International Journal of Injury Control and Safety Promotion
ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20
A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial Chebiwot Kipsaina, Uwom O. Eze & Joan Ozanne-Smith To cite this article: Chebiwot Kipsaina, Uwom O. Eze & Joan Ozanne-Smith (2015) A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial, International Journal of Injury Control and Safety Promotion, 22:3, 193-202, DOI: 10.1080/17457300.2014.884142 To link to this article: http://dx.doi.org/10.1080/17457300.2014.884142
Published online: 18 Feb 2014.
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Date: 07 November 2015, At: 16:23
International Journal of Injury Control and Safety Promotion, 2015 Vol. 22, No. 3, 193–202, http://dx.doi.org/10.1080/17457300.2014.884142
RESEARCH ARTICLE A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial Chebiwot Kipsainaa*, Uwom O. Ezeb and Joan Ozanne-Smitha a
Department of Forensic Medicine, Monash University, Melbourne, Australia; bDepartment of Pathology, University College Hospital, Ibadan, Nigeria
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(Received 30 May 2013; accepted 13 January 2014) This study explored the challenges in establishing a mortuary-based injury surveillance system in a resource-constrained setting of Ibadan, Nigeria. To quantify and detail fatal injuries, in September 2010 to February 2011, a prospective data collection utilised the World Health Organization–Monash draft surveillance system. Findings were compared with other low- and middle-income settings, and surveillance system attributes were assessed. The leading injury mechanism among all age groups was transport related, with 45.6% being vulnerable road users, consistent with comparable settings. Firerelated injury was the second unintentional cause in the Ibadan pilot, unlike Global Burden of Disease estimates for Nigeria, Mauritius and Mexico, where drowning was the second cause. Positive system attributes included timeliness, data field completeness, specificity, flexibility and sensitivity. Despite apparent under-reporting of eligible deaths and questionable representativeness, this study illustrates potential for mortuary data to inform injury prevention policies and programmes in resource-constrained settings. Keywords: fatal injury; standardised surveillance systems; mortuary; low–middle income country
1. Introduction
1.2.
1.1.
In the majority of African countries, sources of fatal injury data have included hospital emergency department-based injury surveillance systems, death certificates or police reports (Coady & Sorlie, 2001; Grills, Ozanne-Smith, & Bartolomeos, 2011; Jones, Martin, Larson, & Levy, 1998; Kobusingye, Guwatudde, & Lett, 2001; Salinas et al., 2008). While informative, these sources are limited as not all cases present to hospital or any other health care facility, and where a death certificate has been available, it has usually been poorly completed (Coady & Sorlie, 2001). Importantly, police statistics represent only those cases reported to the police, and they are mainly road trafficrelated fatalities or homicides (Grills et al., 2011; London, Mock, & Abantanga, 2002; Weiss et al., 2006). To our knowledge, only one mortuary-based surveillance system currently exists in Africa, which is located in South Africa. Other pilot studies, including those in Ethiopia, Ghana and Mozambique, have not resulted in sustainable systems in mortuary settings (Abdella, Bartolomeos, Tsegaye, Bhalla, & Abraham, 2010; Adofo, Donkor, Boateng, Afukaar, & Mock, 2010; Nizamo, Meyrowitsh, & Zacarias, 2006). In South Africa, a gap in systematic and rigorous information systems, which would inform safety promotion
Injury data worldwide
Injury is a significant public health issue. In 2008, the World Health Organization (WHO) estimated that globally, 5.1 million people died from injury which accounted for 9% of all global deaths. The burden of injuries is unevenly represented. An estimated 687,000 people died in Africa as a result of injuries in 2008 accounting for 14% of all injury-related deaths worldwide (WHO, 2011) equivalent to its global population proportion (United Nations Department of Economic and Social Affairs, Population Division, 2011). While countries in the developed world have continued to reduce injury deaths, countries in the developing world have witnessed the reverse in recent years. The issue is perpetuated by the unavailability of adequate data to elevate injury on many government policy agendas. High-quality and reliable data are key to injury prevention and safety promotion (Weiss, Gutierrez, Harrison, & Matzopoulos, 2006). In high-income countries where injury prevention progress has been made, data utilised are from a variety of sources, including vital statistics, coroners, medical examiners, autopsy, toxicology, police and other law enforcement reports (Pearse & Daking, 2007; Steenkamp et al., 2006; Weiss et al., 2006).
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
Fatal injury surveillance in Africa
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initiatives, was identified as a major obstacle to injury prevention interventions (Matzopoulos, Van Niekerk, Marais, & Donson, 2002). Therefore, in 1999, the National Injury Mortality Surveillance System (NIMSS, 2010) was established to provide basic information on external cause deaths. The system initially collated data for individuals admitted to three participating urban mortuaries (Port Elizabeth, Cape Town and Pretoria), including demographic details, injury scene, circumstance and manner of injury, and toxicology information (Matzopoulos et al., 2002). The NIMSS has since expanded to full coverage in two provinces, Gauteng and Mpumalanga, and four cities, Johannesburg, Pretoria, Durban and Cape Town, and to include fatal injury information from 62 medico-legal laboratories in seven provinces with data collected ranging from 39% to 52% of all injury deaths in 2008. Collection from both rural and urban areas allows comparisons across these settings (Donson, 2008a; Safety and Peace Promotion Research Unit [SAPPRU], 2012). A good quality injury surveillance system, as for all public health surveillance systems, should include an evaluation process. The Centres for Disease Control (CDC) surveillance system evaluation framework (CDC, 2001) recommends assessment of the following system attributes: simplicity, flexibility, data quality, acceptability, sensitivity, positive predictive value, representativeness, timeliness and stability with each system emphasising those attributes that are the most important for the objectives of its system (Espitia-Hardeman & Paulozzi, 2005; Recommendations from the Guideline Working Group, 2001).
1.3.
Aims
Building on knowledge from South Africa and other relevant settings, this study aimed to (1) quantify the burden of reported fatal injuries in Ibadan, using a data collection tool developed by WHO and Monash University (Bartolomeos, Kipsaina, Grills, Ozanne-Smith, & Peden, 2012); (2) compare the findings with other countries in similar low–middle income country (LMIC) contexts; and (3) assess the Ibadan pilot system attributes against selected established CDC criteria to explore the Ibadan system’s strengths and limitations and to inform the process of establishing such systems in resource-constrained settings.
cases per year. The UCH mortuary admits an estimated 75% of all mortuary cases from the catchment area mainly through the hospital though deaths outside the hospital are also admitted. 2.2.
The data collection tool was developed during preparation of the WHO–Monash University fatal injury surveillance manual, published in 2012. See Appendix 1 (Bartolomeos et al., 2012; Grills et al., 2011). Detailed information on all cases admitted to the mortuary from September 2010 to February 2011 was collected prospectively. The data was collected by internal staff; no staff were contracted for this data collection. Additionally, a web-based literature search was conducted on Medline, Web of Knowledge and Cochrane databases with the keyword search terms injury, fatal, mortality, mortuary, surveillance, and Africa and Mesh terms. The grey literature was also searched for reports and conference proceedings. Articles and reports matching the following criteria were eligible for comparison: studies and systems that investigated the mortuary as a source of injury studies that examined more than one type of injury, studies undertaken in Africa, studies on humans, in English and available in electronic format. In total, seven articles were retrieved and a reference list search of the retrieved articles was conducted for further relevant articles, but none were found. Of the seven articles obtained, three were included in this study and others not meeting the criteria were excluded. As there is no gold standard system or data with which to compare the Ibadan results, we compared them with NIMSS data from Mpumalanga province in South Africa, which has collected comprehensive fatal injury data since 1999 (Donson, 2008b; SAPPRU, 2012), and pilot studies in Maputo, Mozambique (Nizamo et al., 2006) and Kumasi, Ghana (Adofo et al., 2010). For broad comparison with the Ibadan data, data from two somewhat comparable LMICs, Mauritius and Mexico, with similar tropical climates marked by dry and rainy seasons, and reliable, reasonably complete death registration data (according to WHO) were extracted from Global Burden of Disease (GBD) 2008 estimates. No similar low-income countries have sufficiently good quality data for such comparisons. 2.3.
