The epidemiology of accident traumas and resulting disabilities: report on a WHO symposium, Strasbourg, 19–21 March 1981

EURO Reports and Studies 57 The epidemiology of accident traumas and resulting d isabi I ities Report on a WHO Symposium 1111111 11111 11111 11111 111111111111111111111111111 .. OOOOY5Y7 .. REGIONAL OFFICE FOR EUROPE - World Health Organization COPENHAGEN

EURO Reports and Stud ies 57 The epidemiology of accident traumas and resulting disabilities Report on a WHO Symposium Strasbou rg 19-21 March 1981 REG IONAL OFFICE FOR EU ROPE World Health Organization COPENHAGEN 1982 ICP/ ADR 051(1) ISBN 92 890 1223 4 © World Health Organization 1982 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Conven- tion . For rights of reproduction or translation , in part or in toto, of publications issued by the WHO Regional Office for Europe application should be made to the Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen 0, Denmark. The Regional Office welcomes such applications . The designations employed and the presentation of the material in this pub- lication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organiza- tion in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters . The views expressed in this publication are those of the participants in the Symposium and do not necessaril y represent the decisions or the stated policy of the World Health Organization . PR INTED IN DENMARK ISSN 0250-8710 CONTENTS Introduction ... .... .... . Epidemiology of accidents and trauma lesions Traffic accidents . . . . . . . . . . . . . . Other types of accident ... .... .. . Trends observed in accident epidemiology : methodological problems of evaluation ... ............ . Impact of accidents and injuries on care systems . Emergency services . . . . Admission systems .... Follow-up arrangements . Children ...... . . The elderly . . . . . . Developing countries . Information systems Accident .. . . Injuries . .. . Disability and handicap Conclusions and recommendations . References . . . . . . . . . Annex List of participants Page 2 2 14 16 20 21 22 24 25 25 26 26 31 32 35 37 40 42 INTRODUCTION A Symposium on the Epidemiology of Accident Traumas and Resulting Disabilities was held in Strasbourg from 19 to 21 March 1981 . This meet- ing was arranged by the WHO Regional Office for Europe in cooperation with the French Government as part of the International Week for Pre- vention and Rehabilitation. The Symposium was held to coincide with a scientific meeting on the topic of " Research and handicaps" organized by the French Ministry of Health and Social Security and the French National Institute for Health and Medical Research (INSERM). The meeting was attended by 26 temporary advisers from 14 different countries, 5 observers, a representative of the Council of Europe, and a representative of the International Children's Centre. Dr Leo A. Kaprio, Regional Director , was invited to address the inaugural meeting of the International Week for Prevention and Rehabilitation, which was chaired by Mr R. Montagne , Secretary of State to the Minister of Health and Social Security, and was also attended by Mrs A. Saunier-Seite , Minister for the Universities , Mr J . Matteoli , Minister of Labour and Participation , Mr D. Hoeffel, Minister of Transport , Mr M. Plantier , Secretary of State for Ex-Servicemen , Mr F. Blanchard , representing the Director-General of the International Labour Organisation , and Mr F. Karasek, Secretary-General of the Council of Europe. Dr Kaprio first thanked the French Government for its support in arranging this Symposium, one of the Regional Office's main contributions to the International Year of Disabled Persons. He expressed his satisfaction at seeing the International Labour Organisation and the Council of Europe represented at the inaugural meeting, as their concerns were totally comple- mentary to those of WHO and cooperation with them was now well estab- lished in numerous programmes. He recalled the basic objectives of the International Year of Disabled Persons, including the need to improve the awareness of the community and governments so that they would give full recognition to the human rights of the disabled. He gave particular stress to the risks these rights were open to in a period of economic austerity such as the one every country in the world was experiencing at present. With regard to the prevention of disability and handicap, he noted that action to prevent accidents or resultant traumas was becoming ever more important in public health, since technological development ,.-in modern societies was accompanied by an increased risk of accident, particularly among children, young people, and the elderly. Finally, he stressed the significance of the fact that this Symposium was being held in parallel with the INSERM meeting , since the work of the latter in fundamental research formed a perfect complement to the work of the WHO expert group, with its greater concern for epidemiology and organiz- ation of support services for the disabled. Following the inaugural session, Dr Kaprio also delivered a short address of welcome at the opening of the Symposium. Dr C. Romer , manager of the WHO Global Programme for Accident Prevention, taking the floor in his turn, recalled the purpose of the meeting, which formed part of the Regional Office programme on accident prevention . He stressed the paucity of in- formation available on the characteristics of the problem of disability and handicap resulting from accidents. This situation was largely the result of fragmentation of responsibilities in the treatment of accident victims, the absence of interest in an epidemiological approach in studying acci- dent traumas and their consequences, and the lack of valid indicators for measuring the seriousness of the phenomenon and facilitating comparisons at both country and international level. The aim of the meeting was to tackle these different questions so as to try and develop working hypotheses and plans of action for the future and thereby improve the situation. Professor H. Choussat was elected Chairman of the meeting , Dr V. Janda Vice-Chairman, and Professor P. Minaire Rapporteur. A list of participants is given as an Annex. EPIDEMIOLOGY OF ACCIDENTS AND TRAUMA LESIONS Traffic accidents Methodology A study of the influence of traffic accidents on a care system is governed first and foremost by epidemiology. This presupposes a strict methodology, and this presents difficulties at a number of levels. 2 The selection of relevant indicators is of great importance. Information on the number of accidents and the number of victims (injured or killed) frequently stems from different sources. The presentation of accidents or victims by user category is sometimes difficult and should always be care- fully checked . Assessment of reference values is a delicate matter. It is not difficult to obtain a precise estimate of a reference population (in a state or admin- istrative area) or the number and type of vehicles involved . On the other hand, the number of vehicles per kilometre and the number of passengers per kilometre , reference values of key importance , are not known exactly but generally speaking are calculated on the basis of road counts (vehicles and passengers) or fuel consumption (1) . Some population indices are well known: mortality and morbidity rates , or even years of potential life lost. The number of accidents, injuries or fatalities, as a ratio of the number of vehicles per kilometre, passengers per kilometre , or the amount of fuel used, makes it possible to study the risk factor in road travel. It is of interest to consider the various figures over a period of time, particularly before and after the introduction of given preventive measures. At the same time , this type of comparison must be made prudently. It is important to be sure that the trend observed after one or more preventive measures has been introduced was not in fact detectable in earlier years . There are also seasonal cycles that can lead to error over insufficiently long observation periods. Intercurrent factors can also affect longer-term trends : economic and technical factors (road infrastructure , type and general state of vehicles) , demographic factors (age of drivers, dates of major population movements by road), and climatic factors. As controlled trials in this field are impossible to carry out, however , such approaches to evaluation are the only ones that may be used. Trends in mortality Studies carried out show a decreasing trend in mortality rates per traffic accident since 1970 in most European countries (Table 1) . This trend is of particular interest if it is compared with trends in numbers of vehicles in I 9 countries of the European Conference of Ministers of Transport (ECMT) (Fig. I) . Still there are striking differences : for example, in Greece, Portugal , Spain , and Yugoslavia , the number of fatalities (deaths within 30 days ofan accident) rose by more than 20% between 1970 and 1979. On the other hand, if the total number of traffic accident victims (in- jured and killed) is considered, other differences appear; thus France and Italy, for example, show increases in numbers of victims of 4% and 6% respectively, but the number of injured is increasing faster than the number of fatalities falls (Table 2). 3 ~ Table 1. Trends in fatalities (deaths within 30 days of accident) for 1970 and from 1976 to 1979 Country 1970 1976 1977 1978 1979 1977/76 1978/77 1979/78 1979/70 Austriaa 2 507 2131 2091 2112 2129 - 2% + 1% + 1% -15% Belgium 2949 2488 2 522 2589 2326 + 1 + 3 -10 -21 Denmark 1 208 857 828 849 730 - 3 + 3 -14 -40 Finland 1 055 804 709 610 654 -12 -14 + 7 -38 France a 16 387 14 799 14127 13033 13452 - 5 - 8 + 3 -18 Germany, Fed . Rep . of 19193 14820 14 978 14662 13110 + 1 - 2 -11 -32 Greecea 1 043 1192 1 323 1314 1408 + 11 - 1 + 7 +35 Ireland 540 525 583 628 616 + 11 + 8 - 2 +14 ltalya 10923 9552 8 796 8523 - - 8 - 3 Luxembourg 132 100 110 102 87 +10 - 7 -15 -34 Netherlands 3181 2 431 2 583 2294 1985 + 6 -11 -13 -38 Norway 560 471 442 434 437 - 6 - 2 + 1 -22 Portugal a 1842 3 372 2 799 2825 2842 -17 + 1 + 1 +54 Spain a 5456 6187 6296 6967 6752 + 2 + 11 - 3 +24 Sweden 1 307 1168 1 031 1 034 926 -12 + 0 -10 -29 Switzerlanda 1 660 1164 1 276 1 243 1243 +10 - 3 + 0 -25 Turkey a 5171 7136 5 588? 5476 ? - -22? - 2? Un ited Kingdom 7 499 6 570 6614 6831 6352 + 1 + 3 - 7 -15 Yugoslavia 3684 4357 4860 5380 5472 +12 + 11 + 2 +49 Total, 19 countries 86297 80124 77 556 76906 74 520b - 3 - 1 - 3 -14 Australia 3 798 3583 3 578 3705 3506 - 0 + 4 - 5 - 8 Canadaa 4978 5157 5147 5311 5722 - 0 + 3 + 8 +15 Japan a 21 795 12654 11629 11418 11 006 - 8 - 2 - 4 -50 United States 52627 45523 47876 50226 51090 + 5 + 5 + 2 - 3 a Figures adjusted for the standard definit ion : death with in 30 days (depending on correction factors in use in countries) . Most of the data for 1979 are provisional . b Total for 1979, with figures for 1978 for Italy and Turkey. Source: ECMT (2) . 