, the South African government has taken steps to reduce particularly high rates of sexual violence by broadening the legal definition of rape and improving health services.
Why Was This Study Done?
Previous studies into how useful expert medical evidence is for the police and courts have focused almost exclusively on high-income countries. It is not clear what interventions work best in countries with fewer resources. The researchers wanted to know the impact of medical evidence on how the South African criminal justice system handled cases of rape and attempted rape.
What Did the Researchers Do and Find?
The authors analysed data from police and court files of 1,547 cases of rape or attempted rape first reported in 2003 to a random sample of police stations in Gauteng province, South Africa. They looked for associations between case data and the arrest, charge, trial, and conviction or acquittal of the alleged perpetrator. They included only cases that were closed when they collected data in 2006 and only cases that contained a record of a medical examination of the victim. The researchers used South Africa's then legal definition of rape as “intentional and unlawful vaginal sex with woman without consent.” They analysed cases involving adults and children (aged 0–17 years) separately. They found that the overall conviction rate was very low, with only 3% of adult cases and 7.4% of children's cases resulting in a guilty verdict. Many cases were dropped at each stage of the legal process and DNA evidence was often not collected or, if collected, not analysed. DNA reports were rarely available for the courts. Injuries were not associated with arrests for either adult or children's cases; an arrest took place in 40% of cases without injuries. Child cases were more likely to come to trial if injuries were present, although a guilty verdict was not more likely. The reverse was true in adult cases: the presence or absence of injury was not linked to cases being brought to trial, but if injuries were present, whether genital, nongenital, or both, a conviction was more likely.
What Do These Findings Mean?
One limitation of the research is that the researchers identified statistical associations of events, but this does not prove that one event caused the other. Other possible limitations of the study are that the researchers had access only to cases closed by the police, which may have biased their results, and the quality of the recorded data was very variable. In addition, the research did not consider other factors that may have affected case outcomes, such as how witnesses are perceived in court.
The system to collect and analyse DNA was rarely effective in making evidence available to the courts. It is known from other countries with effective systems that DNA evidence is of no value if the basis of defence is consent; for instance in cases where the accused is an intimate partner of the victim. Injuries appear not to be necessary to secure a conviction but may be seen as useful by the South African courts in corroborating the victim's testimony, at least in adult cases.
The authors conclude that in poor countries, training for nurses and/or doctors who act as forensic medical examiners in how to record injuries and present their evidence in court will be more effective than investing in costly systems for DNA analysis. However, they argue that in South Africa, as a middle-income country with a high proportion of nonintimate partner rapes, there would be benefit in improving the system to collect and analyse DNA evidence rather than abandoning it entirely.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000164.
Further information on rape in South Africa is available from the Tshwaranang Legal Advocacy Centre
Information on rape is also available from the Rape Crisis Cape Town Trust
Emergency rape information, facts about rape, events, legal services, and medical care can be found at the Speakout Web site
The World Health Organization publishes a factsheet on sexual violence, a report on violence and health, as well as guidelines on medico-legal care for victims of sexual violence
doi:10.1371/journal.pmed.1000164
PMCID: PMC2752115  PMID: 19823567

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