2. Methods 2.1.
Setting
The University College Hospital (UCH), one of the largest teaching hospitals in Oyo state in Southwest Nigeria, is situated in the city of Ibadan with a population of about 2,855,000. Its mortuary has a capacity of 3000 admission
Data collection and management
Data analysis
A preliminary data-set was created in an Excel spreadsheet, cleaned and mainly univariate, and descriptive analysis was performed using Stata Version 11. Results were compared with data from the similar poor resourced settings. Relevant to this study, the following attributes were assessed against the CDC surveillance system evaluation
International Journal of Injury Control and Safety Promotion criteria for Ibadan compared with fatal injury data from other African cities or provinces and comparable countries: simplicity, usefulness, acceptability, data quality and completeness, timeliness, representativeness and flexibility.
3.2.
Mechanism and scene of fatal injury in Ibadan
In Ibadan, transport-related injury remains the leading fatal mechanism among all age groups (Table 1). While motorised two-wheeler crashes were the leading cause among persons aged 15–44 years (29.0%), persons aged 45–64 years (37.5%) were more likely to be killed as pedestrians. Almost half (45.6%) of the reported external case deaths were motorised two-wheeler users or pedestrians, followed by other motor vehicle users (19.5%), then firerelated and falls with 13.8% and 8.1%, respectively. Among these cases, five were identified as work-related, three adverse effects of medical or surgical care, two from youth and gang violence and two from domestic incidents. The majority of reported injury deaths occurred on the road, street or highway (67.5%), followed by residential facilities, e.g. for displaced persons, orphans, disabled, police cells (15.5%), (Table 2). Among road deaths, four times more males died (n ¼ 67) than females (n ¼ 16). Among reported deaths in residential facilities, males outnumbered females by 3:1 (Table 2).
3. Results
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3.1. Demographic characteristics A total of 1184 cases were admitted to the UCH mortuary during the study period, September 2010–February 2011. Of these, 304 were coroners’ cases of which 123 resulted from external causes. Of these external cause deaths, i.e. injuries and poisonings, 95 (77.2%) were male and males dominated for all mechanisms; the mean age (SD) was 39.3 years (19.1). Most (50.1%) were in the 15–44 year age group, and for seven (5.6%), age was not recorded. This age distribution is similar to that for both Mpumalanga province and Kumasi city (Ghana), where the mean ages (SD) were 34.0 (17.1) and 32.7 (19.0) years, respectively.
Table 1. External causes of death in Ibadan by mechanism of injury and age group, September 2010–February 2011. Mechanism of injury Motorised two-wheeler crash Pedestrian struck Motor vehicle crash Burns/smoke/fire Falls Violence and suicide Other and unknown Total
0–4 years (%)
5–14 years (%)
15–19 years (%)
20–24 years (%)
25–44 years (%)
45–64 years (%)
65 years (%)
Missing (%)
Total (%)
0 (0.0) 2 (28.6) 0 (0.0) 2 (28.6) 3 (42.9) 0 (0.0) 0 (0.0)
1 (20.0) 1 (20.0) 0 (0.0) 1 (20.0) 0 (0.0) 2 (40.0) 0 (0.0)
0 (0.0) 0 (0.0) 1 (33.3) 2 (66.7) 0 (0.0) 0 (0.0) 0 (0.0)
3 (42.9) 1 (14.3) 0 (0.0) 0 (0.0) 1 (14.3) 1 (14.3) 1 (14.3)
15 (29.4) 7 (13.7) 14 (27.5) 7 (13.7) 2 (3.9) 3 (5.9) 3 (5.9)
6 (19.4) 12 (38.7) 6 (19.4) 3 (9.7) 2 (6.5) 2 (6.5) 1 (3.2)
1 (9.1) 5 (45.5) 1 (9.1) 2 (18.2) 1 (9.1) 1 (9.1) 0 (0.0)
2 (28.6) 0 (0.0) 2 (28.6) 0 (0.0) 1 (14.3) 2 (28.6) 0 (0.0)
28 (22.8) 28 (22.8) 24 (29.5) 17 (23.8) 10 (8.1) 11 (8.9) 6 (4.9)
7
5
3
7
51
32
11
7
123
Table 2. External causes of death by mechanism, scene of injury and sex in Ibadan, September 2010–February 2011 Sex Mechanism Motorised two-wheeler crash Pedestrian struck Motor vehicle crash (excludes two wheelers) Burns/smoke/fire Falls Violence and suicide Other and unknown Scene Road/street/highway Residential facility Private house and yard Medical service area Other public area
Female (%), n ¼ 28
Male (%), n ¼ 95
Total (%), N ¼ 123
3 (10.7) 5 (17.9) 7 (25.0) 7 (25.0) 1 (3.6) 3 (10.7) 2 (7.1)
25 (26.3) 23 (24.2) 17 (17.9) 10 (10.5) 9 (9.5) 8 (8.4) 3 (3.2)
28 (22.8) 28 (22.8) 24 (19.5) 17 (13.8) 10 (8.1) 11 (8.9) 5 (4.1)
16 (57.1) 5 (17.9) 2 (7.1) 2 (7.1) 3 (10.8)
67 (70.5) 14 (14.7) 4 (4.2) 1 (1.1) 9 (9.5)
83 (67.5) 19 (15.5) 6 (4.9) 3 (2.4) 12 (9.8)
Note: Includes firearm discharge, violence with objects, poisoning and suicide by hanging fatal injuries.
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Figure 1. Manner of death for comparable cities of Ibadan, Kumasi, and Maputo and Mpumalanga province.
3.3.
Comparisons of Ibadan findings with selected settings by manner and mechanism of death
As for Ibadan, unintentional transport-related injury was the leading manner of death for Mpumalanga province (South Africa), Maputo city (Mozambique) and Kumasi city (Ghana), respectively, accounting for 86.1%, 46.1%, 59.4% and 60.9% of total reported injury deaths. This was followed by undetermined cases (6.5%) and violence (5.7%) for Ibadan, while in all other settings violence was the second leading manner of death (Figure 1). Although a wide range of mechanisms was recorded in all the four settings, Ibadan was the only setting to record no drowning or electrocution deaths (Table 3). In 5 months, we recorded a total of 123 injury-related fatal cases for Ibadan city alone, which estimates to 295 cases in 12 months.
The UCH mortuary admits 75% of the annual coroner’s fatal cases, we therefore estimated that the total number of mortuary cases in Ibadan for a year to be 393 with 98 (25%) of these cases going to alternative mortuary. Comparisons by age group across the four settings could not be tabulated as each setting categorised age groups differently, but, across all settings, deaths in the age group 15– 44 years accounted for the majority of deaths with transport accounting for a greater percentage (Adofo et al., 2010; Donson, 2008a; NIMSS, 2010; Nizamo et al., 2006). Comparison of reported Ibadan unintentional injury death data with WHO GBD 2008 estimates for Nigeria and two comparable countries, Mauritius and Mexico, is shown in Table 4. When compared to the country results, excluding other unspecified unintentional injuries, Ibadan data indicated deaths from fires (14.6%) as the second leading injury cause, unlike Nigeria as a whole, Mauritius and Mexico where drowning was the second leading cause with 11.6%, 13.5% and 7.4%, respectively. 3.4.
Assessment against selected injury surveillance attributes
Relevant attributes were assessed using the CDC evaluation framework for surveillance systems. 3.4.1.
Usefulness and acceptability
The data system was accepted and reported to be useful and user-friendly by the forensic pathologist Uwom O. Eze [UOE], who prospectively collected the data in his
Table 3. Mechanism of injury by external cause deaths in four comparable cities/provinces.