180 170 160 150 140 130 120 110 90 80 1970 Fig. 1. Trends in numbers of accident victims and mortality at 30 days compared with numbers of vehicles in 19 European member states of the ECMT .... ···• ·······• ······· •········• ·······• 1972 1974 1976 1978 1979 Vehicles Victims Deaths within -- 30 days Source: ECMT (2). By way of comparison, it is important to note the great reduction in the number of fatalities and injuries sustained in Japan during the same period, when the number of vehicles in the country rose by 158%. Table 3 makes it possible to compare data for 1979 in the 19 coun- tries of ECMT with Japan and the United States . This trend in many countries means that secondary preyention can be considered to have shown its effectiveness. The same decade ( I 970-1979) after all saw the adoption of numerous safety measures , both active and passive, for the protection of passengers and drivers. The most widespread active measure has been the use of safety belts . Their effect has been demonstrated in studies (3,4) (Fig. 2, 3 and 4) , but use of the safety belt must be accompanied by public education measures (5). Another active measure is to use special safety sea ts to ensure that children remain seated when they are in a vehicle. Such seats are becoming more and more widely used as parents come to understand the beneficial effect of the system and are thereby ready to adopt active measures . On 5 °' Table 2. Trends in numbers of accident victims (killed and injured) for 1970 and from 1976 to 1979 Country 1970 1976 1977 1978 1979 1977/76 1978/77 1979/78 1979/70 Austria 72653 62 771 64133 60929 63 000 + 2% - 5% + 3% -13% Belgium 107 777 86551 88340 89863 84105 + 2 + 2 - 6 -22 Denmark 26656 20456 20476 20366 17 217 + 0 - 1 -15 -35 Finland 17083 12 510 12018 9311a 9032 - 4 a - 3 a France 336 590 361 322 359 061 339 697 349 214 - 1 - 5 + 3 + 4 Germany, Fed. Rep . of 550988 495401 523120 523 306 499 683 + 6 + 0 - 5 - 9 Greece 25 719 23029 24593 25332 27150 + 6 + 3 + 7 + 6 I re land 9809 8323a 9098 9941 8827 + 9 + 9 -11 a Italy 238444 226903 217 575 215 521 - - 4 - 1 Luxembourg 2499 2 732 2598 2487 2 375 - 5 - 4 - 5 - 5 Netherlands 71406 64 736 67059 64424 58285 + 4 - 4 -10 -18 Norway 12320 10865 13272a 12801 11 384 a - 4 -11 a Portugal 30266 38858 37200 38123 40023 - 4 + 3 + 5 +32 Spain 90652 103 959 107841 116 017 119 755 + 4 + 8 + 3 +32 Sweden 23 537 23011 21947 21607 20478 - 5 - 2 - 5 -13 Switzerland 37 675 29967 32510 33 573 33 708 + 8 + 3 + 0 -11 Turkey 21 650 35917 39958 37125 - + 11 - 7 United Kingdom 363 368 339673 348 061 349 795 334 513 + 2 + 0 - 4 - 8 Yugoslavia 53651 62237 67044 72084 71 890 + 8 + 8 - 0 +34 Total, 19 countries 2092 743 2009 221 2055904 2 042 302 2 003 285b + 2 - 1 - 2 - 4 Australia 95352 91 391 95194 100 667 - + 4 + 6 Canada 183 581? 199 687? 219921? 244 290? - +10 + 11 Japan 997 864 623 691 602156 602899 604 748 - 3 + 0 + 0 -39 United States - 1850 000 1 950000 2 050000 - + 5 + 5 Note: Many of the data for 1979 are provisional . a Finland, Ireland , Norway : changes in procedure for registration of deaths at 1 January of year in question . b Total for 1979 with figures for 1978 for Italy and Turkey. Sourr:e : ECMT (2). Table 3. Comparison of data on population, land area, number of vehicles, and number of fatalities in 1979 for the 19 countries of the ECMT, Japan and the United States 19 countries Japan of ECMT United States Population 410 973000 115 361 000 219 044 000 Land area (km 2 ) 4 476 241 377 480 9359 373 Vehicles 104323000 22 667000 120000 000 Deaths within 30 days 74495 11 006 51 090 Population/km2 92 306 23 Vehicles per 1000 population 254 196 548 Killed per million population 181 95 233 Killed per 100000vehicles 71 49 43 Source: ECMT (2). the other hand, it has proved more difficult to enforce the prohibition on children in the front seats of cars because of the lack of information and because old habits die hard. It is still impossible to estimate the effect of headrests because of the wide variety of systems used and because in most countries calculations of neck injuries caused by the "whiplash" effect are too low (3,4). Passive safety measures include those to door locks (much improved in the past few years, with a consequent reduction in the risk of being thrown out of a vehicle), the strengthening of bodywork , the use of contrasting types of glass on windscreens, and vehicle design itself. The protection of drivers of two-wheeled vehicles is of prime importance because their number is increasing together with the percentage of accidents in which they are involved . Cyclists involved in accidents are very young or , alternatively, more than 65 years of age, while from 50% to 70% of motor- cyclists involved in accidents are found in the 15-25 year age group . The use of safety helmets has reduced the risk of head injury by 30% on average and that of accident fatalities by 40% (3) . The use of visors and leather protective clothing is reducing the number of injuries to face and limbs. Nonetheless , drivers of two-wheelers are still extremely exposed to 7 00 Fig. 2. Injuries observed among 1185 vehicle occupants involved in accidents (1972-1979) 885 occupants (74 .7%) not wearing belts " .,, 1 i i\\ I Skull and face Neck Upper limbs Thorax Abdomen and pelvis Lower limbs Total AIS' ..; 3 701 39% 47 3% 282 16% 243 14% 101 6% 416 23% 1780 89% 2010 AIS' > 3 75 38% 8 4~ 3 1.5% 61 31% 50 25% 23 12% 220 11 % 2.27 injuries/occupant 300 occupants (25.3%) wearing belts .,, 1 ii\\ I a AIS : Abbrev iated Injury Scal e, American Assoc iat ion of Automotive Medic ine. Skull and face Neck Upper limbs Thorax Abdomen and pelvis Lower limbs Total Source : National Organization for Road Safety, Genera l Hospital Centre , Salon-de-Provence, France. AIS' ..; 3 195 28% 30 4% 1()() 14% 153 22% 46 7% 170 25% 694 94% 738 AIS' > 3 17 39% 10 8 5 44 6% 2.46 injuries/occupant Fig. 3. Injuries observed among 773 vehicle occupants involved in accidents ( 1972-1975) 649 occupants (84%) not wearing belts .,, 1 i i\\ I Skull and face Neck Upper limbs Thorax Abdomen and pelvis Lower timbs Total AIS' .; 3 397 34% 20 173 15% 234 20% 56 5% 283 24% 1163 89% 1293 AIS' > 3 43 32% 5 _4 40 31 % 32 25% 10 8% 130 11 % 2.01 injuries/occupant 124 occupants (16%) wearing belts .,, I i i\\ I a AIS : Abbrev iated Injury Scale, American Associat ion of Automotive Medic ine. Skull and face Neck Upper limbs Thorax Abdomen and pelvis Lower limbs Total \D Source : National Organizat ion for Road Safety, General Hospital Centre, Salon-de-Provence, France . AIS' .; 3 49 23% 12 29 14% 55 26% 13 6% 53 25% 211 96% 220 AIS' > 3 5 56% 9 4% 1. 77 injuries/ occupant 0 Fig. 4. Injuries observed among 412 vehicle occupants involved in accidents ( 1976-1979) 236 occupants {57%) not wearing belts I Skull and I face Neck .. ,,j ) Upper limbs Thorax Abdomen and pelvis i()\ I ( Lower limbs Total AIS' .; 3 304 42% 27 4% 109 15% 109 15% 45 6% 133 18% 727 89% 817 AIS ' > 3 32 37% 3 3% 3 3% 21 23% 18 20% 13 14% 90 11 % 3.46 injuries/occupant 176 occupants (43%) wearing belts .. ,, . ·f) a AIS : Abbreviated Injury Scale , American Association of Automotive Medicine . Skull and face Neck Upper limbs Thorax Abdomen and pelvts I Lower limbs Total Source : National Organ ization for Road Safety, General Hospital Centre , Salon-de-Provence , France. AIS' .. 3 146 30% 18 4% 71 15% 97 20% 33 7% 117 24% 482 93% I 517 AIS' > 3 12 34% 2 6% 2 6% 9 26% 5 14% 5 14% 35 7% 2.93 injuries/occupant other vehicles, the circumstances in which accidents occur vary widely even within a single country and from one country to another , and the design and cubic capacity of two-wheeled vehicles also shows great diversity. Faced with the increasing accident risk as a function of engine size (in- creasing from 1 to IO between I 00 cm 3 and I 000 cm3 ), some countries, such as Japan , are introducing steps to prohibit the use of large engine sizes. Accident settings The physical, socioeconomic, and psychological circumstances in which acci- dents occur are still poorly known (6-8) . Little information exists on the personalities of drivers . From the point of view of method , it is interesting to refer to the study model of primary accident risk factors in children and adolescents, given in the report of a technical group on psychosocial factors related to accidents in childhood and adolescence (Fig. 5) (7). The elderly Accidents on the public highway are, together with falls , the principal causes of accidental death among persons of more than 65 years of age . Mortality is higher than for other age groups , although morbidity is lower than general morbidity (9). Elderly victims of traffic accidents are twice as frequently pedestrians as in the general population . In two thirds of cases, such el- derly pedestrians receive head injuries but , more often than not, multiple injury occurs. The elderly are less exposed to other types of traffic accident (cars, two-wheelers) but there, too, the mortality rate observed is higher than in the rest of the population (JO). Sensory, hearing, and vision defects, or a delay in identifying information and carrying out decisions may explain the increased frequency of accidents among elderly pedestrians. The effects of in- gested medical preparations should not be overlooked either. Finally, factors of a psychological nature , rashness due to a desire to seem more capable , or a feeling that they should have priority through seniority may explain the conduct of the elderly in response to traffic . Although the responsibility of the elderly in accidents is more often referred to than that of younger people, the part played by traffic signals that are difficult to understand , traffic lights changing too frequently, or public transport stops which are difficult to reach , should be mentioned as well . Children Children form another category of the population (JI) often involved in traffic accidents. Child mortality rates per accident vary considerably from one country to another (12) . This may be a reflection of the health status 11 Fig. 5. Primary factors in accidents involving children and adolescents Psychosocial factors (endogenous) Predisposing factors Unawareness of risks Lack of experience Need to explore anq innovate Role models (motorcyclist as hero) Risk -taking behaviour Use of a motor vehicle to build up self-esteem Psychological maladjustments !extremes on personality traits, e.g. activity-passivity); " unbalanced" personality