Global Neurotrauma Surveillance: Are National Databases Overrated? Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries".

Injuries are a public health crisis. Neurotrauma, a specific type of injury, is a leading cause of death and disability globally, with the largest burden in low- and middle-income countries (LMICs). However, there is a lack of quality neurotrauma-specific data in LMICs, especially at the national level. Without standard criteria for what constitutes a national registry, and significant challenges frequently preventing this level of data collection, we argue that single-institution or regional databases can provide significant value for context-appropriate solutions. Although granular data for larger populations and a universal minimum dataset to enable comparison remain the gold standard, we must put progress over perfection. It is critical to engage local experts to explore available data and build effective information systems to inform solutions and serve as the foundation for quality and process improvement initiatives. Other items to consider include adequate resource allocation and leveraging of technology as we work to address the persistent but largely preventable injury pandemic.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review.

Purpose of Review: Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings: A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager's four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public-private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary: Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information: The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

Road traffic injuries in Uganda: pre-hospital care time intervals from crash scene to hospital and related factors by the Uganda Police.

A cross-sectional survey was conducted to collect primary data prospectively on pre-hospital care time intervals of Road Traffic Crash (RTC) victims that had been rescued by the Uganda police and to determine what factors were related to those intervals. The survey was conducted between 1 May 2015 and 31 May 2015. The Police responses to 96 RTCs were recorded, but only 74 of them were considered serious enough to warrant hospital transfer, and those 74 are the subject of the analysis. Pre-hospital care time ranged between 10 and 220 min. Seventy-two per cent of the calls were completed within 1 h of call initiation. The scene to hospital transport interval was the longest with a mean of 19.07 min (SD 10.11). Activation time was the shortest interval with a mean of 4.58 min (SD 5.67). Key factors for delays included: understaffing, lack of skills and long distances. A toll-free Universal Access Number, a law mandating provision of free basic emergency medical services at every health facility and gazetting of lanes for emergency services and might decrease on pre-hospital care time and could reduce on the notification and transport time interval respectively.

Postgraduate training for trauma prevention, injury surveillance and research, Uganda.

PROBLEM: The burden of trauma and injuries in Uganda is substantial and growing. Two important gaps that need addressing are the shortage of trained people and a lack of national data on noncommunicable diseases and their risk factors in Uganda. APPROACH: We developed and implemented a new track within an existing master of public health programme, aimed at developing graduate-level capacity and promoting research on key national priorities for trauma and injuries. We also offered training opportunities to a wider audience and set up a high-level national injury forum to foster national dialogue on addressing the burden of trauma, injuries and disability. LOCAL SETTING: The Chronic Consequences of Trauma, Injuries and Disability in Uganda programme was implemented in 2012 at Makerere University School of Public Health in Kampala, Uganda, in conjunction with Johns Hopkins Bloomberg School of Public Health in Baltimore, United States of America. RELEVANT CHANGES: Over the years 2012 to 2017 we supported four cohorts of master's students, with a total of 14 students (9 females and 5 males; mean age 30 years). Over 1300 individuals participated in workshops and seminars of the short-term training component of the programme. The forum hosted three research symposia and two national injury forums. LESSONS LEARNT: Institutional support and collaborative engagement is important for developing and implementing successful capacity development programmes. Integration of training components within existing academic structures is key to sustainability. Appropriate mentorship for highly motivated and talented students is valuable for guiding students through the programme.

Epidemiology of child injuries in Uganda: challenges for health policy.

Globally, 90% of road crash deaths occur in the developing world. Children in Africa bear the major part of this burden, with the highest unintentional injury rates in the world. Our study aims to better understand injury patterns among children living in Kampala, Uganda and provide evidence that injuries are significant in child health. Trauma registry records of injured children seen at Mulago Hospital in Kampala were analysed. Data were collected when patients were seen initially and included patient condition, demographics, clinical variables, cause, severity, as measured by the Kampala trauma score, and location of injury. Outcomes were captured on discharge from the casualty department and at two weeks for admitted patients. From August 2004 to August 2005, 872 injury visits for children <18 years old were recorded. The mean age was 11 years (95% CI 10.9-11.6); 68% (95% CI 65-72%) were males; 64% were treated in casualty and discharged; 35% were admitted. The most common causes were traffic crashes (34%), falls (18%) and violence (15%). Most children (87%) were mildly injured; 1% severely injured. By two weeks, 6% of the patients admitted for injuries had died and, of these morbidities, 16% had severe injuries, 63% had moderate injuries and 21% had mild injuries. We concluded that, in Kampala, children bear a large burden of injury from preventable causes. Deaths in low severity patients highlight the need for improvements in facility based care. Further studies are necessary to capture overall child injury mortality and to measure chronic morbidity owing to sequelae of injuries.

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.

Epidemiology of Child Injuries in Uganda: Challenges for Health Policy

Globally; 90 of road crash deaths occur in the developing world. Children in Africa bear the major part of this burden; with the highest unintentional injury rates in the world. Our study aims to better understand injury patterns among children living in Kampala; Uganda and provide evidence that injuries are significant in child health. Trauma registry records of injured children seen at Mulago Hospital in Kampala were analysed. This data was collected when patients were seen initially and included patient condition; demographics; clinical variables; cause; severity; as measured by the Kampala trauma score; and location of injury. Outcomes were captured on discharge from the casualty department and at two weeks for admitted patients. From August 2004 to August 2005; 872 injury visits for children

The impact of traumatic brain injuries: a global perspective.