Mechanism Motorised two-wheeler crash Pedestrian struck Motor vehicle crash Burns/smoke/fire Falls Firearm discharge Violence with sharp objects Violence with blunt objects Hanging /strangulation Drowning Poisoning Electrocution Other Unknown Total a
Ibadana (Federal Republic of Nigeria) n (%)
Mpumalanga (South Africa) n (%)
Maputo (Mozambique) n (%)
90 (22.7) 90 (22.7) 77 (19.5) 54 (13.8) 32 (8.1) 13 (3.2) 3 (0.8) 16 (4.1) 3 (0.8) 0 (0.0) 6 (1.6) 0 (0.0) 6 (1.6) 3 (0.8)
36 (1.0)b 471 (13.1) 1156 (32.2) 98 (2.7) –d 81 (2.3) 293 (8.2) 95 (2.6) 485 (13.5) 146 (4.1) 74 (2.1) 26 (0.7) 362 (10.1) 271 (7.5)
–d –d 496(43.7) 89 (7.8) 42 (3.7) 99 (8.7) 47 (4.1) 80 (7.0) 48 (4.2) 74 (6.5) –d 17 (1.5) 47 (4.1) 96 (8.5)
3594
1135
393 b
c
Kumasi (Ghana) n (%) 185(12.0) 756 (48.9)c 54 (3.5) 72 (4.7) –d 154 (10.0)e 42 (2.7) 66 (4.3) 80 (5.2) 20 (1.3) 116 (7.5) –d 1545
Note: Data for 12 months were extrapolated from 5 months of data; motorised two-wheeler and bicyclist aggregated; includes transport not classified elsewhere; dno data recorded; eincludes deaths from all objects. Source: Adofo et al. (2010), Donson (2008a, 2008b), NIMSS (2010), Nizamo et al. (2006).
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Table 4. Comparison of Ibadan reported injury deaths with WHO data for Nigeria and comparable countries. Unintentional fatal injuries
Ibadan (n)
%
Nigeria (n)
%
Mauritius (n)
%
Mexico (n)
%
Road traffic accidents Poisonings Falls Fires Drownings Other unintentional
257 6 32 54 0 22
69.3 1.6 8.6 14.6 0.0 5.9
24,850 7297 3373 6497 7422 14,392
38.9 11.4 5.3 10.2 11.6 22.5
186 9 28 18 54 107
46.3 2.1 7.0 4.5 13.5 26.6
13,754 1234 2405 679 2521 13,456
40.4 3.6 7.1 2.0 7.4 39.5
Total
371
63,832
402
34,050
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Source: WHO (2011).
capacity as an in-house consultant with the UCH. There have been no other independent end-user reports of use or applications of the data to date. 3.4.2.
Timeliness
The data in this pilot study were collected prospectively for 5 months. The single investigator completed and uploaded all of the required external cause case data into the data collection programme daily. 3.4.3. Data quality and completeness For several main variables data completeness was 100%, including sex, scene of injury, manner of death, time and date of injury and death, mechanism of injury and immediate medical cause of death. The completeness of information was slightly lower for age and antecedent cause of death, 94.3% and 93.4%, respectively. When mechanism of injury was cross-tabulated with age group and location of occurrence, ‘other’ and ‘unknown’ codes were applied to only 4.9% and 9.8% of cases, respectively. The overall proportion of data collected as ‘other unspecified’ was 5.9%, which is significantly lower compared to the other settings of Nigeria, Mauritius and Mexico, of 22.5%, 26.6% and 39.5%, respectively. 3.4.4.
Representativeness
Marked differences in rank order of injury mechanisms were observed between settings. For unintentional injury mechanisms, except road traffic injuries and burns, the number of reported cases was less than expected for a setting such as Ibadan, and also lower than expected for suicide. 3.4.5.
Specificity
As described above, the lowest proportion of ‘unknowns’ and ‘other’ was observed for Ibadan versus Nigerian GBD estimates, Mauritius and Mexico. Compared to the GBD estimates, greater specificity was achieved in Ibadan including road user type, and special fields of work-related cases, youth or gang violence and domestic incidents.
4. Discussion This study is a response to the ongoing urgent need for timely and reliable data in LMICs as a basis to curb the increasing burden of injuries in these settings. It aimed to identify the strengths and limitations of utilising the mortuary as a source of fatal injury data to potentially inform injury prevention policy and programmes. Best available comparators were used as potentially indicative of underor over-representation of injuries by mechanism in the Ibadan data, and thence to identify potential shortfalls in fatal injury case capture by the Ibadan coronial system.
4.1. Summary of main data findings In the Ibadan study and comparison systems of NIMSS in Mpumalanga province in South Africa (Donson, 2008b), pilot studies in Maputo (Nizamo et al., 2006), Kumasi (Adofo et al., 2010) and vital registration data from Mauritius and Mexico, road traffic crashes were consistently the leading cause of injury among persons aged between 15 and 44 years. Males were over-represented in all settings. In Ibadan, the greatest burden was borne by vulnerable road users, motorised two-wheeler users and pedestrians, described in detail elsewhere (Eze, Kipsaina, & Ozanne-Smith, 2013). The finding of transport-related injury as the leading unintentional external cause of death is further supported by other African studies (Afukaar, Antwi, Ofosu-Amaah, 2003; Bachani et al., 2011; Labinjo, Juillard, Kobusingye, & Hyder, 2009; SAPPRU, 2012). While three studies (Ibadan, Mpumalanga, and Kumasi) identified pedestrians as the main vulnerable road users, only the Ibadan study captured motorised twowheeler users as another group of vulnerable road users. Apart from road traffic injury (RTI), agreement on rankings by mechanism was limited between settings. The WHO global burden of disease report indicates that in Nigeria, drowning and poisoning are among the top five causes of injury death (WHO, 2008). Unlike all of the comparison settings, there were no cases of drowning or electrocution recorded in the five-month Ibadan study but only two poisoning cases and one case of hanging. It is
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probable that such mechanisms of fatal injury are underreported compared with other causes such as RTI, and that the proportion of RTI (Jones et al., 1998) is therefore artificially elevated. This is unlike estimates for Nigeria as a whole, or Mauritius and Mexico where drowning is the second leading cause of unintentional external cause deaths aside from ‘other unintentional injuries’ (NIMSS, 2010; Nizamo et al., 2006). Similarly, in other regional studies, such as Uganda, the leading cause of death was drowning (Kobusingye et al., 2001; Olawale & Owoaje, 2007). Only September to end of October of the wet season, data were included in the Ibadan study, though there is some evidence that drowning in Nigeria, including Ibadan, is focused in the wet season. The absence of any major body of water in Ibadan, unlike coastal cities like Lagos and Port Harcourt, may also be partly responsible for this low figure for drowning. Mexico results skewed the findings and therefore intentional injuries were excluded from comparisons. The Ibadan burns finding agrees with other studies from Nigeria that indicate a high incidence of burn deaths, particularly flame burns due to deliberate damage to property, vandalism of gasoline underground pipelines, and the adulteration of kerosene and petroleum products together with minimal or no first aid (Fadeyibi, Omosebi, Jewo, & Ademiluyi, 2009; Oladele & Olabanji, 2010; Olugbenga, 2005). In Maputo, the leading intentional cause of death was firearm discharge, while in Kumasi it was assault with objects. The above findings could be largely explained by (1) under-reporting of external cause deaths to coroners (Adofo et al., 2010; Burrows & Laflamme, 2007; London et al., 2002); (2) seasonality of deaths (Yu et al., 2009); (3) misclassification of cases such as poisoning, possibly as natural (Wolde et al., 2008); (4) specific underreporting of suicide for social, cultural, religious or economic reasons or misclassification as unknown or undetermined in the absence of a gold standard to identify masked suicide cases (Burrows & Laflamme, 2007). In Ibadan, cultural factors including social stigma and financial reasons are also likely to influence the under-reporting of suicide cases, and suicide remains a crime in Nigerian law (Federal Republic of Nigeria, 1999).
4.2. System assessment 4.2.1. Usefulness and acceptability by end users According to Johnston (2009), it is important to structure a surveillance system such that the information collected is married to end users – those best positioned to make use of it. The pilot nature of the current study has precluded end use of the data to date, apart from its publication in the scientific literature (Eze et al., 2013).
