Is length of stay in hospital a stable proxy for injury severity?

RESEARCH QUESTION: Is length of stay (LoS) in hospital a stable proxy for severity of injury when monitoring time trends in serious injury incidence? OBJECTIVE: To investigate whether LoS metrics (mean, median and proportion exceeding several LoS thresholds) have changed over time for injury diagnoses with known severity. DESIGN: Time series investigation. SUBJECTS AND SETTING: New Zealand population admitted to hospital for injury and discharged during the period 1989 to 1998. MAIN OUTCOME MEASURES: Interpolated median and geometric mean lengths of stay, as well as the proportion of cases that have an LoS greater than or equal to 3, 4, 7 and 14 days in hospital. METHODS: ICD-9-CM diagnoses that are approximately homogeneous in regard to severity of injury (ICD-HS diagnoses) were identified. Trends were investigated in the LoS statistics for: injury and non-injury diagnoses combined; all injury diagnoses; major body sites of injury; severity strata; and ICD-HS diagnoses. RESULTS: Almost without exception, there was a decline in the LoS statistics over time for all diagnoses, all injury diagnoses, each body site of injury investigated, severity strata, and the ICD-HS diagnoses. CONCLUSIONS: Reductions in median and geometric mean LoS over time, as well as reductions in the proportion exceeding selected LoS thresholds, were due to factors other than reductions in the incidence of serious injury; for example, changes in service delivery over time. An LoS threshold should not be used as a proxy for severity of injury if the goal is to monitor time trends in injury incidence.

Conspicuity and bicycle crashes: preliminary findings of the Taupo Bicycle Study.

OBJECTIVE: To describe the methods, characteristics of participants, and report on the preliminary findings of a longitudinal study of cyclists. DESIGN: Web-based survey to establish a cohort of cyclists. SETTING: Participants in the largest mass-participation bicycle event in New Zealand, the Wattyl Lake Taupo Cycle Challenge. PARTICIPANTS: 2469 riders who had enrolled online in the 2006 Wattyl Lake Taupo Cycle Challenge. MAIN OUTCOME MEASURES: Self-reported crashes in preceding 12 months. RESULTS: Of 5653 eligible riders, 2469 (44%) completed the study questionnaire. Mean age was 44 years, 73% were male, and the average number of kilometers cycled per week in the preceding 12 months was 130. The annual incidence of crashes leading to injury that disrupted usual daily activities for at least 24 h was 0.5 per cyclist/year. About one-third of these crashes resulted in presentation to a health professional. The mean number of days absent from work attributable to bicycle crashes was 0.39 per cyclist/year. After adjustment for potential confounders and exposure (kilometers cycled per year), the rate of days off work from bicycle crash injury was substantially lower among riders who reported always wearing fluorescent colors (multivariate incidence rate ratio 0.23, 95% CI 0.09 to 0.59). CONCLUSIONS: Low cyclist conspicuity may increase the risk of crash-related injury and subsequent time off work. Increased use of high-visibility clothing is a simple intervention that may have a large impact on the safety of cycling.

Developing valid indicators of injury incidence for "all injury".

BACKGROUND/AIMS: This paper focuses on the methods used to develop indicators for "all injury" incidence for the New Zealand Injury Prevention Strategy (NZIPS), launched in June 2003. Existing and previously proposed New Zealand national non-fatal injury indicators exhibited threats to validity. Population/ SETTING: The total population of New Zealand. METHODS: The authors proposed fatal and new non-fatal injury indicators for "all injury" based on national mortality and hospitalizations data. All of the candidate indicators were subjected to a systematic assessment of validity, using the International Collaborative Effort on Injury Statistics (ICE) criteria. Based on the results of that validation, the authors identified four proposed NZIPS indicators. RESULTS: The proposed "all injury" indicators were as follows: age standardized injury mortality rate per 100 000 person-years at risk; number of injury deaths; age standardized serious non-fatal injury rate per 100 000 person-years at risk; and number of cases of serious non-fatal injury. The authors identified no threat-to-validity when assessed against the ICE criteria. The estimated numbers and rates of serious non-fatal injury increased over the period, in contrast to the numbers and rates of fatal injury. CONCLUSION: The authors have proposed serious non-fatal injury indicators that they judge suffer substantially less bias than traditional non-fatal injury indicators. This approach to indicator development is consistent with the view that before newly proposed indicators are promulgated, they should be subjected to formal validation. The authors are encouraged that the New Zealand Government has accepted these arguments and proposed indicators, and are starting to act on some of their recommendations, including the development of complementary indicators.

