Surveillance Programme:

Transcription

1 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study National Institute of Mental Health & Neuro Sciences Bengaluru , India

2 Bengaluru City Police Bengaluru Baptist Hospital Bhagwan Mahaveer Jain Hospital Bowring & Lady Curzon Hospital Bengaluru Metropolitan Transport Corporation Victoria Hospital D.G. Hospital St. Philomena's Hospital District Hospital, Tumkur St. Martha's Hospital HOSMAT Hospital St. John's Hospital Jayanagar General Hospital Sri. Siddhartha Medical College, Tumkur Sparsh Hospital Sanjay Gandhi Accident Hospital & Research Institute Bengaluru Injury / Road Traffic Injury Surveillance Programme K.R. Hospital Kempegowda Institute of Medical Sciences & Research Centre M. S. Ramaiah Memorial Medical Hospital Sagar Hospitals Mallige Medical Centre Ravi Kirloskar Memorial Hospital Mallya Hospital National Institute of Mental Health & Neuro Sciences Manipal Hospital In Collaboration with World Health Organization, New Delhi Indian Council of Medical Research, New Delhi Ministry of Health & Family Welfare, New Delhi

3 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES Department of Epidemiology WHO Collaborating Centre for Injury Prevention and Safety Promotion Bengaluru , India NIMHANS i

4 Title: Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study Copyright: NIMHANS ISBN no: X Suggested citation: Bengaluru Injury surveillance collaborators group. Gururaj et al.: National Institute of Mental Health and Neuro Sciences, Publication No. 68, Bengaluru, 2008 Bengaluru Injury surveillance collaborators (Nodal Officers) group: Gururaj, Sateesh V L, Ajith Benedict Rayan, Alfred C Roy, Amarnath, Ashok J, Ashwath Narayan, Birje N.D, Chidananda, Devaraj, Harsha J.N, Kantaraj J, Kirankumar, Krishna Raj, Mabel Vasnaik, Mali Manjunath, Mallikarjun V Abdulpur, Manjunath, Manjunath A.V, Mohan Kumar, Narayanaswamy, Prabhakar, Prakash P.N, Rajeev Mathew, Ramaprasad, Ramesh E Raju, Ramesh K.V, Ramireddy, Ranganath, Rizwan Ali Khan, Sunil Bhat, Suryanarayan S.P, Velu C.V Year of publication: 2008 Key words: Injury; surveillance; Data; Road Traffic Injury; Suicide; Burns; Poisoning; Mortality; Morbidity; Disability; policy and Programme For further details about the programme, contact any of the programme nodal officers or Dr. G. Gururaj Professor & Head Department of Epidemiology WHO Collaborating Centre for Injury Prevention and Safety Promotion NIMHANS, Bengaluru 29 guru@nimhans.kar.nic.in epiguru@yahoo.com ii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

5 Safety and security of people has occupied centre stage of human growth and development in recent years. Every year, thousands of people lose their lives, millions get hospitalized, and several become disabled due to an injury in India. This tragedy need not and will not happen if safety and security of people is given importance in all places and at all stages of our growth and development. It is time adhocism, knee jerk reactions, crisis reactions are replaced with evidence based scientific approaches. People have a right to safety at home, workplace, roads and in all public places. It is the collective responsibility of governments, policy makers, product-vehicle manufacturers (industry), media and people to develop products and environments that are safe to every one in the society. Bengaluru Injury / Road Traffic Injury Surveillance Programme is a collaborative programme between National Institute of Mental Health & Neuro Sciences, 25 hospitals, Bengaluru City Police, Bengaluru Metropolitan Transport Corporation and Bruhat Bengaluru Mahanagara Palike and, facilitated by Indian Council of Medical Research and WHO, India office. The programme aims at reducing / preventing injuries, improving trauma care and strengthening rehabilitation services. NIMHANS iii

6 Partners in Programme Bengaluru City Police Sri. Shankar Bidari, IPS, Commissioner of Police, Bengaluru City Sri. Neelam Achutha Rao, IPS, Fmr. Commissioner of Police, Bengaluru City Sri. Pravin Sood, IPS, Additional Commissioner of Police, Traffic and Security Sri. K. C. Ramamurthy, IPS, Fmr. Additional Commissioner of Police, Traffic and Security Sri. M. N. Reddi, IPS, Fmr. Additional Commissioner of Police, Traffic and Security Sri. M. R. Pujar, IPS, Additional Commissioner of Police, Law and Order Sri. Bipin Gopalakrishna, IPS, Fmr. Additional Commissioner of Police, Law and Order Dr. Parashivamurthy, IPS, Fmr. Commissioner for Road Safety, Karnataka Sri. K. Srinivasa, IPS, Deputy Commissioner of Police (East) Sri. M. A. Saleem, IPS, Fmr. Deputy Commissioner of Police (East) Sri. Rama Subba, IPS, Fmr. Deputy Commissioner of Police (West) Sri. N. Shivaprasad, IPS, Deputy Commissioner of Police (Admin) Sri. N. D. Birje, Assistant Commissioner (Traffic & Planning) and Nodal Officer Sri. Narasimaiah, Assistant Commissioner (Traffic & Planning) and Fmr. Nodal Officer Sri. M. D. Mulla, Fmr. Public Relations Officer and Nodal Officer, Crime Sri. V. Ramaiah, Deputy Commissioner of Police, Public Relations Officer and Nodal Officer, Crime Sri. Raghuveer (Control room) Smt. Girija, Inspector of Police, City Crime Record Bureau, and Mr. Prasanna All staff from Traffic and Law and Order stations of Bengaluru Dr. Harsha, IPS, Superintendent of Police, Tumkur Sri. Harishekaran, IPS, Fmr. Superintendent of Police, Tumkur Sri. Anantha Ramaiah, Additional Superintendent of Police, Nodal Officer, Tumkur, and All the staff from Police Department in Bengaluru and Tumkur National Institute of Mental Health and Neuro Sciences Director - Dr. Nagaraja D Nodal Officer - Dr. Sateesh V. L (Resident Medical Officer) Department of Epidemiology Dr. G. Gururaj, Dr. Girish N. Rao, Dr. Kavita Rajesh, Dr. Umesh Shetty, Dr. Ranganath, Mr. Vijendra S. Kargudri, Mr. Girish B. G., Mr. Manjunath D. P., Mr. Srinivasamurthy, Mr. Basavaraj B, Mr. Lokesh M, Mr. Chandrashekar C, Mr. Raghu R and Mrs. Savitha B. G. Department of Neuro Surgery Dr. Indira Devi, Dr. Chandramouli, Dr. Sampath, Dr. Shibu Pillai, and all unit heads Casualty Medical Officers Dr. Chandrashekharan, Dr. Muralidhara K, Dr. Neetha Nagaraj, Dr. Renukadevi, Dr. Asgaribanu, Dr. Lakshmi Rajamma, Dr. Sridhara, Dr. Jayaprakash, Dr. Keshavamurthy and Dr. Yashoda Medical Records Department Mr. Marie Joseph, Ms. Maria Alphonsa, Mr. Pulla Reddy, Mr. Vivekappa and Mr. Nanjappachar Bengaluru Metropolitan Transport Corporation Sri. Syed Zameer Pasha, IAS, Managing Director Sri. Upendra Tripathi, IAS, Fmr. Managing Director Sri. Dastagir Shariff (CTO) Sri. Narayanaswamy (DTO Accident) - Nodal Officer iv Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

7 Sri. Shankara Bharathi (Assistant Traffic Superintendent) Sri. Vijay B Chandapur (DTO TEe) Mrs. Dakshaini Devi and Mrs. Madhavi Bruhat Bengaluru Mahanagara Palike Dr. S. Subramanya, Commissioner Narayanaswamy, Jt. Director (Statistics) and Staff Bangalore Baptist Hospital Medical Superintendent Dr. Alex Thomas; Dr. Santhosh Benjamin (Fmr. Superintendent); Nodal Officer Dr. Alfred C Roy; Casualty Staff Dr. Niranjan and Sr. Mary Bhagavan Mahaveer Jain Hospital Medical Director Dr. Mohan Reddy; Nodal Officer Dr. Prakash P. N; Casualty Staff Dr. Jamuna, Dr. Suchetha, Dr. Bindu, Dr. Vinayaka and Mr. Arun Arthur Kumar and Mr. Patil Bowring & Lady Curzon Hospital Medical Superintndent Dr. Rajeev Shetty; Resident Medical Officer Dr. Rajanna; Nodal Officers Dr. Amarnath, Dr. K. Sreedhara Murthy, (Fmr.); Casualty Staff Dr. Venkata Rajamma, Dr. Prasanna Kumar, Dr. Sreedhar, Dr. Banumurthy, Dr. Sudha, Dr. Vasanthakumar, Dr. Suresh, Dr. Harish, Dr. Banu; Mr. Raju, Mr. Nagaraja, Mr. Siraj and Mr. Nagaraj D.G. Hospital Chairman Dr. Ramesh H. D; Nodal Officer Dr. Rizwan Ali Khan; Casualty Staff Dr. Ashok Shroff and Dr. Vishvas HOSMAT Hospital Medical Director Dr. Thomas Chandy; Nodal Officer Dr. Ajith Benidict Rayan; Casualty Medical Officer Dr. Bhavani Shankar, Dr. Chetan Ray and Mrs. Valsala and Mr. Sugirth Raj Jayanagar General Hospital KR Hospital Medical Superintendent Dr. Nagaraj K; Nodal Officer Dr. Manjunath; Casualty Staff Dr. Vasudeva Rao, Dr. Sreedhar Murthy, Dr. Srinivas, Dr. Kiran Kumar, Dr. Pushparaj, Dr. Pappu Vitalachar, Dr. Prameela, Dr. Sandya, Dr. Geetha, Dr. Revanna, Dr. Raghunandan, Dr. Thimmappa; Mrs. Geetha and Mrs. Pattar Director Dr. Hariprasad; Medical Superintndent Dr. Sriranga Prasad; ICU Director Dr. Chandrashekhar; Nodal Officer Dr. Harsha J. N; Medical Administrator Mr. Mahesh Kumar NIMHANS v

8 Kempegowda Institute of Medical Sciences and Research Centre Director Dr. K M Srinivasa Gowda; Medical Superintendent Dr. Anjanappa T. H; Administrative Medical Officer Dr. Ramachandra J; Nodal Officers Dr. Devaraj, Dr. Ashwath Narayan and Dr. Gopal B. K, (Fmr.); Casualty Staff Dr. Ramesh, Dr. Shankar and Dr. Prasanna; Medical Records Department Mr. E. Selwyn Jebasingh and Mr. Lingappa; M. S. Ramaiah Hospitals Medical Directors Dr. Sundaresh and Dr.Naresh Shetty; Joint Medical Director Dr. Narendranath; Nodal Officers Dr. Mali Manjunath and Dr. Suryanarayana S. P; Casualty Staff Dr. Satish Varma, Dr. Gopalappa, Dr. Thyagaraj, Dr. Anand Kumar. C, Dr. Pruthvish, Dr. Aruna Ramesh; Mrs. Wilbert Mary, Mrs. Padma, Mrs. Margaret Rosy and Mrs. Shyamala Mallige Medical Centre Director Dr. Sriram; Medical Superintendent Dr. Sudarshini and Dr. Ravishankar Nair, (Fmr.); Nodal Officer Dr. Ramireddy Mallya Hospital President Comm. Indruwadwani; Nodal Officer Dr. Pradeep Naik, Dr. Kirankumar; Casualty Staff Dr. Prameela, Mr. Desican and Mrs. Usha Manipal Hospital Medical Director and Chief - Dr. D. P. Saraswath, Dr. Nagendra Swamy, (Fmr.); Nodal Officers - Dr. Ramesh E. Raju; Mr. T. Pradeep, Mr. P. Kumaran, Mr. Muthanna, Sr. Vimalamma Ravi Kirloskar Memorial Hospital Project Director Dr. Marker; Nodal Officers - Dr. A.V. Manjunath; Mr. Shekarappa Sagar Hospital Chairman Dr. Hemachandra Sagar; Nodal Officers Dr. Sunil Bhat; Dr. Rajeev Mathew, Mr. Stephen and Sis. Mangala Sanjay Gandhi Institute of Trauma Care and Orthopaedics Director Dr. Govindaraju. V; Nodal Officers Dr. Prabhakar, Dr. Ravikumar V (Fmr.); Mr. Agilasithan; Casualty Staff Mr. Yashvanth, Ms. Meera and Mr. Dhananjaya Sparsh Hospital Medical Director Dr. Sharan Patil; Nodal Officer Dr Chidananda; Staff Dr Yohannan John and Ms. Mathilda St. John s Medical College & Hospital Associate Director FR. M. A. Sebastian; Medical Superintendent Dr. Mary Ollapally, Department of Community Medicine Dr. Domnic Misquith, (Professor and Head); Dr. Shanthi; Nodal Officers Dr. Mabel Vasnaik, Dr. Babu Palatti, Dr. Vargeese; Medical Records Department Mrs. Irine Jacob, Sr. Reeta vi Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

9 St. Martha s Hospital Superintendent Sr. Dr. Theresita; Nodal Officer Dr. Mallikarjun V. Abdulpur; Casualty Staff Dr. Shashikanth, Dr. Pai A. G, Dr. Farid, Dr. Gopalaiah, Dr. Lucy Nora, Dr. Vidya and Mr. Anthony St. Philomena Hospital Medical Superintendent Dr. Shankar Prasad; Nodal Officer Dr. C. V. Velu; Casualty Staff Dr. Jayanand, Dr. Ramesh, Dr. Toby, Dr. Deepanjali; Mr. George Victoria Hospital Director Dr. Subhash G. T; Dr. Rajeshwari (Fmr.); Medical Superintendent Dr. Tilak B. G; Dr. Nanjundappa, (Fmr. Medical Superintendent), Dr. Ashok Kumar (Fmr.) Nodal Officer Dr. Kantaraj J; Casualty Medical Officers Dr. Vishwanath A, Mr. Sudeendra, and Dr. Sreedhar S. T, Dr. Gangadhara H. C, Dr. Sathyanarayana B. N, Dr. Shivakumar H. V, Dr. Yalugurudappa, Hanamappa Sankanal, Dr. Cheluvanarayana H. C, Dr. Tyagaraja B. N, Dr. Datta R. K, Dr. Muralidhar C. M, Dr. Ramesh R, Dr. Vishwanath B, Dr. Jayachandra, Dr. Kusuma B. K, Dr. Vijayashree M. S, Dr. Rajareddy, Dr. Prakash M. D, Dr. Srinivas G. A and Dr. Varalakshmi K. A., Dr. Ramesh B and Dr. Siddeshwar; Department of Medicine Dr. Vasantha Kamat, Professor and Head; Department of Surgery Dr. Shivaswamy, Professor and Head; Department of Plastic Surgery Dr. Shankarappa, Professor; Administrative Officer Dr. Shathrunjayan, Asst. Professor; Department of Community Medicine Dr. Riyaz Pasha, Asst. Professor; Medical Records Department Mr. Sudeendra and Mrs. Laxmi Devi RURAL HOSPITALS Siddartha Academy of Higher Education (Deemed to be University) Director & Chancellor Dr. Shivaprasad; Vice-Chancellor Dr. Prabhakaran; Registrar Dr. Srinivasa Gowda K. M; Principal Dr. Sreenivasamurthy; Medical Superintendent Dr. Ramesh Rao, Dr. Jena B. K (Fmr.); Nodal Officer - Dr. Ashok J, Dr. P. Venkatesh; Department of Community Medicine Dr. Rajanna M. S, Professor & Head District Hospital, Tumkur District Surgeon Dr. Pratap Surya and Dr. Siddaiah, (Fmr.); Resident Medical Officer Dr. Rangaswamy; Nodal Officer Dr. Ramaprasad; Casualty Staff All Specialists in District Hospital District Health and Family Welfare Office, Tumkur DHO Dr. Aravindappa; Nodal Officers Dr. Ranganath, (Kallambella PHC); Dr. Krishna Raj (Nittur, PHC), Dr. Ramesh K. V (Sira, CHC), Dr. Mohan Kumar (Kunigal, CHC). And all other staff working in emergency rooms - medical record divisions of hospitals, Bengaluru Metropolitan Transport Corporation and in all police stations of Bengaluru city. and World Health Organisation, India Country office, New Delhi Indian Council of Medical Research, New Delhi NIMHANS vii

10 Table of Contents Foreword Dr. D. Nagaraja, Director, NIMHANS... ix Foreword Sri. Srikumar, Director General and Inspector General of Police, Government of Karnataka... x Foreword Dr. Bela Shah, Senior Deputy Director General and Chief of NCD Division, Indian Council of Medical Research... xi Preface... xii Acknowledgements... xiii Abbreviations...xiv List of Tables... xv List of Figures...xvi Executive summary... xviii 1. Introduction What is an injury? Injury: the scale of the problem Injury surveillance Building Bengaluru Injury Surveillance Programme Planning Surveillance Activities Information sources and existing scenario Preparatory phase (Jan March 2007) Information gathering phase Results Burden, pattern and profile of fatal and non-fatal injuries Road traffic injuries Suicides Burns Poisoning Falls Drowning Animal bites Assault / Violence Prehospital care Nature of injuries Management and outcome Injury: the hidden and unanswered epidemic Injury / RTI surveillance: strengths, opportunities and limitations Inputs to policies and programmes Sustainability issues Recommendations References: viii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

11 Foreword With the growth of the city of Bengaluru and its recent transformation to an internationally acclaimed Centre for knowledge and technology, health, safety and security have become important issues for planners and policymakers. Every day, hundreds of people are injured on the roads, at homes and in workplaces of Bengaluru. Behind every death and injury there is a human face and a family. The pain and agony of the suffering families goes beyond words. With travel becoming an essential need for today s life, road deaths and injuries are increasing significantly and young people die at the formative and productive years of their life. Current efforts in addressing road safety and prevention of other injuries are very minimal, especially in comparison to the increasing human suffering. The psychosocial and mental health impact of injuries is huge and phenomenal, and stays with affected individuals and families for the rest of their life. Data from the report reveal that nearly 5,000 persons die and more than 100,000 hospitalized every year in Bengaluru alone. This man-made carnage has to be stopped or at least reduced. Evidence and information from Western countries indicate that majority of the injuries, including road traffic injuries are predictable and preventable. Even with existing knowledge, there are several interventions, which, if properly implemented can save lives and limbs. With much of focus on communicable disease control and a major perceived role of hospitals being providing trauma care, systematic injury prevention efforts are totally lacking. To develop scientific programmes for road safety and injury prevention, there is need for good-quality information. Meaningful programmes can only be developed based on a good understanding of the current situation and identifying areas where interventions can be effective. In addition, programmes that are implemented need to be monitored and evaluated to see how far they have made a change in reducing deaths and injuries. It is likely that decisions made in the absence of reliable data can only be adhoc and crisis oriented. Since injury data is often lacking, many of the programmes that are developed are not evaluated and hence does not sustain over a period of time. NIMHANS with support from ICMR, WHO and leading organisations in the city of Bengaluru has developed the methodology of Road Traffic Injury/injury surveillance programme and taken a lead role in its implementation. The programme has shown that it is possible to develop a good foundation for present and future programmes based on reliable and good-quality data. Political - administrative support and participation of institutions is crucial to develop these programmes further. I hope this initiative by NIMHANS will be seriously considered by policymakers to develop meaningful road safety, home safety and work safety programmes in the coming years, along with expansion of this initiative across other centres in the country. Prof. D. Nagaraja, Director / Vice-chancellor, NIMHANS, Bengaluru. NIMHANS ix

12 Foreword Recent years have witnessed significant concerns on safety and security of people all over the country especially in economically progressive States like Karnataka. With increasing motorization, industrialization, and urbanization in such states, Road Traffic Injuries are showing an upward head Injuries like burns, falls, poisoning etc have also become equally important issues affecting the safety of people on road, at home or at the work place. Today injuries are a major public health and societal problem in Karnataka and its capital Bengaluru. In 2007, an estimated 30,000 deaths and 7,50,000 hospitalizations occurred in the State due to injuries affecting a large number of people with disabilities and severe socioeconomic hardships. The effect of the traumatic experience of an individual or a family with a patient in hospital is indeed phenomenal. Increase in number of vehicles, infrastructure development and expansion and the necessity for travel have made Road Traffic Injuries a leading cause of death in the young and productive sections of our society. India and its states are facing a unique challenge of different type-size-velocity vehicles on its roads in a heterogeneous traffic environment. Even though there are a few time tested and cost effective solutions handed down by research and road safety programmes in the last 3-4 decades, more efforts are required in the coming years. This scenario calls for formulating and implementing scientifically developed road safety and injury prevention policies and programmes in Karnataka and Bengaluru. To formulate these programmes and strategies, there is a need for good quality, reliable, and scientific information on injury occurrence and related causes. Unfortunately, the scientific analysis of injuries, particularly road traffic injuries has lagged behind due to less importance being given to this aspect. The present initiative by NIMHANS in collaboration with State and city police, Transport department, World Health Organization and Indian Council of Medical Research is indeed a laudable effort. The methodology and the programme developed at NIMHANS would help policy makers and professionals to strengthen safety on roads. Needless to say, quality information should be utilized and applied for development of programmes to save lives in the region. I strongly hope this would be given greater importance in the coming years by Government of Karnataka and city of Bengaluru to strengthen this area. R. Sri Kumar, Director General and Inspector General of Police, Karnataka State, Bangalore x Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