Data collection in Ibadan was strengthened by the forensic pathologist, personally undertaking the data collection and providing feedback on the pilot process. Interest by the forensic pathologist (UOE) during the development of the fatal injury surveillance system (Bartolomeos et al., 2012) enhanced acceptability of utilising the surveillance tool during the study and the potential for rolling it out post-pilot. This practice is similar in countries such as South African and Nepal where data in the medico-legal systems is collected by the participation of the forensic pathologists (Butchart et al., 2001; Subedi et al., 2013). In addition to strong support from individual practitioners for the uptake of mortuary-based surveillance, participation and support of the ministry of health and other stakeholders are essential to support the system and widen implementation and utilisation by end users. The sustainability and utility of the NIMSS in South Africa were attributed to the active mobilisation of a range of stakeholders in government, the private sector and civil society (Butchart et al., 2001; Donson, 2008b). 4.2.2.
Data quality, completeness and simplicity
The level of completeness is measured by assessment of the proportion responses to data elements that include ‘others’, ‘unknown’ or ‘unspecified’. Data quality is rated as high when the proportional use of unspecified codes is less than 20%–25% (Bhalla, Harrison, Shahraz, & Fingerhut, 2010; CDC, 2001; Espitia-Hardeman & Paulozzi, 2005; Mitchell, Williamson, & O’Connor, 2009). Bhalla et al. (2010), in estimating the global burden of injuries, rated data as high quality when the proportion of ‘dump codes” was smaller than 20%, while Mitchell and Williamson in the development of an evaluation framework for injury surveillance systems considered 25% or less of unspecified codes as high quality (Mitchell et al., 2009). During the fatal injury surveillance manual development stage (Grills et al., 2011), the use of a short simplified form aimed to minimise the proportion and use of ‘dump codes” in order to enhance data quality. The availability of simple, clear and detailed codes may have contributed to minimising the use of unspecified codes in the current study. 4.2.3.
Specificity
Detailed data are required to inform and target injury prevention policies and programmes. Bhalla et al. (2010) found that verbal autopsy, as the main source of fatal injury data in many developing countries including Nigeria, recorded only the nature of fatal injuries and where the ICD classification was used, the data were often aggregated. The current study serves to demonstrate the feasibility of collecting detailed data on cause of death,
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manner and mechanism of injury using a simple standardised tool in a poorly resourced setting. A comparison of fatal injuries in this study with the WHO global burden of disease estimates shows that the mortuary is able to provide more detailed data on the medical cause of death, and manner and mechanism of injury. This information is the central premise of formulating injury prevention policies to curb the growing issue of preventable deaths from injury. 4.2.4. Representativeness Although the Nigerian law stipulates that every citizen is mandated to report all external cause deaths to the authorities, many deaths go unreported. Nigeria is one of the WHO regional African countries with no detailed mortality data (Mathers, Boerma, & Ma Fat, 2009). There is currently no fatal injury surveillance system in existence in Nigeria for benchmarking and the available data from police were only on fatal RTI which limited our ability to compare with other causes of injury. The representativeness of the external cause cases reported to the coroner for Ibadan remains unknown, though from comparisons with other settings it appears that external cause deaths, especially non-RTI deaths, are under-reported. 4.2.5. Timeliness The timely collection and entry of fairly complete data over the study period by a single part-time operator demonstrate the feasibility of the system for wider use, with relatively low resource demands. 4.2.6.
Flexibility
This was the first study using the surveillance tool at the UCH. The flexibility of the system was, however, demonstrated by the fact that a provision was made for users to add variables relevant to their context, such as work relatedness, domestic-related incidents, fatal adverse effects of medical or surgical care, youth or gang violence as included in Ibadan. Importantly, the provision of a narrative text in the medical cause of death section also allows flexibility for additional information capture.
4.3.
Implications for fatal injury surveillance in Africa
Countries with mortuary-based surveillance systems have demonstrated their usefulness in augmenting other data sources and prioritising, informing and monitoring injury prevention programmes, including advocacy activities (Butchart et al., 2001; Grills et al., 2011; National Coroners Information System [NCIS], 2009; Steenkamp et al., 2006). Such systems are mainly in high-income countries,
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except for South Africa and Cali Colombia. Other LMIC systems documented have been pilot studies. In Uganda, two hospital-based trauma registries have been trialled (Kobusingye & Lett, 2000), and other multinational injury surveillance pilot studies in Kenya, Nigeria, Uganda, Zambia and Democratic Republic of Congo have been undertaken (Zavala et al., 2008). These studies have largely demonstrated the usefulness of surveillance in documenting injury morbidity, with an unsurprising poor capture of mortality cases. In the South African context, identifying a research agency to coordinate the mortuary-based surveillance system and to combine data from different sources, including forensic pathology, hospital records, police records and state chemical laboratories, have been effective (Butchart et al., 2001). The inclusion of forensic pathology reports has meant that information that is not routinely collected in vital registration statistics is captured (Weiss et al., 2006). This finding was similar and relevant to the present study and to countries in similar contexts establishing surveillance systems. There were no funds allocated to this study. The tools used were existing ones and the computer was provided by the investigator (UOE), showing that by utilising already available tools, a small investment in human resources and a computer, the mortuary can be a source of useful information to potentially inform injury prevention policy and programmes. During its establishment, the NIMSS identified personnel and resource-constraint issues similar to those encountered by the present study. In Ghana’s morbidity study, the investment in nursing personnel to collect injury data was acknowledged as worthwhile in obtaining useful injury information (Adofo et al., 2010). In terms of sustainability of the system, as also indicated by other studies, the availability of appropriate infrastructure also needs to be in place. The discrepancies in results highlight the gap that still exists in quality of data from LMICs. Despite frequent reports of motor vehicle crashes or fatal drownings in the media, injuries in Africa continue to be a neglected public health issue. To date, the role of quality data has not been accepted as a necessary step in resolving the problem, rather as another research project. This will need to change in order to adequately inform policy, action and progress. 4.4.
Limitations
The findings presented in this study may have been affected by a number of further limitations. Deaths resulting from suicide, poisoning or drowning are likely to be under-reported for cultural, social and potentially geographical reasons. In cases where death occurred at or near home, the deceased may have been buried before being reported to any authority or health facility, if ever.
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Since the study was conducted mostly in the dry and short rainy season, the influence of seasonality on representativeness could not be determined. However, seasonal variation is well documented with higher proportions of injuries such as drowning reported during the rainy season (Rahman, Mashreky, Chowdhury, Giashuddin, & UhaaI, 2009). Mortuary systems capture only mortality data, yet morbidity also contributes substantially to the burden of injuries.
5. Conclusions This pilot study is a step towards quantifying the burden of fatal injuries in Ibadan, Nigeria, and potentially Africa, more broadly using the mortuary as a source of data. Under-reporting of injury cases to the coroner in Ibadan is still a major issue, although it is apparently less marked for road traffic fatalities. While the system provides detailed information on the circumstances of deaths that would otherwise be unavailable, the issue of under-reporting of eligible deaths currently limits the value of the Ibadan data. Nevertheless, this data and the feedback from the investigator indicate that the tool is simple and userfriendly and can be utilised in Ibadan to collect data to inform fatal injury prevention policies and programmes. The way forward then to establishing a fatal injury surveillance system in Ibadan would be to first identify specific limitations including systemic issues of underreporting and how to address them. We recommend that dialogue with coroners, police, forensic pathologists, other medical staff and other stakeholders within the Nigerian coronial system be initiated and fostered in this process. The global movement towards re-orienting the forensic disciplines to include a prevention role should be fostered through training practitioners, especially forensic pathologists, on their role in collecting high-quality and accurate data for injury prevention purposes.
6. Ethics This pilot study was conducted at UCH in compliance with the Helsinki declaration on biomedical research in human subject guidelines, deemed negligible risk research not requiring ethics committee approval in Nigeria. Confidentiality of patient identity and personal health information were maintained. All subjects were deceased.
Acknowledgements The authors wish to thank the Violence and Injury Prevention Department the World Health Organization (WHO), Dr Nathan Grills and the International Advisory Group for contributing to the design of the data collection tools, and Dr Virginia Routley for her comments on the manuscript.
The contribution made by Chebiwot Kipsaina was completed as part of her Doctorate of Public Health candidature, Monash University, Australia.