Injury outcome indicators: the development of a validation tool.

BACKGROUND: Researchers have previously expressed concern about some national indicators of injury incidence and have argued that indicators should be validated before their introduction. AIMS: To develop a tool to assess the validity of indicators of injury incidence and to carry out initial testing of the tool to explore consistency on application. METHODS: Previously proposed criteria were shared for comment with members of the International Collaborative Effort on Injury Statistics (ICE) Injury Indicators Group over a period of six months. Immediately after, at a meeting of Injury ICE in Washington, DC in April 2001, revised criteria were agreed over two days of meetings. The criteria were applied, by three raters, to six non-fatal indicators that underpin the national road safety targets for Canada, New Zealand, and the United Kingdom. Consistency of ratings were judged. CONSENSUS OUTCOME: The development process resulted in a validation tool that comprised criteria relating to: (1) case definition, (2) a focus on serious injury, (3) unbiased case ascertainment, (4) source data for the indicator being representative of the target population, (5) availability of data to generate the indicator, and (6) the existence of a full written specification for the indicator. On application of these criteria to the six road safety indicators, some problems of agreement between raters were identified. CONCLUSION: This paper has presented an early step in the development of a tool for validating injury indicators, as well as some directions that can be taken in its further development.

Diagnosis based injury severity scaling: investigation of a method using Australian and New Zealand hospitalisations.

OBJECTIVE: To assess the performance of the International Classification of Diseases (ICD) based injury severity score, ICISS, when applied to two versions of the 10th edition of ICD, ICD-10 and ICD-10-AM. DESIGN: ICISS was assessed on its ability to predict threat to life using logistic regression modelling. Models used ICISS and age as predictors and survival as the outcome. SETTING: Australia and New Zealand. Patients or SUBJECTS: Hospitalisations with an ICD-10-AM principal diagnosis in the range S00-T89 from 1 July 1999 to 30 June 2001 (Australia) or 1 July 1999 to 31 December 2001 (New Zealand). INTERVENTIONS: None. MAIN OUTCOME MEASURES: The models were assessed in terms of their discrimination, measured by the concordance score, and calibration, measured using calibration curves and the Hosmer-Lemeshow statistic. RESULTS: 523 633 Australian and 124 767 New Zealand hospitalisations were selected, including 7230 and 1565 deaths respectively. Discrimination was high in all the fitted models with concordance scores of 0.885 to 0.910. Calibration results were also promising with all calibration curves being close to linear, though ICISS appeared to underestimate mortality somewhat for cases with an ICISS score less than 0.6. Overall ICISS performed better when applied to the Australian than the New Zealand hospitalisations. Australian and New Zealand hospitalisations were very similar. ICISS was also only a little more successful when ICD-10-AM rather than mapped ICD-10 was used. CONCLUSIONS: ICISS appears to be a reasonable way to estimate severity for databases using ICD-10 or ICD-10-AM. It is also likely to work well for other clinical variants of ICD-10.

Missing cyclists.

OBJECTIVES: (1) For crashes on a public road, to compare serious cyclist crashes involving a motor vehicle with cyclist crashes not involving a motor vehicle, in terms of threat to life and length of stay in hospital. (2) To determine the proportion of all serious crashes involving cyclists on public roads which are recorded by the police. (3) To determine the degree to which under-reporting of serious crashes involving cyclists and motor vehicles on public roads is associated with various demographic, environmental, and injury factors. STUDY DESIGN: Records for the period 1995-99, of cyclists seriously injured on a public road and hospitalised were linked to the traffic crash report (TCR) database maintained by Land Transport Safety Authority (LTSA). RESULTS: Of the 2925 cyclist crashes on public roads, only 652 (22%) could be linked to a TCR. Of the crashes involving motor vehicles (n = 1033), only 562 (54%) could be linked to the LTSA database. Age, ethnicity, injury severity, and cumulative length of stay were the only variables that predicted whether hospitalised cycle crash cases were more likely to have a corresponding TCR. There were substantial numbers of cyclist only crashes which typically are not captured in the TCR database. Nine percent of these resulted in serious or worse injury (that is, International Classification of Diseases/abbreviated injury scale score of 3+) and 7% resulted in hospital stays greater than seven days. CONCLUSION: Greater effort and precision needs to be applied to routinely document the burden of cyclist crashes, especially cyclist only crashes.

