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September 29, 2000


  • Currie G, Kerfoot KD, Donaldson C, Macarthur C. Are cost of injury studies useful? Injury Prevention 2000; 6(3):175-176. (E.45.06 S)

    Studies from the US and Canada have attempted to estimate the economic costs associated with injury. The rationale for these studies is often to provide data for priority setting (both research and policy). Cost of injury studies may be useful in the political sense, for example, by raising public and political awareness of the burden of injury. The authors argue, however, that such studies are not helpful in the context of setting priorities for resource allocation and research activities, and that concentration on cost of injury studies may divert policy makers from what they need to know in order to maximize societal benefits from resource allocation. In this paper, they describe the cost of injury method, explain why cost of injury studies have limited usefulness, and explain how health economics can better contribute to the field of injury prevention.
  • Faelker T, Pickett W, Brison RJ. Socioeconomic differences in childhood injury: a population based epidemiologic study in Ontario, Canada. Injury Prevention 2000; 6(3):203-208. (E.40.04 S)

    The purpose of this study was to determine whether risks for childhood injury vary according to socioeconomic gradients. A population based, retrospective study was conducted, where the percentage of individuals living below the poverty line (described ecologically using census data) was the primary measure of socioeconomic status. The setting was a catchment area of a tertiary medical centre that provides emergency services to all area residents. Area residents aged 0-19 years during 1996 were included. Injuries that occurred during 1996 were identified by an emergency department based surveillance system. The study population was divided into socioeconomic grades based upon percentages of area residents living below the poverty line. Multiple Poisson regression analyses were used to quantify associations and assess the statistical significance of trends. 5894 childhood injuries were identified among 35380 eligible children; 985 children with missing socioeconomic data were excluded. A consistent relation between poverty and injury was evident. Children in the highest grade (indicating higher poverty levels) experienced injury rates that were 1.67 (95% confidence interval 1.48 to 1.89) higher than those in the lowest grade (adjusted relative risk for grades 1-V: 1.00,1.10,1.22,1.42, 1.67; Ptrend < 0.001). These patterns were observed within age/sex strata; for home, recreational, and fall injuries; and for injuries of minor and moderate severities. Socioeconomic differences in childhood injury parallel mortality and morbidity gradients identified in adult populations. This study confirms that this health gradient is observable in a population of children using emergency department data. Given the population based nature of this study, these findings are likely to be reflected in other settings. The results suggest the need for targeted injury prevention efforts among children from economically disadvantaged populations, although the exact requirements of the optimal prevention approach remain elusive.
  • Tursz A, Crost M. Sequelae after unintentional injuries to children: an exploratory study. Injury Prevention 2000; 6(3):209-213. (E.45.02 S)

    The purpose of this study was to determine the frequency and categories of sequelae related to accidental injuries (of all types) in childhood. A prospective follow up study was conducted on a geographically defined population near Paris, France. The study concerned all child residents of one health care district, aged under 15 years, and hospitalised in the two public hospitals of the district, and/or transported by mobile emergency units, after an accident, during a one year period (in 1981- 82; n = 785). Initial severity was scored using the injury severity score (ISS). Sequelae were defined as established impairments (leading or not to disabilities), identified by physicians, reporting their clinical diagnosis or complaints by the child and/or the family. After a follow up period of 3.6-29.2 months after the accident, six children died and 78 (10%) were lost to follow up. Among the 701 others, 73 (10.4%) presented 80 sequelae, major (limiting daily activities) in 44 children (6.3%), with no gender difference. These increased significantly with age. The main causes of major sequelae were eye injuries and sports related injuries to the limbs. ISS did not correlate well with sequelae, but the maximum abbreviated injury scale appeared to be a better predictor of long-term functional prognosis. Prospective follow up and population based studies are still needed, especially on children's injuries initially perceived as benign, such as most of the sports related injuries in our study.
  • Alkon A, Ragland DR, Tschann JM, Genevro JL, Kaiser P, Boyce WT. Injuries in child care centers: gender-environment interactions. Injury Prevention 2000; 6(3):214-218. E.71.02 S)