structure Sociopathic behaviour (e.g. aggressiveness, deviance) Family dysfunctions !chronic family syndrome) Precipita ting facto rs Heightened emotional tension lendocrinological and psychological) Alcoholic condition Driving under influence of medicines or drugs I especially hallucinogenic) 12 \ Increased vulnerability and/or risk si tuation Environmental factors (exogenous) Predisposing factors Habitual use of a two-wheeled vehicle without due protection Lack of body protection I helmet , gloves, etc.) Increased commercial advertising promoting vehicles that are dangerous Inadequate age-specific driving regulations Inadequate enforcement of existing laws Increasing need to make long trips to and from work , school , etc. Inadequate or excessively expensive public transport I Precipitat ing facto rs i--. Special traffic conditions , Social pressure to "perform " in a certain I+- way !travelling in groups) Use of poorly maintained vehicles Use of stolen vehicles Accident of children in such countries. It is sometimes extremely difficult to extract the percentage of mortality by traffic accident from the overall percentage of child mortality by accident or disease (R.H . Jackson, personal communi- cation). A high rate of accident mortality may be a reflection of a low rate of mortality due to other causes, or vice versa. Another cause of error is to do with the age groups studied: in a group between O and 14 years , mortality from the neonatal period and infant mortality are included, which is not the case for a 1 -14 year age group. It may thus be difficult to describe trends in child mortality from traf- fic accidents over the years. However , it is to be pointed out that in rela- tion to traffic the healthy child should be considered as suffering from a sensory handicap. A complete field of vision enabling objects far to one side to be seen , or the ability to locate sound and its direction and move- ment, are not acquired at the same time as the ability to walk. Discrimination between right and left, all-round perception of traffic, and an ability to master natural impulses are not completely present at preschool ages. On the practical level, a child is incapable of crossing a street alone without excessive risk before the age of 9, and use of bicycles outside protected zones is not safe before the age of 12 (J 2) . Types of injury Certain types of injury are interesting indicators for the epidemiology of traffic accidents . Injuries to the head and neck are far more frequent in traffic accidents than in other accidents. This is also true of the thorax , the abdomen and the pelvis, which contain viscera and essential organs for heart-lung and neurological function. The upper limbs are relatively well protected while injuries to the lower limbs are no more frequent in traffic accidents than in other types of accident. Injury to the skull , thorax or abdomen involves a high rate of instant death. Thoracic injury, in particular , is forming a steadily higher proportion of instant death . The wearing of safety belts has , however, considerably reduced the seriousness of injuries observed, measured on the AIS scale (Fig. 2, 3 and 4). This improvement is particularly significant for skull and face injuries and thoracic injuries , and for passengers occupying the front seats of vehicles. In all, 11 % of subjects admitted to emergency services in Great Britain presented with skull injury and half of those hos- pitalized with skull injuries were traffic accident victims (3). Of a series of 2748 injuries observed in 1186 passengers of vehicles collected over a clearly defined geographical area , 30% had injuries to the skull or face, 26% to the lower limbs, 17% to the thorax , 14% to the upper limbs, 8% to the abdomen, the pelvis and the spinal column, and 3% to the neck . Traumatic lesions of the spinal cord account for more than 70% of all meduliary damage (13). Fractures of the spinal column are accompanied by damage to the spinal cord in 14-39% of all cases depending on the level of 13 the fracture , the cervical column having the highest rate of medullary compli- cations (averaging from 23% to 30% of cases according to country and to the series studied). In half of all spinal cord cases this was due to traffic accidents and the proportion varies little from country to country. The average age of those suffering from spinal cord injuries as a result of traffic accidents is about 30 for all countries. It is lower than that of other persons suffering from injury to the spinal cord. The most significant fact is the high proportion of tetra- plegics resulting from damage to the cervical spinal cord (14). At the Centre for Traumatology and Rehabilitation in Brussels, the rate increased from I 5 .5% of all spinal cord lesions as a result of trauma in 1967 to 32% in 1980. This spectacular and worrying rise may have something to do with the existence of specialized care centres to which the more serious cases are more readily referred and also with the improvement in procedures governing the recovery of accident victims and the development of the road traffic network. The posi- tive or negative aspects of safety belts remain to be studied, unlike the positive effect noted on road accident mortality rates of persons wearing safety belts. Other types of accident Here, the problems connected with method are at least as important as in the road traffic accident sphere. The lack of precision in causes of death is particularly striking. Falls Depending on the country, falls are a widely varying cause of death (from one to four times between Bulgaria and Spain on the one hand and Austria and France on the other) (12). The reason for this is probably differences in data collection. The various figures given, however , show clearly that falls are a major and constantly rising cause of accidental death among persons of more than 65 years of age. Fatal falls only represent between 1% and 3% of deaths, according to country, but 75% of fatal falls take place among the elderly. Moreover , the incidence of falls as a cause of death increases in the last few decades of life. Such falls take place at times of intense ac- tivity, during the night and in the home , in two out of every three cases (R.H. Jackson, personal communication). In two out of every three instances an extraneous cause is found : stair- case steps, inadequate lighting, etc. In two out of every five cases falls occur on the way to the toilet. The intrinsic causes of death are cardiovascular or neurological. The role played by alcoholism should not be underestimated . Difficulties in walking, poor balance , poor muscle tone , pyramidal damage , a dementia or confusion syndrome all increase the risk, as does a lack of physical fitness. Deaths due to falls among old people are much higher where there is no rapid help . One out of every ten falls results in a fracture (15,16) . 14 The prevention of falls among old people involves better definition of persons at risk and risk factors , and a detailed study of the first fall observed because another and more serious fall is then highly probable ; it also pre- supposes improvements to and adaptation of housing for the elderly, with the establishment of simple alarm systems. Sports accidents Accidents resulting from sports most often affect limbs (80% of all cases), particularly the lower limbs (50%). The low proportion of injury to the skull, thorax or abdomen explains the reduced mortality generally observed. On the other hand , depending on country, damage to the spinal cord in sport- ing accidents accounts for between 3% and 12% of spinal cord damage. In half of all cases tetraplegia , i.e. serious injury, is the outcome (K. Franke, personal communication). The most frequent causes are shallow water diving , rugby, horse-riding, mountaineering, and gymnastics. Preventive information and proper training should limit serious accidents from sports or games. Drowning In many countries the number of accidents due to drowning seems to be decreasing. A reduction in death rates by drowning, particularly amongst children , has thus been observed in Norway, for example (4.4 per 100 000 pop- ulation in 1969 and 2.4 per 100000 in 1978), and in the Netherlands , Swe- den and Finland. On the other hand , the most striking increases have been recorded in the United States among boys aged 1-4 (12). Household accidents Each year in Great Britain 6000 people die as a result of accidents in the home, 100 000 are admitted to hospital, and some 1 million receive treatment from their general practitioner (J 7). In a period of six months in 1977, 30 097 domestic accidents were recorded in 20 hospitals in England and Wales. The types of injury were the following: Number Percentage Cuts 10609 34.4 Fractures/ dislocations 3 738 12.1 Contusions 3 296 10.7 Sprains 2 747 8.9 Burns 1 100 3.6 Scalds 1011 3.6 15 Number Percentage Wounds from a pointed object 810 2.6 Inhalation/ingestion 788 2.6 Foreign body in an orifice/in the eye 753 2.4 Concussion 356 1.2 Splinters 248 0.8 Poisoning 57 0.2 Electric shock 17 0 .1 Suffocation 8 In 6 .6% of all cases hospitalization proved necessary; hospital stays lasted from I to 4 days in 53 .7% of all cases admitted, but more than 30 days in 14.9% of such cases. The death rates are underestimated because of the problems experienced in collecting data: 55% of all fatalities occur in hospital, 7% are found dead on arrival in hospital, and the remaining cases have been found dead or have died at home. Domestic accidents are not the same among children as they are among adults (J 8). Only 2 .5% of such accidents affect nursing infants from O to 8 months. Out of a group of 25 810 cases affecting children of 0-14 years of age studied over a 12-month period , 31.1 % were due to poisoning through medical or nonmedical products, 22.3% were due to head injuries , 12 .8% to fractures, and 13% to burns. However, in some developing countries burns are more frequent than poisoning, the chief substances incriminated being petrol and paraffin (J 9). Trends observed in accident epidemiology: methodological problems of evaluation The epidemiology of road accidents must take into account the socioeconomic features of the point of observation. This much is shown by the study of infantile mortality percentages per accident as compared with overall infant mortality or percentages of mor- tality by traffic accident in relation to other types of accident. Although it has been falling off in certain countries since 1972 or 1973, mortality continues to rise in others . Here, it appears to be of interest to note some of the trends recorded in certain countries outside the European Region where road accident death rates are increasing