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Appendix 1. Mortuary fatal injury data form
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A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial Chebiwot Kipsaina, Uwom O. Eze & Joan Ozanne-Smith To cite this article: Chebiwot Kipsaina, Uwom O. Eze & Joan Ozanne-Smith (2015) A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial, International Journal of Injury Control and Safety Promotion, 22:3, 193-202, DOI: 10.1080/17457300.2014.884142 To link to this article: http://dx.doi.org/10.1080/17457300.2014.884142
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Date: 07 November 2015, At: 16:23
International Journal of Injury Control and Safety Promotion, 2015 Vol. 22, No. 3, 193–202, http://dx.doi.org/10.1080/17457300.2014.884142
RESEARCH ARTICLE A standardised mortuary-based injury surveillance system: lessons learned from the Ibadan Nigerian trial Chebiwot Kipsainaa*, Uwom O. Ezeb and Joan Ozanne-Smitha a
Department of Forensic Medicine, Monash University, Melbourne, Australia; bDepartment of Pathology, University College Hospital, Ibadan, Nigeria
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(Received 30 May 2013; accepted 13 January 2014) This study explored the challenges in establishing a mortuary-based injury surveillance system in a resource-constrained setting of Ibadan, Nigeria. To quantify and detail fatal injuries, in September 2010 to February 2011, a prospective data collection utilised the World Health Organization–Monash draft surveillance system. Findings were compared with other low- and middle-income settings, and surveillance system attributes were assessed. The leading injury mechanism among all age groups was transport related, with 45.6% being vulnerable road users, consistent with comparable settings. Firerelated injury was the second unintentional cause in the Ibadan pilot, unlike Global Burden of Disease estimates for Nigeria, Mauritius and Mexico, where drowning was the second cause. Positive system attributes included timeliness, data field completeness, specificity, flexibility and sensitivity. Despite apparent under-reporting of eligible deaths and questionable representativeness, this study illustrates potential for mortuary data to inform injury prevention policies and programmes in resource-constrained settings. Keywords: fatal injury; standardised surveillance systems; mortuary; low–middle income country
1. Introduction
1.2.
1.1.
In the majority of African countries, sources of fatal injury data have included hospital emergency department-based injury surveillance systems, death certificates or police reports (Coady & Sorlie, 2001; Grills, Ozanne-Smith, & Bartolomeos, 2011; Jones, Martin, Larson, & Levy, 1998; Kobusingye, Guwatudde, & Lett, 2001; Salinas et al., 2008). While informative, these sources are limited as not all cases present to hospital or any other health care facility, and where a death certificate has been available, it has usually been poorly completed (Coady & Sorlie, 2001). Importantly, police statistics represent only those cases reported to the police, and they are mainly road trafficrelated fatalities or homicides (Grills et al., 2011; London, Mock, & Abantanga, 2002; Weiss et al., 2006). To our knowledge, only one mortuary-based surveillance system currently exists in Africa, which is located in South Africa. Other pilot studies, including those in Ethiopia, Ghana and Mozambique, have not resulted in sustainable systems in mortuary settings (Abdella, Bartolomeos, Tsegaye, Bhalla, & Abraham, 2010; Adofo, Donkor, Boateng, Afukaar, & Mock, 2010; Nizamo, Meyrowitsh, & Zacarias, 2006). In South Africa, a gap in systematic and rigorous information systems, which would inform safety promotion
Injury data worldwide
Injury is a significant public health issue. In 2008, the World Health Organization (WHO) estimated that globally, 5.1 million people died from injury which accounted for 9% of all global deaths. The burden of injuries is unevenly represented. An estimated 687,000 people died in Africa as a result of injuries in 2008 accounting for 14% of all injury-related deaths worldwide (WHO, 2011) equivalent to its global population proportion (United Nations Department of Economic and Social Affairs, Population Division, 2011). While countries in the developed world have continued to reduce injury deaths, countries in the developing world have witnessed the reverse in recent years. The issue is perpetuated by the unavailability of adequate data to elevate injury on many government policy agendas. High-quality and reliable data are key to injury prevention and safety promotion (Weiss, Gutierrez, Harrison, & Matzopoulos, 2006). In high-income countries where injury prevention progress has been made, data utilised are from a variety of sources, including vital statistics, coroners, medical examiners, autopsy, toxicology, police and other law enforcement reports (Pearse & Daking, 2007; Steenkamp et al., 2006; Weiss et al., 2006).
*Corresponding author. Email: [email protected] Ó 2014 Taylor & Francis
Fatal injury surveillance in Africa
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initiatives, was identified as a major obstacle to injury prevention interventions (Matzopoulos, Van Niekerk, Marais, & Donson, 2002). Therefore, in 1999, the National Injury Mortality Surveillance System (NIMSS, 2010) was established to provide basic information on external cause deaths. The system initially collated data for individuals admitted to three participating urban mortuaries (Port Elizabeth, Cape Town and Pretoria), including demographic details, injury scene, circumstance and manner of injury, and toxicology information (Matzopoulos et al., 2002). The NIMSS has since expanded to full coverage in two provinces, Gauteng and Mpumalanga, and four cities, Johannesburg, Pretoria, Durban and Cape Town, and to include fatal injury information from 62 medico-legal laboratories in seven provinces with data collected ranging from 39% to 52% of all injury deaths in 2008. Collection from both rural and urban areas allows comparisons across these settings (Donson, 2008a; Safety and Peace Promotion Research Unit [SAPPRU], 2012). A good quality injury surveillance system, as for all public health surveillance systems, should include an evaluation process. The Centres for Disease Control (CDC) surveillance system evaluation framework (CDC, 2001) recommends assessment of the following system attributes: simplicity, flexibility, data quality, acceptability, sensitivity, positive predictive value, representativeness, timeliness and stability with each system emphasising those attributes that are the most important for the objectives of its system (Espitia-Hardeman & Paulozzi, 2005; Recommendations from the Guideline Working Group, 2001).
1.3.
Aims
Building on knowledge from South Africa and other relevant settings, this study aimed to (1) quantify the burden of reported fatal injuries in Ibadan, using a data collection tool developed by WHO and Monash University (Bartolomeos, Kipsaina, Grills, Ozanne-Smith, & Peden, 2012); (2) compare the findings with other countries in similar low–middle income country (LMIC) contexts; and (3) assess the Ibadan pilot system attributes against selected established CDC criteria to explore the Ibadan system’s strengths and limitations and to inform the process of establishing such systems in resource-constrained settings.
cases per year. The UCH mortuary admits an estimated 75% of all mortuary cases from the catchment area mainly through the hospital though deaths outside the hospital are also admitted. 2.2.
The data collection tool was developed during preparation of the WHO–Monash University fatal injury surveillance manual, published in 2012. See Appendix 1 (Bartolomeos et al., 2012; Grills et al., 2011). Detailed information on all cases admitted to the mortuary from September 2010 to February 2011 was collected prospectively. The data was collected by internal staff; no staff were contracted for this data collection. Additionally, a web-based literature search was conducted on Medline, Web of Knowledge and Cochrane databases with the keyword search terms injury, fatal, mortality, mortuary, surveillance, and Africa and Mesh terms. The grey literature was also searched for reports and conference proceedings. Articles and reports matching the following criteria were eligible for comparison: studies and systems that investigated the mortuary as a source of injury studies that examined more than one type of injury, studies undertaken in Africa, studies on humans, in English and available in electronic format. In total, seven articles were retrieved and a reference list search of the retrieved articles was conducted for further relevant articles, but none were found. Of the seven articles obtained, three were included in this study and others not meeting the criteria were excluded. As there is no gold standard system or data with which to compare the Ibadan results, we compared them with NIMSS data from Mpumalanga province in South Africa, which has collected comprehensive fatal injury data since 1999 (Donson, 2008b; SAPPRU, 2012), and pilot studies in Maputo, Mozambique (Nizamo et al., 2006) and Kumasi, Ghana (Adofo et al., 2010). For broad comparison with the Ibadan data, data from two somewhat comparable LMICs, Mauritius and Mexico, with similar tropical climates marked by dry and rainy seasons, and reliable, reasonably complete death registration data (according to WHO) were extracted from Global Burden of Disease (GBD) 2008 estimates. No similar low-income countries have sufficiently good quality data for such comparisons. 2.3.