13 Foreword I am pleased to share with you The Injury Surveillance Report brought out by National Institute for Mental Health and Neurological Sciences, Bangalore. The Department of Epidemiology is a WHO collaborating Centre for Injury Prevention and Safety Promotion and has conducted extensive epidemiological studies on road traffic related injuries. Worldwide injuries are recognized as a major public health problem that places a significant strain on the government and communities. Road traffic injuries cause over 1 million deaths and 50 million injuries world over in a year. Official figures in India estimate that in 2007, 4,20,000 road crashes were recorded which is 6% more than the number of crashes in It has resulted in over 1.1 lakhs deaths and 4.6 lakhs injuries in the country. These figures are still underestimates as many of the accidents go unreported. The problem is being recognized by the Government of India and efforts are being taken at various levels for their prevention. The Ministries of Transport, Health and Urban planning along with other related sectors are working together to identify various strategies at different levels. Steps are being taken to improve the data collection system, provide better emergency care for survivors and victims', strengthen advocacy programs for road safety and intensify the enforcement system. ICMR has been a partner to the Ministry of Health and Family Welfare in research activities related to road traffic injuries. In it conducted multi-stakeholder workshops and coordinated a feasibility study on injury surveillance with NIMHANS, Bangalore and BJ Medical College, Pune. This project was undertaken with the support of many hospitals, medical colleges, police, and other related agencies. The study highlighted various operational and logistic issues related to the conduct of injury surveillance in the hospitals. Road traffic injuries has also been identified as a key area under the ICMR's INDO-US Joint Collaboration on Environment and Occupational Health. Two workshops and a Joint meeting of the team from US and officials from the Ministries of Health and Family Welfare, Transport, Urban planning, industry, insurance, licensing, and enforcement agencies were held during These activities highlighted the need for surveillance and improvement of prehospital and emergency care services in the country. The present report highlights the findings of the Bengaluru Injury Surveillance Program that was launched by NIMHANS in ICMR has strongly supported this activity that addresses issues related to the methodology, strengths, and limitations of Road Injury Surveillance. The findings will surely help the policy makers to develop better strategies for prevention of road traffic injuries. While progress has been made, much more is still to be done. Unless additional steps are taken, projections show that Road Traffic injuries will be the third leading contributor for disease burden in the world. Let us make collective efforts to prove it wrong. Dr. Bela Shah, Senior Deputy Director General and Chief of NCD Division, Indian Council of Medical Research NIMHANS xi

14 Preface In recent times, injuries have become a day-to-day event in our lives. Recently, injuries are being recognized as an emerging public health problem by policy makers and professionals. While there is enormous concern at all levels including media about the day-to-day tragic events, efforts towards prevention and control are few and yet to begin. Road traffic injuries, suicides, burns, occupational injuries and others contribute significantly to deaths, hospitalizations, disabilities and socioeconomic losses. Reliable and good quality data is the foundation to build injury prevention and control programmes. Information is required on - the magnitude and characteristics of injuries, nature of the affected people, situation - context - circumstances of injury occurrence, characteristics of products and vehicles contributing for injuries, prehospital and trauma care practices and others to formulate effective policies and programmes, proper implementation of which can result in significant reduction of injuries. The current information systems systems in India and its districts and cities only provide information on numbers and very little beyond that. Even these numbers are under reported, and hence the real burden, profile and pattern of the problem are not clearly known. The present feasibility study on Injury/Road Traffic Injury Surveillance was undertaken in Bengaluru in collaboration with City Police, transport department and 25 hospitals. Instead of building entirely new systems, the approach was to strengthen the existing systems to obtain "small amounts of good quality information" for developing injury prevention and control programmes. More than 300 professionals from police department and emergency rooms of hospitals participated in information gathering activities. The present report outlines the methodology of surveillance programme and also the type of data that can be generated through such programmes. At the same time, the strengths - opportunities - limitations and barriers have been identified to know the scope of injury surveillance. Surveillance data can provide meaningful inputs for developing policies and programmes, capacity strengthening, prioritization of problems, resource allocation and can provide directions for interventions. Whether the implementation of interventions resulted in a meaningful change will once again be shown by surveillance data. The development of specific and targeted intervention require more research from health, safety agencies, product/vehicle manufacturers and others on different dimensions. Using the findings of the study, a set of 10 simple fact sheets have been developed to highlight individual type of injuries. In addition, the five public health alerts reiterate the need for systematic interventions, that have been proven to be effective all over the world. In this approach, one has to be cautious to keep the surveillance simple and cost effective without overburdening the systems. The nature - contents - amount of data to be collected should be decided "apriori" and quality should be ensured. Most importantly, there is need for building mechanisms to ensure that the data collected is used meaningfully and not a waste of time and resources. Further, the type and nature of institutions to be involved along with quality control mechanisms should be put in place. The efforts of this collaborative group will be amply rewarded, if, Parliamentarians, Policy makers and Professionals recognize the seriousness of the emerging injury epidemic and facilitate multisectoral institutional based activities for prevention and control of injuries. Dr. G. Gururaj Professor & Head Dept. of Edidemiology and WHO Collaborating Centre for Injury Prevention and Safety Promotion, NIMHANS, Bengaluru. xii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

15 Acknowledgements The Bengaluru Road traffic injury/injury surveillance programme is a collaborative effort between NIMHANS, Bengaluru city police, Bengaluru transport development Corporation, 25 hospitals and NGO's. Nearly 300 professionals have participated in the programme from various organisations. Listing individual names will run into several pages, but sincere thanks to all of them for taking interest in developing this programme. Specially, thanks to all nodal officers for taking leadership role in their respective organisations. Thanks to Dr. D. Nagaraja, Director / Vice Chancellor for being a constant source of support and guidance along with taking keen interest in the programme. Sincere thanks to Indian Council of Medical Research and World Health Organisation, India country office for facilitating the study and providing financial support. Especially, we are thankful to Dr. Bela Shah, Dr. Geetha Menon, Dr. Cherian Varghese and Dr. Kavita Venkataraman for all help and support in developing the programme. Specially, my colleagues Dr. Girish N Rao and Dr. Kavita Rajesh participated and supported the programme at all levels from planning to finalization of report. Their immense contribution was beneficial in completing this feasibility study and moving to the next phase of programme. My sincere thanks to both of them for all contributions towards this programme. Thanks to Sri. Vijendra S Kargudri and Sri. Girish BG for co-ordinating data editing and efficient data management. We are grateful to Sri N. Gopalkrishna, Assistant Editor, NIMHANS and Ms. Manasi Paresh Kumar for help in editing the manuscript. Thanks to M/s. Aditi Enterprises for design and printing of the report, factsheets and public health alerts. NIMHANS xiii

16 List of Abbreviations CMO : Casualty Medical Officer CBHI : Central Bureau of Health Intelligence CC : Co-ordinating Centre CCRB : City Crime Records Bureau CDs : Communicable Diseases ER : Emergency Room ETCR : Emergency Trauma Care Record FIR : First Information Report HICs : High Income Countries ICD : International Classification of Diseases ICECI : International Classification of External Causes of Injuries ICMR : Indian Council of Medical Research IPC : Injury Prevention and Control LMICs : Low and Middle Income Countries MCCD : Medical Certification of Cause of Death MLC : Medico-Legal Case NCRB : National Crime Records Bureau NIMHANS : National Institute of Mental Health & Neuro Sciences NCDs : Non-Communicable Diseases NGO : Non-Governmental Organization OTC : Over The Counter RMO : Resident Medical Officer RTI : Road Traffic Injury SRS : Sample Registration Scheme WHO : World Health Organization xiv Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

17 List of Tables Table 1: Example of Haddon's matrix as applied to two wheeler road traffic injury... 4 Table 2: Strengths and limitations of different strategies Table 3: Inventory results of the staffing pattern at casualty depts. of various hospitals Table 4: Inventory details on the approximate patient load in the casualty department of various hospitals Table 5: Bengaluru city - A socio-demographic profile Table 6: Motorization index for Bengaluru Table 7: Distribution of fatal and non-fatal injuries Table 8: Number of fatal injuries registered with police, Jan - Dec Table 9: Non-fatal injury registrations in Emergency rooms of select hospitals, April-March Table 10: Education & occupation of persons in RTIs Table 11: Environmental factors Table 12: Education & occupation levels among completed & attempted suicides Table 13: Major causes of suicide for different age groups Table 14: Education and occupation distribution of non-fatal fall injuries Table 15: Place of first aid for injured persons Table 16: Place of first aid for non-fatal injured persons Table 17: Severity of injuries in ER facilities Table 18: Injury pattern with reported and estimated figures NIMHANS xv

18 List of Figures Figure 1: Epidemiological model of an injury caused by a motorcycle collision... 4 Figure 2: The injury spectrum... 4 Figure 3: India injury pyramid... 5 Figure 4: Road accident deaths in India, Figure 5: State wise distribution of RTIs in India, Figure 6: State wise distribution of suicides in India, Figure 7: Designing and building a surveillance system... 9 Figure 8: Sources of information for injury Figure 9: Map of Bengaluru showing the location of various partner hospitals Figure 10: Vehicular growth in Bengaluru Figure 11: Distribution of deaths in Bengaluru, Figure 12: External causes of injuries Figure 13: Age - sex distribution of injury deaths Figure 14: Bengaluru injury pyramid Figure 15: Traffic deaths in Bengaluru ( ) Figure 16: Suicides in Bengaluru ( ) Figure 17: Age-sex distribution of fatal & non-fatal injuries Figure 18: Place of injury occurrence Figure 19a: Injury causes Figure 19b: Injury causes for rural non-fatal injuries Figure 20: Place of occurrence of RTIs Figure 21: Distribution of RTI deaths based on place of death Figure 22: RTIs in Bengaluru Figure 23: Age-sex distribution of RTI deaths Figure 24: Time of crash in fatal and non-fatal injuries Figure 25a: Road user categories in urban fatal and non-fatal injuries Figure 25b: Road user categories in rural non-fatal injuries Figure 26a: Injury collision pattern amongst pedestrians Figure 26b: Pedestrian activity at time of injury Figure 27a: Collision pattern of two-wheeler rider/pillion Figure 27b: Crash pattern and type of collision among two-wheeler rider/pillion Figure 27c: Use of helmets among two-wheeler riders Figure 28a: Bicyclist hit by Figure 28b: Crash pattern and type of collision among bicyclist xvi Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

19 Figure 29a: Car occupant hit by Figure 29b: Crash pattern and type of collision among car occupants Figure 29c: Usage of seat belts among car drivers Figure 30: Month of occurrence, suicides Figure 31: Age-sex distribution of completed & attempted suicides Figure 32: Place of occurrence of completed and attempted suicides Figure 33: Methods of suicide Figure 34: Suicide situation Figure 35: Time of completing and attempting suicides Figure 36: Age-sex distribution of burn injuries Figure 37: Place of occurrence of burns Figure 38: Distribution of burn injuries as per time Figure 39: Fatal & non-fatal poisoning - age-sex distribution Figure 40: Place of poisoning Figure 41: Age-sex distribution, falls Figure 42: Place of occurrence, falls Figure 43: Age-sex distribution, drowning Figure 44a: Age-sex distribution of assault / violence injuries Figure 44b: Place of assault / violence Figure 45: First aid care for persons with fatal and non-fatal injuries Figure 46: Personnel delivering first aid for fatal and non-fatal injuries Figure 47a: Mode of transportation in urban Bengaluru Figure 47b: Mode of transportation in rural Bengaluru Figure 48: Time interval between time of injury and registration, fatal & non-fatal, all injuries Figure 49: Time interval between time of injury and registration, fatal & non-fatal, RTIs Figure 50a: Body parts injured in RTIs Figure 50b: Body parts injured in assault/violence Figure 50c: Body Parts injured in Falls Figure 51: Extent of burns among fatal & non-fatal burn injuries Figure 52: Status of injured persons at hospital entry Figure 53: Mode of management Figure 54: Pathways of research Figure 55: Inputs for RTI prevention and control Figure 56: Need for an intersectoral approach NIMHANS xvii

20 Executive Summary The city of Bengaluru has grown by leaps and bounds during the last decade. A "cosy & comfortable Bengaluru" has changed to a "Bruhat Bengaluru", embracing a population of 8 million in its day to day activities. As a senior citizen remarked "the city is a living testimony to what socioeconomic changes can make for a one time peaceful city". As city planners and administrators take pride in many positive developments of education, information technology, raising living standards, vibrancy and hope for millions, etc. safety and health have also become matters of great concern. Injuries, hitherto referred as accidents, have emerged as an important public health problem in the city. It has become common to read, listen, witness or even experience an injury in our day-to-day lives. Many times these are considered as accidents, events due to bad times, or simply an act of fate. Till a few years, many High Income Countries (HICs) of the world had similar understanding of injuries and were doing, what we are doing today. This changed with information - knowledge - data - evidence and evaluation and resulted in significant changes in the way we use roads, live at home or work in different places. This knowledge and information came from years of research that resulted in a better understanding of injury phenomenon in terms of burden, characteristics, causes, risk factors, determinants, impact and outcome. Surveillance is one such activity that will help in recognizing the burden of injuries, identifying broad risk factors and causes, prioritizing activities, monitoring and evaluating interventions, capacity development, and stimulating further research. Even though India has considerable experience in Communicable Disease (CD) surveillance, Injury and Road Traffic Injury surveillance is new and its importance is recently gaining recognition. In India, during 2007, there were 315,641 injury related deaths and 493,515 persons sustained injuries as per NCRB report. The report also provides detailed information as per states, cities and on major sociodemographic variables (age, sex, time, categories and an overview of causes). This information though extremely useful, needs to be strengthened with data on causes, risk factors and specific attributes of each injury by further systematic studies. Further, local data in states, cities and rural areas are required to develop locally relevant programmes. To develop systematic and scientific injury prevention - Road traffic injury prevention, trauma care and rehabilitation programmes, comprehensive information on epidemiological characteristics of injuries are required. Reliable and good-quality information is the basic foundation and one of the requirements for injury prevention and safety promotion programmes. Till date, all over India, police sources of data have been the only ones available for understanding injuries and health sector information has been lacking and research studies have been limited. The police collect large amount of information for medico legal and administrative requirements. Despite this and even though health, transport sectors collect data on deaths and injuries, the data has several limitations in terms of completeness, coverage, quality, utility and integration. xviii Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

21 Data is often not available in some vital areas that are essential to develop prevention, management and rehabilitation programmes. Surveillance has been recognised as an important activity to develop goodquality information which can act as the basis for larger programmes. Contrary to popular belief, surveillance can be built on existing systems with appropriate strengthening at different levels. Injury surveillance defined as systematic collection, analysis, interpretation, dissemination of data along with feedback and action is an essential component of injury prevention and road traffic injury prevention programmes. Injury/RTI surveillance is the foundation on which other data components can be established. If implemented well, it can provide information on the burden and magnitude of the problem, injury patterns and profiles, major characteristics of injured and killed persons, risk factors, pattern of care and outcome. The amount of data that is made available depends on the amount of information collected from different sources in varied sittings. Using surveillance as the first level of activity, additional activities such as trauma registries, risk factors studies, focused research activities, product / vehicle related research, behavioural studies and multidisciplinary crash and injury investigations can be added to develop comprehensive understanding of injury / RTU phenomenon. Injury/RTI surveillance data will be useful in recognising the public health impact of the problem, prioritisation process, resource allocation, capacity development, monitoring the impact of interventions and stimulating further research. The present injury/rti surveillance activity was started as a feasibility study to understand the process and issues, develop methodology, and implement a programme with necessary tools. The study was undertaken in Bengaluru, Pune and New Delhi during The initiative in Bengaluru was coordinated and initiated by department of Epidemiology and the WHO collaborating Centre for injury prevention and safety promotion at NIMHANS. The programme was developed in a collaborative manner between NIMHANS, Bengaluru city police, Bengaluru Metropolitan Transport Corporation, 25 major hospitals from rural and urban areas and NGO's. Attempts are being made to develop this feasibility work into a long-term activity, so that continuous data is available on a regular basis. The programme beginning with consultation of stakeholders, undertook the preliminary activities of situation analysis, review and utility of available data, need for good-quality data, mechanisms required for information collection along with dissemination and feedback activities. Data collection formats were developed and implemented along with training of personnel in police and hospitals. During a one year period, information was collected from 3,427 (total % coverage) injury deaths, 53,448 (total 68,498-78% coverage) hospitalised patients and 113 fatal bus crashes. The present report summarises the situation and lays a roadmap for the future. Information gathered in this one year reveals that - nearly 5,000 individuals have lost their lives and more than 100,000 were hospitalised due to an injury in In the hospitals, injuries accounted for 21% of ER registrations, 10% admissions and 30% of total deaths. Majority of those killed and injured were in younger age groups of 16 to 45 years and were predominantly men. Road traffic injuries and suicides were two major injury problems in the city of Bengaluru. Pedestrians, two wheeler riders and pillions, and pedal cyclists were involved in greater numbers. Crashes between these vulnerable road users and heavy vehicles resulted in higher deaths and serious injuries. Suicides were commonly due to consumption of organophosphorus compounds and drugs, occurring at a time when the person was alone and at home. Burns, poisoning, falls were other major injuries responsible for deaths and hospitalisations. Trauma care NIMHANS xix

22 was found to be inadequate and poor, requiring immediate strengthening. Nearly half of the injured reaching the hospitals were in moderate to severe levels of severity requiring further management. Implementation of the programme during the last one year and its continuation during the last few months reveals that road traffic injury and injury surveillance is possible, feasible and can be developed within the existing systems. While data on deaths could be collected from police after improving their data collection capacity, hospitals can collect injury data using the uniform emergency trauma care record. Opportunities exist for integrating both police and hospital information, more so with technology tools. Administrative support, training of personnel, monitoring and regular feedback are highly essential for sustainability of programme. Apart from collecting data, it is crucial to build capacity within the existing systems for careful analysis and interpretation of data. Discussions with policymakers and professionals indicated that the data developed will be useful to develop new activities as well as to monitor existing programmes. Surveillance data can be extremely useful to identify new and emerging problems with the passage of time. Despite the usefulness of data and the programme, several limitations need to be addressed and activities initiated for long-term continuation of programme. These include cooperation from police and hospital staff, administrative approvals, continuous training programmes, mechanisms for analysis - dissemination - applications, systematic feedback, resource allocation, leadership roles and others. Most importantly, the data developed must be utilised for developing intervention programmes on a continuous basis. If the data collected is not utilized for the benefit of the common man to reduce injuries, it will only have limited utility. At this juncture, injury (RTI) prevention and control is a shared activity among several sectors and there is no dedicated -lead agency to address prevention and control issues. Mechanisms to guide-direct-co-ordinateimplement-monitor- and evaluate need to developed in the coming days. Surveillance should be developed in a phased manner with a focus on select injury causes in select institutions. There are several opportunities and mechanisms to use data as strong evidence to develop scientific programmes for injury prevention and control. It is hoped that this experience and learning will help professionals across the country to initiate activities for injury prevention and control on a scientific basis using evidence based approaches. xx Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

23 1. Introduction Injury and violence is one of the leading causes for death and disability worldwide, more so in Low and Middle Income Countries (LMICs). Recent years have witnessed a rapid increase in motorization, industrialization, migration, urbanization, changing life styles, habits and value systems of people. The influence of print and visual media is also much larger today. While this ongoing epidemiologic, demographic and socio-economic transition has seen a decline of some communicable diseases, it has also seen the emergence of injuries as a leading health problem (1). India and Bengaluru are no exception to this change. India has made substantial progress in communicable disease control, expansion of Non-Communicable Disease prevention and control programmes and development of trauma care services in managing the unfolding triple epidemics of today. Undoubtedly, the best of trained health professionals and state of art health facilities are rapidly emerging. The country has not lagged behind in offering high quality health care services and medical tourism is emerging in a big way. Augmentation of facilities and improvement in the quality of services is receiving greater attention of policy makers and administrators. Increasing participation and contribution of the largely unregulated private health sector (large chain of specialty hospitals, teaching hospitals, nursing homes, family practitioners and local doctors of Indian systems of medicine), increasing costs of health care, greater burden on individuals and families are some accompanying changes in this scenario. Most of the health care at individual and family level are still met by out of pocket expenditure. Injuries affect the most economically productive sections of our society, thereby depleting precious human resources along with huge socio economic losses to the individual, family and national economy. No single day passes in our lives without injuries making a direct or indirect appearance. Injuries are common and affect all people, more so the productive sections of our society. Road traffic injuries, falls, burns, poisoning, occupational / work related injuries, suicides, violence / assault and animal bites are some common injuries. Individuals in the age-group of 5-44 years and also men are the most affected. People in middle and lower income strata of society are more vulnerable, thus making them poor due to economic impact of injuries. Health sector bears the maximum brunt by providing care for affected individuals and families. At the same time, policies and programmes to address this problem are emerging few and limited. Recently, there is a growing recognition that injuries are a major killer in our society. Research and experience of High Income Countries (HICs) in the world reveal that majority of injuries are predictable and preventable. In India, systematic and scientific efforts in injury prevention and control are yet to begin. While injuries have declined in many developed parts of the world, it has been steadily rising in India. The need to adopt and suitably modify lessons from HICs is crucial for injury prevention and control in India to avoid repetition of mistakes and to make appropriate decisions by recognition of principles. The last four decades of research and policy developments across the world have shown that injuries are predictable, preventable, but needs a systems approach. In the absence of coordinated, integrated and intersectoral approaches, injury prevention and control is at cross roads and without direction in India. Injury prevention and control should be evidence based and data driven. Good quality, reliable and representative information is very vital to formulate injury prevention programmes. However, in India, comprehensive information is often lacking or, at best, patchy. Though police data on injuries are available to a limited extent, health sector information has been totally missing. Further, even the collected information is not systematically and scientifically analysed to develop a better understanding of injury pattern, profile and determinants. Even the available data are not aptly utilized in policy and programme development. Nevertheless, the scenario has begun to change and time is appropriate to give a major push and direction for this area. NIMHANS 1