Traumatic brain injury (TBI), according to the World Health Organization, will surpass many diseases as the major cause of death and disability by the year 2020. With an estimated 10 million people affected annually by TBI, the burden of mortality and morbidity that this condition imposes on society, makes TBI a pressing public health and medical problem. The burden of TBI is manifest throughout the world, and is especially prominent in Low and Middle Income Countries which face a higher preponderance of risk factors for causes of TBI and have inadequately prepared health systems to address the associated health outcomes. Latin America and Sub Saharan Africa demonstrate a higher TBI-related incidence rate varying from 150-170 per 100,000 respectively due to RTIs compared to a global rate of 106 per 100,000. As highlighted in this global review of TBI, there is a large gap in data on incidence, risk factors, sequelae, financial costs, and social impact of TBI. This should be addressed through planning of comprehensive TBI prevention programs in LMICs through well-established surveillance systems. Greater resources for research and prioritized interventions are critical to promote evidence-based policy for TBI.

Emergency medical systems in low- and middle-income countries: recommendations for action.

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. This paper makes the point that emergency care can make an important contribution to reducing avoidable death and disability in low- and middle-income countries. But emergency care needs to be planned well and supported at all levels--at the national, provincial and community levels--and take into account the entire spectrum of care, from the occurrence of an acute medical event in the community to the provision of appropriate care at the hospital. The mix of personnel, materials, and health-system infrastructure can be tailored to optimize the provision of emergency care in settings with different levels of resource availability. The misconception that emergency care cannot be cost effective in low-income settings is demonstrably inaccurate. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, the ongoing costs of emergency care can result in better outcomes and better cost-effectiveness. Every country and community can and should provide emergency care regardless of their place in the ratings of developmental indices. We make the case for universal access to emergency care and lay out a research agenda to fill the gaps in knowledge in emergency care.

Road safety - threats and opportunities for poor countries.

Chances are that everyone reading this will either have lost a close friend, relative, or work colleague in a road traffic crash in the last couple of years. Chances are, the reports said it was an "accident". There might even have been police reports giving the "cause of the accident." Now, think about the meaning of the word "accident" - most people would agree it is an unpredictable event, one for which you could not possibly have prepared - it just happened. Now, think again. Can we predict what will happen when a cyclist's unprotected head hits the concrete at 100 kms an hour? Can we predict what will happen when a powerful car races down a road a few meters away from the entrance of a primary school, just as the kids are leaving school? Can we predict what will happen when a matatu (commuter mini bus) driver gets behind the wheel at dusk, after a few bottles of alcohol, heading for a destination six hours away? And can we predict what will happen when a mosquito bites a baby, just after feeding on a person sick from malaria? Well - chances are, the first three scenarios will be called accidental, and the last one will be targeted for prevention! The truth is, all four are perfectly predictable, and preventable. The more than 3,200 persons dying on the world's road every day have become predictable - we know they will happen, we know where they will happen, and what kind of people will be involved. Yet the majority of communities and governments still call them accidental, and make no concrete provision for their prevention.

The effect of an overpass on pedestrian injuries on a major highway in Kampala - Uganda.

OBJECTIVES: To describe the pedestrian population, their use of an overpass, and to assess pedestrian perceptions and responses to the risk of traffic crashes, determine pedestrian injuries in relation to traffic flow, and compare traffic crash and pedestrian injury rates before and after the overpass construction. SETTING: The study was conducted in Nakawa trading center approximately six kilometers from the center of Kampala city on a major highway. The trading center has a busy market, small retail shops, industries, a sports stadium, offices, low cost housing estates, schools, and an estimated population of 6,226 residents, 15.1% of them students. METHODOLOGY: Pedestrian road behavior and traffic patterns were observed, and police traffic crash records reviewed, one year before and one year after overpass construction. A convenient sample of overpass and non-overpass users was interviewed to assess their perceptions of risk. RESULTS: A total of 13,064 pedestrians were observed (male: female ratio= 2.2:1). The overall prevalence of pedestrian overpass use was 35.4%. A bigger proportion of females (49.1%) crossed on the overpass compared to males (29.2%). More children (79.7%) than adults (27.3%) used the overpass. The majority of pedestrians (77.9%) were worried about their safety in traffic but only 6.6% thought of the overpass as an appropriate means to avoid traffic accidents. Traffic was not segregated by vehicle type. Mean traffic flow varied from 41.5 vehicles per minute between 0730-0830 hours, to 39.3 vehicles per minute between 1030-1130 hours and 37.7 vehicles per minute between 1730-1830 hours. The proportion of heavy vehicles (lorries, trailers, tankers, and tractors) increased from 3.3% of total vehicle volume in the morning to 5.4% in the evening (t = 2.847, p <0.05); 44.0% of the collisions occurred in the evening with 35 pedestrian casualties before and 70 after the overpass intervention. CONCLUSIONS: The prevalence of pedestrian overpass use was low with adult males least likely to use it. Pedestrians had a high perception of risk, which did not seem to influence overpass use. Pedestrian were more likely to be injured during slow traffic flows. There were more traffic crashes, and pedestrian injuries, but fewer fatalities after the construction of the overpass.