    The purpose of this study was to examine child characteristics (age, gender) and child care center environments (socioemotional quality, physical safety) that jointly predict injuries for preschool children. A two-year prospective study of 360 preschool children, ages 2-6 years, was conducted in four urban child care centers. Composite scores for center quality and physical safety were derived from on-site observations, and injury rates were based on teacher reports. Poisson regression analyses examined age, gender, center quality, center safety, and the interactions of gender with quality and safety as predictors of injury incidence over one child year. Age was significantly associated with injury rates, with younger children sustaining higher rates. An interaction between gender and center quality also significantly predicted injury incidence: girls in low quality centers experienced more injuries, while girls in high quality centers sustained fewer injuries than their male peers. Finally, an interaction between gender and center safety showed that girls in high safety centers sustained more injuries than boys, while girls in low safety centers sustained fewer injuries. Injuries occur even in relatively safe environments, suggesting that in child care settings, the socioemotional context may contribute, along with physical safety, to the incidence of injury events. Further, gender specific differences in susceptibility to environmental influences may also affect children's vulnerability and risks of injuries. The prevention of injuries among preschool children may thus require attention to and modifications of both the physical and socioemotional environments of child care.
  • Nathens AB, Neff MJ, Goss CH, Maier RV, Rivara FP. Effect of an older sibling and birth interval on the risk of childhood injury. Injury Prevention 2000; 6(3):219-222. (E.40.08 S)

    : Certain family structures have been identified as putting children at high risk for injury. To further define children at highest risk, the authors explored the effect of an older sibling and birth interval on the risk of injury related hospital admission or death. Data were analyzed using a case-control design. Cases and controls were identified by linking longitudinal birth data from Washington state (1989-96) to death certificate records and hospital discharge data obtained from the Washington State Comprehensive Hospital Abstract Reporting System and frequency matched in a 1:2 ratio on year of birth. Cases consisted of singleton children 6 years of age or younger who were hospitalized or died as a result of injury during the years 1989-96. Multivariate logistic regression was used to identify and adjust for confounding variables. There were 3145 cases and 8371 controls. The adjusted odds ratio for injury in children with an older sibling was 1.50 (95% confidence interval 1.37 to 1.65). The effect was greatest in children under 2 years of age, and in those with a birth interval of less than two years. As the number of older siblings increased, so did the risk of injury, with the highest risk in children with three or more older siblings. These data suggest that the presence of an older sibling is associated with an increased risk of injury. The risk is highest in those with very short birth intervals. Potential mechanisms for this increased risk may relate to inadequate parental supervision. Pediatricians and other care providers need to be alert to these identifiable risk factors and then direct preventive strategies, such as home visits and educational programs, toward these families.
  • Kohen DE, Soubhi H, Raina P. Maternal reports of child injuries in Canada: trends and patterns by age and gender. Injury Prevention 2000; 6(3):223-228. (E.40.08 S)

    This study examines gender and age differences in maternal reports of injuries in a cross sectional group of children aged 0-11 years. The cause, nature, body part injured, and location of injury are explored, as are the associations with family socioeconomic indicators and associations with limitations in activities. Data for 22831 children and their families come from cycle 1 of the Canadian National Longitudinal Survey of Children and Youth collected in 1995. Descriptive analyses and chi2 tests for trends are used to examine injury variations by child gender and age. Logistic regressions are used to examine the relationship between socioeconomic indicators and injury and the associations between injury and limitations in activities. Consistent with findings from hospital data, boys experience more injuries than girls, and injuries increase with child age. Falls are the most common sources of maternally reported injuries, followed by scalds/poisonings for young children and sports injuries for school aged children. The majority of injuries occur in or around the home for young children, but at school for older children. For maternal reports of childhood injuries, single marital status is a risk factor for boys. Maternally reported injuries occur in 10% of Canadian children and many of these are associated with limitations in activities. Preventative strategies should take both child age and gender into consideration.