24 Several initiatives at international and national levels in recent times have paved the way for this change. The World report on Road Traffic Injury Prevention (2), World report on Violence & Health (3) and few national reports (4, 5, 6) have recommended injury surveillance and good data as an important tool to reduce the growing burden of injuries in all countries. Efforts to improve police, transport and health data has been on the anvil for past few years. Road Traffic injury surveillance initiative in select cities on a pilot basis by the Indian Council of Medical Research has just been completed in 2007 / 08 (7). Injury surveillance across trauma care centres is under the consideration of the Ministry of Health, Government of India. Research in the areas of suicide and violence prevention, though limited, has recommended good data as a primary need to develop National Suicide Prevention policy and Programmes (8). The report of the National Commission on Farmers ( and Prevention of Domestic Violence Act ( ncw.nic.in/domesticviolencebill2005.pdf) include measures for reduction of suicides by strengthening the evidence base. Violence prevention is gaining importance with an active judiciary and NGO network along with recognizing the importance of information. Work related injuries, though on the increase, has not received much attention as majority are employed in the unorganised sectors. The media has been spreading safety messages and have contributed significantly to building a safety movement in the country and available statistics are quoted many times. Most importantly, people, at least in urban areas, are thinking of safety as an important component. What is most crucial is the fact that all these initiatives should be driven by data based decision making. Many of the Indian states and cities are moving towards road safety, though home safety and work safety have lagged behind. The national road safety policy for India is in final stages of approval. National policies on transport development, urban improvement and infrastructure expansion have included an element of road safety. Many Indian states have evolved independent road safety policies and plans. Ministries of transport, home affairs, social welfare and urban development have begun supporting safety programmes. Highway expansion and improvements, Golden Quadrilateral Project, new plans and investments in infrastructure expansion are gathering pace. Multilateral projects of World Bank, Asian Development Bank and others are moving rapidly. Infrastructure development projects in Karnataka, like B TRAC 2010 of Government of Karnataka for Bengaluru city have identified road safety information system as one of the 10 main components. Helmet legislation & enforcement, programmes on reducing drinking and driving, speed control measures through road engineering and use of speed cameras, pedestrian safety are all inching forward. Awareness programmes are conducted, though not systematic and co-ordinated. Ministry of Health & Family Welfare has been focusing on strengthening trauma care across the country and several states have taken up this as a priority area. While new initiatives need to be formulated and implemented, ongoing activities should be monitored and evaluated for their effectiveness and efficacy. This is possible with surveillance, combined with good research and evaluation studies. Given the magnitude and burden of the problem, the efforts for prevention, management and rehabilitation are pitiably low. The obvious questions are - Why should young people lose their lives or become disabled on road, at work or at home?, why should families suffer?, why should the country be losing precious human resources?, why should people end up with lifelong disabilities?, why are injuries on the increase despite the availability of enormous knowledge towards prevention and control?,. These questions are becoming topics of debate as injury and violence related issues have moved on to the front page of the newspapers and prime time issues on television channels. Consequently, people today have begun to debate, discuss and demand safety on roads, at home and in work places. In response, in recent years, there has been a greater concern across several ministries on the need for prevention. To transform this concern to action, quality information forms the first step in making injury prevention and control a reality as mere concern alone is not enough, but calls for action. The current information available primarily from police (9) and to a limited extent from health is totally inadequate to formulate injury and road safety programmes in the country. In recent years, the Government of India, World Health Organization, Indian Council of Medical Research and several professionals from health, transport, police, urban and rural development and NGOs have identified 2 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

25 information strengthening as the basis for injury prevention and road safety programmes. Good information, undoubtedly, provides a foundation and direction for development of sustainable programmes. With this in view, the present programme on injury and Road traffic injury surveillance in Bengaluru has an important place to understand the current scenario, examine the feasibility and develop a methodology to generate information and facilitate its greater application in road safety and injury prevention programmes across the country. 2. What is an injury? Commonly, injuries are considered as accidents, Accident simply means that it just happens and nothing can be done about it. The term injury by definition means that there is a body lesion due to an external cause, either intentional or unintentional, resulting from a sudden exposure to energy (mechanical, electrical, thermal, chemical or radiant) generated by agent - host interaction (10). This generation & transfer of energy in an injury event (or crash) lead to tissue damage when it exceeds the physiological tolerance of the individual. On the contrary, injury can also occur due to sudden withdrawal of a vital requirement of the body, for example, withdrawal of air in drowning. Thus, an injury is damage to a body organ, which occurs rapidly, with sudden energy transfer being the reality and reason. In injuries, there is a definite interaction between agent, host and environment, is an acute event, occurs in varying severities and with chances of repeated occurrence. Global understanding of injury causation and mechanism has revealed that injuries are not just accidents, as exemplified by the 2004 World Health Day slogan Road safety is no accident Types of injury Injuries are classified in number of ways. A commonly used method is to classify injuries as intentional, unintentional and undetermined injuries, based on intent of injury occurrence. Unintentional injuries are also referred to as accidental injuries, while intentional injuries are self-inflicted or caused by others. The latter include suicides, homicides, injuries due to violence against women, children and elderly, those due to wars, riots and conflicts, etc., A second common method of classifying injuries is according to the mechanism which caused the injury, like road traffic crashes, poisoning, falls, fires/ burns, drowning, fall of external objects and others. A third method of classifying injuries is according to place of occurrence like road injuries, home injuries, sports injuries and work related injuries based on place of occurrence of injury. The fourth method is based on anatomical types and location of injuries depending on body organs injured like head injuries, facial injuries, injury to long bones etc. A continuation of this is seen as fractures, contusions, haemorrhage, etc. International Classification of Diseases (11) and International Classification of External Causes of Injuries (12) are commonly used for systematic and scientific classification of injuries all over the world. A particular classification chosen is primarily determined by the purpose of a (or more) programme(s) and availability of resources. Commonly, the first three methods (viz., intent, mechanism, place) are preferred, as changes can be made in products and environment, to prevent injuries occuring in future Understanding injuries Historically, in 1970, William Haddon Jr., proposed a matrix for consideration of all factors involved in injury causation at different time periods and at various levels (13). This involved identifying what can be done for people, products and the environment before injury, during an injury and after its occurrence (Table 1). This concept has revolutionized injury prevention since 1970s all over the world, and can be used to analyze any type of injury, identify interventions that might prevent such an event from happening again or reducing the harm done. Injuries occur due to a combination of agent, host, vector and environment factors. The epidemiological NIMHANS 3

26 triad of agent, host and environment has been used in our understanding of communicable diseases earlier and injuries too have similar dimensions like any other public health problem. There is a clear need to understand injury mechanisms to develop intervention programmes. Figure 1: Epidemiological model of an injury caused by a motorcycle collision ENVIRONMENT Slippery roadway VECTOR Motorcycle HOST Rider Source: (19) AGENT Collision (mechanical) force or energy) The case of an injury to a motorcycle rider involved in a motorcycle collision is shown in Figure 1. Here, the host is the rider, vector is a motorcycle, agent is the mechanical force or energy and environment is the road. Similarly, in an act of interpersonal domestic violence in which a husband causes injury to his wife, the host is the injured person, the agent is the energy (physical assault), the vector is the person inflicting injury and the environment include domestic situation and societal norms and values that allow for such behaviours to occur. Using a model of this type helps in identifying factors involved in an injury. This would help policymakers, professionals, product manufacturers and others to identify situations and target interventions to prevent such injuries from happening in the future or reduce the harm done when they happen. For instance, in the first example, there may be factors about the rider, the motorcycle or the road that contributed to the crash. One or more of these can be changed in order to prevent such incidents in the future. Interventions that might be done by anyone thinking about these elements is given in Table 1. Some appropriate interventions that might prevent such collisions from happening in future are given below and several more can be added to this list. Implementing helmet & drink drive laws Reducing speeds with safety in focus Increasing visibility of two-wheelers and/or riders Strengthening brake & light systems Improving pre hospital & emergency care Overall safety improvement of roads and others Use of injury spectrum is another useful method to understand injuries. This method (figure 2) maps an injury over time, starting with its exposure, followed by the event, through the occurrence of injury time finally resulting in disability or death. Understanding this time spectrum can help in developing interventions that can either prevent injury or lessen the impact of injury. Figure 2: The injury spectrum EXPOSURE EVENT INJURY DISABILITY DEATH Source: (19) Based on this understanding, injury prevention and control is broadly classified as primary prevention, secondary prevention and tertiary prevention. Primary prevention involves preventing the event from occurring or preventing it from leading to injuries. This involves taking all necessary steps to see that injuries do not happen and includes all activities that are done to make people, products and their environment safer. Secondary prevention involves early diagnosis and appropriate management of an injury. Most of the times health professionals are involved in providing care and services for injured people. This includes all activities right from application of basic first aid at the place of injury to stopping an injury from having serious consequences. Tertiary prevention aims at improving the final outcome and involves preventing further complications through rehabilitation programmes. Table 1: Example of Haddon s matrix as applied to two wheeler road traffic injury Human Vehicle Environment Pre-event Increase awareness about safe Increase visibility of vehicle Implement safety features on driving, helmet wearing, drink roads driving etc. Event Early transfer to hospital and Better braking systems of Crash protective road side required care two wheelers stationary objects Post-event Rehabilitate and improve health Improve safety technologies Facilities for early rescue of care services and components injured persons 4 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

27 3. Injury: the scale of the problem The precise number of deaths and injuries due to specific causes are not clearly available in India. The National Crime Records Bureau (NCRB) at national (9), state and city levels are the primary sources of information in the country. The national agency collects, compiles and publishes annual reports based on data received from state and city agencies. An overview of current scenario is provided in Annexure 1. Nearly 4, 59,709 injury deaths and 2.5 million injuries were reported in India in RTIs and suicides, being 2 major injuries, accounted for 1, 14, 590 and 1, 2, 637 deaths, respectively. A recent national review (1) has estimated that a million injury deaths and 30 million hospitalizations occur every year. Southern Indian states reported higher number of deaths, reasons for which can be several and not clearly defined. In Karnataka, suicides and 8762 RTI deaths were reported followed by 1593 homicidal deaths for the year In the same year, 1, 82, 321 persons were injured as per police reports with a ratio of nearly 1:5. Combining both accidental and suicidal causes it was observed that there were 19, 390 accidental and 12, 304 suicidal deaths during Bengaluru city reported 5,660 injury deaths with suicides (2429) and RTIs (961) topping the list; burns were the 3rd leading cause with 371 deaths. Road traffic injury alone claimed nearly 1,000 lives while injuring 6,591 people as per official reports. Studies, both in India and outside, indicate that injuries are underreported in all parts of the world (14, 15, 16). In India, while official statistics are able to capture large majority of deaths, non-fatal injuries of various severities are highly underreported. Data from HICs & studies from India indicate that for every person killed by injury, approximately 30 persons are hospitalized and roughly 100 times are treated in hospital emergency rooms and then released (1, 2). For each death from injury, there are many more injuries that result in hospitalization, treatment in emergency departments or treatment by practitioners in formal and/or informal health sectors. Studies in Bengaluru and Haryana have shown that injury problems are much higher in the community than officially reported figures (17, 18). Recent studies (14, 15, 16) using verbal autopsy methods have shown that injury deaths contribute for 13 18% of total deaths varying from place to place. The recent national review on injuries estimated that in 2005, 8,50,000 (nearly a million) persons were killed and 17,000,000 hospitalized (1) (Figure 3). If unchecked, numbers will increase to 1,100,000 deaths and 22,000,000 hospitalizations of serious injuries by Road traffic Injuries, suicides, burns, poisoning, violence are all major causes of deaths and disabilities and figures 4, 5 & 6 show trend of RTIs deaths and state wise distribution of RTIs and suicides, respectively, for the year Deaths (1) Serious Injuries (20) Minor Injuries (50) Figure 3: India Injury Pyramid Source: (1) 8,50,000 (upto 10,00,000) 17,000,000 (upto 20,00,000) 42,500,000 (upto 50,00,000) To formulate effective injury prevention and control (IPC) programmes, information is required on what types of injuries occur? Who are the affected people? What are their characteristics? Where and how injuries occur? What are the causes?, what are the agent host environment factors that can be modified? and what needs to be done towards prevention, improving trauma care and rehabilitation?, etc. The currently available data from police reveal the number of deaths due to different causes of injuries in India and Bengaluru. The data also provide broad characteristics of injuries like age, gender, some socio-demographic correlates, while risk factors and causes are not delineated clearly. However, information on number of deaths alone is not enough to formulate injury prevention programmes. Even though state-level and NIMHANS 5

28 city level information is available, it once again indicates the broad characteristics of injuries but does not specifically inform as to what can be done to reduce these injuries. Numbers are also collected by different agencies like transport department, City Corporation and others for their own use. The collected information is not used for prevention and control, but more for administrative and legal purposes. In addition, total information is not available in the public domain for researchers and policy analysts. Thus, information is piecemeal, fragmented and not integrated. Given these limitations of existing data, the BISP in the city of Bengaluru aimed at collecting small and relevant information from large number of participating organizations in a uniform way to understand injury profiles and characteristics with the major goal of improving injury information systems for future activities. In thousands Figure 4: Road Accident Deaths in India, Figure 5: State wise distribution of RTIs in India, 2007 (Rate / 100,000 population; National average 10.1) State Rate Goa 21.3 Haryana 18.6 Tamil Nadu 18.2 Andhra Pradesh 16.9 Karnataka 15.4 Himalchal Pradesh 15.3 Chandigarh 14.4 Rajasthan 12.7 Delhi 12.7 Maharashtra 11.9 Gujarat 11.3 Kerala 11.2 Uttaranchal 10.4 Madhya Pradesh 9.3 Arunachal Pradesh 9.1 State Rate Sikkim 8.8 Punjab 8.2 Jammu & Kashmir 7.9 Orissa 7.7 Uttar Pradesh 6.7 Tripura 6.4 Jharkhand 5.9 West Bengal 5.6 Assam 5.4 Meghalaya 5.3 Manipur 4.4 Nagaland 4.2 Mizoram 3.6 Bihar 3 Chattisgarh 1.3 Figure 6: State wise distribution of Suicides in India, 2007 (Rate / 100,000 population; National average 10.8) State Rate/100,000 Kerala 26.3 Karnataka 21.6 Tamil Nadu 20.9 Chattisgarh 20.7 Sikkim 20.7 Tripura 20.3 Andhra Pradesh 18.2 West Bengal 17.0 Goa 16.9 Maharashtra 14.3 Orissa 10.9 Arunachal Pradesh 10.8 Assam 10.3 Haryana 10.3 Gujarat 10.0 State Rate/100,000 Madhya Pradesh 9.2 Delhi 8.9 Chandigarh 7.8 Rajasthan 6.9 Himachal Pradesh 6.2 Jharkhand 4.3 Meghalaya 3.5 Punjab 3.2 Mizoram 2.9 Uttarakhand 2.6 Uttar Pradesh 2.1 Jammu & Kashmir 1.9 Manipur 1.5 Nagaland 1.1 Bihar Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

29 4. Injury surveillance The term surveillance as used in public health field refers to ongoing, continuous and systematic collection, analysis, interpretation and dissemination of health information (19). It includes collecting information on individual cases or assembling information from records, analyzing and interpreting information, reporting and providing feedback into programmes. Surveillance is a continuous activity with an inbuilt feedback mechanism and an action component. It is also the best way of monitoring changing trends, identifying new/ emerging problems, selecting interventions and measuring the impact of interventions in a timely manner. Surveillance data can be a meaningful input to several programmes and activities of various ministries, government departments, health professionals, transport, police, NGOs and all others interested in injury prevention. In India, few surveys have been undertaken in recent years by individual researchers. A summary of Indian studies is available in the recent report entitled Injuries in India: A National Perspective (1). In Bengaluru, few studies have been undertaken by NIMHANS on epidemiological, preventive and public health aspects of road traffic injuries, brain injuries, suicides and violence ( In New Delhi, TRIPP at IIT has made significant contributions in road safety and transport management ( Few medical colleges and engineering and transport departments have also undertaken studies in their respective areas of interest. Studies and reports available from independent agencies like WHO, World Bank, IndiaClen, NGO s and other agencies have added substantial information. However, these have been stand alone - one time studies and provided useful information for interventions and policymaking process. A surveillance programme has not been in place and this collaborative activity is the first of its kind being undertaken in Bengaluru and also in Pune, India. Details of the programme are available in the recently published report from Indian Council of Medical Research (7) Why do injury surveillance? Without reliable information on the burden, pattern, trends and causes of injuries, it is difficult to develop any systematic interventions. Hence, in India, lack of reliable information on injury burden and impact has been one of the major barriers for absence of systematic programmes for injury prevention and control. Consequently, many of the measures are ad hoc, at times unscientific, and have not made any significant change. In the absence of systematic information, the injury problem is poorly recognised even though evidence exists that the burden is huge and systematic interventions can be put in place. Nearly 15% of deaths are due to injuries (14 16). Many of the efforts required like allocation of resources, human resource and capacity development, systematic efforts for care and management, injury prevention interventions, and others have not received much importance. Hence, injuries have been a clearly neglected problem and a hidden epidemic for many decades in India. While reporting systems generally present total numbers, Injury surveillance is the first step in understanding the burden and characteristics of injuries. This needs to be supplemented with focussed and systematic research (e.g., trauma registries) and multidisciplinary crash and injury investigations by experienced teams. By bringing data in a continuous manner, new insights into programmes can be developed in focussed areas. Surveillance generates data that helps in understanding the: Magnitude of the problem and its characteristics Changing trends Populations at risk General and select risk factors, and Impact of interventions By identifying what interventions are likely to work (time tested solutions should be implemented without further delay while waiting for surveillance NIMHANS 7

30 systems to develop) with such information, it is possible to design and apply appropriate scientific interventions and monitor the results along with assessing the impact of interventions. Local, regional and national injury surveillance systems will provide data required for planning and delivering effective injury prevention programmes to communities and to the country at large. It will help planners and administrators to take appropriate action on a continuous and regular basis. Further, it helps societies to advocate for positive changes that are required for safety of everyone How is injury surveillance different from surveillance of CDs and NCDs Public health problems confronting societies are broadly classified as Communicable Diseases (CDs), Non-Communicable Diseases (NCDs) and injuries. The epidemiology of various conditions has focussed on identifying agent host and environment characteristics, thus being able to target specific interventions to reduce deaths, morbidity and disability. Surveillance of CDs has been in place for a long time and health sector has been the prime mover in this area. NCD surveillance is a new entrant and efforts to identify risk factors (e.g., tobacco use, alcohol intake, unhealthy diet, physical inactivity, and others) and targeted diseases (cancer and stroke) have been developed. In injuries, as highlighted in the previous sections of this report, the agent host environment concerns are different even though the primary foundation and principles of disease occurrence remain the same. The mechanism, context, situation, risk groups are different for injuries and vary within different injury groups, despite commonalities. Consequently, information requirements for surveillance differ for different types of injuries, even though some will be general and common. Hence, injury surveillance focuses on characteristics of injured and killed, major injury causes and selected risk factors along with outcome of injuries depending on the place, type and extent of information gathering. There are major differences in surveillance of CDs, NCDs and injuries and hence, type, source and extent of information gathering analysis interpretation and utilization vary across different groups. It is once again crucial to highlight that injury surveillance provides broad and specific information (depending on the extent and depth of surveillance) and should be supplemented with data from focussed, targeted and specific studies to obtain further insights. Injury surveillance, thus is often the first step in the larger information networks. Most importantly, action based on surveillance data is different for 3 major groups mentioned earlier. A quick reaction from concerned public health agencies (epidemic outbreaks) is possible and helps in further transmission of disease. Surveillance for NCDs and their risk factor requires broader inputs from several ministries. Injury surveillance will be useful, sustainable and cost effective, if policiesprogrammes-action plans- and interventions can come up based on data. The data recipients should be able to act and see whether their actions made any difference to deaths and injuries through surveillance. This needs to be addressed from early stages by creating mechanism to share, disseminate, apply and implement injury prevention and control programmes. RTI / Injury surveillance also does not necessarily mean building new systems for data collection. The existing systems and methods can be improved, strengthened and utilized to develop information that can be applied for injury prevention and control programmes Characteristics of Surveillance Programme For any surveillance programme to be operational and sustainable, it should be Simple Acceptable Sensitive Reliable Representative Sustainable Timely Cost effective and, most importantly, Useful The essence of surveillance is to collect small quantities of good, reliable and useful information (by well defined methods) and apply it to develop policies, programmes and interventions, thereby reducing the occurrence or harm from injuries. 8 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

31 5. Building Bengaluru Injury Surveillance Programme As surveillance is a systematic activity, it involves continuous and systematic collection of information from designated sources to develop injury prevention programmes. The steps of developing and implementing a surveillance programme are given in figure 8, as proposed by WHO. These steps might overlap in different stages depending on resources and ongoing activities. The present report on feasibility of establishing RTI / injury surveillance programme in Bengaluru identifies the steps, processes, data availability, limitations and barriers along with opportunities for improvement. The report should be seen as a process input to the larger programme and reveals the type of data that can be generated in a continuous surveillance programme. Figure 7: Designing and building a surveillance system 1. Identify stakeholders 5. Access available resources 4. Identify data sources 12. Monitor and evaluate 11. Train staff and activate system Source: (19) 2. Define system objectives 3. Define a case 6. Inform and involve stakeholders 7. Define data needs 8. Collect data 9. Establish a data processing system 10. Design and distribute reports 6. Planning Surveillance Activities 6.1. Stake holder's involvement It is important to involve all stakeholders in injury prevention and control including ministries of health, police, transport, urban and rural development, social welfare, education, industries and commerce, media, NGOs and others. Recognising the role and contributions of all stake holders is crucial as it is an inter-sectoral and coordinated activity. In Bengaluru, stakeholders from - Police (Traffic, Crime and Law and Order), Health (Directorate of Health Services, Directorate of Medical Education, officials from Integrated Disease Surveillance Programme and all hospital administrators), Heads (Directors, Chief Executive Officers, Senior administrators) of major hospitals, Transport (transport department and Bengaluru Metropolitan Transport Corporation), Bruhat Bengaluru Mahanagara Palike, social welfare, urban development, National Highway Authority and Non- Governmental Organizations working with injury issues were contacted, sensitised and involved in the programme. The first formal meeting of stakeholders was held on February 3, 2007 at NIMHANS. The interactions started with a situation analysis based on available data, and recognized the importance and utility of good quality information along with identification of injuries as a health problem. Even though the roles and responsibilities of participating members were different, the need for joint collaborative programmes was recognized as a felt need. The interactions focussed on who is collecting information?, what information is already gathered?, what information needs to be collected?, how it will be collected and utilized? Following this, all stakeholders have met in series of review meetings and training programmes. Individual discussions were also held with stakeholders on several occasions. The identified roles and responsibilities for selected major partners were as follows: NIMHANS 9