Dental and maxillofacial injuries among older New Zealanders during the 1990s.

Not only is the number of older people increasing in New Zealand, but a greater number of them are keeping their own teeth, with predictable consequences for the costs of treating (and rehabilitating) dental and maxillofacial trauma in that group. The aim of the study was to describe the occurrence of dental and maxillofacial trauma involving New Zealanders aged 65 and over during the 1990s. The investigation was a secondary analysis of routinely collected, national-level compensation and hospital treatment data. The analysis showed that: (1) there was an increase in the rate and absolute number of injuries among older people; (2) the dental trauma rate was highest among males in the youngest age group, while the facial fracture rate was highest among older females; and (3) there was a general increase in the contribution of falls to the occurrence of trauma. Measures which aim to reduce the occurrence of falls among older people will also reduce the oral and maxillofacial trauma rate in that age group.

A model of traffic crashes in New Zealand.

The aim of this study was to examine the changes in the trend and seasonal patterns in fatal crashes in New Zealand in relation to changes in economic conditions between 1970 and 1994. The Harvey and Durbin (Journal of the Royal Statistical Society 149 (3) (1986) 187-227) structural time series model (STSM), an 'unobserved components' class of model, was used to estimate models for quarterly fatal traffic crashes. The dependent variable was modelled as the number of crashes and three variants of the crash rate (crashes per 10,000 km travelled, crashes per 1,000 vehicles, and crashes per 1000 population). Independent variables included in the models were unemployment rate (UER), real gross domestic product per capita, the proportion of motorcycles, the proportion of young males in the population, alcohol consumption per capita, the open road speed limit, and dummy variables for the 1973 and 1979 oil crises and seat belt wearing laws. UERs, real GDP per capita, and alcohol consumption were all significant and important factors in explaining the short-run dynamics of the models. In the long-run, real GDP per capita was directly related to the number of crashes but after controlling for distance travelled was not significant. This suggests increases in income are associated with a short-run reduction in risk but increases in exposure to a crash (i.e. distance travelled) in the long-run. A 1% increase in the open road speed limit was associated with a long-run 0.5% increase in fatal crashes. Substantial reductions in fatal crashes were associated with the 1979 oil crisis and seat belt wearing laws. The 1984 universal seat belt wearing law was associated with a sustained 15.6% reduction in fatal crashes. These road policy factors appeared to have a greater influence on crashes than the role of demographic and economic factors.

Measure for measure: the quest for valid indicators of non-fatal injury incidence.

In this edition of Public Health, McClure and colleagues report on research that considered the criterion validity of indicators based on serious long bone fracture and length of stay in hospital. They found that neither were sensitive or specific indicators for serious injury as defined by an Injury Severity Score (ISS) of 16 or more. They contend that their study findings ' em leader strongly support a return to a measure similar in intent to that encapsulated in the original UK Green Paper em leader '. We contend that their analysis does not provide any empirical evidence to support their view that there should be a return to the Green Paper: Our Healthier Nation indicator. Furthermore, we consider the analyses that they carry out to validate both the Saving Lives: Our Healthier Nation and the serious long bone fracture indicators are flawed. We agree that national (or state) indicators are very influential. They encourage preventive action and resource use aimed at producing favourable changes to these indicators. However, each of the four non-fatal indicators considered in their analysis have problems. Formal validation of existing indicators is necessary and the following aspects of validity should be addressed: face; criterion; consistency; and completeness and accuracy of the source date. Taking into account the current national data systems in England, possible options for one or more national non-fatal unintentional injury indicators have been proposed in our paper. Furthermore, the International Collaborative Effort on Injury Statistics (ICE) Injury Indicators Group is about to embark on the development of a strategic framework for the development of valid indicators of non-fatal injury occurrence.

Personal and situational influences on drink driving and sober driving among a cohort of young adults.