to a worrying degree. Finally, the breakdown of traffic accidents by hour , day, or month varies widely from one country to another. Thus, in Kuwait , the death rate per I 00 million vehicles/kilometre fell from 10.9 in 1977 to 8.5 in 1978 (20), but in 1975 and 1976 in the United Kingdom and the United States the same figures were 2.5 and 2 .2 , 16 respectively. The death rates per 100000 registered vehicles rose from 108 .2 to 119 .5 (3 7 .5 and 33 .4 in the United Kingdom and the United States), while the death rate per resident fe ll from 3 7 .6 to 31 .7 . However, in Kuwait the number of vehicles in relation to the population was 0.38 in 1978 and 0.35 in 1977, as compared with 0.32 and 0.65 in the United Kingdom and the United States , respectively. In the province of Zaria , Nigeria (21,22), with a population of 94 300, 2734 persons were victims of traffic accidents in the period January 1974 - December 1976 and 617 died , particularly pedestrians (25 .6%) . In Nigeria also, in the period 1967-1 975, the rate for traffic accident victims rose from l 54 to 269 per million population. From 1965 to 1973 the num- ber of deaths per traffic accident rose by 167% (rising from 2079 to 5552 per annum). Between 1957 and 1979 in Delhi (23), the number of deaths per traffic accident rose by 461 %, while in the same period the increase in population was l 56% and the number of vehicles increased by l 677%. In fact , figures and trends vary according to the country (24,25). Jamaica , Kenya , Malawi , Nigeria and Zambia, for example, had a steeper rise in the number of victims per traffic accident between 1961 and 1971 . More- over, the situation was exacerbated during the last few years of the same decade ( 1968 - 1971) in particular, because of the increase in the number of two-wheelers and the persistence of a large number of accidents involving pedestrians. Although it is true that mortality rates are falling in many countries and for a very wide range of types of accident and injury, however, the reduction in morbidity per accident is less easy to appreciate so clearly. In particular, estimates for the seriousness of injuries are widely disparate. Until recently, the seriousness of injury was in practice linked to mortality caused by these injuries . A low rate of infantile mortality, including accident deaths , can therefore be considered as an indicator of good performance on the part of the public health services . The discrepancy shown up by the improved mortality rates , which are remaining stable or declining, and the deteriorating trend in morbidity means that many children are being kept alive who will create definite new rehabilitation problems for care systems and for living conditions. The same statement may be made for the other end of life, among people aged more than 65 years. Numerous systems for measuring the seriousness of injuries have been tried, either based on , or often grafted on to , epidemiological studies. As trauma following accidents often results in long periods of disability, the real prospects for prevention can only be understood by measuring such disability. In this way an appreciation may be made of "primary" prevention , i.e. of the accident itself, and particularly "secondary" preven- tion, i.e. of injuries due to the accident. 17 The trend is to concentrate on three different elements which we must return to subsequently: - diagnosis (the affected organ) , - functional disturbances (disability), - seriousness (mortality). In the epidemiological studies there is therefore a tendency, for the reasons quoted above, for various criteria to be used in understanding func- tional disturbances, viz .: Abbreviated Injury Scale, or AIS, which centres on the affected organ and the immediate seriousness of the injuries. The duration of hospitalization. There exists a link between the sequelae of accidents and the duration of hospitalization (Table 4), and it is diffi- cult to envisage an accident with grave sequelae without hospitalization having taken place , or after hospitalization of less than IO days. It is diffi- cult, however, to establish the degree of this correlation. Thus it has proved possible to show that cyclists present with less serious sequelae than motor- cyclists or that sequelae increase as a function of age among individuals hospitalized for more than IO days after the accident (1). The duration of disability, which includes the length of hospitalization and which can be calculated operationally from the outset, as in Denmark where the calculation is performed at the emergency unit, or subsequently, as in France , by measuring the length of total temporary disability (TTD) , a concept that is recognized in law and administratively. It should be stressed that the length of hospitalization and disability do not have a common corre- lation. Moreover , such attempts at evaluation are only in their infancy, and correlations are not available for every type of accident, accident victim or injury , and the various circumstances or factors associated with them. Out of 2270 persons surviving an accident, 8.1 % suffered medical disability (26) . In 80% of the different cases the degree of disability did not exceed 20% and in 92% of all cases it was no higher than 30%. A study of disability pension holders (Table 5) provides another method of evaluation. We should now stress, however , the extreme difficulties encountered by investigators when they want to evaluate accidents by staying as close as possible to reality, because of the absence of any consensus on definitions such as those of se rious injury, impairment, disability, handicap , sequelae. In this way the social and economic impact of minor injuries not re- quiring hospitalization (skull, spinal injuries without fracture , with brief loss of consciousness, for example) is under-assessed. 18 Table 4. Number of injured hospitalized, number of days of hospitalization, and mean duration of hospital stay, in Finland in 1978 Admissions Hospital Mean duration of Diagnosis a daysb hospitalization (in thousands) (in thousands) (in days) 1. Concussion (850) 4.6 23 5 2. Fracture of neck of femur (820) 4.5 169 38 3. Fracture of tibia and fibula (823) 3.2 51 16 4. Fracture of ankle (824) 3.0 34 11 5. Fracture of radius and ulna (813) 2.3 16 7 6. Fracture of humerus (812) 1.8 23 13 7. Other comp I ications of surgical procedures (998) 1.8 16 9 8 . Fracture of face bones (802) 1.6 10 6 9. Cerebral laceration and contusion (851) 1.6 53 32 10. Fracture of other and unspecified parts of the femur (821) 1 .6 37 24 Total for all types of injury and poisoning (800-999) 61 836 14 a Numbers in brae kets a re those used in the ninth revision of the International Classification of Diseases ( I CD). b In addition, 40 000 hospitalization days were calculated for fracture of vault of skull (No. 800 in the ICD) and 43 000 for fracture of the vertebral column (Nos 805 and 806 of the ICD). What is more, the registration of accidents is normally made in a very limited initial period. The long-term consequences of serious accidents cannot be correctly identified during this short initial period. 19 1. 2. 3 . 4 . 5. 6. 7 . 8 . 9. 10. Table 5. Types of trauma affecting disability pension holders in the 16-64-years age group,a in Finland at 1 January 1980 Diagnosisb Number of pension holders Cerebral contusion (851 )c 2198 Amputation of leg (897) 792 Fracture of the vertebral column with spinal cord lesion (806) 654 Other and unqualified skull fractures (803)d 641 Fracture of the vertebral column without mention of spinal cord lesion (805) 607 Fracture of tibia and fibula (823) 529 Amputation of arm and hand (887) 523 Fracture of other and unspecified parts of the femur (821) 297 Fracture of neck of femur (820) 292 lntracranial injury of other and unspecified nature (854) 219 Total number of pension holders (800-999) 9 745 a 3 .15 million individuals out of a total population of 4 .75 million. b Numbers in brackets are those used in the ninth revision of the Inter- national Classification of Diseases (I CD). c lntracranial trauma of different types (850-854) : 2 705 . d Fractures of skull (800-804) : 752 . IMPACT OF ACCIDENTS AND INJURJES ON CARE SYSTEMS Primary prevention , which is designed to avert accidents themselves, does not depend solely on the care and treatment systems . It also depends on the type of accident, extraneous causes, the number of victims, their age and sex, and the physical , socioeconomic and psychological circumstances in which 20 accidents may occur. The care systems do, however, play an important part in this sphere because only they can provide the information needed in order to be ab le to choose from among the various preventive programmes , as can be seen from the following diagram: __jWORK ACCIDEN~OSPITAL __. REHABl lTATION 7~g:0EOL I Type Diagnosis - Referral - Advice I I Documentation PREVENTION __________ __, Nonetheless , the impact of accidents on care systems occurs on the one hand at the structural level and on the other at the level of organiz- ation of care corresponding to the immediate and long-term treatment of accident victims . Emergency services The need for emergency assistance at the site of accidents is not open to question. Such assistance, however, may differ widely according to geo- graphic and socioeconomic circumstances prevailing in each particular case . Three types of personnel providing assistance may be envisaged: - untrained or partially trained personnel : family, village or neighbour- hood auxiliary personnel ; - trained emergency personnel: ambulance personnel, fire brigade or police; - medical personnel alerted by telephone or telecommunications and brought to the site of an accident by the fastest possible means, even by helicopter in exceptional circumstances. Irrespective of the type of personnel used at the site of accidents, the organization of the emergency system is of prime importance. This organiz- ation must have a threefold base: - an effective communications system with a special telephone number (in France 15 , in Belgium 900, in the United Kingdom 999, etc.) and constant liaison between the emergency assistance team, police forces , and the hospital of admission; 21 - integration of the emergency care system, transport system for the injured, and structure of the admitting hospital; - adequate transport from the site of the accident to the hospital, the aim of the transport being to enable the physician to take responsi- bility for treatment as swiftly as possible. However, there is a certain discrepancy between two possible solutions: - either the emergency treatment team is medically highly qualified and the transport system is more or less a "hospital unit" in