32 Roles & Responsibilities of Partnering Hospitals Nominating nodal officer Facilitating training of CMO's/ Medical records personnel/others Printing of forms as per individual requirements Participating in information collection Using data for hospital and community programmes Participating to identify, promote, implement and evaluate joint activities Roles and responsibilities of nodal officers in hospitals Sensitising and sharing information with all persons in casualty Organizing training as and when required Ensuring information collection Establishing quality control Designating a place and person to keep data sheets Examining data as and when required Development of joint programmes and Coordinating in strengthening logistics supportforms /printing etc. Role and Responsibilities of Police Providing consent and designating a Nodal Officer Facilitating data collection from individual stations Facilitating training of staff from individual stations Developing joint mechanisms for data pooling Supporting development of joint reports Identifying mechanisms for sharing of data Leading interventions in all possible areas, and Participating in evaluation activities Roles and Responsibilities of transport sector Participating and designating Nodal Officer Developing mechanisms for data collection and pooling Facilitating training of staff Facilitating data collection on bus related crashes Development of joint reports Identifying mechanisms for sharing of data Leading interventions in transport department, and Participating in evaluation activities Roles and Responsibilities of Co-ordinating Centre - NIMHANS (with all partners) Initiating the programme Developing operational guidelines Providing training to police and hospital staff Facilitating data collection in hospitals Undertaking data collection at NIMHANS Developing quality control mechanisms Developing computer data entry/analysis formats Undertaking joint analysis and interpretation Providing individual and collective data to police and all hospitals Preparing joint reports in consultation and agreement with all partners Organizing meetings with all stakeholders once in 3 months (on rotation) Identifying and supporting development of prioritised interventions to be implemented by police, transport, health and others Expanding programme to districts and state Organizing annual meetings, and Providing leadership for the programme 6.2. Focus of surveillance The types of injuries included in surveillance need to be clearly defined in the beginning. Problem definition determines the structure and content of the surveillance system including potential sources of information and how this will be collected. It clearly outlines what injuries would be placed under surveillance?, what information needs to be collected?, and how it should be utilized?. Under the proposed surveillance programme, it was decided to include Road traffic injuries Falls Burns Poisoning Suicides and Assault/violence While the focus was on all injury causes, the major focus was on road traffic injuries as identified by stakeholders. It was decided to include occupational injuries in later stages of the programme Goals, purpose and objectives The overall goal of the programme is to achieve a reduction in injury (RTI and others) deaths, 10 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

33 hospitalisations and disabilities in Bengaluru. The purpose and objectives of Bengaluru Injury/Road traffic Injury Surveillance Programme were to: Identify various stakeholders and delineate the process of information collection along with strengths and limitations of existing data capture systems. Collect and analyse data from selected participating health care institutions, police sources and transport sector on specific aspects of RTIs and other injuries. Examine the merits and demerits of data collected and identify mechanisms for improving quality of data. Facilitate application and utilization of data for planning and implementing intervention programmes through various policies and programmes. The scope of the present feasibility study ( ) was to develop a mechanism of information collection - pooling - analysis - application - dissemination and to examine the possibility of developing a long term / continuous activity in Bengaluru. 7. Information sources and existing scenario 7.1. Sources of information The different agencies collecting injury related information in the city of Bengaluru are police, hospitals, transport, city corporation vital registry division, insurance and NGOs. The sources of data within these agencies include information from police reports, hospital records, death registers, and data from Transport Department. The latter specially collects data on crashes where city public transportation vehicles are involved and compiles them on a regular basis. Summary information is also forwarded in prespecified formats to the City Crime Records Bureau and to the Police Department. Figure 8: Sources of information for injury Vital Death Registration Urban Hospitals Police Deaths BISP Rural Hospitals Transport injuries involving Buses Police reports It was decided to collect data on injury mortality from police sources as previous studies have shown that majority of deaths are reported to police. Bengaluru City Police collect information on various aspects of RTIs and other injuries (any unnatural death) under the medico-legal rubric. All deaths due to road crashes, suicides, homicides and other unnatural (suspicious) deaths are considered medicolegal and police are entrusted with the primary responsibility of documenting information. Information is based on the formats provided by NCRB. A review of the road crash death and other injury death records revealed that large body of information is collected on every case and processed as per administrative and legal requirements. A major limitation of this approach has been that information on preventive aspects that can be helpful for planners and policymakers are not clearly available. Secondly, the collected data is not compiled and analyzed systematically at the city or state level. Thirdly, information is distributed across the 35 traffic and 103 law and order police stations of the city and is not available in any systematic format in a central place for examination. Fourthly, information is not brought to the attention of all stakeholders and is not applied for programmes and hence decisions made are not evidence based. The flow of information for RTIs is given in Annexure 2. It is to be noted that for all deaths due to injuries, a First Information Report (FIR) is completed which NIMHANS 11

34 contains informant details, enquiry details, mahajar (accident enquiry) and medical reports. Recently, city police have introduced a system wherein for every road death, possible remedial measures of how it could have been prevented (based on what caused the crash) has to be filed and report sent to Deputy Commissioner of Police. The Information contained in FIR focus on: Administrative details Identification details Police station limits Section of Indian Penal Code Date / Time / Day Location Vehicle involved / Property damaged, Brief details of injury Name of hospital Outcome, and Action taken Since there is no online computerization facility in all police stations, mostly the data is handled manually. FIR and summary sheets are the final information available for each case. Initially information for surveillance has to be extracted from FIR and summary sheet. A review of the existing police information system revealed that: Lack of a uniform reporting format for injuries Information systems are piecemeal and fragmentary Different types of records received from casualty rooms of hospitals for reporting injuries to police (along with duplication of work) Manual handling of data Frequent transfer of officials and personnel Lack of analysis of data Absence of linkage of records between police and health Absence of a centralized agency to process, analyse and utilize data Absence of systematic reporting to concerned stakeholders, society at large and others, and Medico legal problems of a continuous nature Hospital records Hospitals and health professionals (doctors, nurses, specialists, technicians, medical record staff, etc.) provide care for injured persons across the city and round-the-clock. Information is collected in medical records as per the practices followed by individual hospitals. An inventory of few hospitals prior to the beginning of the surveillance programme revealed that the methods, practices and procedures varied from hospital to hospital. Information on road traffic injuries (especially deaths), suicides, homicides and other unnatural deaths are commonly reported to the police in different formats (as followed by individual hospitals). A review of the system indicated that information is not collected on injury nature, causes, situation, circumstances, use of protective equipments or pre-hospital care details, except the source of referral. The diagnostic and management details are written in detail to document care for patients. There is no central agency or organization within the health sector that collects information from all the hospitals, analyses and processes data and brings it on a common format to develop intervention programmes. Limitations of Health Sector Information No uniform data formats in the hospitals The death certificate does not mention injury as associate or antecedent condition, even when injury has been cause of death; injury deaths are reported to police separately Information on injury patterns, profile and causes not available Data on pre-hospital care factors not elicited Data on injury care and disability details are not available, analyzed or reported Hospitals do not use ICD-10 classification or the ICECI classificatory systems Overburdened and overstretched emergency staff in hospitals (more so in public sector hospitals) Injury surveillance system is absent in the country No information system with in the health sector Lack of resources (money, manpower, time and other facilities) Rudimentary information systems on RTIs and other injuries Very few hospital based studies A summary of merits and demerits of extracting data from existing and proposed systems are given in table 2. It can be seen that there are many 12 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

35 Table 2: Strengths and limitations of different strategies Strategies Strengths Limitations Extracting data from MLC records and other hospital records Prospective documentation of information From Injury registry to injury surveillance Information already documented by Casualty Medical Officers (CMOs) Registers readily available. Uniform information collected from all hospitals in a uniform way. Possible to collect information relevant for prevention, management and rehabilitation. Can be integrated with police records. Facilitates application of data, if there is timely analysis. Gives initial window period for preparations and capacity strengthening. Can sensitise staff for various activities. Each hospital maintains records in different ways and there is no uniformity. Information is piecemeal and depends on interest of the CMO. Vital information on preventive and emergency care aspects not available. Focuses mainly on medico legal aspects. Difficult to read through at times. Requires direction from national or local ministries and administrative approvals. Success depends on participation and cooperation of hospital staff. Needs initial investment for 1-2 years for capacity strengthening of staff and streamlining of procedures at all levels. Without feedback and use of data, exercise would be useless, as staff would not be keen on completing forms. Administrative approvals will be the first step. Continuity between and shift from registry to surveillance is crucial. disadvantages in the current methods of documenting information in ERs. Coupled with lack of central data collection agency for any city of India, the end result is working in a vacuum. As there was no uniformity, it was decided in the stakeholders meeting that all hospitals will adopt a system of documenting information in a uniform manner using a common protocol supplemented by training and sensitisation programmes Selection of centers for surveillance In the stakeholders review meeting it was decided that injury death information will be extracted from 35 traffic and 103 law and order police stations as all deaths are reported to police authorities on a regular basis soon after the occurrence of an event. For selection of hospitals a list of all hospitals was drawn up in the beginning. For phase 1, 21 urban and 4 rural hospitals based on the criteria of - Geographical coverage Availability of round the clock trauma care Location of the hospitals and, Willingness to participate were identified. It was estimated that these hospitals would cover nearly 60-70% of injury registrations and hospitalisations. In order to test the feasibility in district & rural areas, the neighbouring district of Tumkur was identified. The reasons for choosing this district were location, status of rapid industrialization & migration, presence of a highway and proximity to Bengaluru. The district police were sensitised on this programme. The Government district hospital and Siddhartha Medical College Hospital along with 2 community health centres and 2 Primary Health centres were invited to participate in phase 1 of the programme Hospitals Inventory A scoping study was undertaken in the beginning to identify the caseload in emergency rooms, type and nature of personnel available, type of documents maintained, information flow and other aspects (Table 3 and 4). NIMHANS 13

36 Figure 9: Map of Bengaluru showing the location of various partner hospitals Bangalore Injury Surveillance Hospital Code List Code Hospital 01 Bangalore Baptist Hospital 02 Bhagwan Mahaveer Jain Hospital 03 Bowring & Lady Curzon Hospital 04 D G Hospital 05 Hosmat Hospital 06 Jayanagar General Hospital 07 Kempegowda Institute of Medical Science & Research Centre 08 K R Hospital 09 M S Ramaiah Memorial Hospital 10 M S Ramaiah Medical Teaching Hospital 11 Mallige Medical Centre 12 Mallya Hospital 13 Manipal Hospital 14 NIMHANS 15 Ravi Kirloskar Memorial Hospital 16 Sagar Apollo Hospital 17 Sanjay Gandhi Accident Relief Centre 18 Sparsh Hospital 19 St. John s Medical College & Hospital 20 St. Martha s Hospital 21 St. Philomena s Hospital 22 Victoria Hospital Sl No Table 3: Inventory results of the staffing pattern at casualty depts. of various hospitals Hospital Nature of Hospital Doctors Interns/ Residents Nursing Staffs Nursing students Medical record officials State of computerisation 1 Bangalore Baptist Hospital Pvt. teaching nil Present No 2 Bhagawan Mahaveer Jain Hospital Pvt. teaching 10 nil 16 5 Present Yes* 3 Bowring & Lady Curzon Hospital Govt Present No 4 D.G. hospital Private nil Present Yes 5 General hospital, Jayanagar Govt 2 nil 16 nil Present No 6 Hosmat Hospital Private Present Yes 7 K.R. Hospital Private Present Yes 8 KIMS Hospital Pvt. teaching Present Yes 9 M. S. Ramaiah Hospital Pvt.teaching nil Present Yes 10 Mallige Medical Centre Private 4 nil 6 nil Present Yes 11 Mallya Hospital Pvt. teaching 3 nil 12 nil Present Yes 12 Manipal Hospital Pvt. teaching 10 nil 15 5 Present Yes 13 NIMHANS Govt teaching Yes Present Yes 14 Ravi kirlosker Hospital Private 7 nil 6 nil Present Yes 15 Sagar Hospital Private 7 nil 17 nil Present Yes 16 Sanjay Gandhi Institute of Trauma & Orthopaedics Govt Present No 17 Sparsh Hospital Private nil Present Yes 18 St. John s Medical College Pvt. teaching Present Yes 19 St. Philomena s Hospital Pvt. teaching 6 nil 10 nil Present Yes 20 St. Martha s Hospital Pvt. teaching 3 nil 10 4 Present Yes 21 Victoria hospital Govt teaching Present No 22 District hospital, Tumkur Govt teaching nil Present No 23 Siddharatha Medical College, Tumkur Pvt. teaching nil Present No * yes indicate that only the admission counter and sections of hospitals are computerised. 14 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

37 Table 4: Inventory details on the approximate patient load in the Casualty department of various hospitals Sl No Hospital No. of patients attending casualty/week No. of Injury Patients in casualty /week 1 Bangalore Baptist Hospital 320 to to 70 2 Bhagawan Mahaveer Jain Hospital to 20 3 Bowring & Lady Curzon Hospital 180 to to D.G. Hospital 50 to to 20 5 General Hospital, Jayanagar 130 to to 60 6 Hosmat Hospital 100 to to 60 7 K.R. Hospital 120 to to 15 8 KIMS Hospital 130 to to 60 9 M.S. Ramaiah hospital 450 to to Mallige Medical Centre 300 to to Mallya Hospital 230 to to Manipal Hospital 480 to to NIMHANS 550 to to Ravi Kirloskar Hospital 130 to to Sagar Hospital 280 to to Sanjay Gandhi Institute of Trauma & Orthopaedics 30 to to Sparsh Hospital 70 to to St. John's Medical College 680 to to St. Martha's Hospital 340 to to St. Philomena's Hospital 500 to to Victoria Hospital 750 to to District Hospital 250 to to Sri Siddhartha Medical College 100 to to 3 The scoping study highlighted that various categories of personnel were available in institutions depending on the type of organization. Commonly, in medical college teaching hospitals - casualty medical officers, nurses, residents, postgraduate students, interns and medical records personnel work round the clock to provide care for patients. In other hospitals, primarily of a private nature, casualty medical officers and nurses are the only routine personnel. The review of the existing hospital information system revealed that: Information is collected in detail on patient care and management Information collection depends on attending physician Different types of records maintained in casualty rooms with duplication of work(number of records maintained for injuries varied from 1 15 across hospitals) No central processing of data in hospitals Absence of systematic reporting to any agency, as there is no designated agency Lack of a uniform reporting format for injuries Transfer and turnover of staff at regular and frequent intervals Medico legal problems Reluctance on the part of some hospitals to undertake shared responsibility Information is piecemeal and fragmented No information on preventive aspects NIMHANS 15

38 8. Preparatory phase (Jan - March 2007) 8.1. Administrative approvals The State Director General of Police and City Commissioner of Police provided permission and passed necessary official orders for all police officers to extend support. The Sr. Deputy Director General of ICMR provided a letter of appeal to all institutions. The State Director of Medical Education and Director of Health services sent necessary instructions to medical colleges in Bengaluru and Tumkur, and also to district hospital in Tumkur Point of Information collection on injury and deaths The police receive information on deaths occurring in different places and also on injuries from few hospitals. Even though it is mandatory for hospitals to report all injuries, only few of them report as per their individual practices. For injury deaths, the point of information collection was the individual police stations (35 traffic and 103 law and order) and the first information report and summary sheet were chosen as the source of information. It was decided to extract information from FIRs into a common format under the surveillance programme. Depending on the need, rest of the documents were reviewed at times of need (especially in situations where investigation was not completed). In the hospitals, data was collected from casualty departments, as it is the first point of contact for injury patients. It was also agreed that data would be collected uniformly in a standard format along with training of all involved personnel. Information was collected as part of the history taking process or soon after treatment procedures were completed Defining Information requirements Any injury surveillance programme should outline core data for the programme and include optional items depending on the need. A draft questionnaire outlining the various elements of surveillance from police reports was developed by co-ordinating centre at NIMHANS based on information needs of stake holders and experience of earlier studies. The stakeholder s consultation meetings reviewed these data elements and identified them as core data elements for the programme. The focus of information collection in the beginning was on - Basic identification and brief sociodemographic details Information on injury and death (place, type, activity, intent) Details of road traffic deaths (where, who, how and selected risk factors) Details of other types of injury and deaths (intent, place, type), Pre-hospital care (first aid, transport, referral) Management and outcome Two types of proforma were developed (one for RTI deaths and another for other injury deaths), key reason being that traffic and non-traffic deaths are handled separately. A common format for reporting injury events to police was also developed and agreed upon by all hospital authorities. Specific details on burns, suicides, assault and poisoning have been included in the proforma. The contents of all forms were discussed between partners and consensus was arrived at and agreed upon. The methodology was discussed at length in the nodal officer s training programme held on 3 March, 2007 and members suggested changes and the same were incorporated into the proforma. It was decided to focus on core data elements with scope for expansion in due course of time. The responsibility of identifying personnel to complete the surveillance form was left to individual hospitals to identify the necessary personnel. However, majority were trained to ensure uniformity in data collection. An operational-training manual (available on request) was developed for training of all involved personnel from police and health. The manual included description of purpose of collecting information, various variables brief description coding patterns - methods of filling up of the forms. 16 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

39 8.4. Pilot study A pilot study was undertaken on 50 FIRs from police stations. The pilot study showed that it was possible and feasible to transfer and collect data in a uniform format. Trained staff from NIMHANS did data collection during this phase. On an average, it took 8-10 minutes to complete a form depending on the experience of the person filling up the proforma. A similar attempt was made in few of the hospitals during the pilot phase of the programme. A common ERTCR (Emergency Room Trauma Care Record) was developed. On an average, it took about 5 6 minutes to collect information by direct interviews with injured patients or their attendants. However, there were problems experienced with unknown patients brought by police. Following the pilot phase, the findings were discussed with stakeholders and nodal officers. The proforma was revised accordingly. The revised police and hospital format was accepted as the core data element form with provision for addition of information at later stages of the programme Training of Police and health personnel In the beginning, the field research officers from NIMHANS were trained in data collection. These people had basic qualifications in sociology, social work, rural development, or in other areas and had prior research experience in health. In the police department, the writers of police stations were invited for training programmes. Since capacity development is a systematic activity, repeat programmes were done to improve contents and quality of data. The training focussed on understanding contents of proforma, definitions used, method of entering and coding, checking for completeness and other aspects. The details of the training programme held for the writers in the police department are provided in annexure 4. In the hospital, training of casualty staff (Casualty Medical Officers, nursing personnel and medical records staff) was crucial to ensure completeness, coverage and uniformity in data collection. It was essential to do this in a phased manner, as there were large numbers of people to be trained (due to frequent change of personnel). The training focussed on purpose of the programme, persons responsible for data collection, nature of information being collected, coding patterns and ensuring safety of completed forms to be collected. Training was also offered to different personnel depending on roles and responsibilities of the personnel. Series of training programmes have been conducted under the programme as shown in annexure 4. In order to develop uniformity in data collection procedures, the first training program of all nodal officers (Bengaluru City Police and 25 identified hospitals) was conducted at NIMHANS on 3 March, About 40 nodal officers attended the programme. The various component discussed in the training were Need for surveillance programme The roles and responsibilities of individual institutions Roles and responsibilities of nodal officers Need for training of staff in individual institutions Methods of data collection in emergency rooms Contents of the proposed questionnaire Brief description of the individual items Time of completion of forms Responsibility of staff in ensuring completeness and accuracy of data Collection & storage of surveillance forms in the emergency rooms Transfer of forms to the coordinating centre Broad outline of data analysis Reporting formats to stakeholders & hospitals Feedback to individual institutions and to the nodal officers Data pooling mechanisms Methods of data utilization by individual institutions Following the nodal officers training, casualty personnel of various hospitals nursing staff and medical records personnel were invited for training programmes. Eighteen orientation and training programmes were conducted in different institutions. In this process, large number of people were sensitised on various aspects of data collection, NIMHANS 17

40 utilization and application components with local data and examples. For the casualty department personnel, the training was focused on Need for surveillance programme Need for training of staff in individual institutions Contents of the proposed questionnaire Brief description of the individual items When to complete forms Completion of forms as per coding Responsibility of staff in ensuring completeness and accuracy of data Collection & storage of surveillance forms in the emergency rooms Advantages to individual staff members and institutions Methods of data utilization by individual institutions A consensus was reached on many of the items and methodology of data collection - pooling - transfer - analysis - reporting and feedback of the programme. The training was held in the local language with simple examples and colloquial terms. Several questions that came up were answered and wherever needed in the proforma changes were incorporated. In the rural areas, staff from district hospital and Siddhartha Medical College hospital was trained on the various aspects of the programme in a similar manner. 9. Information collection phase 9.1. Supply of forms As agreed in the stakeholders and nodal officers meeting, the CC took up the responsibility of printing and supply of forms to all institutions for the first 3 months to start the process. Accordingly, the forms were first made available to all hospitals during March, The hospitals were requested to print their own forms with their name and logo as per the requirements. After initial administrative delays, by the 3 rd or the 4 th month, almost all hospitals (except 1) printed their own forms and continued to use them. With the evolution of the programme, it was proposed to shift from paperbased forms to online transmission depending upon the availability of computer facilities. Discussions have begun with local IT companies to develop a suitable software package Data collection mechanisms Information capture has been in progress from April 1, 2007 and two different mechanisms were evolved for data collection purposes. From the police records and primarily from FIRs, information was transferred to the surveillance questionnaire on a day-to-day basis. From April 2007, the station staff completed the forms soon after investigations were completed or during the course of investigation. The programme started in 4 police stations, expanded to 10 and then covered all police stations, both traffic and law and order. As of July 2008, writers of 35 traffic stations and 103 law and order stations were trained. These trained staffs send the completed forms to the nodal officer in police department. Quality control mechanisms were established through cross checks, sampling records for reliability and validity checks and for completeness. In the hospitals, information was collected from injury patients in emergency rooms with effect from April 2007 after initial training. It was agreed that data would be collected in casualty departments soon after completing treatment procedures or as part of history taking process. Different modalities of operations were evolved in different situations. In 5 of the major hospitals, CC staff in collaboration with local team of doctors undertook data collection. As doctors were 18 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