  • Osberg JS, Stiles SC. Safety behavior of in-line skaters . Injury Prevention 2000; 6(3):229-231.(E.62.04 S)

    Injuries from in-line skating have risen sharply in many cities around the world. To understand risk taking behavior and safety practices associated with urban in-line skating, 2210 outdoor skaters were observed in Boston, Massachusetts. Estimated age, gender, use of helmets, wrist guards, elbow and kneepads were recorded. Skaters were coded as beginner, average, or advanced, and skating locations were classified as street, sidewalk, or bicycle path. About 60% of skaters wore wrist guards, but only 5.7% wore helmets. Males wore less protective equipment than females, and were more likely to skate on streets. Beginners and advanced skaters wore more protective gear than average skaters did. Surprisingly, street skaters wore less protective gear than skaters on sidewalks or paths did. Renewed focus on the importance of wearing helmets is needed. Given the higher injury risks for males, clinicians and public health experts need to target male skaters in prevention efforts. In addition, average and advanced skaters need to be convinced that even though they have improved, it is still important to wear protective gear.
  • Danis RP, Hu K, Bell M. Acceptability of baseball face guards and reduction of oculofacial injury in receptive youth league players. Injury Prevention 2000; 6(3):232-234. (E.63.02 S)
    The purpose of this study was to assess the relative injury reduction effect and acceptability of face guards on batter's helmets. A non-randomized prospective cohort study among 238 youth league baseball teams in Central and Southern Indiana was conducted during the 1997 season. Coaches, parents, and players were asked to respond to pre-season and post-season questionnaires. Approximately one half of the teams were supplied with face guard helmets (intervention); all others used this protection at their discretion (comparison). Parents, players, and coaches on the intervention teams reported a reduction in the incidence ococulofacial injuries compared with comparison team respondents (p=0.04). There was no reported adverse effect of face guard use on player performance. Helmet face guards should be required for batters to prevent facial injuries in baseball.


  • McLoughlin E, Fennell J. The power of survivor advocacy: making car trunks escapable. Injury Prevention 2000; 6(3):167-170. (E.52.02 S)

    Survivor advocates are powerful workers for injury prevention. Some of the major prevention successes have been due in large part to their efforts. This case history examines the four-year campaign to prevent entrapment in car trunks (or boot) through the routine installation of interior trunk releases. It traces how a life-altering event began a cluster of activities leading to product redesign and regulation to prevent injury. The following elements were key: data and the lack thereof, identification of possible solutions, newsworthy tragedies and media advocacy, politics and sympathetic lawmakers, an agency with regulatory authority, manufacturers, and trade associations. Survivors can assist the injury field because the personal and the professional complement each other in advocacy. Public health professionals can assist survivor advocates by sharing research, data and organizational skills, and by helping to secure grants.
  • Waller PF, Eribes CM. Children dying in car trunks: how adequate are child death databases? Injury Prevention 2000; 6(3):171-174. (E.52.02 S)

    The purpose of this study was to determine the frequency of and circumstances surrounding child deaths resulting from inadvertent entrapment in motor vehicle trunks in the US by querying child fatality review databases. A telephone survey was conducted with the persons or offices identified as having primary responsibility for child fatality review programs in each state. The survey requested information on the number of child deaths resulting from trunk entrapments, the ages of the victims, the time period covered by the surveillance system, and variables concerning the circumstances surrounding each incident. All states reported that these deaths are exceedingly rare, with most reporting no such events in recent history. However, state databases could not be readily accessed to identify such deaths. There was enormous interstate variation in guidelines governing the population covered by the child fatality review process. The age range varied greatly from one jurisdiction to another, and often only children in the state's welfare system were included. Interstate differences in practices preclude meaningful compilation of data across jurisdictions. It was not possible to ascertain the incidence of inadvertent entrapment of children in vehicle trunks because there is no consistency in the available databases. A national database of child fatalities, based on standardized guidelines and definitions, is needed to identify causes and magnitude of specific child deaths, in order to design, implement, and evaluate interventions.
  • Kopjar B. Population preventable fraction of bicycle related head injuries . Injury Prevention 2000; 6(3):235-238. (E.51.02.02 S)