itself, and the speed of transfer to the admitting hospital may then be relegated to a second priority, as is the case in France with the Services d'Aide medicale urgente (SAMU); - or the emergency treatment team has few medical qualifications and transport to hospital must be very fast. Admission systems These must depend on the geographical and socioeconomic environment as well. The choice may be between a highly qualified traumatology unit as- sociated with a medically well qualified emergency service and capable of administering the necessary care, including neurosurgical treatment, and a less specialized unit centred on a general reanimation department, calling in specialist surgeons when necessary. The specialist unit necessarily covers a more extensive catchment area and can easily serve also as a centre for research and excellence in its domain. The all-round reanimation unit aims at coverage of a smaller geographical area. At all events, in both cases the choice must also be dictated by studies of the cost-benefit type. These studies , which for the moment do not exist, should be based on the final outcome of treatment, i.e. on the residual disability or handicap. Adequate care must be provided by the most competent team possible whether or not it is permanently at full strength or brought up to strength on request by the physician in charge. Particular mention should be made of lesions to the central nervous system (brain and spinal cord): reference to the experience of a number of countries indicates that it would appear desirable to have available special units manned by highly trained personnel taking care of the injured from as soon as possible after the accident. Here too, however, precise cost and benefit studies would need to be performed so as to compare different systems. It is extremely desirable for medical rehabilitation activities to be initi- ated as soon as possible, well before the injured are sent to rehabilitation units . In this area there is , in practice , a lack of organization on the part of most health systems. Initial treatment ends all too often with conventional 22 somatic care. Inadequate initial medical rehabilitation, however, exacerbates residual disability and handicap. The methods applied are generally speaking much too passive, the accident victim is bedbound far too long, and stays in the initial admission unit far too long, with the unit's activities being limited after a certain period to postoperative or post-trauma observation of a type that is insufficient from the standpoint of rehabilitation. Shortcomings in this field are in the first place due to inadequate train- ing of medical and paramedical personnel, particularly of nurses. The training provided does not have a long-term view of the patient and is bound up with day-to-day provision of care without looking ahead toward future re- integration with society. This shortcoming must be corrected during under- graduate studies and as a part of permanent post-university refresher train- ing. The conventional hospital organization - in particular its various hier- archies - also undermines this approach because it encourages the accident victim to remain immobile and dependent. Paramedical rehabilitation person- nel (physiotherapists , ergotherapists) do not have access to the patient during the initial phase of treatment , both because not enough are recruited and because of a hidebound approach to routine, yet the restoration of bed bound accident victims to movement should be the responsibility of a team and not of a single practitioner. An interpenetration of the various rehabilitation professions, up to and including interchangeability of roles, is to be desired. Admission to a specialized rehabilitation and retraining unit is an im- portant turning point for the accident victim, who thereafter is in a posi- tion to receive treatment from an all-round team (medical specialists , kinesi- therapists, ergotherapists , voice and hearing specialists , psychologists, social workers , etc .) . The treatment administered at this stage is based on functional diagnosis rather than on the initial diagnosis and is angled towards a return to the normal environment in the best possible conditions. It is important for the injured person's medical history, containing initial diagnostic and therapeutic data and subsequent functional reports , to follow him after leaving hospital and to be forwarded to follow-up departments , but the same file should also be supplied to the hospital of initial admission . The absence of such feedback is one of the reasons for the present lack of information on the true seriousness of injuries and accidents . Rehabilitation consists of a number of elements which each injured person should benefit from and which can be broken down as follows : - medical rehabilitation at as early a stage as possible , - social rehabilitation , - occupational rehabilitation , - specialized education and rehabilitative learning for children . Both at country level, and at United Nations level, different ministries or agencies are responsible for various aspects of rehabilitation. However , the 23 aim of rehabilitation is to prevent , reduce or compensate disability and thereby handicap. This is an aim which cannot be compartmentalized . The solution would seem to lie in the development of individual rehabilitation programmes , training programmes for rehabilitation at local , national or international level , and rehabilitation programmes conducted in cooperation between different countries. The various international and national agencies should act in a coordinated manner to produce programmes that could be used in a variety of geographical and socioeconomic settings . The role of the medical specialist in rehabilitation is fundamental to coordination. At the same time it is essential to have some interchange with other medical special- ties (paediatrics, geriatrics , cardiology, etc.). Follow-up arrangements Rehabilitation of accident victims should not be limited to hospitals or specialist centres . It should also continue and be provided by all-round teams operating in the community itself. The goal is to bring the rehabilitation consumer closer to his own background. Continuation of medical rehabilitation is necessary but should be com- bined with social, psychological , educational and occupational support for the accident victim. To do so , reliance must be placed on informal assistance and support networks existing in the community. Depending on the situation, brief periods of hospitalization should be arranged so that a complete check-up may be made , temporary intensive training may be given, and the burden on the family may be lightened. It is at this stage that compensation for accident victims looms particu- larly large. In many countries financial compensation for disability is provided for the accident victim. If such compensation is too high resumption of work will be less likely and the accident victim will be turned into an invalid, with his dependence accentuated. However , resumption of work sometimes reduces compensation as well , and this seems to be an excessive penalty. The establishment of compensation levels poses major problems. Exist- ing tariffs have led to confusion and major distortions and have lost much of their meaning. Tribunals , work accident compensation funds, military pensions, and insurance schemes all have widely varying compensation scales. Compensation should really be made according to the nature and serious- ness of the residual disability or handicap , irrespective of the etiology or type of accident. To provide the right level of compensation the impairments of various functions in the accident victim should therefore be studied, together with their impact and the need for outside assistance, with account being taken of the degree of functional impairment. The correlation between these elements and initial diagnosis and injuries is no easy matter but enables the financial , physical and mental cost of an accident to be more accurately viewed and compensation to be more justly made. 24 Children Child accident victims (G. Kjellberg, personal communication) require special care. Front-line treatment is of decisive importance and must also be carried out by the most competent personnel but, irrespective of the health care system, duty medical staff are never the most experienced. Hospital organization arrangements must be sufficiently free to enable the child's family to be brought in at any moment. Very early links must be established with the rehabilitation centre and the mother and child protec- tion departments. An accident to a child is a trial for the family. It is therefore important for the child's return to the family environment to be prepared at a very early stage and very carefully so as not to create an additional psychologi- cal handicap . The family must be ready to take charge of the child. This presupposes that it should be sufficiently provided with information on the child 's state and prognosis, expressed in language that is as non-technical as possible. A family crisis sets in during the 4-6 weeks following the accident. This crisis combines a feeling of guilt towards the child with a feeling of fear: fear of the child's death , an alteration in his personality, residual motor handicap . The oldest and most painful of memories (childbirth, trauma , hospitalization) are often reawakened on this occasion. For a 6-12 month period an adaptation phase sets in during which the initial reactions are gradually erased . This initial critical reaction tends to be softened by psychological treat- ment, which must be integrated with medical care. Social care is of particular importance in the case of child accident victims and is all too often neglected by medical and paramedical person- nel. It is concerned with food, housing , education, lifestyles . It must keep the child's family as free as possible. It must be carried out at local level by social workers who are familiar with the local and family environment of the child. The elderly The epidemiology of accidents and their consequences among the elderly has been referred to above. The scale of the problem must lead to provision not only of primary prevention programmes but also of suitably tailored treatment programmes . Elderly people react much more unfavourably to passive medical treat- ment. The immobility syndrome, already well known , leads swiftly to skin damage , bone changes , changes in articulation and digestion , cardiovascular , urinary and mental alterations which exacerbate sequelae even where they do not precipitate death . Thus , in France , the average permanent disability 25 rate is 