41 busy with heavy casualty workloads, it was felt that this was essential. Over a period of time, some doctors / nurses in these hospitals started completing forms on their own. However, since there was only one CC staff working on data capturing, there was difficulty in capturing night time and week end cases and some information has been found missing. In few hospitals, CMO s and nurses undertook the responsibility of data collection, while medical records personnel undertook data collection in 2 of the hospitals. In order to encourage hospital staff for local use of data and also for administrative requirements the surveillance forms were printed in duplicate (with a carbon copy). One copy of the form was retained within the hospitals as the ERTCR and the other one was forwarded to the CC for data entry. The nodal officer in each hospital supervised the data collection process and also ensured proper storage of forms. The CC staff visited each of the hospitals on a fixed day at a fixed time to collect all the completed forms Data management steps The writers of traffic and law and order police stations collected information from the police records and primarily from FIRs with effect from Jan The data forms were sent to the nodal officer under the programme before 5th of the following month. All forms were transferred to the CC by 10th of the month for computerization. The information collected was used for the subsequent training programme on a regular basis for continued strengthening of the programme. A uniform format for documenting transfer of completed data sheets was maintained in the police department and hospitals to ensure completeness and transparency of entire procedures Data pooling from other sources In addition to information collected from police and hospital sources, data was also collected from the statistics division of health dept of BBMP, transport department, NGOs, and others for a comprehensive examination of injury scenario in the city of Bengaluru Quality control issues Quality control at different stages of data collection, transfer and entry is crucial to obtain quality data under the surveillance programme. In order to maintain internal and external validity of the whole programme, mechanisms were developed to ensure these aspects. Initially I. Total number of forms received was crosschecked independently with medical record division of hospital. II. The CC team examined all forms for completeness and coverage from all received forms. III. Random checks by coordinating centre on information gathering were done. IV. Resurvey of patients (5%) was done by independent teams on a monthly rotational basis to ensure accuracy & completeness of data collection Classification & Coding methods Even though ICD and ICECI are well-established injury coding and classification methods, it was proposed to introduce this at later phases of the programme. The primary reason for this was that majority of the health professionals were not trained in these classification procedures and were unfamiliar with coding aspects. Majority of hospitals do not use ICD classification systems for any reporting. Hence, the coding and classification was done at the coordinating centre. Over a period of time, professionals from member institutions will be trained in these aspects and will be integrated into the overall programme Computerization process A team of data manager and data entry operator was constituted in the beginning and trained in all aspects. A data entry format on EPI INFO windows version 3.3 was developed, tested and used for data entry and analysis purposes Monitoring and Feedback steps Inbuilt mechanisms were developed to ensure systematic monitoring of the programme. At the hospital level, data collected from casualty was cross checked with medical record statistics to ensure coverage of cases. At the ER level, the nodal officers ensured inclusion of all cases, completeness of all forms, NIMHANS 19

42 transfer to a location in ER for storage and transfer to coordinating centre at weekly intervals. Coordinating centre staff ensured uniformity and completeness of data collection with random checks and independent monitoring of 5% cases. A weekly meeting (Tuesday afternoon) was held regularly to monitor progress, recognize problems, identify solutions and review progress. All received forms from different sources were examined for coverage and completeness. Missing information was included from records, wherever possible. Meeting with all nodal officers once in 3 months helped in reviewing progress, identifying remedial measures for problems, ensured better cooperation, and to work out future steps. Continuous contact of the CC staff with all institutions was an inbuilt activity under the programme. Periodical visits and communication on a regular basis was undertaken to ensure completion of all activities as per time schedule. The programme coordinator and the team visited police and hospital departments at periodical intervals and held discussions with nodal officers, ER staff, medical record staff and hospital administrators Sharing and disseminating of information As surveillance is an ongoing continuous activity, the analyzed data need to be shared with all the partners and feedback becomes a regular feature of the programme. As discussed in the stakeholders and nodal officer s meeting, information was disseminated in number of ways. The primary reason for using so many combined methods was to encourage people to get actively involved and also to ensure that feedback becomes an inbuilt activity. All reports were developed, circulated and disseminated under the title of Bengaluru Injury Surveillance Programme Individual institutions were provided with their respective data for the previous 3 months (on a CD) on a regular basis. Member institutions were encouraged to examine, use and develop reports for their institutional activities. Data was constantly reviewed in the nodal officers meeting and used in all training programmes. Information was made available to member institutions as and when required. Mechanisms were evolved to ensure that all partnering institutions have access to data at any time. It was decided to bring out a set of fact sheets based on data as advocacy and awareness documents. 10. Results The city of Bengaluru The city of Bengaluru is a recognizable landmark on the national and global map for its technological, educational and economic growth. For the current programme, the city of Bengaluru (as per boundaries delineated by then BMP. A brief profile of the city is given in Table 5. An understanding of the programme area is crucial for a number of activities to strengthen the programme. Table 6 and Figure 10 show the motorization pattern in Bengaluru during the past decade. The motorization index (number of vehicles / Population x 1,00,000) has increased from 164 to 416, resulting in an increase in absolute number of Vehicles Registered (lakhs) Figure 10: Vehicular Growth in Bengaluru Year Wheelers M/Cars A/R. Cabs Source: accessed on October 1, Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

43 Table 5: Bengaluru City A Socio Demographic Profile Sl No Parameters 1 Area 800 sq. kms 1 2 Population 7 million 1 2 Density 2980/sq.km 2 3 Contribution to Karnataka state population 11% 4 Sex Ratio (Females/1000 males) Life expectancy at birth 64.2 years 6 Crude birth rate/ Crude death rate/ Decennial growth rate 1.3% 9 Total number of slums Total population in slums 4,30, Slum population% Socially disadvantaged population (%) Literacy rate% Total number of schools and colleges Total number of factories Total number of police stations (35 traffic law & order) Total number of hospitals (including public, private hospitals & nursing homes) Total number of Drug stores Total number of General practitioners Total length of roads 1500 kms 1 21 Total number of police personnel (traffic) 3, Total number of police personnel (law and order) 11, Total number of registered vehicles 3.13 million Number of alcohol selling outlets (CL-2, 4, 5, 6, 6A, 7, 9, 14 & 15) Licensees Indian Made Liquor sold for the year lakh CBs Total revenue from IML & Beer Rs.3478cr 13 Source: Year Karnataka Education Departments; 8 Small, Medium and Large scale industries Corporation; 9 BCP Bengaluru City Police; 10 KSPCB Karnataka State Pollution Control Board; 11 Karnataka state Drugs control General Karnataka State Beverages Corporation Limited Table 6: Motorization Index for Bengaluru 2- Wheelers M/Cars A/R. Cabs Others Total Population* Motorization Index Source: accessed on October 1, 2008 vehicles from 0.8 million to 3.1 million over a 14 year period. As on , there were 3.1 million registered vehicles in the city. Interestingly, among the total vehicles, motorized two wheelers contributed for nearly ¾th of total vehicles, registering an increase from 0.6 million in 1995 to nearly 2.2 NIMHANS 21

44 million by It is estimated that nearly 3 million vehicles (including vehicles coming from outside city) traverse the city roads every day. With the growth of population, the share of pedestrian trips has also increased substantially. Significantly, the public transport systems chiefly comprising of buses increased from 2,098 in 1998 to 5071 during The transport patterns indicate that walking, cycling, travel on motorcycles and bus travel account for a major transport share with car and other vehicle occupants accounting for roughly 10% of total vehicles. Using the methodology highlighted in the previous sections of this report, information was collected from Police, transport, city corporation and hospital sources from January 2007 (police and transport) and April 2007 (hospitals), respectively, by combination of different methods. Overall mortality information (all cause deaths) was also collected from the vital statistics division of Bengaluru Mahanagara Palike for the year 2005 (latest year for which data was available). Injury mortality information was collected from police sources as it captures death related information (due to its medico legal nature, compensation needs and legal purposes). Since the transport department collects data from most of the fatal and serious non-fatal road traffic injuries and since the focus is different, it was collected separately, even though some of them are entered in police records. Morbidity data was captured from emergency rooms of 25 participating hospitals. The data in the forthcoming sections are presented together as fatal and non-fatal injuries and has been examined for all injuries and separately for Road traffic Injuries, suicides, falls, burns, poisoning and drowning. The transport data primarily focusing on involvement of bus crashes are provided in a separate report and should be read in conjunction with this report to obtain a total picture of road traffic injuries in Bengaluru. Information from rural Bengaluru will be provided in future reports Injury burden With different agencies handling different types of data related to injuries, information was not available from all agencies for the year Hence, attempt has been made to examine and pool data from 3 major sources of vital death events from corporation records, fatal injury data from police records and non-fatal injury data from hospital sources. The two data sources have been related to obtain comprehensive picture of injury burden for one year Injury deaths in Bengaluru (city death records) In 2006, injuries contributed for 9% of total deaths in Bengaluru. Out of the total of 27,314 deaths, 2,397 (9%) were injury deaths as per official reports of Vital Statistics Division, Bengaluru Mahanagara Palike (20). Police sources reported higher deaths for 2006, probably due to inclusion of deaths from outside city, improper documentation of causes of deaths in death certificates and addition of unclassified unnatural deaths. In 2006, police sources had registered 4,334 deaths, while the city authorities had registered 2,397 deaths (MCCD death registration). The difference between the two could be due to the fact that residents of Bengaluru have to register with city authorities, while police could have registered injury deaths from residents outside Bengaluru. Secondly, inclusion of hospitals and reporting practices of hospitals also influences deaths in corporation. Thirdly, since cause of death is not accurately mentioned in death records, actual injury deaths might be higher. Fourthly, police records include a category of others or unspecified causes, reasons for which are not clearly known. Figure 11: Distribution of deaths in Bengaluru, 2006 Other deaths 91% Total Injury Deaths 9% Among the injury deaths as per vital records, Road traffic injuries were the major cause of death (46%), followed by burns (17%). Suicides, which include burns, poisoning, drowning and hanging contributed for 8% of total deaths. Falls resulted in 7% of deaths. The completion, coverage and quality of information in death certificates is known to influence the type of data and hence, the causes of death might vary on these factors. In nearly, 9% of deaths, the underlying cause of injury were not mentioned clearly. 22 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

45 Figure 12: External causes of injuries Other external causes of accidental Injury 9% Assault 1% Poisoning 10% Animal bites 1% Late effects 8% Burns 17% Drowning 1% Falls 7% Road Accidents 46% * Suicide classified on intent accounted for 8% Injury deaths is included in burns, poisoning, drowning, misclassification is likely. revealed that RTIs remained a major cause in all age groups. Suicides emerged as a major cause in all age groups, except years, while burns were higher in years and 65+ years. Women in younger age groups had higher extent of burns in total deaths. Figure 13: Age sex distribution of injury deaths Age wise injury deaths in males % >65 6% <15 5% % Age wise injury deaths in females % >65 7% <15 11% % Nearly three fourths of injury deaths occurred in the age group of years. Children and elderly accounted for 7% and 6% of deaths respectively. The male to female distribution was 64% and 36% with a ratio of 2:1. This clearly highlights that injuries are a problem of the young and middle-aged people, an observation that is uniform all over the world. A selective examination of age specific mortality Female 36% Total Deaths % Male 64% % Injury Deaths Female 30% Male 70% 11. Burden, Pattern and profile of fatal and non-fatal injuries During the 12-months of 2007/08, 4,334 deaths and 68,498 injured persons were reported from police and 21 hospitals in the city of Bengaluru (Tables 7 & 8) respectively. The actual number of non-fatal injuries is likely to be much higher as only 21 hospitals (city has more than 150 health care institutions where injury patients are likely to go for care) have been included (and hence rates are not provided due to incompleteness of the data). In 2007, police had registered 4,334 accidental, suicidal and unnatural deaths. Detailed examination of records revealed that deaths due to non-injury causes were included; these have been excluded from analysis and 3,427 (80%) deaths due to a recognized injury cause are included in this report. Adding a correction factor of 25% (due to non-reporting, deaths occurring outside city, late injury deaths, misclassification, unclassified deaths, etc.,) it is estimated that the city might have lost 5,000 lives due to an injury in Table 7: Distribution of fatal and non-fatal injuries Month/Year Jan 2007 Fatal 387 Non-fatal Total Feb 364 March 394 April May June July August Sept Oct Nov Dec Jan Feb 5505 March 5572 Total In the hospitals, injuries contributed for 21% of casualty registrations, 9% of admissions and 31% of deaths during the 12 month period. (Information on deaths was collected separately from medical NIMHANS 23

46 Table 8: Number of fatal injuries registered with Police, Jan Dec 2007 Month RTI deaths Other Injury deaths Total Jan Feb March April May June July August September October November December Total records). In some of the larger public sector hospitals, almost every 5th patient in the ER was due to an injury. This reflects on the enormous workload and the huge burden on staff in the casualty departments of all hospitals. Figure 14: Bengaluru Injury pyramid Deaths (1) 5000 Serious Injuries (20) 1,00,000 During the 12 months period, the enrolment of patients into surveillance programme increased significantly. The coverage of patients in the study period varied between 72 85% across hospitals with an average of 80% and data was incomplete for 20% of patients. Among the 68,498 registered patients, it was possible to collect information from 53,448 (80%) subjects. The non-availability of data for the remaining 20% were due to weekend cases, limited staff at night times, changing monthly rotation of doctors, and patients referred immediately upon arrival in ER. Hence, in the following sections, data from 53,448 patients are included for further analysis. Four of the hospitals viz., NIMHANS, Victoria hospital, Bowring hospital and St. John s Medical College hospital contributed for 56% of total injury patients. From the programme point of view, it clearly points out that selecting few major health care institutions in larger cities (where injury surveillance systems are absent) will help in building the programme over a period of time. The actual number of non-fatal injuries is difficult to establish. Minor Injuries (50) 2,50, Injury trends The city has seen a constant and continuous increase in injuries over a period of time. In overall terms, injury deaths increased from 2,152 in 2000 to 4,334 in 2007, while the population and motor vehicles increased by 20% and 150% in the same period. Increase in RTIs and suicides has been significant as RTIs increased from 500 to 1,000 during the 7 year period, while suicides increased from 1,731 to 2,430 in the same period (Figures 15 & 16). Detailed information on non-fatal injuries is not available as this is the first large-scale attempt collecting information from hospitals. Even though police collect information from reported / registered nonfatal injuries, they have been found to be incomplete due to underreporting factors. Figure 15: Traffic deaths in Bengaluru ( ) Using conservative figures of 1:20:50, for deaths to serious injuries to mild injuries, in 2007, there were an estimated 5,000 injury deaths, nearly 100,000 serious and 250,000 mild injuries Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

47 Figure 16: Suicides in Bengaluru ( ) Injury variations During the 12 month period, 4,334 deaths (average of 361 deaths per month) and 68,498 hospitalizations (on an average of 5,708 per month) were registered under the programme (Table 9). As discussed in section earlier, an estimated 5,000 deaths and more than 100,000 serious injuries are likely to occur each year, considering the inclusion of only 21 hospitals and under-reporting by police Place distribution The broad geographical occurrence of injuries was available for only deaths from police records and found to be difficult in hospitals due to nonavailability of total address among patients or their attendants at the time of hospital contact. Information on geographical distribution of injury deaths will help in identifying areas with highest injury occurrence and helps to formulate and implement area wide intervention programmes. Needless to mention, place distribution has to be examined as per individual injury cause. With further use of GIS and other systems, even micro level interventions for certain types of injuries (e.g., RTIs) can be developed. Among the 103 Law and Order Police stations, highest number of injury deaths was reported from Wilson Garden (146), Madiwala (116), Upparapet (111), Peenya Industrial area (108) and Subramanyapura (86) areas. Lowest injury deaths were registered in Rajajinagar (28), Koramangala (28), Jeevan Bhima Nagar (29), High Grounds area Sl No Table 9: Non-fatal injury registrations in ERs of select hospitals, April-March 2007 Hospital total casualty registrations casualty injury registration 1 Bowring Hospital Baptist Hospital Bhagavan Mahaveer Jain Hospital Ravi Kirlosker Hospital St. John Hospital & Medical College Sparsh Hospital Sanjay Gandhi Institute of Trauma & Orthopaedics NIMHANS D G Hospital St. Martha's Hospital St. Philomena's Hospital Mallya Hospital NA NA Sagar Apollo Hospital Jayanagar General Hospital NA NA Manipal Hospital M. S. Ramaiah Hospital HOSMAT KIMS Hospital Victoria Hospital K. R. Hospital Mallige Hospital Total % total admissions injury admissions % total deaths injury deaths % NIMHANS 25

48 Figure 17: Age-Sex distribution of Fatal & Non-fatal injuries (%) Fatal Non - Fatal < Male Female Total > 70 0 < Male Female Total > 70 and Indiranagar (27 each). The differences in injury rates in different areas needs to be ascertained with further research and could broadly be due to socioeconomic living standards, migration of people, transport and travel patterns, area / land utilization, varying enforcement limits and others Age and Sex distribution Injury is predominantly a problem of young people. The age groups of years accounted for 61% of total injury deaths and 70% of total hospital contacts. Children up to 18 years contributed for 6% of total deaths and 10% of hospital contacts, while elderly accounted for 11% of deaths and 5% of hospital contacts, respectively. The male to female distribution varied with a ratio of 2-3:1 as per injury causes. In years, there were more injuries and deaths among women compare to men. Among fatal and non-fatal injuries, men accounted for 84% and 82%, respectively Socio-economic characteristics Generally, it is known that the number of deaths and injuries are higher in lower and middle income groups. The poor are more vulnerable to injury and also have limited access to care due to their inability Figure 18: Place of injury to pay in private hospitals and absence of insurance. Data once again showed that deaths were higher among those with less education. In the total series, those above graduate levels were just 10% compared to 60% of those with lower levels or no education. In addition, deaths among other injury causes were more among those with lower levels of education compared to road traffic injury deaths. The occupational status indicated that those from unskilled and skilled labour categories were represented in greater numbers (34%) as compared to professional categories of 3%. Students accounted for 6.3% of injury deaths. Information on place of residence revealed that 92% of injury deaths were among those residing within Bengaluru Place of Injury Highest number of injury deaths occurred on road and at home with 43% and 39%, respectively. The pattern was similar for non-fatal injuries with roads and home contributing for 57% and 25%, respectively. Even though injuries were seen in all other places, it was comparatively more in construction site area, hotels and lodging establishments, major water bodies like wells and lakes (contributing for specific type of injuries.) Religious place 1% College campus Others 1% 6% Road 43% Well/lake 2% Hotel (lodging establishment) 1% Shopping area 2% Home and premise 39% Building under construction 3% Work places 2% Fatal School 1% Home 25% Workplace 9% Public place 6% Others 2% Non - Fatal Road 57% 26 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

49 Figure 19a: Injury Causes Occupational injury 1% Other unnatural deaths 24% Road traffic injury 28% Assault 1% Burns 11% Poisoning 9% Drowning 2% Fall 6% Hanging 18% Urban Fatal Stab / cut 2% Sports 1% Road traffic injury 46% Occupational injury 1% Poisoning 10% Others 2% Animal bites 3% Assault 17% Hanging 1% Fall 9% Urban Non-Fatal Burns 5% Drowning 1% Fall of object 2% Injury causes Among the various types of injuries, 5 major causes of injury deaths were Road Traffic Injuries (943-28%), hanging (604-18%), burns (360-11%), poisoning (296-9%), and falls (209-6%). The other major injury causes were drowning and animal bites to the extent of 1.8% and 0.4%, respectively (Figure 19a & 19b). Similarly, for non-fatal injuries, RTIs were the leading cause for nearly half (46%) of hospital contacts, followed by assaults and violence (17%) and poisoning (10%). RTIs (47%), assault (22%) and poisoning (12%) were the leading causes for hospital contact in rural areas Injury Intent Based on intent, 31% were unintentional, while 32% intentional and 24% and 14% being unnatural Figure 19b: Injury Causes for Rural Non-fatal injuries Animal bite 5% Others 6% Fall 6% Poisoning 12% Assault 22% Burns 2% Road traffic injury 47% and unknown, respectively. Among non-fatal injuries, 70% accounted for unintentional, while 27% and 3% were intentional and undetermined deaths, respectively. 12. Road Traffic Injuries Estimated deaths: 1,100 Estimated serious injuries: 40,000 In 2007, 943 road traffic deaths were reported to the Bengaluru City Police. Earlier reports on RTIs from NIMHANS and data from City Crime Records Bureau have revealed that road traffic deaths and injuries have increased over a period of time. With regard to non-fatal injuries, a total of 26,191 patients were registered in study hospitals providing a ratio of 1:28 for fatal to non-fatal injuries. In the same period, the police had registered only 6,591 nonfatal injuries, indicating severe underreporting, even in comparison with 21 hospitals to the extent of 75% as per the present study Road traffic deaths have increased from nearly 500 to 1000 over a period of 7 years in the city of Bengaluru (2000 to 2007). The changing trend is shown in figure 15. Earlier studies from NIMHANS have confirmed that while all deaths are reported to police for medico-legal or compensation purposes, only serious injuries are reported to police (17). Based on data inputs from different sources, the Planning Commission of the Government of India (21) and Sunder s Committee (22) have estimated NIMHANS 27