OBJECTIVES: To compare personal and situational influences on incidents involving drink driving with those involving sober driving. METHODS: Information on a range of road safety practices was sought in face to face interviews conducted with 969 members of the Dunedin Multidisciplinary Health and Development Study cohort at age 26 years. A total of 750 study members reported an incident that involved the opportunity to consume alcohol and also travel by motor vehicle. Of these, 87 were classified as "drink drive incidents" and 663 as "sober drive incidents". RESULTS: Study members who were male, of lower socioeconomic status, had no school qualifications, or were dependent on alcohol or marijuana at age 21 were significantly more likely to report a drink drive incident at age 26. Compared with the sober drive incidents, the drink drive incidents were more commonly associated with driving alone, drinking at bars, and no advanced planning. For drink drive incidents the amount of alcohol consumed was influenced by the conviviality of the occasion, whereas for sober drive incidents it was the need to drive. One quarter of those reporting drink drive incidents stated they had used marijuana and/or LSD at the event at which they drank. CONCLUSIONS: Drink drive and sober drive incidents differed, particularly with regard to decisions made before the event. Prevention efforts could usefully be targeted toward these decisions.

Serious facial fractures in New Zealand from 1979 to 1998.

We present data on the incidence, aetiology, age, sex and ethnic distribution of facial fractures in New Zealand for the 20-year period from 1979-1998. Most facial fractures (78.9%) occurred in males with a rate of 65.5/100,000, person-years compared with 21% in females with an incidence of 17/100,000. While the injury rate peaked in males between the ages of 20-24 years (200/100,000), it peaked between 15-19 years (34.7/100,000) in females. The most common causes of facial fracture in both genders were assault (14/100,000) and being unintentionally struck by an object or person (9.5/100,000) which is consistent with similar data from South Africa and the USA. The rates of fracture in Maori (68.1/100,000) were approximately twice those of Pacific Islanders (37/100,000) or other ethnic groups (34.2/100,000).

Adolescent injury morbidity in New Zealand, 1987-96.

OBJECTIVES: Adolescents are over-represented in injury statistics. New Zealand is privileged in having a hospital discharge database allowing for analysis of non-fatal injury data at a national level. An epidemiological description of adolescent injury morbidity is provided and options for prevention are discussed. METHOD: People aged 15-19 years admitted to hospital for their injuries in the period 1 987-96 were identified from the New Zealand Health Information Service morbidity data files. The manner, causes, and nature of injury were examined. Injury prevention strategies were reviewed. RESULTS: The incidence of hospitalised injury was 1,886 per 100,000 person years. The victims were male (70%). The leading causes of injury were road traffic crashes, sports injuries, and self poisoning. The most common injury diagnoses were head injuries (29%) and limb fractures (21%). Road traffic crashes produced the highest proportion of serious injuries. CONCLUSIONS: Road traffic crashes, sports injuries, and self inflicted poisoning, stood out as areas with the greatest potential for reducing the burden of injury in late adolescence. Graduated driver licensing shows promise as an injury prevention measure but remains inadequately implemented. Policies to reduce self inflicted poisoning are of unknown efficacy, and evidence is awaited on the effectiveness of measures to reduce injury in sport.

The New Zealand Blood Donors' Health Study: baseline findings of a large prospective cohort study of injury.

INTRODUCTION: Cohort studies have contributed important scientific knowledge regarding the determinants of chronic diseases. Despite the need for etiologic investigations, this design has been infrequently used in injury prevention research. OBJECTIVES: To describe the baseline findings of the New Zealand Blood Donors' Health Study, a large prospective study designed to investigate relationships between lifestyle, psychosocial factors, and serious injury due to road crashes, falls, self harm, assault, work, sport, and recreation. METHODS: Participants were recruited from fixed and mobile collection sites of a voluntary non-profit blood donor program. Baseline exposure data (for example risk taking behaviors, alcohol and marijuana use, sleep habits, and depression) were collected using a self administered questionnaire. Outcome data regarding serious injury will be collected prospectively through computerized record linkage of participants' unique identifiers to national morbidity and mortality databases. RESULTS: In total, 22 389 participants enrolled in the study (81% response rate). The diverse study population included 36% aged 16-24 years, 20% rural residents, and large variability in exposures of interest. For example, in the 12 months before recruitment, 21% had driven a motor vehicle when they considered themselves over the legal limit for alcohol, and 11% had been convicted of traffic violations (excluding parking infringements). Twelve per cent had seriously considered attempting suicide sometime in their life. CONCLUSIONS: This is the first, large scale cohort study investigating determinants of serious injury in New Zealand and among the largest worldwide. Preliminary findings from prospective analyses that can inform injury prevention policy are expected within five years.

Drowning-related deaths in New Zealand, 1980-94.