    This study analyzes the population attributable fraction (PAF) of bicycle head injuries due to non-helmet use. The concept of the PAF and Levin's formula for its calculation were used to develop mathematical models for estimation of: (i) attributable fraction of bicycle related head injuries in the population due to non- helmet use, (ii) expected proportion of helmeted cases among all head injuries, and (iii) estimate of the helmet use rate in the population based on patient case information. The PAF was calculated for a sample of injuries from Stavanger, Norway. Levin's formula was used to calculate the PAF. Two additional mathematical models were developed for calculating the expected proportion of helmeted cases and the estimation of the helmet use rate in the population. The calculation examples for all models are shown. It was estimated that 133 out of 210 injuries could have been avoided in Stavanger between 1990 and 1996 if all children aged 0-14 had used helmets. If applied correctly, the PAF is a valid and useful indicator for the population effects of bicycle helmets. The models developed in this study may help to better interpret and predict the population effects of helmet promotion interventions.
  • Speier J. Child passenger restraints. SB 567. 2000. CaliforniaVehicle Code. (E.52.02.06 S)

    Under existing law, it is unlawful for any parent or legal guardian, when present in a motor vehicle, as defined, to permit his or her child or ward who is less than 4 years of age or weighs less than 40 pounds to be transported on the highway in the vehicle without using a specified child passenger restraint system. 9-26-2000. This bill would require any parent or legal guardian to secure the child or ward in a child passenger restraint system unless the child or ward is at least 6 years of age or older or weighs 60 pounds or more. In addition, this bill would increase the fines for violating this provision.
  • Levy DT, Vernick JS, Howard KA. Relationship between driver's license renewal policies and fatal crashes involving drivers 70 years or older. Journal of the American Medical Association 1995; 274(13):1026-1030. (E.52.02 S)

    The purpose of this study was to assess the relationship between state driver's license renewal policies and fatal crashes involving drivers aged 70 years or older (seniors). Poisson regression methods were used to isolate the relationship between different state policies mandating vision tests, knowledge tests, or road tests for driver's license renewal and fatal crashes involving senior drivers. The analysis controlled for differences among states, other than their renewal policies, likely to influence senior motor vehicle crashes, 1985 through 1989. All fatal crashes identified in the National Highway Traffic Safety Administration Fatal Accident Reporting System involving at least one driver aged 70 years or older were included. The main outcome measure was the number of fatal crashes per state in which at least one of the drivers was aged 70 years or older. When a single fatal crash involved more than one senior driver, each was included. State-mandated tests of visual acuity, adjusted for license renewal period, were associated with lower fatal crash risk for senior drivers (relative risk, 0.93; 95% confidence interval, 0.89 to 0.97). Knowledge tests, when added to vision tests and applied only to seniors, provided a nonsignificant reduction in the senior fatal crash risk (relative risk, 0.91; 95% confidence interval, 0.79 to 1.05). Tests of vision and knowledge for senior drivers at license renewal merit further attention as a means of improving senior traffic safety.


  • Kellermann AL, Fuqua-Whitley DS, Sampson TR, Lindenmann W. Public opinion about guns in the home. Injury Prevention 2000; 6(3):189-194. (E.96 S)

    The purposes of this study were to: (1) Determine the frequency of gun ownership, acquisition, and transfer; (2) assess gun storage practices; and (3) compare the views of firearm owning and non-owning adults regarding the protective value of keeping a gun in the home. Over three different time periods (1995, 1996, and 1999) stratified, random digit telephone surveys were conducted in a five county area of metropolitan Atlanta, Georgia. Five hundred adults (aged 21+ years) responded to each survey. The proportion of Atlanta area households reporting firearm ownership was generally stable over this interval (38%, 40%, and 35% respectively). The percentage of gun owning households containing a handgun (approximately 75%) was stable as well. In 1995, more than half of gun owning households kept one or more guns unlocked; since that time, the trend has been gradually downward. In 1995, 44% of gun owning respondents kept one or more guns loaded, compared with 38% in 1996 and 40% in 1999. A majority of respondents to all three surveys (55%) agreed with the statement "A home with a gun is less secure than a home without a gun, because a gun can be involved in an accidental shooting, suicide or family homicide". Among five home security measures, respondents rated a burglar alarm most effective and keeping a gun in the home least effective. In Atlanta, many households keep a firearm for protection, but they are ambivalent about the associated risks. These findings suggest that education about gun safety should include a discussion of the risks of unsafe storage, and non-lethal alternatives for home security.
  • Kivlin JD, Simons KB, Lazoritz S, Ruttum MS. Shaken baby syndrome. Ophthalmology 2000; 107(7):1246-1254. (E.80.02.04 S)