50 Figure 20: Place of Occurrence Highway 24% Fatal Highway 16% Non - Fatal City/ Municipal Road 64% Inner Roads 10% Rural Roads 1% Others 1% City/ Municipal Road 63% Inner Roads 9% Rural Roads 11% Others 1% the ratio of deaths to serious injuries to less severe injuries as 1:20:70 for the Indian region. Considering the above observations and inclusion of only 21 hospitals in the present study, it is estimated that there would have been 1000 deaths and 40,000 non-fatal injuries in Bengaluru in Place of RTIs Information on place of occurrence of RTIs is important in number of ways. Recognizing broader high crash locations helps for developing area wide interventions in engineering, enforcement and trauma care. Identifying precise location of RTIs in each area helps for micro level interventions, commonly referred to as black spot analysis. The latter approach can help for in-depth crash investigation and analysis, but caution has to be exercised as these black spots are likely to change over a period of time. Information on category of roads involved in RTIs helps in putting improved preventive strategies on different categories of roads. For e.g., if highway crashes lead to more deaths, then it indicates the need for better road safety practices on highways. Data from the present programme revealed that the place of occurrence of crashes was primarily on city municipal roads in 2/3 rd (64%) of road deaths while 1/4 th (24%) had occurred on highways originating from the city in different directions (Figure 20). Among non-fatal injuries 16% had occurred on highways. This indicates that highway crashes are more severe resulting in more deaths and serious injuries. Information on place of death in a crash indicates the need for different preventive strategies. For example, large number of crash site deaths can only be minimized by primary prevention, while deaths enroute to hospital and in-hospital deaths can be reduced by better pre-hospital and acute care strategies. Nearly 29% of deaths occurred at the crash site, 22% during transportation to a hospital and remaining 49% in the hospital (Figure 21). This pattern varied as per road user categories as more number of pedestrians died at crash site compared to other categories. Figure 21: Distribution of RTI deaths based on place of death In the Hospital 49% At Crash Site 29% During Transport to Hospital 22% From the total list of 35 police stations reporting RTIs, the top ten areas registering highest number of fatal and non-fatal RTIs are provided in figure 22. Micro level studies are required to identify the precise location of RTIs in these boarder geographic areas. Some of the characteristics of these areas include high density of population, located on the out skirts of the city, greater economic and transportation activities, heavy movement of vehicles, poorer socio-economic sections of society and decreased enforcement areas. Also in recent years, some amount of infrastructure expansion has been marked in these areas. 28 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

51 Figure 22: RTIs in Bengaluru Sl. No. Traffic P. S. Fatal Non-Fatal 1. K.R.Puram Madivala Traffic Fatal and Non Fatal Combined 3. Yeshwanthapura Bytarayanapura Banasawadi Peenya Adugodi Airport Vijayanagar R.T.Nagar Banashankari Jayanagar lndiranagar Yelahanka Mico Layout Basavanagudi Malleshwaram Hebbala Cubbon Park FrazerTown Ashoknagar K.S. Layout Kamakshipalya Shivajinagar Halasuru Halasuru Gate Rajajinagar Wilson Garden Sadashivanagar High Grounds Upparpet Chamarajapet Magadi Road Chickpet City Market Socio demographic characteristics Informant categories Information on notification patterns helps in understanding awareness in the society on RTIs and, to a certain extent on what people can do as first responders in the event of a road crash. The informants of road deaths and injuries were primarily family members (28% and 45%), roadside people (14% and 20.1%), police (18% and 3%), friends and colleagues (21.9%) The Age-sex distribution was almost similar for fatal and non-fatal injuries. Nearly 29% of fatal and 38% of non-fatal injuries occurred in the age group of years. Road deaths and injuries among children was 5% and 7%, while elderly accounted for 10% and 3%, respectively. In both the groups, males were predominant with a ratio of 6:1 and 4:1, respectively. Figure 23 indicates that road deaths and injuries increased from 15 th year, reached a peak during years, remained at higher levels till 60 s and started declining thereafter Information on education and occupation serve as proxy indicators for income (as it is difficult to calculate income in any setting, especially amidst constraints of time and methodological issues), indicating the burden of RTIs in different sections in Figure 23: Age-sex distribution of RTI deaths (%) Fatal Non - Fatal < > < > 70 Male Female Total Male Female Total NIMHANS 29

52 Table 10: Education & Occupation of persons in RTIs (%) Education Fatal Non-Fatal Occupation Fatal Non-Fatal Illiterate Unemployed Primary Retired Middle & Secondary Homemaker Sec. High school & PUC Student Graduate Unskilled labourer Post graduate Skilled labourer Not Known Clerical Not applicable Business Professional Others Not known Not applicable the society. Information was not available in nearly 20% of non-fatal injuries and has been excluded from this analysis. Nearly 30% of the killed were either not educated or only up to primary levels of education. Those completing pre-university, graduate and postgraduate levels accounted for 30%, 13% and 2%, respectively. Among non-fatal injuries, nearly 10% were with lesser education, while graduates and above were represented to the extent of 30%. The occupational status of those killed and injured revealed that majority were in poor and middle-income categories as they belonged to unskilled and skilled labour categories. Those employed in professional white collar working groups were present among 4% of fatal and 11% of non-fatal injuries, respectively. Students, housewives and retired categories contributed for 7%, 7% and 5% of deaths, respectively. Death or hospitalization due to RTI brings sudden and unexpected financial problems to individuals and families forcing them to generate finances to meet the emergency situation Time of crashes The time of occurrence of crashes is a vital indicator for developing number of programmes in prevention and hospital care. This information can sensitise road planners and builders on number of issues (e.g., visibility factors) and for hospitals to be in a state of preparedness. Beginning from 6 am (crashes were less during 12 midnight to 6 am), occurrence of fatal and non-fatal crashes reached a peak during 8 12noon, declined thereafter, increased further during 6 pm 11 pm. Nearly 30% of fatal and 23% non-fatal crashes occurred between 7 pm and 12 midnight. These timings correspond to peak traffic hours, high density of vehicles on roads, police being primarily involved in maintaining traffic flow in central parts of the city to avoid traffic jams, and severe violations (speeding and overtaking) by road users as everyone is in a hurry to move. During night times, alcohol influence and visibility factors are also major contributing factors. Figure 24: Time of Crash in fatal and non-fatal injuries Hrs Fatal Non- Fatal Involvement of alcohol Information on alcohol consumption by the killed / injured person or the driver of the counter part vehicle was not totally available in the series. Discussion with police and hospital personnel revealed that this was not specifically documented for reasons of difficulty in producing evidence in courts or for compensation purposes and for humanitarian reasons. However, the available information revealed that 7% of the killed drivers and 1% of counter part drivers were under influence of alcohol at the time of crash. Among non-fatal injuries, alcohol presence was found in 13% of RTIs as documented by physician certification based on presence of smell of alcohol. It is likely that a large size of Don t Know category would include those under the influence of alcohol. Previous studies at NIMHANS have documented presence of alcohol in road crashes to be between 25-35% in the city of Bengaluru (24, 25, 26). 30 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

53 Figure 25a: Road User Categories in urban fatal and non-fatal injuries (%) Others Fatal Others Non - Fatal Lorry occupant Other 4 wheeler occupants Bus occupant Bus / Truck Driver Three-wheeler occupant Three-wheeler occupants Car occupant Car occupant Bicyclist Bicyclist Two-wheeler pillion Two-wheeler pillion Two-wheeler rider Two-wheeler rider Pedestrian Pedestrian Road user categories There were nearly 24 categories of road users for deaths and injuries in the heterogeneous traffic scenario of Bengaluru. For ease of understanding, smaller categories have been grouped into selected major categories. Among the various road user categories killed in RTIs, pedestrians were the largest category to the extent of 52%. Two wheeler riders and pillions contributed for 26% and 11%, respectively. Bicyclists and car occupants had succumbed in road crashes to the extent of 5% and 3%, respectively. Auto rickshaw passengers were killed in 1.8% of deaths. In sharp contrast, among non-fatal injuries, more than half of injured brought to hospitals were two wheeler riders (42%) and pillions (9%), with pedestrians constituting one fourth of the series. Car drivers and passengers were injured in 5% of hospital contact RTIs. In the rural areas, the first and second places were taken by two wheeler riders and pedestrians, followed by bus/truck occupants Pedestrian deaths and injuries Nearly, 500 pedestrians were killed on the roads of Bengaluru during the year The killed and injured pedestrians were highest in the age group of years and were primarily men. Interestingly, one fourth of the injured and killed pedestrians were children and elderly. Analysis of crash patterns among fatal injuries revealed Figure 25b: Road User Categories in rural non-fatal injuries (%) Unknown Others Car driver Other 4-wheeler driver Bus/truck driver Three-wheeler driver Car occupant Bicyclist Other 4-wheeler occupant Three-wheeler occupant Two-wheeler pillion Bus/truck occupant Pedestrian Two-wheeler rider that 24% were hit by cars, 22% by two wheelers and 18% by buses. Trucks and auto rickshaws had collided with pedestrians in 16% and 8%, respectively (Figure 26a). Activity performed at the time of crash revealed that nearly 60% were crossing the road, 28% were walking, 8% standing, 2% working and 2% playing on the road. Other categories included sleeping on the road and standing near bus stops (Figure 26b). Figure 26a: Injury collision pattern amongst pedestrians Van 10% Two wheeler 22% Truck 16% Auto 8% Bus 18% Tractor 2% Car/Jeep 24% Figure 26b: Pedestrian Activity at time of injury (%) Don t know Sleeping on the Road Fatal Sleeping Going/Coming from school Unspecified Non - Fatal Playing on the Road Working on the Road Standing on the Road Walking on the Road Working Playing Others Standing on the Road Walking Crossing Road Crossing NIMHANS 31

54 Two wheeler deaths and injuries In 2007, 346 two wheeler drivers/pillions were killed in the city. Two-wheeler collision with larger trucks and buses were common to the extent of 32% and 23%, respectively, followed by crash with another twowheeler (28%) (Figure 27a). Data on collision pattern indicated that hit from back (one ways have become the norm on many roads) was commonest (40%), followed by hit from side (15%) and head-on collision (13%) (Figure 27b). Speeding, overtaking, negotiating turns resulting in skid and fall and sudden application of brakes were some of the responsible factors for deaths. The city of Bengaluru has partial helmet legislation in place making helmet usage mandatory for riders of two wheeler vehicles. The usage of helmets was low as revealed by the finding that more than half had not worn a helmet at the time of crash in both police and hospital data. This number could be much higher, as injured or family members of those killed might have reported that person was wearing a helmet. In addition, this was not properly recorded. Figure 27a: Collision pattern of two-wheeler rider/pillion Van 2% Two wheeler 28% Auto 1% Bus 23% Truck 32% Car/Jeep 8% Hit a fixed object 4% Tractor 2% Figure 27b: Crash pattern and type of collision among Two-wheeler Rider/Pillion Hit pedestrian 1% Others 4% Skid & Fall 12% Over turn 3% Nose to tail collision 5% Hit from side 15% Head on collision 13% Hit a fixed object 7% Hit from back 40% Figure 27c: Use of helmets among two-wheeler riders Not known 13% No 51% Fatal NA 1% Yes 35% No 40% Non - Fatal Not known 22% Yes 38% Proper documentation, and field observational studies are essential to show changing patterns of use, and impact of helmet legislation and enforcement Bicyclist injuries and deaths Bicycles are a common mode of transport, especially among children. They are small in size, inconspicuous and often unprotected. Collision with heavy vehicles like trucks (28%), buses (21%), cars and jeeps (19%) had proved fatal. Collision with a two-wheeler was responsible for 19% of deaths. In more than half of deaths, cyclists were hit from back, while head-on collisions and hitting a stationary object was responsible for 11% of deaths each. Van 3% Two wheeler 19% Figure 28a: Bicyclist hit by Auto 1% Bus 21% Truck 28% Tractor 1% Car/Jeep 19% Hit a fixed object 8% Figure 28b: Crash pattern and type of collision among bicyclist Skid & Fall 4% Over turn 1% Nose to tail collision 7% Others 6% Hit from side 7% Head on collision 11% Hit a fixed object 11% Hit from back 53% Car occupant(s) deaths and injuries The growth of motorcars in Bengaluru has been significant, though at a lesser pace compared to motorcycles. An increase in young drivers and women in particular has been noticeable on the streets of Bengaluru. Figures 29a-29c indicate crash characteristics and patterns among car occupants in fatal injuries. Nearly 60% of those killed and injured were in years age group, with a male to female ratio of 2:1. Majority of the times, the car driver had collided with another car (57%) or with a two-wheeler (20%). Cars had hit stationary objects like trees, median, buildings in 8% of the crashes. 32 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

55 Hit a fixed object 8% Figure 29a: Car occupant hit By Tractor 4% Car/Jeep 57% Bus 1% Truck 8% Two wheeler 20% Auto 1% Van 1% Figure 29b: Crash pattern and type of collision among car occupants Hit from side 14% Hit from back 33% Nose to tail collision 5% Over turn 14% Hit a fixed object 13% Skid & Fall 1% Others 14% Hit pedestrian 1% Head on collision 5% Figure 29c: Usage of Seat Belts among car drivers-fatal & Non-fatal Fatal Not known 38% Non - Fatal Not known 88% Not applicable 8% No 4% No 50% Yes 12% Of the total collisions, rear end collisions (33%), side collisions (14%) and overturns (14%) were commonly documented. Information on seat-belt usage among car drivers, though not accurate, revealed that only 12% of non-fatally injured drivers had worn seat-belts. This information was totally missing in police records Fatal and non-fatal bus crashes Information on pattern and profile of bus crashes are provided separately in the report entitled "Crash Reporting and Analysis of Fatal Bus Crashes " (26). Nearly 117 deaths were reported from BMTC crashes during Collision of a heavy vehicle like bus with smaller size road users resulted in deaths due to greater and sudden transfer of large amounts of energy Environment and vehicle factors Information on contributory vehicle factors for crashes resulting in deaths was limited as they were not clearly documented in the proforma. Overall, 60% of the vehicles did not have any mechanical defect while problem in remaining 40% were primarily attributed to brake failures, lighting defects, steering failure, tyre defects and axel cuts. The distribution varied slightly, particularly among the counter part vehicle where mechanical defects were absent in 87% of vehicles. This may not be the real scenario as this was not investigated fully and information was not available. Road and environment factors play a significant role in road crashes. Detailed information was not available in majority of crashes. However, as per reports, significant number of crashes had occurred on straight roads (89%), concrete metalled roads (79%) and roads with good visibility (89%). These parameters indicate that there is need for detailed crash analysis in a systematic way and current data point to the fact that speeding and overtaking are primary contributory factors. Table 11: Environmental Factors Frequency Percent No mechanical defect with victim's vehicle No mechanical defect with counterpart vehicle Straight road Concrete road Good visibility on road at crash time NIMHANS 33

56 13. Suicides Estimated deaths: 3,000 Estimated serious injuries: 20,000 Suicides are a major public health problem in recent years due to globalisation, changing values of people and a combination of many other factors. Suicides in young are a matter of great concern due to its impact on young lives. During the year 2007, there were 2429 suicides as per reports from City Crime Records Bureau. Suicides have to be established on intent and there was difficulty in ascertaining intent, and hence misclassification was common. Due to misclassifications between suicidal, accidental, homicidal and unknown categories; ongoing investigation in some cases; and inclusion of many unknown deaths as suicides, the precise numbers were difficult to obtain. In the total, 27% were intentional and information available from 912 defined suicidal deaths is included in this analysis. In the same period, 21 hospitals had registered 5,328 attempted suicides. Nearly 50% of deaths were falling in RTIs and other unnatural deaths. Precise numbers of suicides in this were difficult to obtain. The ratio of completed to attempted suicides was 1: 6. The real numbers could be much higher as data from attempted suicides was collected from only 21 hospitals. The incidence of completed and attempted suicide from previous studies have been found to be 34 and 252 per 100,000 population, respectively (26). Previous hospital based and population based studies have shown the ratio between completed and attempted suicides to vary between 1: 8 to 1: 10 (26, 27). The ratio of completed: attempted: suicide ideators in a recent population based study has been found to be 1: 7: 22 (27). There was no significant variation across different months for completed and attempted suicides. However, highest numbers of suicides were seen during January to July with correspondingly high numbers during the months of February to May. The second half of 2007 documented less number of suicides. The precise reasons need to be identified for this variation and a possible reason could be due to high number of suicides among 16 to 25 years related to academic reasons during the first half of the year. Men and young people were represented to a higher extent in both completed and attempted suicides. Highest number of suicides was documented in the age groups of years in the total series. The proportional distribution in years, years, years, years and years was 16.2%, 21.6%, 20.3%, 11.2% and 9.5%, respectively. More suicides were reported among women in younger age groups of years (51% completed and 57% attempted suicides), while in all other age groups men were higher. The male to female ratio was 2:1 in the series. Among persons completing suicides, the sociodemographic characteristics revealed that people with less than 8 grades of education (illiterates, and primarymiddle school levels) constituted 60% of the total series. Less than 20% were educated beyond secondary schools levels including graduate and post-graduate levels. Among the various occupational categories, 30% of suicides were amongst skilled and unskilled labourers, while students, housewives and those in business categories were 10%, 18% and 6% respectively. Professional categories represented 4% of completed Figure 30: Month of Occurrence, Suicides Jan Feb Mar Apr May Jun Jul Aug Sep Completed Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Attempted Oct Nov Dec 34 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

57 Figure 31: Age-sex distribution of completed & attempted suicides (%) 30 Completed 35 Attempted Male Female Total Male Female Total < > 70 < > 70 Figure 32: Place of occurrence of completed and attempted suicides Hotel (lodging establishment) 2% Shopping area 2% Completed Well/lake 1% Others 10% School 1% Public place 3% Play ground 1% Unknown 2% Attempted Others 2% Road 2% Education campus 1% Agricultural area 1% Work place 1% Home 82% Agricultural field 1% Work place 2% Home 86% suicides. Housewives and students were in increased numbers for attempted suicides (Table 12). Table 12: Education & occupation levels among completed & attempted Suicides (%) Education Completed Attempted Illiterate Primary Middle Secondary, high school & PUC Graduate Post graduate & Above Not applicable 0.5 Occupation Unemployed Retired Housewife Student Unskilled labourer Skilled labourer Clerical Business Professional category Others Not applicable Home was the commonest place of suicidal act or attempt as more than 80% of the completed and attempted suicides occurred at home. The other places of completing suicides were hotels and lodging establishments (2%), farm and agricultural areas (1%), public water bodies (1%) and others. Small number of suicides also occurred in public service shopping areas, educational establishments and factory premises (Figure 32). The methods of suicides were primarily hanging (61%), poisoning (25%), burns (12%) and drowning (1%) among completed suicides (Figure 33). In sharp contrast, poisoning was more common in attempted suicides (87%) with attempt to hanging and self-immolation being 4% and 6%, respectively. Self immolation was more frequent among young women in years. There was no significant variation between the place of residence or other socio-demographic characteristics. Others included drowning (0.1%), falling from height (0.5%) and falling in front of moving vehicles (0.3%) NIMHANS 35

58 Figure 33: Methods of Suicide Hanging 61% Completed Poisoning 87% Attempt to hang 4% Attempted Others 1% Self Stab/cut 2% Drowning 1% Poisoning 25% Burns 12% Burns 6% Others 1% Nearly 75% completed the suicidal act at a time when they were alone in the house and only 12% when other family members were around, but not in the immediate vicinity of the affected individual. Alone in house 75% Figure 34: Suicide situation In presence of others 12% Outside house 13% The time of attempting suicides was primarily during 9 am 6 pm when the person was likely to be alone without much care and supervision from other family members. The time of completed suicides was high during day time, probably linked to family members being away on work or other reasons and person being alone at home. The pattern was slightly different in attempted suicides with higher numbers reported during 4 pm - 11 pm. Figure 35: Time of completing and attempting suicides Hrs Completed Attempted The direct and indirect association of alcohol in suicide causation is a known phenomenon worldwide. Alcohol involvement and suicides have been linked in number of ways in previous studies by NIMHANS (24-27). There were difficulties in obtaining information on alcohol in the present programme due to medico legal reasons as highlighted in the earlier sections of this report. Informal enquiries revealed that not much importance was given to this issue for humanitarian reasons and difficulties in measuring alcohol presence. The available data indicate that alcohol was directly incriminated in % of completed and attempted suicides. As this information may not be accurate, it is not a realistic indicator as previous studies have shown that nearly 30% of suicides are linked to alcohol (25, 28). It was commonly observed that some of the poisonous substances like organophosphorus compounds and drugs were mixed with alcohol or consumed under alcohol influence. A number of products were used for completing or attempting suicides. These included a variety of organophosphorus compounds, insecticides (herbicides, rodenticides and fungicides, etc.,), variety of drugs (barbiturates, sedatives, hypnotics, analgesics, etc.,), and household chemicals (like dishwashing liquids and others). The long list of individual products identified indicates the easy availability and the fact that any available substance was used for the purpose of ending one s life. These products could be available at home or could have been easily bought from nearby shops without any questions being asked. Understanding causes and risk factors is very crucial as preventing suicides mainly rests on this premise. The precise causes of suicides were difficult to establish in the present study by a surveillance approach. Identifying risk factors requires analytical 36 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

59 approaches and due to non-availability of total information, this has not been attempted. However, some of the major causes as listed in the police records were presence of physical illnesses (n=123), family problems (n=122), frustration in life (n=97), presence of mental disorders (n=52) and financial problems (n=43). Number of other reasons was related to suicides as shown in Table 13. There were also precipitating triggering operating factors within the large group of causes cited above as responsible factors. The table below for completed suicides is provided mainly as an indicator highlighting the need for more focussed and in-depth studies in hospitals and communities. The causes for attempted suicides was not included for the hospital part as it was found to be difficult to elicit this information in emergency room settings. Table 13: Major causes of suicide for different age groups Causes Missing < > 70 Total Physical Illness Family Problems Alcoholism Finance Problems Mental disorder Marriage Problems Frustration in life Unemployment School related Poverty Death in family Exam failure Love disappointment Issueless Career problems Business loss Retired life Pregnancy related Suicide by friend Illicit relationship Dowry harassment Sexual abuse Miscellaneous Unknown cause NIMHANS 37