13.5%, covering all initial lesions among persons aged over 60, while it is only I 0.2% for all accident victims as a whole (9). Even though in many countries the number of elderly persons is rising, a certain fatalism seems to reign over the need for dynamic , effective and all- round treatment of elderly patients. Facilities for rehabilitation open to this category of individual are insufficient and in any case less than those pro- vided for the rest of the population . It may also be wondered why com- pensation given, for equally serious sequelae, is 30-50% less than that which other age groups may claim. Developing countries As has been seen above, the number of accidents is increasing in developing countries. The accident victims are the young. In some cases the injured per- son may receive immediate care and, on his return , be covered by the primary health care system. However, the cost of further treatment and rehabilitation may be insupportable for certain countries. These particular geographic and socioeconomic conditions suggest that local resources should be used and that there should be a new direction for accident prevention programmes . For that to happen it would seem to be urgent to develop and utilize a reliable data collection mechanism for acci- dents in this range of countries. Figures for disability and resultant handicap are practically nonexistent in developing countries. Right from the start, initial data and residual disability should be linked so that public health agencies may be guided towards providing overall treatment of accident victims. In addition , it seems to be of prime importance to integrate acci- dent prevention activities with the rehabilitation of accident victims in the primary health care system. INFORMATION SYSTEMS Viewed from the standpoint of definitions , teaching, research, treatment or compensation , accident information services in use at present seem not to meet in full the needs of the necessary overall treatment of accident victims and the global evaluation involved in it (Fig. 6). For example, taking account of initial injuries alone, a distinction be- tween the seriously injured and the slightly injured seems difficult to make. An apparently minor injury may be accompanied by protracted disability at high cost. The duration of hospitalization is not a totally reliable criterion either. The concept of the duration of disability would seem to measure the real seriousness of injuries and of accidents more accurately. The definition 26 Iv -.J Fig. 6. Progress of an accident victim's condition and overall treatment pattern No injury Death Recovery ~-------~•No disability ACCIDENT ► l~JURl~S ► IMPAl~MENT ► Dl~ABILITY ► HANDICAP PREVENTION - NOTIFICATION EMERGENCY ASSISTANCE TRANSPORT HOSPITAL - TREATMENT PREVENTION MEDICAL AND SOCIAL REHABILITATION HOME- FOLLOW-UP MEDICAL AND SOCIAL REHABILITATION of disability remains vague, however, and often ignores the psychological and social aspects of an accident and of injuries. The compensation rates allotted, in France for example, essentially depend on initial diagnosis or on the initial macroscopic description of the case in anatomical and pathological terms. At the other extreme of trauma prognosis, understanding of handicap is distorted by the lack of precise definition. The number of persons with a permanent or temporary handicap (Table 6) has been rated at between 8% and 10% of the population. At the same time, the definitions of estimated handicap vary from one country to another. Above all it is rarely possible to know the initial cause of handicap: accident , illness or congenital condition . Similarly, it is impossible to understand the effect that clifferent methods of accident recovery or transportation of the victim to hospital , surgical inter- vention , reanimation , rehabilitation , etc ., may have on residual handicap. All that can be known is the aggravating effect of certain defects in the victim at the moment of accident - alcoholism or obesity, for example. Finally, no health system appears to be capable of calculating the impact of accidents or, more particularly, of traffic accidents on overall clisability figures in a given community. These difficulties spring from the following . (a) Certain terms should correspond to precise definitions. In this regard participants at the Symposium restated the definitions given in the Inter- national classification of impairments, disabilities, and handicaps (28): - An impairment or anomaly is any loss or temporary or permanent ab- normality of an anatomical, psychological or physiological structure or function resulting from an accident and an injury at the moment the initial treatment phase ends. - Disability is the functional result of impairment and corresponds to a total or partial restriction of ability to perform an activity within the range of those considered normal for an individual. An impairment may not necessarily be accompanied by any disability. The techniques involved in rehabilitation are directed at [removing] clisability. - Handicap is the disability experienced by an inclividual in his usual environment; it varies according to the situations with which the individual is confronted . Compensation, however, is usually based on impairment, much more rarely on disability and handicap. Whereas at the time of the accident and immediately thereafter the seriousness of injuries is a function of the risk to life, subsequently residual clisability and handicap are what ultimately govern the seriousness of an accident. 28 Table 6. Causes of disability and estimated numbers of handicapped in the world Etiology Congenital disorders: mental retardationa inherited somatic impairment nongenetic disorders Communicable diseases : poliomyelitis trachoma leprosy onchocerciasis other communicable diseases Noncommunicable somatic diseases Functional psychiatric disorders Chronic forms of alcoholism and drug abuse Trauma/injuries : traffic accidents occupational accidents accidents in the home miscellaneous Malnutrition Other causes Total Correction for possible duplication (- 25%) Total a Not always congenital cases. Estimated number of handicapped (world population : 4000 million) Millions % 40 7 .7 40 7.7 20 3.9 1.5 0 .3 10 1.9 3.5 0.7 0 .2 40 7 .7 100 19.3 40 7 .7 40 7 .7 30 5.8 15 2.9 30 5 .8 3 0.6 100 19.3 2 0.4 516 100.0 129 387 29 In the light of these definitions it will be realized that the concept of the length of hospital stay is limited in value with regard to the injury and the impairment, and may be extended to the rehabilitation phase in varying degrees, according to the country and the case in question. The duration of disability would be a more exact concept but a precise definition of what is meant by disability should be made . Does it mean the in- ability to work , to receive normal wages , to move around freely on one's own, to drive one's own vehicle, to be independent in all actions to do with every- day life , or is it simply the inability to move the injured part of the body? (b) The lack of follow-up in the file of an accident victim is a major cause of fragmentation of information . There is all too o ften a gap between the traumatology file and the medical and social rehabilitation file . This is in part due to the lack of rehabilitation training among traumatology personnel. (c) However , account should also be taken of the need to align care with the development of a trauma . At the outset , concerns are mainly of a diagnostic nature and are designed to apply conventional treatment - for example , the diagnosis of a ruptured spleen leads to a splenectomy. As soon as the injury has been stabilized , however , where there is no complete recovery and an impairment persists, treatment is switched en- tirely towards restoration or compensation for the loss of function and hence for disability. At this stage obviously diagnostic concerns are not aban- doned and the presence of a physician with a rehabilitation specialty will permit diagnosis of any new deterioration, complication or other inter- current condition. Once the initial diagnosis has been made, however, and the proper treatment has been given, the direction to be adopted should basically be towards overall and individual function in the patient : for example , where a fractured femur has been operated on, bearing the weight of the body, movements of the joints , followed by assisted and unassisted walking. In cases of residual disability there is always a transition from the "diagnostic" phase to the "functional" phase, but in a manner that is more or less highly organized according to local conditions. Even if the accident victim is referred to the most sophisticated rehabilitation centre it is another course of treatment which is instituted and another file which is opened. However, the interweaving of the two phases in a single file and a seamless follow-up is of fundamental importance for continuity of care and overall evaluation of the evolution of a condition, from acci- dent to handicap ._ Such interweaving should make it possible during the initial phase to bear constantly in mind the subsequent development in an accident victim's situation and, during the following phase, to know where the patient comes from and what he has undergone , so as to ensure constant information feedback. 30 Treating accident and handicap from this standpoint, information ser- vices are to be found at the following levels. Accident An accident monitoring system should, in the first place , collect the follow- ing information: - personal demographic characteristics of the accident victim, - characteristics of the accident, including the site of the accident and causative mechanism of the injuries, - the driver's personality traits . Information should not be limited to the local population or the popula- tion seeking medical assistance at a hospital. The Danish accident monitoring system thus includes, after the accident victim's national identity number , the geographical location of the accident and contact with the care unit. A special code makes it possible for accident victims to be distinguished from other acute cases . The following code number records the causation of the accident , with two levels of detail . Finally, another code number describes the activity of the accident victim at the moment of the accident (Fig . 7-10) . Unfortunately, such data are often hard to find and are collected by different departments . They can , nevertheless , be collected by members of different professions with no specialized training but who are sufficiently motivated, and with no assistance from investigators or additional coders. ,-... 