2. Methods 2.1.
Setting
The University College Hospital (UCH), one of the largest teaching hospitals in Oyo state in Southwest Nigeria, is situated in the city of Ibadan with a population of about 2,855,000. Its mortuary has a capacity of 3000 admission
Data collection and management
Data analysis
A preliminary data-set was created in an Excel spreadsheet, cleaned and mainly univariate, and descriptive analysis was performed using Stata Version 11. Results were compared with data from the similar poor resourced settings. Relevant to this study, the following attributes were assessed against the CDC surveillance system evaluation
International Journal of Injury Control and Safety Promotion criteria for Ibadan compared with fatal injury data from other African cities or provinces and comparable countries: simplicity, usefulness, acceptability, data quality and completeness, timeliness, representativeness and flexibility.
3.2.
Mechanism and scene of fatal injury in Ibadan
In Ibadan, transport-related injury remains the leading fatal mechanism among all age groups (Table 1). While motorised two-wheeler crashes were the leading cause among persons aged 15–44 years (29.0%), persons aged 45–64 years (37.5%) were more likely to be killed as pedestrians. Almost half (45.6%) of the reported external case deaths were motorised two-wheeler users or pedestrians, followed by other motor vehicle users (19.5%), then firerelated and falls with 13.8% and 8.1%, respectively. Among these cases, five were identified as work-related, three adverse effects of medical or surgical care, two from youth and gang violence and two from domestic incidents. The majority of reported injury deaths occurred on the road, street or highway (67.5%), followed by residential facilities, e.g. for displaced persons, orphans, disabled, police cells (15.5%), (Table 2). Among road deaths, four times more males died (n ¼ 67) than females (n ¼ 16). Among reported deaths in residential facilities, males outnumbered females by 3:1 (Table 2).
3. Results
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3.1. Demographic characteristics A total of 1184 cases were admitted to the UCH mortuary during the study period, September 2010–February 2011. Of these, 304 were coroners’ cases of which 123 resulted from external causes. Of these external cause deaths, i.e. injuries and poisonings, 95 (77.2%) were male and males dominated for all mechanisms; the mean age (SD) was 39.3 years (19.1). Most (50.1%) were in the 15–44 year age group, and for seven (5.6%), age was not recorded. This age distribution is similar to that for both Mpumalanga province and Kumasi city (Ghana), where the mean ages (SD) were 34.0 (17.1) and 32.7 (19.0) years, respectively.
Table 1. External causes of death in Ibadan by mechanism of injury and age group, September 2010–February 2011. Mechanism of injury Motorised two-wheeler crash Pedestrian struck Motor vehicle crash Burns/smoke/fire Falls Violence and suicide Other and unknown Total
0–4 years (%)
5–14 years (%)
15–19 years (%)
20–24 years (%)
25–44 years (%)
45–64 years (%)
65 years (%)
Missing (%)
Total (%)
0 (0.0) 2 (28.6) 0 (0.0) 2 (28.6) 3 (42.9) 0 (0.0) 0 (0.0)
1 (20.0) 1 (20.0) 0 (0.0) 1 (20.0) 0 (0.0) 2 (40.0) 0 (0.0)
0 (0.0) 0 (0.0) 1 (33.3) 2 (66.7) 0 (0.0) 0 (0.0) 0 (0.0)
3 (42.9) 1 (14.3) 0 (0.0) 0 (0.0) 1 (14.3) 1 (14.3) 1 (14.3)
15 (29.4) 7 (13.7) 14 (27.5) 7 (13.7) 2 (3.9) 3 (5.9) 3 (5.9)
6 (19.4) 12 (38.7) 6 (19.4) 3 (9.7) 2 (6.5) 2 (6.5) 1 (3.2)
1 (9.1) 5 (45.5) 1 (9.1) 2 (18.2) 1 (9.1) 1 (9.1) 0 (0.0)
2 (28.6) 0 (0.0) 2 (28.6) 0 (0.0) 1 (14.3) 2 (28.6) 0 (0.0)
28 (22.8) 28 (22.8) 24 (29.5) 17 (23.8) 10 (8.1) 11 (8.9) 6 (4.9)
7
5
3
7
51
32
11
7
123
Table 2. External causes of death by mechanism, scene of injury and sex in Ibadan, September 2010–February 2011 Sex Mechanism Motorised two-wheeler crash Pedestrian struck Motor vehicle crash (excludes two wheelers) Burns/smoke/fire Falls Violence and suicide Other and unknown Scene Road/street/highway Residential facility Private house and yard Medical service area Other public area
Female (%), n ¼ 28
Male (%), n ¼ 95
Total (%), N ¼ 123
3 (10.7) 5 (17.9) 7 (25.0) 7 (25.0) 1 (3.6) 3 (10.7) 2 (7.1)
25 (26.3) 23 (24.2) 17 (17.9) 10 (10.5) 9 (9.5) 8 (8.4) 3 (3.2)
28 (22.8) 28 (22.8) 24 (19.5) 17 (13.8) 10 (8.1) 11 (8.9) 5 (4.1)
16 (57.1) 5 (17.9) 2 (7.1) 2 (7.1) 3 (10.8)
67 (70.5) 14 (14.7) 4 (4.2) 1 (1.1) 9 (9.5)
83 (67.5) 19 (15.5) 6 (4.9) 3 (2.4) 12 (9.8)
Note: Includes firearm discharge, violence with objects, poisoning and suicide by hanging fatal injuries.
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Figure 1. Manner of death for comparable cities of Ibadan, Kumasi, and Maputo and Mpumalanga province.
3.3.
Comparisons of Ibadan findings with selected settings by manner and mechanism of death
As for Ibadan, unintentional transport-related injury was the leading manner of death for Mpumalanga province (South Africa), Maputo city (Mozambique) and Kumasi city (Ghana), respectively, accounting for 86.1%, 46.1%, 59.4% and 60.9% of total reported injury deaths. This was followed by undetermined cases (6.5%) and violence (5.7%) for Ibadan, while in all other settings violence was the second leading manner of death (Figure 1). Although a wide range of mechanisms was recorded in all the four settings, Ibadan was the only setting to record no drowning or electrocution deaths (Table 3). In 5 months, we recorded a total of 123 injury-related fatal cases for Ibadan city alone, which estimates to 295 cases in 12 months.
The UCH mortuary admits 75% of the annual coroner’s fatal cases, we therefore estimated that the total number of mortuary cases in Ibadan for a year to be 393 with 98 (25%) of these cases going to alternative mortuary. Comparisons by age group across the four settings could not be tabulated as each setting categorised age groups differently, but, across all settings, deaths in the age group 15– 44 years accounted for the majority of deaths with transport accounting for a greater percentage (Adofo et al., 2010; Donson, 2008a; NIMSS, 2010; Nizamo et al., 2006). Comparison of reported Ibadan unintentional injury death data with WHO GBD 2008 estimates for Nigeria and two comparable countries, Mauritius and Mexico, is shown in Table 4. When compared to the country results, excluding other unspecified unintentional injuries, Ibadan data indicated deaths from fires (14.6%) as the second leading injury cause, unlike Nigeria as a whole, Mauritius and Mexico where drowning was the second leading cause with 11.6%, 13.5% and 7.4%, respectively. 3.4.
Assessment against selected injury surveillance attributes
Relevant attributes were assessed using the CDC evaluation framework for surveillance systems. 3.4.1.
Usefulness and acceptability
The data system was accepted and reported to be useful and user-friendly by the forensic pathologist Uwom O. Eze [UOE], who prospectively collected the data in his
Table 3. Mechanism of injury by external cause deaths in four comparable cities/provinces.