60 14. Burns Estimated deaths: 500 Estimated serious injuries: 5,000 Burn injuries are extremely common and frequently reported in the media. Burns constitute an important public health problem and 95% of the global burn deaths and disabilities occur in low and middle income countries like India (29). Burns occurs due to a variety of products ranging from electrical, thermal, mechanical and radiant in nature. These injuries can be suicidal (which is very common among women in years), homicidal or accidental. WHO highlights that it is possible to reduce burn mortality and morbidity through combination of measures aimed not only by reducing the likelihood of occurrence of fire but also by reducing the severity and impact of a burn injury through appropriate trauma care practices. However, it is a major challenge for countries like India where the social, cultural and economic circumstances and causes are different in comparison to many high income countries. Further, the epidemiological characteristics are not well understood. Nearly 360 persons (11%) lost their lives due to burns injury in the city of Bengaluru in 2007 as per police reports. At the same time, 2,517 persons were hospitalized with a ratio of 1:7. It is likely that numbers could be higher as many of those receiving care in other institutions and those with minor injuries are not included in this report. The actual numbers of deaths, hospitalisations and minor burns could be about 500:5,000:15,000, respectively, giving a ratio of 1: 10: 30 specifically for burns in Bengaluru. One major public sector hospital (Victoria hospital) reported highest number of burns as it has an exclusive burn injury management facility with care available in many private health care institutions. Among the total, 1/3 rd were suicidal, 6% homicidal and 60% reported it to be accidental in nature. It is possible that misclassification could have occurred with accidental deaths. Two thirds of injured and killed persons were brought or reported by family members. Highest number of burn deaths occurred in April (56), January (42), and July (37) with lowest numbers in September and December. No specific reasons could be attributed for this variation. In similarity with the other injuries, burn related deaths were high in the younger age groups of years, with one fifth each occurring in and years (Figure 36). Interestingly, ¼ of burn deaths occurred in less than 20 years age group. Women were overrepresented in years in both fatal and non-fatal burn injuries. The male to female distribution was 2:1 in the total series, while it was 1:2 among those in younger age groups. This phenomenon has been reported by many Indian studies and causes are primarily attributed to cultural issues. Nearly 80% of burns occurred among those with lower levels of education in comparison to 4% in the higher educational categories. Disaggregated data based on occupation, revealed that burns Figure 36: Age-sex distribution of Burn injuries (%) 30 Fatal 30 Non - Fatal Male Female Total Male Female Total < > 70 0 < > Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

61 Figure 37: Place of occurrence of burns Work place 1% Road 1% Others 19% Fatal Railways 0% Public place 3% School 0% Work place 13% Agricultural field 0% Unknown 0% Road 1% Others 0% Non - Fatal Home 79% Home 83% among housewives higher (41%), followed by people in labourer categories (20%). Five percent of burns were among student population in the series. There was no significant variation between fatal and non-fatal injuries with regard to education and occupation as low income households were at greater risk of burn injuries. Three fourths of burn deaths and injuries occurred at home and remaining were seen in industrial areas and other places. Burn injuries, specially non-fatal injuries, were higher in evenings, while fatal injuries were common during both day and night times. The involvement of alcohol was poorly documented in both police and hospital records. Nevertheless, 6% of deaths among men could be linked to alcohol Figure 38: Distribution of burn injuries as per time Fatal Non-Fatal consumption based on available information. Majority of the burns were reported as stove bursts, and accidental burns and had occurred inside the house. Kerosene stoves, gas cylinders, oil lamps, cooking materials and hot liquids were the primary agents responsible for burn injuries. The causes of burns were not clearly known in majority of the instances Poisoning Estimated deaths: 500 Estimated serious injuries: 10,000 Deaths and injuries due to poisoning are common events. Instances of poisoning with adulterated liquor and contaminated food, though not included in this report, are also frequently reported in the media. In an environment of unregulated supply and availability of a variety of organophosphorus compounds, Over the Counter (OTC) medicines, household products and other dangerous chemicals, poisoning can be suicidal, accidental and homicidal in nature. Causes of poisoning are unclear even at national level as there are no reported nor investigated causes as seen in reports of national and state crime record bureaus. Nearly 300 people (9% of total deaths) lost their lives due to a poisoning act in the city of Bengaluru during 2007, while 10% of those hospitalized due to an injury were due to poisoning. Among them, 75% were men and 25% were women. Highest number of poisoning deaths was seen in years (36%), while poisoning among teenagers in years was 13%. Among the non-fatal poisoning cases 60% were in the age group of years. In similarity to burns, in both fatal NIMHANS 39

62 Figure 39: Fatal & Non-fatal poisoning - Age-sex distribution < Fatal Male Female Total > < Non - Fatal Male Female Total > 70 and non-fatal poisoning injuries, there were more women in the younger age groups (16 34 years). More than 90% of poisoning case occurred within urban Bengaluru area. The number of poisoning deaths month wise varied from 11 in October to 29 in January. The first 6 months of the year reported higher poisoning deaths and no specific reasons could be identified for this phenomenon in this programme. The time distribution of poisoning deaths and injuries was similar to other injuries with a higher occurrence from afternoons and reaching a peak by evening and night times. Available information on socio-demographic correlates revealed that majority were with either no education or with lower levels of education and only 20% were in the educated categories of high school and above. Once again, skilled and unskilled labourer categories accounted for 1/3 of poisoning deaths, while it was 11%, 4% and 10% among students, housewives and businessmen. Information on alcohol consumption was poorly documented; 11% of fatal and 6% of non-fatal poisonings was linked to alcohol consumption and nearly 15% had long-term alcohol consumption habit. Most of the cases of poisonings were suicidal (80%) with homicidal and accidental poisoning being about 1-2% and 18-19% respectively. Home was the commonest place for deaths (58%) and injuries (86%) due to poisoning (Figure 40). Poisoning was also seen in hotels, public places and educational institutions, indicating the need for better vigil and security. In ¾ of deaths due to poisoning, the product responsible was primarily organophosphorus compounds and OTC drugs. However, the range of products varied from anti mosquito repellents to intensely lethal products. Similarly among drugs, all types of drugs were involved in deaths and injuries due to poisoning. While the source and method of obtaining these products were not enquired, it is apparent that regulating the availability, household supervision and greater public awareness are required for reducing poisoning deaths and injuries. The causes of poisoning could not be clearly documented in the data collection process. Figure 40: Place of poisoning Public place 7% School / College 1% Work place 2% Fatal Work place 3% Public place 3% Road 2% Agricultural field 1% Non - Fatal School / College 1% Others 24% Road 8% Home 58% Others 4% Home 86% 40 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

63 16. Falls Estimated deaths: 500 Estimated serious injuries: 10,000 Falls are one of the important causes of injury deaths and disabilities. The epidemiology of falls has not been understood in detail as it occurs in number of places like homes, roads, public places, schools, construction sites and others. A so called simple fall in a bathroom can turn out to be a life long disabling condition for the injured person, while fall at a construction site can result in instantaneous death. The precise causes of falls vary as per location, context and situation requiring in-depth research for a better understanding. During the year 2007, 209 deaths (6% of total injury deaths) were reported due to falls. All fall deaths occurred within the city of Bengaluru. In a one year period 4,986 were brought to hospitals with a history of fall injury. The ratio of fatal to non-fatal fall injuries was 1:25. Once again, numbers could be higher as only smaller number of institutions was included in the programme and deaths due to falls are not routinely reported to police, unless they are of a medico legal nature. Among the deaths, males and females accounted for 83% and 17%, respectively. Deaths among females were comparatively higher in the younger age groups (<20 years) and elderly. In both fatal and non-fatal injuries, males accounted for 80% of falls (ratio of 4:1 between men and women). Children (<15 years) accounted for 10% of fatal and 20% of non-fatal injuries, while elderly (60+ years) accounted for 6% of fatal and 7% non-fatal injuries. Interestingly, in both fatal and non-fatal injuries, women in younger and elderly age groups were represented in higher numbers compared to men. Highest number of fall related deaths were seen in years to the extent of 58%. Figure 41: Age-sex Distribution, Falls < Fatal Male Female Total > < Non - Fatal Male Female Total > 70 Table 14: Education and occupation distribution of non-fatal fall injuries Education Percent Occupation Percent Illiterate 15.7 Unemployed 2.6 Primary 19.0 Others 4.2 Middle & Secondary 17.0 Not known 13.4 Secondary, High-school & PUC 16.0 Not applicable 8.3 Graduate 9.0 Retired 1.7 Post graduate 0.6 Homemaker 5.9 Not known 12.8 Student 19.0 Not applicable 9.9 Unskilled labourer 25.4 Skilled labourer 12.3 Clerical 1.2 Business 3.5 Professional 2.6 NIMHANS 41

64 The distribution among educational and occupational categories was in similarity with other type of injuries. Substantially higher number of deaths was seen in the poorer sections of the society comprising of individuals with lower levels of education and income primarily coming from uneducated and manual labourer categories. Less than 10% of deaths were seen in higher income groups and amongst higher levels of education. There was no significant variation with regard to the distribution of fall deaths in various months. Nevertheless, the first 6 months of the year registered higher number of fall deaths. Nearly, 40% of fall related deaths occurred in the morning hours and 1/3 during afternoon and early evenings. The place of fall was primarily home in 30% of deaths. Falls on road (18%), at construction sites (17%) were the other primary categories of falls. Falls in agricultural areas and shopping areas contributed for 2% of deaths in the total series. Similarly for non-fatal injuries, 40% occurred at home, followed by 31% in work places and 18% on roads (Figure 42). Among children, falls on road and play sites was commonly seen to be resulting in non-fatal injuries College Campus Figure 42: Place of occurrence, Falls Construction sites Home and premise Alcohol was found to be a primary influencing factor as nearly 11% of fall deaths among men in 18+ years occurred under the influence of alcohol. Most of (75%) the deaths due to falls occurred from a height of 10 feet and above. The cause for the occurrence of fall was not clearly known for majority of the deaths. Others Fatal Road Non-Fatal Work places 17. Drowning Estimated deaths: 120 Estimated serious injuries: 150 Even though, cases of recreational drowning are reported in a sensational way by the media, very little information is available in a collective and cumulative manner. The city of Bengaluru has not witnessed cyclones and floods as seen in other parts of India. There have been deaths due to drowning during rainy season: people getting washed away, deaths due to building collapse after heavy rains, apart from drowning in recreational spots both within and peripheral parts of the city. It is essential to note that drowning carries high mortality as many individuals die within few minutes. The present programme tried to capture drowning deaths and injuries in totality. In the study period, 62 individuals died and 31 were brought to hospitals due to drowning in the year 2007 in the city. Among them 75% were men and 25% were women. Nearly half of drowning deaths occurred in years with the highest number being in years. Majority of the drowning deaths occurred among individuals living within the city of Bengaluru. Non-fatal drowning among children (< 15 years) and in women of middle age groups was also observed in the study. Contrary to the observations on educational occupation in other injury deaths, majority of those with drowning were with higher levels of education and in student and other professional categories. This indicates that much of the drowning was related to recreational activities. Nearly, half of drowning deaths occurred during the summer months as compared to the second half of The timing of drowning deaths was predominantly during afternoons and late evenings and very less in morning or late night hours. The 42 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

65 commonest places of drowning were wells, lakes and ponds in and around the city. Nearly 8% of deaths were linked to alcohol consumption at the time of drowning. Majority of the deaths occurred in presence of others especially when groups of people had gone for recreational activities within or outside the city. Figure 43: Age-sex Distribution, Drowning < Fatal Male Female Total > < Non - Fatal Male Female Total > Animal Bites Estimated deaths (Dog bites): 50 Estimated serious injuries (Dog bites): 50,000 According to NCRB, in India, during the year 2006, 301 persons were injured and 864 got killed because of animals. Though a specific distinction is not made, less than 1% of the reported injuries and deaths are due to snake bites / animal bites. Of greater concern with animal bites is the 100% fatality due to Rabies. 56% of the global rabies deaths is from Asian Continent and India contributes to nearly two thirds of this burden. With an estimated 20,000 deaths and 17 million animal bites, there is one death every 30 minutes and 1 animal bite every 2 seconds in India. Recently, the city of Bengaluru has witnessed unprecedented debates and discussions on stray dog menace and dog bites in particular. The debates have resulted in formulation of guidelines on how stray animals should be handled on roads and at home. The Department of Community Medicine at Kempegowda Institute of Medical Sciences runs an Anti rabies clinic, conducts research on rabies including rabies surveillance. The department is also helping BBMP in developing policies on Prevention of human Rabies including dog population control. The dog census undertaken in the city of Bangalore revealed that there were an estimated 3.2 lakhs dogs (1.8 lakhs stray dogs & 1.4 lakhs pet dogs) in BBMP area. Available reports from BBMP shows that there were 21,121 recorded animal bite cases in Bangalore city for the year and 38 human rabies cases were admitted to Epidemic Diseases Hospital (EDH), Bangalore. This obviously is an underreported number as there is no mandatory reporting of animal bites. Data from BISP reveal that, less than 1% of the registered injuries were due to animal bites. A key reason was that animal bite cases are most often referred to other centres and even when attended they are generally not managed in the casualty. Over a one year period, no deaths were recorded by the police due to animal bites, while, 1,737 persons were registered from one centre. Dog bites was the commonest injury seen in the series. Homes and roads were the commonest place of bite (40% each). Cases were reported from almost all places like play sites, agricultural lands, public parks and near schools and colleges. Interestingly, 35% of animal bites occurred in children less than 15 years age group. NIMHANS 43

66 19. Assault / Violence Estimated deaths: Estimated serious injuries: 25,000 Violence is a growing problem all over the world, more so in rapidly economizing societies. Violence is a commonly used term and includes homicides, assault, rape, injuries due to riots and wars, abuse of elderly women children, custodial related injuries, etc. The precise magnitude of the problem and its causes are difficult to establish in a surveillance programme and requires focused investigation. Data from Bengaluru Injury Surveillance Programme (BISP) revealed that during 2007, there were 28 deaths (<1%) and 8,499 (16%) first time hospital contacts giving a ratio of 1: 300 for fatal to non-fatal injuries. The non-fatal injuries registered were primarily due to interpersonal violence and domestic violence but also included other types of violence. Majority were brought to hospitals in a state of acute injury by family members or friends / acquaintance. Figure 44a: Age-sex distribution of assault/violance injuries Fatal Non - Fatal Male Female Male Female > < > 70 Men predominated in hospital series in a ratio of 4:1 (6,777 men and 1,722 women). Nearly 2/3 violence occurred in years with highest numbers in years (41%). Violence was common (more than 80%) among individuals with low education and income backgrounds. Alcohol was a major factor in 9% of injured and 7% of counterpart individuals. Three common places of violence related injuries were home (35%), roads (28%) and public places (28%). Six percent of the injured came directly from their workplace, following an injury. The commonest pattern of violence was physical fights, injuries due to commonly available objects at home or on roads. Figure 44b: Place of assault / violence Home Road Public place Work place Others Unknown School Fatal Non-Fatal Agricultural field 20. Prehospital Care Good surveillance programmes can often reflect the status of trauma care services and identify areas of strengthening. Previous studies in Bengaluru have been limited and examined the pre hospital care in road traffic injuries, traumatic brain injuries and suicides (24, 25). A study in 2001 examined trauma care facilities across 25 hospitals of Bengaluru (30). However, these studies have been isolated, and 44 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

67 not continuous in nature. In a surveillance programme, examination of these factors can reveal the changing patterns and identify critical elements, helping in prioritization and policy setting process. Trauma care issues included under surveillance were - availability of first aid, mode of transportation, time interval between injury occurrence to reaching one of the study hospitals, referral patterns and number of hospital contacts before reaching a definitive hospital. While these formed a set of vital factors contributing for availability, accessibility and affordability of emergency and pre-hospital care, the quality of care not received nor provided were included. The provision of first aid to an injured person depends on place, nature and severity of injury along with availability. As there are no specified first responders, people in the vicinity are the first responders, who often make the decision of what should be done. Thus, it is common to see large number of people gathering at the site of injury. Secondly, it depends on the knowledge and practice of these responders and what they do. Commonly, in a road crash, the scenario is more of confusion, altercation and fights among people, rather than shifting the person to the nearest site of care (In India, it is common to see people fighting, beating up the driver, setting the vehicle on fire, etc., a form of people s justice). Thirdly, it also rests with the existing medico legal practices in the society as it is common to see people lying unattended for fear of later legal complications or police enquiries among public (The hon. Supreme court has ruled that people attending to road crash victim need not be involved in later stages). The definition of first aid varies in the local context and in the present study even care in a first contact hospital was considered as first aid as this was the first available care. In totality, nearly one third (28%) of fatal and half (48%) of non-fatally injured persons received some type of first aid more so in the first contact hospital. However, the number of persons receiving first aid soon after a fatal injury varied from 10 50% depending on the type of injury. In non-fatal injuries, the numbers were slightly higher ranging from 24% to 65%. In road crashes, the proportions were 55% for non-fatal injuries and 21% for fatal injuries, while for burns it was 32% and 57%, respectively. In suicides, 22% fatal and 40% non-fatal cases received some first aid (figure 45). Figure 45: First aid care for persons with fatal and non-fatal injuries Suicide Road traffic injuries Poisoning Others Hanging Fall Burns Assault/Violence Non-Fatal Fatal The place of delivery of first aid is crucial as it depends on the practice of save and stabilize or scoop and run. In Bengaluru and many parts of India, at the injury site, people administer first aid with whatever they know or can do, rather than any systematic interventions that can save life or minimize the extent of further damage. Further, people generally do not wait for an ambulance even if it is a severe or fatal injury. Only 7% of fatal and 2% of non-fatal injuries received first aid at injury site (this was comparatively higher for assault, burns and after hanging / attempt for hanging). This indicates the presence of a scoop and run practice as injured were taken to nearby hospitals by those present at the site of injury. Nearby Government / public hospitals was the most common place of providing first aid in more than 50% of injuries. This was INJURYCAUSE Table 15: Place of first aid for injured persons (%) fatal injuries At injury Site Near by govt hospital Near by private hospital Medical college hospital Nursing home Others Road traffic injury Fall Assault/Violence Burns Poisoning Drowning Hanging Others NIMHANS 45

68 Table 16: Place of first aid for non-fatal injured persons (%) Non - Fatal INJURYCAUSE At injury Site Medical college Near by Govt. Hospital Near by private hospital/nh GPs + Pvt. clinic Others Road traffic injury Assault Burns Drowning Fall Others Poisoning Suicide Figure 46: Personnel delivering first aid for fatal and non-fatal injuries Police 1% Nurse 1% Public 3% Family members 5% Others 1% Fatal Nurse 1% Self medication 1% Others 1% Non - Fatal Doctor 89% Doctor 97% closely followed by Private health care institutions in 32% and 42% of fatal injuries. The involvement of general practitioners and common responders like police was less than 1% in the series. Who delivers first aid is an important aspect as what is delivered depends on the knowledge and skills of the person and the extent he/she goes in translating that knowledge to action. In the present study, as many people received their first aid in public or private hospitals, it was commonly the doctor or nurse involved in delivery of first aid care. More than 90% of first aid deliverers were doctors. Mode of transportation of an injured person is critical as the aim is to reach the nearest health care centre in the safest possible way within a short period of time. Data from non-fatal injuries revealed that the commonest transportation vehicle was private means of transport through private vehicles (cars or taxis) or a 3 wheeled auto rickshaw in 42% and 29% of cases, respectively. Police vehicles extended support by transporting 3% of injured persons. Transfer through ambulances was seen in 19% of injuries and this was mainly for inter-hospital referrals. Only 13% of injured persons used an ambulance for immediate transportation of patients. Transfer through ambulance was comparatively higher for burn injuries (32%) and suicides (24%) and only 20% for RTIs. The rural component of the study revealed that 13% were transported by ambulance and three out of four injured persons were shifted in private vehicles. Figure 47a: Mode of transportation in urban Bengaluru (%) Private vehicle / taxi Autorickshaw Ambulance Govt. vehicle Police vehicle Figure 47b: Mode of transportation in rural Bengaluru (%) Private vehicle / taxi Ambulance Autorickshaw Govt. vehicle Police van Walking Walking Others Others 46 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

69 Time interval between injury and reaching a definitive hospital is crucial for preventing deaths and reducing severity of injuries. Information on this was available from 2,542 (75%) fatal and 48,775 (93%) non-fatal injuries. Among fatal injuries, <5% reached the hospital in less than an hour, while 27% reached in <3 hours. Rest of them were referred to participating hospitals from other referral centres for a wide variety of reasons ranging from facilities to patient choices. Forty percent of those who died reached centres after 24 hours, including 1/3 of road traffic deaths as shown in figures 48 and 49. Variations were not significant across injury causes. In non-fatal injuries, 30% reached hospitals within 1 hour and 44% reached within 3 hours. Nearly one out of 4 patients came to the hospital beyond 24 hours indicating delays in care. Data has to be interpreted cautiously as care provided in first contact hospitals has not been examined in detail. Figure 48: Time interval between time of injury and registration, Fatal & Non-fatal, all injuries < 1 hr 1-3 hrs 3-6 hrs 6-12 hrs hrs Fatal Non-Fatal Figure 49: Time interval between time of injury and registration, Fatal & Non-fatal, RTIs < 1 hr 1-3 hrs 3-6 hrs 6-12 hrs hrs hrs Fatal hrs 1-2 days 1-2 days 2-3 days > 3 days Non-Fatal 2-3 days > 3 days The source of referral indicates the place of first contact highlighting the possibility of strengthening services across different institutions. Among fatal injuries, the referral to the final hospital was mainly from Government (54%) and private hospitals (22%). In contrast, overall 53% of injured persons reached a hospital on their own and this was the most common practice in assault / violence (72%), attempted suicides (60%), and accidental poisoning (62%); nearly half (47%) of injured persons in a RTI also reached directly on their own. Government hospitals and private hospitals referred 22% and 18% of injured persons, respectively. The referral from private teaching hospitals was less as the available facilities are comparatively better in these hospitals. It is a common practice in Bengaluru to see patients being referred from one hospital to another for a number of reasons. Some of the common reasons are type nature severity of injuries (polytrauma patients and those seriously injured are referred depending on availability of specialties), nature of hospital (public or private), availability of facilities in health care institutions and affordability of care (expenses depend on nature of hospital, injury management practices and ability of patients and their families to pay along with availability of insurance with people). In the present programme, it was observed that among fatal injuries, 70% of patients visited more than 1 hospital. Among those visiting more than 1 hospital, it varied from 50% for fall related injuries to 13% in burn injuries. In non-fatal injuries, more than 90% visited at least 1 other hospital. The smaller number in burn injuries is primarily because exclusive burns care and management is available in one of the larger public sector hospital. Among non-fatal injuries, since the first contact hospital was chosen the numbers were around 10%, but majority were referred from these hospitals to other hospitals. NIMHANS 47