OBJECTIVE: To describe the epidemiology of drowning in New Zealand for the period 1980-94. METHODS: Drowning-related incidents were identified by linking New Zealand Health Information Service and Water Safety New Zealand databases. RESULTS: 2,606 drowning-related incidents were identified. In three-quarters of the incidents, drowning was listed as the immediate cause of death. The majority of drownings were unintentional (85%), involved males (76%), and 0-4 and 15-24 year age groups had the highest rates. Boating was the leading cause of unintentional drowning (28%) followed by swimming and other water sports (19%), motor vehicle drownings (13%) and falls or slips (12%). CONCLUSIONS AND IMPLICATIONS: Although there has been a significant decline in drownings, New Zealand compares poorly internationally. In particular, our unintentional drowning rate is twice that of Australia. For New Zealand to continue to make substantial progress in addressing its overall drowning rate, we need to continue and strengthen our efforts in priority areas, in particular those due to motor vehicle crashes and boating and among pre-schoolers, adolescents and young adults. Motor vehicle traffic crashes warrant closer attention than has been the case to date.

Fatal work related injuries in agricultural production and services to agriculture sectors of New Zealand, 1985-94.

OBJECTIVES: To describe work related fatal injuries to agricultural workers in New Zealand to identify priority areas for further research and injury control measures. METHODS: Injury deaths in New Zealanders aged 15-84 inclusive for the period 1985-94 were identified and the coroner's files for these obtained. These files were then reviewed to determine whether the death arose as a result of work activities. Those deaths considered to be work related were coded for information relating to decedent demographics and the circumstances of the fatal injury. Work related deaths from injury occurring in the agricultural production and services to agriculture sectors were analysed. RESULTS: The rate of fatal injuries to male agricultural workers over the study period was 21.2/100 000, with injury deaths in the agricultural sectors accounting for nearly a quarter of all work related fatal injuries in New Zealand in that time. There was no significant decline in fatal injuries to agricultural workers in the study decade. Workers in the 65-84 age bracket were at substantially higher risk of fatal injury than other age groups. Machinery and motor vehicles were commonly associated with fatal injury, with overturns on or next to embankments and slopes being the most frequent scenario. CONCLUSIONS: The results of this study highlight fatal injuries in older workers and machinery incidents (particularly tractors overturning) as priority areas for further research into contributing factors and injury control measures.

Child injury morbidity in New Zealand, 1987-1996.

OBJECTIVES: New Zealand is one of a small number of countries that has a national hospital discharge database. The aim of this study was to use these data to provide an epidemiological description of child injury morbidity and to discuss options for prevention. METHODOLOGY: Using national data, all public hospital admissions for the fiscal year 1995/6 were identified and grouped according to cause. This allowed identification of all children (0-14 years) hospitalized for injury in the period 1987-1996. Causes of injury, diagnoses and injury severity were examined in four age groups. RESULTS: Injury was the second leading cause of public hospital admissions. Children were hospitalized with injury at the rate of 1333 per 100 000 person-years. The victims were predominantly male (61%). In all age groups, falls were the leading cause of morbidity. 'Striking events', motor vehicle traffic crashes and poisoning were also major contributors to the child injury toll. The commonest injury diagnosis was a fracture of the upper limb (25%), followed by intracranial injury (18%). CONCLUSIONS: The leading causes of injury morbidity were noted to differ from previously reported leading causes of injury mortality. Review of the data in light of research literature suggests the need for policy changes to make alternatives to motor vehicle transportation safer and to encourage increased use of child restraints in order to reduce road traffic trauma. Legislation requiring child-resistant packaging for all toxic medications and household products is necessary to reduce rates of child poisoning. Further research is required on policies concerning playground equipment heights and surfacing requirements, and on interventions for hot water scalds.

The prevalence and correlates of psychological distress following physical and sexual assault in a young adult cohort.

Among a birth cohort of New Zealand's 21-year-olds, 41% experienced physical or sexual assault in the previous 12 months. The level of psychological distress experienced by the 374 victims was determined in interviews assessing for symptoms indicative of posttraumatic stress disorder and ratings of impairment in activities of daily living. Of the 141 women victims, 32.6% were identified as experiencing psychological distress as were 9.9% of the 233 men. For men, bivariate analyses showed psychological distress was significantly associated with factors indicative of increased assault severity, and for women an increased likelihood of distress was associated with the location of assault and the relationship to the assailant. Positive indicators of social support were not significantly associated with less adverse psychological outcomes. However, for both men and women, resisting the assailant was associated with a reduced likelihood of psychological distress. Multivariate analyses revealed that for both women and men, unemployment uniquely predicted variance in distress, over and above that accounted for by characteristics of the assault.