1- z w □ (.) (.) <( z □ w > ...J 0 > z Fig. 7. Code for distinguishing between acute illness and accident INJURED? YES NO Accident Patients Contact with YES victims frightened, an accident in shock Suicides Acute No contact with NO Assaults illness an accident Violence Injury No injury All types of emergency 31 Fig. 8. Code for recording the circumstances of an accident PERSON WHO t ♦ PLACE WHERE ♦ t TIME WHEN ♦ IMPACT WHY ♦ ♦ MODE OF IMPACT WHICH/WHO ♦ ♦ INJURIES HOW MEASURES TAKEN] ! [ WHICH/WHO OUTCOME HOW MANY HOW LONG REHABILITATION Injuries The possibility of describing, classifying and quantifying the seriousness of injuries in relation to their cause and their progress involves clinicians, epi- demiologists and public health researchers. Numerous indices, systems or indicators have been proposed . An information system on accident injuries studied retrospectively must meet a number of criteria (29): 32 - validity of prediction allowing correlation with one or more measure- ments of outcome: death, disability, morbidity, for example; - correlation with indicators of seriousness, such as the type and length of treatment, its cost and the assessment of the physician; - simplicity and logical presentation for medical and paramedical personnel; - reproducibility from one user to another for the same patient and from one examination to another for the same patient with the same user; - ease of access to basic data contained in the patient's file; - independence of indices in relation to the treatment applied. Fig. 9. Information collection model RESIDENT POPULATION TRANSIENT POPULATION UNINJURED PERSONS NOT SEEKING TREATMENT SEEKING TREATMENT OUTSIDE HOSPITAL POPULATION EXPOSED T O ACCIDENTS SEEKING TREATMENT SEEKING HOSPITAL TREATMENT .__ ____________ .,ADMISSION ? 33 Fig. 10. Model for accident monitoring procedures ,------------ POPULATION------------~ I I • ... \ \ PREVENTION --- LIVING CONDITIONS -----------+-, OTHER BODIES i ACCIDENTS • STAFF REGISTRATION------ MOTIVATION l DATA i RESEARCH ANALYSIS --------i MOTIVATION i INFORMATION • DISSEMINATION OF INFORMATION -------------' ~~t' RE-EDUCATION ! SURVEILLANCE ACTION ORGANIZATION PRIORITIES AND GOALS CENTRAL PREVENTION DEPARTMENT KNOWLEDGE t ~-----ATTITUDES-----~ 34 The Abbreviated Injury Scale (AIS) is the most widely used system for assessing the gravity of injuries (29) . A derivative of it, the Injury Severity Score (JSS), is equally widely used for assessing the quality and quantity of emergency medical care . This system for data collection on accidents has been constantly im- proved since its introduction in 1971. Significant correlations have been established between the AIS/ISS system and the seriousness of 434 head injuries observed in Glasgow, based on the Glasgow coma scale, the Glasgow results scale, the length of hospitalization, the number of days spent in inten- sive care , and the total cost of hospitalization. Although initially intended for traffic accidents , the system has been used for other types of accident, such as falls. The system seems to have been used as much by medical and para- medical clinical teams as by students , or by nonclinical research workers , sociologists or mathematicians. Computerized conversion trials have been attempted between the ninth revision of the International Classification of Diseases and the AIS/ISS system. So far the trials have not proved conclusive. However , it is certain that if such conversion were possible the collection of data from medical files would be considerably simplified . The greatest difficulty concerns assessment of residual disability and handicap. The AIS scale has shown itself to be a good tool for evaluating prevention programmes and protective devices . Thus , a study relating to 1185 passengers in vehicles involved in accidents provided the following results (Fig. 2-4). AIS ..; 3 AIS > 3 Belt worn n = 300 94% 6% Belt not worn n = 885 89% 11% Even though the AJS code clearly indicates life-threatening hazards, the disability resulting from a nonfatal accident does not seem to be taken into account in this system. Correlation trials are on the way, however. Disability and handicap Measurements of disability and handicap have been undertaken in a num- ber of countries. Studies may be of a comprehensive type such as those in the Netherlands: 8 .7% of the population has a handicap , i.e . one or more major functional disorders; 42% of that total suffers from impaired func- tioning of the lower limbs; 15 .I% of men and 11 .4% of women are handi- capped as the result of an accident. In 37.2% of all cases the accident was a traffic accident and in 22 .9% of all cases an accident in the home. In 1979 35 in the Netherlands, 1205 accident victims were treated in various rehabili- tation units , 599 of whom were there as the result of traffic accidents. Of that number, 134 are permanently bound to a wheelchair . Studies also exist per type of injury; thus , in the departement of the Rhone in France the incidence of spinal cord injuries as a result of acci- dents is 18.5 per million population , of which 42 .8% are due to traffic accidents (30.7%: four-wheeled vehicles; 12.1 %: two-wheelers). The incidence of tetraplegia is particularly high in traffic accidents : 33 .2% (four-wheeled vehicles) and 20.3% (two-wheelers) as against 16.3% for falls (14) . The various studies are of great importance in understanding the economic impact of such injuries or for public health planning, but they provide only very little information on disability and still less on the resultant handicap . If studies are conducted, for example, on patients permanently requiring a wheelchair as the result of an accident , a category of such users may be picked out who are totally independent with regard to their everyday lives, driving their own cars and often having a profession. Obviously they still encounter architectural barriers but are capable of leading a satisfactory life with a minimum of external assistance . On the other hand, other wheel- chair users who are independent, for example, so far as certain intellectual activities are concerned , need assistance in using toilets , in getting up in the morning and going to bed in the evening. Finally, another group are totally dependent; this is the case for victims suffering from severe head injuries associated with damage to the spinal cord . It is thus necessary to perfect a classification system enabling functional defects and resultant handicaps to be recorded . The International classi- fication of impairments, disabilities, and handicaps (ICIDH) , drawn up by WHO (28) , is one such effort. Use of it may assist in evaluating the state of injuries in a person . It can be used in two ways : - to estimate the disability of individuals at a given moment , permitting the collection of useful data for architecture , transport and life- style planning, etc. ; - for the study of cohorts of injured persons in a given period of time, as is being done for survival rates in cancer studies , for example . Feasibility studies should be undertaken with a view to wider utilization of this classification system. Adaptations may also be necessary depend- ing on where such studies are used and on the cases studied . At all events , study of resultant disability requires in the first place the existence of a system for evaluation of such disability. It is also essential to obtain accurate information on the medical or social rehabilitation pro- cedures used. There is still no precise code for these various procedures . Measurements of disability may be greatly facilitated by using data possessed by the national social insurance systems or sick benefit schemes, 36 although this presupposes the existence of standard individual identification systems for all the different public services. There may also be legislative obstacles to the use of information on an individual at one and the same time by more than one public body. Units of measurement and the stress given to certain variables often vary widely from one system to another. The ideal information system must thus , in the last analysis, include three elements, each of them partly known and used but capable of being improved: - a system for information collection on the accident and on injuries caused by the accident (AIS/ISS type); - a system for recording the procedures used both for conventional medical or surgical treatment and for the medical and social rehabili - tation of the patient (the various treatments given, for example); - a system for evaluating disability and resultant handicap (ICIDH type) . These three types of system, more or less well developed, are now already being used separately for different purposes: the epidemiologist and the traumatologist are concerned with the accident-injury system; the social security bodies and the public health planners need to know the type and number of medical interventions made ; rehabilitation or public health specialists, social workers , housing planners, transport planners , etc., will use the functional approach to disability and handicap. A surviving accident victim is concerned with all these elements, be- cause he passes through them or encounters them one after another (Fig. I I). Thus , it is a succession of sometimes very short but sometimes much longer phases that must be understood, collected and codified if a coherent in - formation system as close as possible to reality on the accident and its con- sequences is to be developed . The activities of public bodies must be directed at each of these different phases. Each has its role in feedback, and the feedback lays the groundwork for preventive action on the environment. To separate them from one another would be artificial because at the present moment it is impossible to forecast handicap at the moment of an accident and from the handicap it is not possible to reconstitute the accident. CONCLUSIONS AND RECOMMENDATIONS I. The application of techniques and technologies to the study of accidents should be better developed than it is at present , and in this regard it seems of fundamental importance to develop statistical indicators and methods for data collection and analysis that would make it possible to arrive at more 37 w 00 Fig . 11. Organization of treatment and information following an accident I ► ENVIRtNMENT HANDICAP e j DISABILITY I I I I t-- - - - - - - - - - -►INFORMATION ◄- - - - - - - - - - t REHABILITATION I I I l ~ MEDICAL TREATMENT IMPAIRMENT ◄ I 0 + ACCIDENT 10 INJURY DIAGNOSIS sensitive evaluations of the types of injury and their degree of seriousness. The same considerations apply to the evaluation of disability and handicap as a result of accidents. 