Mechanism Motorised two-wheeler crash Pedestrian struck Motor vehicle crash Burns/smoke/fire Falls Firearm discharge Violence with sharp objects Violence with blunt objects Hanging /strangulation Drowning Poisoning Electrocution Other Unknown Total a
Ibadana (Federal Republic of Nigeria) n (%)
Mpumalanga (South Africa) n (%)
Maputo (Mozambique) n (%)
90 (22.7) 90 (22.7) 77 (19.5) 54 (13.8) 32 (8.1) 13 (3.2) 3 (0.8) 16 (4.1) 3 (0.8) 0 (0.0) 6 (1.6) 0 (0.0) 6 (1.6) 3 (0.8)
36 (1.0)b 471 (13.1) 1156 (32.2) 98 (2.7) –d 81 (2.3) 293 (8.2) 95 (2.6) 485 (13.5) 146 (4.1) 74 (2.1) 26 (0.7) 362 (10.1) 271 (7.5)
–d –d 496(43.7) 89 (7.8) 42 (3.7) 99 (8.7) 47 (4.1) 80 (7.0) 48 (4.2) 74 (6.5) –d 17 (1.5) 47 (4.1) 96 (8.5)
3594
1135
393 b
c
Kumasi (Ghana) n (%) 185(12.0) 756 (48.9)c 54 (3.5) 72 (4.7) –d 154 (10.0)e 42 (2.7) 66 (4.3) 80 (5.2) 20 (1.3) 116 (7.5) –d 1545
Note: Data for 12 months were extrapolated from 5 months of data; motorised two-wheeler and bicyclist aggregated; includes transport not classified elsewhere; dno data recorded; eincludes deaths from all objects. Source: Adofo et al. (2010), Donson (2008a, 2008b), NIMSS (2010), Nizamo et al. (2006).
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Table 4. Comparison of Ibadan reported injury deaths with WHO data for Nigeria and comparable countries. Unintentional fatal injuries
Ibadan (n)
%
Nigeria (n)
%
Mauritius (n)
%
Mexico (n)
%
Road traffic accidents Poisonings Falls Fires Drownings Other unintentional
257 6 32 54 0 22
69.3 1.6 8.6 14.6 0.0 5.9
24,850 7297 3373 6497 7422 14,392
38.9 11.4 5.3 10.2 11.6 22.5
186 9 28 18 54 107
46.3 2.1 7.0 4.5 13.5 26.6
13,754 1234 2405 679 2521 13,456
40.4 3.6 7.1 2.0 7.4 39.5
Total
371
63,832
402
34,050
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Source: WHO (2011).
capacity as an in-house consultant with the UCH. There have been no other independent end-user reports of use or applications of the data to date. 3.4.2.
Timeliness
The data in this pilot study were collected prospectively for 5 months. The single investigator completed and uploaded all of the required external cause case data into the data collection programme daily. 3.4.3. Data quality and completeness For several main variables data completeness was 100%, including sex, scene of injury, manner of death, time and date of injury and death, mechanism of injury and immediate medical cause of death. The completeness of information was slightly lower for age and antecedent cause of death, 94.3% and 93.4%, respectively. When mechanism of injury was cross-tabulated with age group and location of occurrence, ‘other’ and ‘unknown’ codes were applied to only 4.9% and 9.8% of cases, respectively. The overall proportion of data collected as ‘other unspecified’ was 5.9%, which is significantly lower compared to the other settings of Nigeria, Mauritius and Mexico, of 22.5%, 26.6% and 39.5%, respectively. 3.4.4.
Representativeness
Marked differences in rank order of injury mechanisms were observed between settings. For unintentional injury mechanisms, except road traffic injuries and burns, the number of reported cases was less than expected for a setting such as Ibadan, and also lower than expected for suicide. 3.4.5.
Specificity
As described above, the lowest proportion of ‘unknowns’ and ‘other’ was observed for Ibadan versus Nigerian GBD estimates, Mauritius and Mexico. Compared to the GBD estimates, greater specificity was achieved in Ibadan including road user type, and special fields of work-related cases, youth or gang violence and domestic incidents.
4. Discussion This study is a response to the ongoing urgent need for timely and reliable data in LMICs as a basis to curb the increasing burden of injuries in these settings. It aimed to identify the strengths and limitations of utilising the mortuary as a source of fatal injury data to potentially inform injury prevention policy and programmes. Best available comparators were used as potentially indicative of underor over-representation of injuries by mechanism in the Ibadan data, and thence to identify potential shortfalls in fatal injury case capture by the Ibadan coronial system.
4.1. Summary of main data findings In the Ibadan study and comparison systems of NIMSS in Mpumalanga province in South Africa (Donson, 2008b), pilot studies in Maputo (Nizamo et al., 2006), Kumasi (Adofo et al., 2010) and vital registration data from Mauritius and Mexico, road traffic crashes were consistently the leading cause of injury among persons aged between 15 and 44 years. Males were over-represented in all settings. In Ibadan, the greatest burden was borne by vulnerable road users, motorised two-wheeler users and pedestrians, described in detail elsewhere (Eze, Kipsaina, & Ozanne-Smith, 2013). The finding of transport-related injury as the leading unintentional external cause of death is further supported by other African studies (Afukaar, Antwi, Ofosu-Amaah, 2003; Bachani et al., 2011; Labinjo, Juillard, Kobusingye, & Hyder, 2009; SAPPRU, 2012). While three studies (Ibadan, Mpumalanga, and Kumasi) identified pedestrians as the main vulnerable road users, only the Ibadan study captured motorised twowheeler users as another group of vulnerable road users. Apart from road traffic injury (RTI), agreement on rankings by mechanism was limited between settings. The WHO global burden of disease report indicates that in Nigeria, drowning and poisoning are among the top five causes of injury death (WHO, 2008). Unlike all of the comparison settings, there were no cases of drowning or electrocution recorded in the five-month Ibadan study but only two poisoning cases and one case of hanging. It is
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probable that such mechanisms of fatal injury are underreported compared with other causes such as RTI, and that the proportion of RTI (Jones et al., 1998) is therefore artificially elevated. This is unlike estimates for Nigeria as a whole, or Mauritius and Mexico where drowning is the second leading cause of unintentional external cause deaths aside from ‘other unintentional injuries’ (NIMSS, 2010; Nizamo et al., 2006). Similarly, in other regional studies, such as Uganda, the leading cause of death was drowning (Kobusingye et al., 2001; Olawale & Owoaje, 2007). Only September to end of October of the wet season, data were included in the Ibadan study, though there is some evidence that drowning in Nigeria, including Ibadan, is focused in the wet season. The absence of any major body of water in Ibadan, unlike coastal cities like Lagos and Port Harcourt, may also be partly responsible for this low figure for drowning. Mexico results skewed the findings and therefore intentional injuries were excluded from comparisons. The Ibadan burns finding agrees with other studies from Nigeria that indicate a high incidence of burn deaths, particularly flame burns due to deliberate damage to property, vandalism of gasoline underground pipelines, and the adulteration of kerosene and petroleum products together with minimal or no first aid (Fadeyibi, Omosebi, Jewo, & Ademiluyi, 2009; Oladele & Olabanji, 2010; Olugbenga, 2005). In Maputo, the leading intentional cause of death was firearm discharge, while in Kumasi it was assault with objects. The above findings could be largely explained by (1) under-reporting of external cause deaths to coroners (Adofo et al., 2010; Burrows & Laflamme, 2007; London et al., 2002); (2) seasonality of deaths (Yu et al., 2009); (3) misclassification of cases such as poisoning, possibly as natural (Wolde et al., 2008); (4) specific underreporting of suicide for social, cultural, religious or economic reasons or misclassification as unknown or undetermined in the absence of a gold standard to identify masked suicide cases (Burrows & Laflamme, 2007). In Ibadan, cultural factors including social stigma and financial reasons are also likely to influence the under-reporting of suicide cases, and suicide remains a crime in Nigerian law (Federal Republic of Nigeria, 1999).
4.2. System assessment 4.2.1. Usefulness and acceptability by end users According to Johnston (2009), it is important to structure a surveillance system such that the information collected is married to end users – those best positioned to make use of it. The pilot nature of the current study has precluded end use of the data to date, apart from its publication in the scientific literature (Eze et al., 2013).