    The purpose of this study was to examine the comprehensive ophthalmologic experience with the shaken baby syndrome at one medical center, including clinical findings, autopsy findings, and the outcome of survivors. A retrospective, noncomparative case series was conducted on 123 children admitted from January 1987 through December 1998 for subdural hematomas of the brain secondary to abuse. Clinical features of eye examinations of the patients during their admission and after discharge and histopathologic observations for patients who died were retrieved from medical records and statistically analyzed. Visual response and pupillary response on initial examination, fundus findings, final vision, neurologic outcome of survivors, and death were analyzed. Ninety percent of the patients had ophthalmologic assessments. Retinal hemorrhages were detected in 83% of the examined children. The retinal hemorrhages were bilateral in 85% of affected children and varied in type and location. Nonophthalmologists missed the hemorrhages in 29% of affected patients. Poor visual response, poor pupillary response, and retinal hemorrhage correlated strongly with the demise of the child. One child who died had pigmented retinal scars from previous abuse, a condition not previously observed histopathologically to our knowledge. One fifth of the survivors had poor vision, largely the result of cerebral visual impairment. Severe neurologic impairment correlated highly with loss of vision. Shaken baby syndrome causes devastating injury to the brain and thus to vision. Retinal hemorrhages are extremely common, but vision loss is most often the result of brain injury. The patient's visual reaction and pupillary response on presentation showed a high correlation with survival. Good initial visual reaction was highly correlated with good final vision and neurologic outcome. According to the literature, when retinal hemorrhages are found in young children, the likelihood that abuse occurred is very high. Nonophthalmologists' difficulty in detecting retinal hemorrhages may be an important limiting factor in identifying shaken babies so they can be protected from further abuse.

Alcohol/Drug Use:

  • Hingson RW, Heeren T, Jamanka A, Howland J. Age of Drinking Onset and Unintentional Injury Involvement After Drinking. Journal of the American Medical Association 2000; 284(12):1527-1533. (E.40.02 S)

    In 1997, unintentional injury was the leading cause of death for persons aged 1 to 34 years. Approximately one third of deaths due to unintentional injury in the United States are estimated to be alcohol related. Onset of drinking at an early age has been found to be associated with alcohol dependence, but whether early-onset drinking increases risk for unintentional injury while drinking is unknown. The purpose of this study was to explore whether persons who started drinking at an early age are more likely to have experienced unintentional injuries while under the influence of alcohol. The National Longitudinal Alcohol Epidemiology Survey, a cross-sectional survey conducted in 1992 of a representative sample of the US population, was used. A total of 42,862 randomly selected adults (response rate, 90%; mean age, 44 years) were the study population. Unintentional injury involvement while under the influence of alcohol by age of drinking onset (categorized as <14 years, each age from 14-20 years, or >/=21 years) was the main outcome measure. Relative to respondents who began drinking at age 21 years or older, those who started before age 14 years as well as those who started at each intervening age up to 21 years were significantly more likely to have been injured while under the influence of alcohol, even after controlling for history of alcohol dependence, heavy drinking frequency during the period that they drank most, family history of alcoholism, and other characteristics associated with earlier onset of drinking. After adjusting for these variables, odds ratios for having been injured while under the influence of alcohol were as follows: for younger than 14 years, 2.98; age 14 years, 2.96; age 15 years, 3.14; age 16 years, 2.38; age 17 years, 2.12; age 18 years, 1.33; age 19 years, 1.42; and age 20 years, 1.39.Drinking onset at ages younger than 21 years is associated with having experienced alcohol-related injuries.

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