2. The development of such indicators and analysis methods would make it possible to evaluate the public health importance of accidents and the injuries they cause , without this having to be based solely on the study of mortality rates that only permit a rough estimate of the phenomenon. Of the other indicators that should be taken into consideration, those relating to the duration of hospitalization , the duration of disability, and the disability and pension rates should be mentioned . Studies should be carried out in order to promote a degree of uniformity in this area which would permit a mini- mum of intercoun try comparisons to be arrived at. 3. The AIS injury code is a useful tool for estimating the initial serious- ness of injuries. It should be used for all types of accident (accidents in the home, sports). 4. In order to arrive at a better understanding of the history of injuries , and thereby to have a better definition of the measures to be implemented to prevent them or to mitigate their effects, some injuries (eye, brain, spinal cord, for example), some types of accident and some groups of accident victims, should be the subject of longitudinal studies taking accoun t of the initial injuries , the methods of treatment applied (including rehabilitation) and residual disability and handicap. 5. It would be interesting to set up regional accident and injury observation centres, in particular in developing countries, where priorities for action for the prevention and treatment of trauma must be speedily defined. 6. Disability and handicap scales, derived for example from the Inter- national classification of impairments, disabilities, and handicaps and suitably adapted to the circumstances of accidents must, in particular , be perfected for systematic utilization. 7. The possibility of a single file bringing together the various phases in the state of each accident victim should be studied and used to permit complete feedback on the accident and its consequences. 8. It is important to include rehabilitation in initial treatment , using spe- cialized medical and paramedical personnel, and training traumatology and reanimation personnel to take overall charge of accident victims. Specific training programmes for this area must be developed. 39 REFERENCES l . Hatton, F . et al. Evaluation «historique» des mesures preventives des accidents de la circulation routiere en France . In: Seminaire ADElF, octobre 1980. Le Vesinet, lnstitut national de la Sante et de Recherche medicale (INSERM). 2. Premier rapport statistique sur /'evolution des accidents de la route en 1979. Paris , European Conference of Ministers of Transport, 1980 (document CM(80) 25). 3. Seat belts and other devices to reduce injuries from traffic accidents: report on a WHO Technical Group. Copenhagen, WHO Regional Office for Europe, 1981 (EURO Reports and Studies, No. 40). 4 . Mackay, GM. Restraint systems: their use and effectiveness. Copenhagen, WHO Regional Office for Europe, 1981 (document ICP/ADR 035) . 5. Education in traffic safety: report on an Ad hoc Technical Group. Copen- hagen , WHO Regional Office for Europe, 198 1 (document ICP/ ADR 013) . 6 . The influence of alcohol and drugs on driving: report on a WHO Ad hoc Technical Group. Copenhagen, WHO Regional Office for Europe, 1981 (EURO Reports and Studies , No . 38). 7. Psychosocial factors related to accidents in childhood and adolescence: report on a WHO Technical Group. Copenhagen , WHO Regional Office for Europe, 198 1 (EURO Reports and Studies, No. 46) . 8. Prevention of road traffic accidents: report on a WHO Working Group . Manila, WHO Regional Office for the Western Pacific, 1979 (docu- ment ICP/ADR 001). 9 . Marget, H. & Picard , P. la reparation du dommage chez le vieillard en /980. Paris, Association generale des Societes d'Assurances contre les Accidents. 10. Planek , T. & Fowler, C. Traffic accident problems and exposure character- istics of the aging driver. Journal of gerontology, 26: 224-230 ( 1976). 11. Deschamps , JP. Prevention of traffic accidents in childhood: report on a WHO Study carried out in conjunction with the International Children's Centre and the University of Uppsala. Copenhagen, WHO Regional Office for Europe , 1981 (EURO Reports and Studies , No. 26). 12. Marcusson , H. & Oehmisch , W. La mortalite causee par !es accidents chez !es enfants : donnees provenan t d'un choix de pays de differents continents 1950-1971 . Rapport de statistiques sanitaires mondiales, 30 : 1 (1977). I 3. Tricot , A. Epidemiologie et etiologie des lesions medullaires ./n: Maury, M. la paraplegie chez l'adulte et /'en/ant. Paris , Flammarion , 1981 . 14 . Minaire , P. et al. Epidemiology of spinal cord injury in the Rh6ne-Alpes Region , France , 1970-75 .Paraplegia, 16 : 76-87 (1978-79). 40 15. Wild, D. et al. How dangerous are falls in old people at home? British medicaljournal, 282 : 266-268 (1981). 16. Sheldin, J.H. On the natural history of falls in old age. British medical journal, No . 5214, pp. 1685 -1690 (I 960). I 7. Department of Prices and Consumer Protection. The Home Accident Sur- veillance System. London , Consumer Safety Unit, 1977 . 18. Department of Prices and Consumer Protection. The Home Accident Sur- veillance System: analysis of domestic accidents to children. London , Consumer Safety Unit, 1979. 19. Child accidents: report on the first Arab Conference on Child Acci- dents, Baghdad, 27-30 November 1978. Beirut, Arab Research Center for Injuries. 20. Bayoumi, A. The · epidemiology of motor vehicle crashes in Kuwait. Quarterly journal of the American Association for Automotive Medi- cine, 3(1): 26-32 (1981). 21. Siddique, A.K. & Abengowe, C.U. Epidemiology of road traffic accidents in developing communities: Nigeria, an example. Tropical doctor, April, pp. 67-72 (1979). 22. Asogwa, S.E. Road traffic accidents: a major public health problem in Nigeria. Public health, 92 : 237 -245. 23. Bawa, P.S. Delhi traffic police. A study on fatal road accidents in Delhi in 1979. Delhi , Road Safety Club of India (Publication 4476). 24. Jacobs, G.D. & Fouracre, P.R. Further research on road accident rates in developing countries. Crowthorne, United Kingdom , Transport and Road Research Laboratory (Supplementary report 270). 25. Jacobs, G.D. & Bardsley, M.N. Road accidents as a cause of death in developing countries. Crowthorne, United Kingdom , Transport and Road Research Laboratory (Supplementary report 277). 26. B;, 0 . Road casualties: an epidemiological investigation. Oslo , Universi- tetsforlaget, 1972. 27. Road traffic accident statistics: report on a WHO Ad hoc Technical Group. Copenhagen , WHO Regional Office for Europe, 1979 (EURO Reports and Studies , No. 19) . 28. International classification of impairments, disabilities, and handicaps. Geneva, World Health Organization , 1980. 29. National Center for Health Services Research. Draft final report from the Woodstock Trauma Severity Index Conference. Hyattsville, MD, US Department of Health and Human Services , 1981. 41 Annex LIST OF PARTICIPANTS Temporary advisers 42 Professor B. Bourret ,° Chief Surgeon , Hospital Centre, Salon-de-Provence, France Professor Miinnever Bertan ,b Institute of Community Medicine , School of Medicine , Hacettepe University, Ankara , Turkey Professor H. Choussat, Honorary Professor , University of Bordeaux II , France (Chairman) Professor K. Franke ,0 Senior Physician , Surgical Clinic, Berlin-Pankow Hospital, Berlin , German Democratic Republic Professor C. Galasko ,0 Department of Orthopaedic Surgery, Hope Hospital , Salford , United Kingdom Professor C. Got,0 Poincare Hospital , Garches , France Dr F. Hatton , National mstitute of Health and Medical Research, Le Vesinet , France Professor G. Huauit ,0 St Vincent de Paul Hospital, Paris, France Dr R.H. Jackson, Department of Paediatrics , Royal Victoria Infirmary, Newcastle-upon-Tyne , United Kingdom Dr V. Janda ,0 Department of Rehabilitation Medicine, Postgradua te Medical Institute , Prague , Czechoslovakia (Vice-Chairman) a Participation expenses paid by the Government of France. b Participation expenses paid by WHO. Dr J.T. Jones, Senior MedicaJ Officer, Department of HeaJth and Social Security, London , United Kingdom Dr G. Kjellberg,0 Department of Paediatrics , University HospitaJ, UppsaJa, Sweden Mr T. Kruse ,0 Accident Analysis Group, Odense University Hospital , Denmark Professor E. Mackenzie,b Division of Health Care Organization , Johns Hopkins School of Hygiene and Public HeaJth, BaJtimore , MD, USA Professor P. Minaire,° FunctionaJ Rehabilitation Department , St Etienne Regional Hospital Centre , France (Rapporteur) Dr Paeslack, Orthopaedic Clinic, Schlierbach, Heidelberg , FederaJ Re- public of Germany Dr N. Reynes, Directorate-General of Health and HospitaJs, Ministry of HeaJth and Social Security, Paris, France Mr M.J. Roper-HaJl,b Edgbaston, Birmingham, United Kingdom Dr C. Rousseau , Physical Injury Documentation Centre , Niort , France Dr J. Sengler ,0 Assistant Physician , Mulhouse HospitaJ Centre , France Professor R.T. Smith ,0 Department of Behavioural Sciences, Johns Hopkins School of Hygiene and Public HeaJth , BaJtimore , MD, USA Professor P. Thestrup Andersen, Orthopaedic Department, Copenhagen County Hospital, Gentofte, Denmark Dr A. Tricot,° Chief of Medicine, Centre of Traumatology and Rehabili- tation, Brugmann Hospital, Brussels , Belgium Dr R. Vos,0 Ministry of Health and Environmental Protection, Leid- schendam, Netherlands 0 Participation expenses paid by the Government of France. b Participation expenses paid by WHO. 43 Professor M. Weiss ,0 Polish Medical Academy, Warsaw, Poland Dr M . Zivkovic, Director , Institute of Physical Medicine and Rehabili- tation, Igalo, Yugoslavia Representatives of other organizations Commission of the European Communities Dr U. Vidali, Principal Adviser, Directorate -General of Employment and Social Affairs , Brussels, Belgium Council of Europe Mr H. Sciclun,0 Strasbourg, France International Children 's Centre Dr Y.H. Des Fontaines-Merckx, Paris , France Observers 44 Professor A. Chaumont, Institute of Forensic Medicine , Faculty of Medicine , Strasbourg, France Dr Girard, Department of Geriatric Medicine, Toulouse Hospital Centre, France Professor R. Honkanen, Department of Community Medicine, University of Kuopio, Finland Ms M. Mutterer, Director , Rehabilitation Centre, Mulhouse, France Dr R. Ottinger, Functional Rehabilitation and Convalescence Centre, Strasbourg, France Dr H. Perret , Ile-de-France Regional Directorate for Health and Social Affairs, Paris , France a Participation expenses paid by the Government of France . World Health Organization Regional Office for Europe Dr C .J. Romer , Manager , Global Programme for Accident Prevention Headquarters Dr E.A. 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