Data collection in Ibadan was strengthened by the forensic pathologist, personally undertaking the data collection and providing feedback on the pilot process. Interest by the forensic pathologist (UOE) during the development of the fatal injury surveillance system (Bartolomeos et al., 2012) enhanced acceptability of utilising the surveillance tool during the study and the potential for rolling it out post-pilot. This practice is similar in countries such as South African and Nepal where data in the medico-legal systems is collected by the participation of the forensic pathologists (Butchart et al., 2001; Subedi et al., 2013). In addition to strong support from individual practitioners for the uptake of mortuary-based surveillance, participation and support of the ministry of health and other stakeholders are essential to support the system and widen implementation and utilisation by end users. The sustainability and utility of the NIMSS in South Africa were attributed to the active mobilisation of a range of stakeholders in government, the private sector and civil society (Butchart et al., 2001; Donson, 2008b). 4.2.2.
Data quality, completeness and simplicity
The level of completeness is measured by assessment of the proportion responses to data elements that include ‘others’, ‘unknown’ or ‘unspecified’. Data quality is rated as high when the proportional use of unspecified codes is less than 20%–25% (Bhalla, Harrison, Shahraz, & Fingerhut, 2010; CDC, 2001; Espitia-Hardeman & Paulozzi, 2005; Mitchell, Williamson, & O’Connor, 2009). Bhalla et al. (2010), in estimating the global burden of injuries, rated data as high quality when the proportion of ‘dump codes” was smaller than 20%, while Mitchell and Williamson in the development of an evaluation framework for injury surveillance systems considered 25% or less of unspecified codes as high quality (Mitchell et al., 2009). During the fatal injury surveillance manual development stage (Grills et al., 2011), the use of a short simplified form aimed to minimise the proportion and use of ‘dump codes” in order to enhance data quality. The availability of simple, clear and detailed codes may have contributed to minimising the use of unspecified codes in the current study. 4.2.3.
Specificity
Detailed data are required to inform and target injury prevention policies and programmes. Bhalla et al. (2010) found that verbal autopsy, as the main source of fatal injury data in many developing countries including Nigeria, recorded only the nature of fatal injuries and where the ICD classification was used, the data were often aggregated. The current study serves to demonstrate the feasibility of collecting detailed data on cause of death,
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manner and mechanism of injury using a simple standardised tool in a poorly resourced setting. A comparison of fatal injuries in this study with the WHO global burden of disease estimates shows that the mortuary is able to provide more detailed data on the medical cause of death, and manner and mechanism of injury. This information is the central premise of formulating injury prevention policies to curb the growing issue of preventable deaths from injury. 4.2.4. Representativeness Although the Nigerian law stipulates that every citizen is mandated to report all external cause deaths to the authorities, many deaths go unreported. Nigeria is one of the WHO regional African countries with no detailed mortality data (Mathers, Boerma, & Ma Fat, 2009). There is currently no fatal injury surveillance system in existence in Nigeria for benchmarking and the available data from police were only on fatal RTI which limited our ability to compare with other causes of injury. The representativeness of the external cause cases reported to the coroner for Ibadan remains unknown, though from comparisons with other settings it appears that external cause deaths, especially non-RTI deaths, are under-reported. 4.2.5. Timeliness The timely collection and entry of fairly complete data over the study period by a single part-time operator demonstrate the feasibility of the system for wider use, with relatively low resource demands. 4.2.6.
Flexibility
This was the first study using the surveillance tool at the UCH. The flexibility of the system was, however, demonstrated by the fact that a provision was made for users to add variables relevant to their context, such as work relatedness, domestic-related incidents, fatal adverse effects of medical or surgical care, youth or gang violence as included in Ibadan. Importantly, the provision of a narrative text in the medical cause of death section also allows flexibility for additional information capture.
4.3.
Implications for fatal injury surveillance in Africa
Countries with mortuary-based surveillance systems have demonstrated their usefulness in augmenting other data sources and prioritising, informing and monitoring injury prevention programmes, including advocacy activities (Butchart et al., 2001; Grills et al., 2011; National Coroners Information System [NCIS], 2009; Steenkamp et al., 2006). Such systems are mainly in high-income countries,
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except for South Africa and Cali Colombia. Other LMIC systems documented have been pilot studies. In Uganda, two hospital-based trauma registries have been trialled (Kobusingye & Lett, 2000), and other multinational injury surveillance pilot studies in Kenya, Nigeria, Uganda, Zambia and Democratic Republic of Congo have been undertaken (Zavala et al., 2008). These studies have largely demonstrated the usefulness of surveillance in documenting injury morbidity, with an unsurprising poor capture of mortality cases. In the South African context, identifying a research agency to coordinate the mortuary-based surveillance system and to combine data from different sources, including forensic pathology, hospital records, police records and state chemical laboratories, have been effective (Butchart et al., 2001). The inclusion of forensic pathology reports has meant that information that is not routinely collected in vital registration statistics is captured (Weiss et al., 2006). This finding was similar and relevant to the present study and to countries in similar contexts establishing surveillance systems. There were no funds allocated to this study. The tools used were existing ones and the computer was provided by the investigator (UOE), showing that by utilising already available tools, a small investment in human resources and a computer, the mortuary can be a source of useful information to potentially inform injury prevention policy and programmes. During its establishment, the NIMSS identified personnel and resource-constraint issues similar to those encountered by the present study. In Ghana’s morbidity study, the investment in nursing personnel to collect injury data was acknowledged as worthwhile in obtaining useful injury information (Adofo et al., 2010). In terms of sustainability of the system, as also indicated by other studies, the availability of appropriate infrastructure also needs to be in place. The discrepancies in results highlight the gap that still exists in quality of data from LMICs. Despite frequent reports of motor vehicle crashes or fatal drownings in the media, injuries in Africa continue to be a neglected public health issue. To date, the role of quality data has not been accepted as a necessary step in resolving the problem, rather as another research project. This will need to change in order to adequately inform policy, action and progress. 4.4.
Limitations
The findings presented in this study may have been affected by a number of further limitations. Deaths resulting from suicide, poisoning or drowning are likely to be under-reported for cultural, social and potentially geographical reasons. In cases where death occurred at or near home, the deceased may have been buried before being reported to any authority or health facility, if ever.
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Since the study was conducted mostly in the dry and short rainy season, the influence of seasonality on representativeness could not be determined. However, seasonal variation is well documented with higher proportions of injuries such as drowning reported during the rainy season (Rahman, Mashreky, Chowdhury, Giashuddin, & UhaaI, 2009). Mortuary systems capture only mortality data, yet morbidity also contributes substantially to the burden of injuries.
5. Conclusions This pilot study is a step towards quantifying the burden of fatal injuries in Ibadan, Nigeria, and potentially Africa, more broadly using the mortuary as a source of data. Under-reporting of injury cases to the coroner in Ibadan is still a major issue, although it is apparently less marked for road traffic fatalities. While the system provides detailed information on the circumstances of deaths that would otherwise be unavailable, the issue of under-reporting of eligible deaths currently limits the value of the Ibadan data. Nevertheless, this data and the feedback from the investigator indicate that the tool is simple and userfriendly and can be utilised in Ibadan to collect data to inform fatal injury prevention policies and programmes. The way forward then to establishing a fatal injury surveillance system in Ibadan would be to first identify specific limitations including systemic issues of underreporting and how to address them. We recommend that dialogue with coroners, police, forensic pathologists, other medical staff and other stakeholders within the Nigerian coronial system be initiated and fostered in this process. The global movement towards re-orienting the forensic disciplines to include a prevention role should be fostered through training practitioners, especially forensic pathologists, on their role in collecting high-quality and accurate data for injury prevention purposes.
6. Ethics This pilot study was conducted at UCH in compliance with the Helsinki declaration on biomedical research in human subject guidelines, deemed negligible risk research not requiring ethics committee approval in Nigeria. Confidentiality of patient identity and personal health information were maintained. All subjects were deceased.
Acknowledgements The authors wish to thank the Violence and Injury Prevention Department the World Health Organization (WHO), Dr Nathan Grills and the International Advisory Group for contributing to the design of the data collection tools, and Dr Virginia Routley for her comments on the manuscript.
The contribution made by Chebiwot Kipsaina was completed as part of her Doctorate of Public Health candidature, Monash University, Australia.
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Appendix 1. Mortuary fatal injury data form
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