Comparison of work related fatal injuries in the United States, Australia, and New Zealand: method and overall findings.

OBJECTIVES: To compare the extent, distribution, and nature of fatal occupational injury in New Zealand, Australia, and the United States. SETTING: Workplaces in New Zealand, Australia, and the United States. METHODS: Data collections based on vital records were used to compare overall rates and distribution of fatal injuries covering the period 1989-92 in Australia and the United States, and 1985-94 in New Zealand. Household labour force data (Australia and the United States) and census data (New Zealand) provided denominator data for calculation of rates. Case definition, case inclusion criteria, and classification of occupation and industry were harmonised across the three datasets. RESULTS: New Zealand had the highest average annual rate (4.9/100,000), Australia an intermediate rate (3.8/100,000), and the United States the lowest rate (3.2/ 100,000) of fatal occupational injury. Much of the difference between countries was accounted for by differences in industry distribution. In each country, male workers, older workers, and those working in agriculture, forestry and fishing, in mining and in construction, were consistently at higher risk. Intentional fatal injury was more common in the United States, being rare in both Australia and New Zealand. This difference is likely to be reflected in the more common incidence of work related fatal injuries for sales workers in the United States compared with Australia and New Zealand. CONCLUSIONS: The present results contrasted with those obtained by a recent study that used published omnibus statistics, both in terms of absolute rates and relative ranking of the three countries. Such differences underscore the importance of using like datasets for international comparisons. The consistency of high risk areas across comparable data from comparable nations provides clear targets for further attention. At this stage, however, it is unclear whether the same specific occupations and/or hazards are contributing to the aggregated industry and occupation group rates reported here.

Barriers to safe hot tap water: results from a national study of New Zealand plumbers.

INTRODUCTION: Many countries still have unacceptably high hospitalizations and deaths from scalds from hot tap water. Prevention strategies implemented in some countries may not work in others. Legislation aimed at changing environments that are conducive to hot tap water scalds may not be effective in many situations for a number of reasons, including lack of acceptability and practicality. METHOD: A qualitative study of a purposefully selected group of craftsman plumbers across New Zealand was conducted using a structured format with open ended questions. The questionnaire was administered by telephone. Information was sought on the opinions, knowledge, and practice of these plumbers regarding hot tap water safety in homes. RESULTS: Several barriers to hot tap water safety in homes were identified by the plumbers. These included common characteristics of homes with unsafe hot tap water, such as hot water systems heated by solid fuel, and public ignorance of hot tap water safety. Other factors that emerged from the analysis included a lack of knowledge by plumbers of the hazards of hot tap water, as well as a lack of importance given to hot tap water safety in their plumbing practice. Shower performance and the threat to health posed by legionella were prioritized over the prevention of hot tap water scalds. CONCLUSION: The findings of this study allow an understanding of the practical barriers to safe hot tap water and the context in which interventions have been applied, often unsuccessfully. This study suggests that plumbers can represent a barrier if they lack knowledge, skills, or commitment to hot tap water safety. Conversely, they represent a potential source of advocacy and practical expertise if well informed, skilled, and committed to hot tap water safety.

Child injury mortality in New Zealand 1986-95.

OBJECTIVES: Injury has been described as 'the last major plague of the young'. We provide an epidemiological description of injury, as a leading cause of death in New Zealand, and identify options for prevention. METHODS: We identified all deaths due to any cause for the period 1986-95 from the national data and calculated the potential years of life lost for each death. For the same period, we identified all injury deaths for children aged 0-14 years. Causes of injury were examined in four age groups. RESULTS: In the population as a whole, injury was the fourth leading cause of death and the leading cause of potential years of life lost. Injury killed children at the rate of 16.8 per 100,000 person-years. The victims were predominantly male (62%) and 52% were under 5 years of age. In infancy (<1 year of age), suffocation was the leading cause of injury mortality. From 1 to 14 years of age, motor vehicle traffic incidents were the leading cause of mortality. CONCLUSIONS: Motor vehicle traffic incidents, drowning, suffocation and suicide stood out as areas with the greatest potential for reducing child injury mortality. A number of existing prevention strategies show promise (e.g. child restraints), others are inadequately implemented (e.g. swimming pool fencing) or are of unknown efficacy (e.g. government suicide prevention policies). Strategies to reduce infant suffocation and child non-traffic pedestrian deaths remain to be developed and tested.