70 21. Nature of injuries Organization and delivery of trauma care services depends on number of factors like nature type severity of injury, availability of facilities and resources and ability of people to pay for care. Head injury was the commonest cause of death in ¾ of road crashes, while injury to chest and abdominal regions were documented in 23% and 1% of deaths. Among non-fatal injuries, injuries to head/face, upper limb and lower limb were present in 66%, 35% and 46% of crashes, respectively (Figure 50a, 50b & 50c). Neither detailed anatomical injury nor clinical diagnosis was included in the programme. Figure 50b: Body Parts injured in Assault/violence Head - 29 Face - 47 Neck - 2 Chest - 10 Upper limb - 40 Abdomen - 9 Spine - 2 Lower limb - 15 Figure 50a: Body Parts injured in RTIs Fatal Head - 77 Face - 19 Neck - 4 Chest - 23 Upper limb - 25 Abdomen Spine - 5 Non-Fatal Head - 43 Face - 27 Neck - 2 Chest Upper limb - 35 Abdomen - 3 Spine - 2 Figure 50c: Body Parts injured in Falls Head - 53 Face - 26 Neck - 2 Chest - 5 Lower limb - 37 Lower limb - 46 Upper limb - 22 Abdomen - 5 Spine - 5 Lower limb - 32 Figure 51: Extent of burns (%) among fatal & non-fatal burn injuries (shown in blue) % % Fatal % % % >60 24% Non - Fatal % % % >60 64% % % % 48 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

71 The extent of burns was more than 60% in 2/3 of deaths (Figure 51). Regrettably, 10% had died even though the extent was less than 30%. Among nonfatal burns, nearly 70% had <60% of burns. The present programme has adopted very simple method of classification to assess injury severity. Being a surveillance programme, it was decided to include this practical method as trauma care physicians in some hospitals were not familiar with scientific methods of injury severity assessment like AIS, IIS, GCS, GOS, TRISS or other methods. In addition, detailed documentation and severity ascertainment of each injury was not done; for medico-legal purposes, detailed description of injuries was done separately. The injury severity was considered mild (only ER care), moderate (requiring hospital stay upto 6 hours and needed X-rays, blood or IV transfusion, expert consultation etc.,) and severe (admission exceeding 6 hours and intensive management). Based on this classification, it was observed that one third were mild in nature. One third of RTIs and less than 10% of burns, poisoning and attempted suicides were considered mild injuries. Most of the RTIs, burn injuries, drowning, attempted suicides and falls were moderate to severe in nature (Table 17), indicating the need for comprehensive and integrated management approaches. This also reflects that minor injuries can be provided care in nearby health centres or general practitioners. Table 17: Severity of injuries in ER facilities Injury Cause Mild Moderate Severe Assault Burns Drowning Fall Others Poisoning Road traffic injury Suicide Urban Total Rural Bengaluru Management and Outcome The status of injured person at the time of reaching hospital reflects severity of injury and the need for hospital care. The number of patients brought dead was 1% in the series. Every tenth patient with a poisoning drowning attempted suicide was in an unconscious state, while reaching hospital. Semi and unconscious patients ranged from 30% in poisoning and suicide patients to as low as 3% in assaults. Overall, 85% were conscious at the time of hospital entry. Among road traffic injuries, one out of 8 10 patients were in semiconscious or unconscious state, necessitating the need for intense management and the need to deliver efficient care. These situations also pose difficulties in patient management as well as in data collection for surveillance programme, especially when they are not accompanied by family members or known persons. Figure 52: Status of injured persons at hospital entry Semiconscious 8% Unconscious 6% Brought dead 1% Conscious 85% Information on the managerial practices of injuries revealed that nearly 31% were provided care and discharged home with advice on follow-up, while more than half were admitted for further medical and or surgical lines of management (Figure 53). The admission rates were highest for burns, falls, RTIs and attempted suicides. Those treated in ER NIMHANS 49

72 and further referral was high for RTIs and falls. One out of every 6 patients was referred to another hospital for number of reasons like patient choices, lack of facilities (bed, investigation, manpower, etc.,), affordability, and at times included medico legal reasons as well. Treated in emergency room & sent home 31% Treated in emergency room & referred to another hospital 15% Figure 53: Mode of management Others 1% Admitted for medical surgical care 53% The outcome of injuries was assessed at the end of ER stay and may not be truly indicative of real outcome as those admitted and intervened were not followed-up in the programme. However, it sheds light on issues like care patterns and limitations. Majority improved in their vital status and got stabilized after reaching casualty, but required further care and management. Nearly 2% of patients died in ER and combined with those brought dead, the total number of deaths at ER was 3%. Highest number of deaths was seen among those with burns and drowning, while the status of nearly 40% with poisoning, attempted suicides deteriorated indicating need for aggressive management. 23. Injury: The hidden and unanswered epidemic Information systems and existing gaps Any prevention and control programme needs a good foundation to work through policies and programmes; such programmes obviously need good quality and reliable information. The injury information system till date in Bengaluru has been fragmented and patchy with different systems operating in their individual ways as per their administrative and legal requirements. Four common sources of injury information are police, corporation vital registration sources, transport and health. Police data is the only source of injury information and even this is of limited value for policies and programmes. The data is not comprehensive, quality is moderate, not analysed, disseminated and utilized by all stake holders at local levels (city or state). Even though health sector provides care for number of patients in individual hospitals, there has been no injury information system in health sector. Further, each hospital follows its own individual practices. In the absence of timely and scientific information, it has not been possible to develop implement monitor and evaluate any systematic policies and programmes. The present programme facilitated by ICMR and WHO and coordinated by NIMHANS is the first systematic effort to build a surveillance activity with existing data sources. Beginning with stake holder s consultation and a series of preparatory activities, information was gathered from nearly 4,334 injury deaths, 113 BMTC involved road crashes and 68,498 hospital registered injury patients for the year The city police, transport officials, nodal officers and their representatives in various institutions along with staff from Coordinating centre facilitated information collection and pooling. Hopefully, this joint collaborative effort, being first and unique in the country will be strengthened, improved and continued in the coming days. All partners and their teams need to be complimented for this unique collaborative effort. Burden of Injuries As per the death records of the Bengaluru city police, injuries constituted 9% of total deaths and 60% of these were in 5-44 age group in Injuries as an antecedent or associated cause of death might not have been properly documented in death records. 50 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

73 Nearly 4,500 deaths are estimated to occur every year with 90,000 hospitalizations for injury care and management. Even though it is mandatory to report all unnatural deaths, some deaths could have been missed or misclassified due to various reasons. The difference between the two could be due to registration of outside and late deaths Further, nearly half the patients discharged from hospitals will have varying levels of disabilities requiring short term and long term rehabilitation services. Thus, it has been possible to assess injury burden and to highlight that nearly 5,000 deaths and > 1,00,000 hospitalisations are likely to occur every year in Bengaluru due to injuries. Nearly half of them are discharged with disabilities and approximately half live with long term disabilities. A problem of this magnitude is not to be ignored as there are individuals and families behind these numbers. Everyday, persons lose their lives, seek hospital care and become disabled for short or long periods of time along with severe (and unestimated) economic losses in Bengaluru due to injuries. Needless to say injuries are a major public health problem and city authorities and parliamentarians should place injuries on the public health agenda of programmes. Scientifically designed and systematically planned programmes need to be implemented, monitored and evaluated for decreasing deaths and disabilities in the coming years along with proper integration and coordination. In a do nothing scenario or if the present scenario continues, Injuries will result in an estimated loss of 10,000 lives, 2,00,000 hospitalizations and 50,000 persons with disabilities every year by 2015 (1). These numbers are conservative estimates and are likely to be influenced by many factors. Profile and Pattern Examination of both fatal and non-fatal injuries reveals that Road Traffic Injury is the leading injury in the city of Bengaluru. This is closely followed by burns, poisoning and falls as other major injuries. Based on intent, suicides are a leading cause and include hanging, poisoning and burns. With growing urbanization, motorization, infrastructure expansion and liberalized economic policies, it is natural to forecast an increase in road deaths/ injuries and other injuries in the coming years. In Bengaluru, every year, nearly 1,100 persons die in road traffic injuries and 2,500 suicides occur along with other injuries. Despite the enormity of the problem, there has been a glaring absence of institutional mechanisms and injury prevention policies at the ground level. In comparison to other health problems, injuries primarily affect young people and predominantly men. The loss of more than 5000 young people with hospitalisations of >100,000 persons and disabilities of a long term nature among 30,000 persons should Table 18: Injury pattern with reported and estimated figures Deaths Serious Injuries Reported Estimated Reported Estimated serious injuries Road Traffic injury ,191 40,000 Fall ,000 Burns ,000 Poisoning Drowning Animal bites ,121 50,000 Violence / assault ,000 Hanging Fall of objects NK NK NK NK Mechanical injuries NK NK NK NK Total Estimated numbers based on Annexure 3 NIMHANS 51

74 grasp the attention of every policy maker and parliamentarian. Children saved from communicable diseases are only becoming victims of injuries at the later stages of their life. The loss of young lives due to an injury should be a wake up call for all concerned and realistic programmes should be in place. Injuries and Socio-economic losses In the present programme, using the proxy variables of education and occupation, it was observed that injury significantly affects the middle and lower socio-economic sections of the society. At a time when poverty reduction programmes and a number of other socio-economic improvement programmes are being implemented, it is a hard reminder that injuries add to the existing and growing pool of poverty in the society. The poor and middle classes are also unable to afford growing costs of injury care and hence, become more poorer. Injury among young men places enormous burden on the individual and family forcing them to generate resources for care and hospitalisation along with rehabilitation. Many individuals and families lose income and wages, make loans, sell assets, women get into forced employment resulting in an acute crisis. Loss of productivity, compensation, insurance liabilities and long term / permanent loss are added issues. The loss of a breadwinner brings in severe economic hardships, adding to the spiralling cycle of poverty. This adds to the loss of precious human resources in our society. RTIs alone are estimated to result in loss of 3 % of GDP (Rs. 55,000 crores or 5,50,000 million) every year in India, while cost of other injuries is not known.(6) It needs to be highlighted that collecting information on occupation and income is difficult in a surveillance programme. Urban rural differences The data from National Crime Records Bureau and State Crime Records Bureau indicate that nearly 15% of injury deaths, especially road traffic injuries and suicides occur in the major 32 metros of India. The findings from the present programme strongly support this observation. Even though the present programme was a urban based activity, a rural component was included with the enrolment of district hospital, medical college hospital, two community health centres and two primary health centres to examine the feasibility of developing similar programme in a rural area. A future publication will clearly outline injury burden and profile in rural areas but preliminary results indicate that the load on emergency departments of rural hospitals is quite large. Coupled with the fact that facilities for management and rehabilitation are limited in rural areas, majority of the injured persons are referred to urban areas for follow-up care, thus adding to the burden in urban hospitals. Role of Alcohol Several independent epidemiological studies by NIMHANS have shown that nearly 1/3 of the adult Indian male population are regular alcohol users and nearly a third of all injuries are linked to alcohol (23 25). Nearly, 30% of night road crashes are associated with alcohol usage. Indian drinking patterns being different from those in the west, alcohol use is a major risk factor for the person behind the wheel, machine or any product. In the present study, alcohol was documented in <15% of fatal and non-fatal injuries in both police and hospital records. Discussion with participating members revealed that documentation of alcohol was poor and limited due to medico-legal issues. A common refrain was that If we mention alcohol in the records, we need to provide evidence in Courts of Law at a later date. If we do not do blood and breath alcohol estimations and, if physician certification is not accepted, from where do we get the evidence? Secondly, it was also reported that documenting alcohol comes in the way of compensation and insurance claims (in RTIs) and the affected families may be put to greater economic hardships. Thirdly, in the absence of facilities for blood or breath alcohol estimations, border line cases are often missed out. In addition, alcohol also interferes with clinical diagnosis, management and outcome. Documenting alcohol information among all injuries in fatal and non-fatal injuries is very crucial to develop any systematic programmes. Emergency and pre-hospital care Five important factors that determine the outcome and impact with reference to emergency care are - availability of first aid or early care, time interval between injury and hospital contact, mode of transportation, triage and, referral services. The present programme has clearly demonstrated the poor status of emergency care in Bengaluru as revealed by the fact that more than 50% of patients 52 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

75 reached hospital on their own, two thirds of patients reached a definitive hospital beyond 3 hours, more than 70% travelled in a three wheel auto rickshaw and more than 20% were referred from more than one hospital. The severity of injuries like burns, poisoning and attempted suicides was consequently high by the time patients reached the hospital. The use of ambulance was < 20%, an increase of 5% over a 10-year period. Majority of the patients were provided first aid by doctors and/or nurses in public or private hospital with no involvement of first responders like police, teachers, students and others. The city also does not have systematic first aid programmes that are conducted regularly and on a continuous basis and, earlier efforts have been isolated efforts. It is important that first aid becomes a regular component of curriculum in schools and colleges, police training programmes, training programmes of drivers of all categories especially heavy vehicles and other first responders. It is also important to make traffic alterations to allow movement of ambulances without hindrance, as it is common to see ambulances stuck in traffic for long period of time. Trauma care issues - Acute Care Integrating emergency care with acute care in hospitals is a critical requirement to improve trauma outcomes. Hospitals and ERs should be in a state of preparedness to manage injury patients. Even though trauma audits were not a part of the current programme, data indicate the need for trauma audits in the coming months. Generally it was observed that facilities in public hospitals were limited in terms of manpower, beds, investigative facilities and supportive services. More than a third of patients were referred to the next hospital after contact with the study hospital. Quality of care also requires considerable improvement in public sector hospitals including district hospitals. On the contrary, the cost of care in private hospitals was found to be expensive and beyond the reach of people without insurance. The documentation of trauma care aspects in medical records has been found to be inadequate, since trauma audits are not a common practice in many hospitals. Upgrading facilities (manpower, basic facilities) in public sector and private hospitals, up-scaling skills of doctors and nurses, developing guidelines and protocols for minimum care (by all hospitals) for injury patients and trauma audits should be given importance to reduce deaths, severity and complications from injuries. Medico-Legal aspects Injuries are riddled with medico-legal complexities due to lack of guidelines, directions, supervisory and coordinating agencies. During the course of the programme, these issues were examined in detail and discussed with stakeholders and partners on multiple occasions (copy of the report available on request). While there is need for tough regulations, there has to be appropriate guidelines on what is medico legal and what is not medico legal. The current medico-legal practices interfere in number of ways like- documenting proper information, multiplicity of records and procedures, huge time spent in documentation, confusion with regard to reporting to police, doctor s time spent in documenting/writing registers and attending courts, opportunities for manipulations of records at convenience and a host of other problems. Nearly, 75% of the doctors reported that these issues interfered in patient management due to complexity of legal issues and their attendance in courts as and when called for. However, their presence and sharing of information in courts had not influenced the outcome in any significant way. Most importantly, medico-legal complexities interfere in the appropriate care for the patient and even today, significant number of health care institutions would not like to get involved with the police or the law. As a result, patients would not reach the hospitals fearing interference from police. Even when they reach, the procedures were found to be cumbersome and often resulted in transfer and referral of patients from one hospital to another. Thirdly, the information shared by patients and their families was often found to be unreal as noticed by the fact that most of the suicides are due to chronic stomach pain, burns due to stove bursts and poisoning being accidental. These issues highlight the need for re-examination of the existing practices and availability of clear guidelines along with decriminalizing injuries. Essentially, injuries are major public health problems. Intervention and their effectiveness The primary purpose of surveillance is to provide data for action. The data from the present feasibility study has shown the type of data that can be NIMHANS 53

76 available to planners and policy makers to formulate strategies, approaches and action plans that will reduce the burden of injuries in the coming years. It needs to be highlighted that surveillance provides the foundation and more focused research from health, transport, police, law, vehicle-product makers and behavioral sciences are required to develop targeted and specific interventions. The data clearly show that road safety, home safety and work safety are 3 major domains for further programmes. It has been acknowledged that there is no single solution and thus, multiple actions are required from number of stakeholders. A detailed discussion on what interventions need to be developed is beyond the scope of this report and is outlined in recent WHO publications and expert committee reports. A list of proven, effective, and sustainable interventions is given in Annexure 5. It is essential to develop mechanisms for implementation of these programmes through institutional approaches. Role of Research and need for information Injuries are multi-factorial events with causes lying in agent, host, environment and the systems as outlined in the earlier sections of this report. Like any other health problem, injuries have an epidemiological profile and characteristics that need to be unravelled to identify areas of specific interventions. Broadly, the interventions could be primary (injuries will not occur at all), secondary (minimize harm in the event of an injury) and tertiary (rehabilitate after an injury) and are aimed at people, products and environment through education, engineering, enforcement and emergency care. To implement these preventive strategies, there is need for policies and programmes that are evidence based and data driven. A surveillance programme of the present nature provides clues on changing patterns and profiles, identifies broad characteristics and shows directions for programme implementation, monitoring and evaluation, along with identifying areas for further research. As surveillance lays the foundation, focussed research will identify the specific determinants of injuries for remedial measures. It is crucial to acknowledge at this juncture that injury related research is limited due to lack of researchers, institutions, funding and support systems. This is an area of high importance for Bengaluru and India to address injury epidemic in the coming years. 24. Injury / RTI Surveillance: Strengths, opportunities and limitations Strengths Injury surveillance is often the first step in understanding injuries. The present report shows that a well designed surveillance programme provides information on: Magnitude of problem Pattern and profile of injuries Geographical distribution Major/ Selected risk factors Responsible product/object causing injury. Nature severity and outcome of injuries. Most importantly, it is essential to realize that RTI/ injury surveillance data from surveillance needs to be supplemented with focused research activities (e.g., trauma registries, risk factor studies) and multidisciplinary crash investigations to develop specific and targeted interventions at local levels. Surveillance is an activity which drives number of other activities by setting a platform for agenda setting, prioritisation of activities, allocation of resources, developing policies and programmes along with monitoring of activities. Information from surveillance programme will help to develop and provides direction for a number of activities as shown in Figure 54. An example of how effective surveillance data can be used is given in Annexure Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

77 Figure 54: Pathways of research Inputs to policies and programmes Trauma registries Focused risk factor studies Multidisciplinary crash / injury investigation Highway crash analysis Vehicle related research Research from other disciplines Mortality Injury / RTI surveillance Morbidity Figure 55: Inputs for RTI prevention and control Monitoring and evaluation Surveillance and Research Human resources and training Legislation and human rights Road Safety Policy, plans and programmes Information systems from police, health and others Intervention Programmes in different settings Advocacy Organization of pre-hospital and trauma care Planning and budgeting for Road Safety Opportunities There is already a system within police department for collecting information on injury deaths. RTIs, suicides, homicides and other unnatural deaths are already included in this system. The present system can be strengthened with reorganization of data collection mechanisms and effectively utilized for injury surveillance. Information on characteristics of RTIs and other injuries can be systematically collected with a focus on getting quality information and not mere numbers. A revised format for data collection is provided in Annexure 7. The present programme has shown that it is possible to collect data on who are killed (age, sex, residence, education, occupation), nature of RTIs (location, road user category, position in vehicle, maneuver, collision nature, place of death), Basic details for other injuries (nature, place, and intent needs extra effort) Vehicle details ( type and year of manufacture) situation and context of injuries (location urban / rural ; highway / non highway ; junction./ midblock, etc., ), use of protective equipment like helmets, seat-belts, child restraints, basic details on trauma care (first aid referral, time interval and mode of transport for hospital deaths), and place of death Information on product and environment related factors will be difficult to get in a NIMHANS 55

78 surveillance programme and requires special efforts. The Central/District Crime Records Bureau already exist in all cities and districts. With appropriate directions and training, these units can be made more functional to obtain good quality data. Similarly, information on non-fatal injuries can be collected in hospitals with appropriate guidelines from health and/or home ministry. Information that can be collected include socio-demographic characteristics (age, sex, place of residence), nature of injury (RTIs, suicides, burns, poisoning, drowning, falls, disasters, Details of RTIs (location, road user category, type of impacting vehicle), use of protective equipment ( helmets, seat-belts, child restraints) characteristics of other injuries (situation context - product responsible), trauma care (first-aid, referral, time interval, transportation mode), type and severity (body parts involved, mild-moderate-severe), and mode of management (admission or referral) and outcome (death or referral or ER care). A revised format is provided in Annexure 8. Doctors, nurses, PG students, interns, medical records personnel can be involved in data collection, depending on availability of staff. This will also be a part of their training and will equip them with skills to understand injury and trauma related issues. Computerization will overcome problems existing in paper based systems. Injury surveillance can be expanded in a phasewise manner. As health systems have been sensitized on surveillance through IDSP and NCD risk factor surveillance, ample opportunities exist for introducing injury surveillance. The major focus of surveillance should be on RTIs and suicides in medical college apex specialty hospitals proposed level 1 trauma care centres in phase 1, concentrating on moderate and severe injuries. Surveillance can also be facilitated with development of trauma registries in selected institutions. After initial strengthening of programme it can be expanded to larger hospitals. If information can be captured from upto 70% of institutions in a geographical area, it will be helpful in understanding RTIs/injuries in that area. Hospital data will not bring out clear and total information on product and environment related factors and requires additional inputs. Barriers and limitations Injury surveillance as a component of larger injury prevention and control is yet to make its beginning in a perceptible way in Bengaluru and India. The present programme is the first of its kind being developed on a scientific approach in an integrated manner with participation of all sectors and professionals in a coordinated manner. As the programme is in its early stages, several barriers and limitations have been identified that need to be overcome for sustainability in the long run. Despite the enormity of the injury burden and impact, there is no national injury prevention and control policy, programme or a plan in India or in Karnataka or in Bengaluru. Road safety policies are just emerging and have included accident analysis and research as a major component. Each of the sectors work independently on their priorities and programmes without information, coordination and integration. There is need for a central agency or unit or division at national, state and city levels capable of guiding, coordinating, implementing, monitoring and evaluating IPC programmes. Sustainability of ongoing data collection, analysis, interpretation and application is crucial for success of injury surveillance programme. The capacity for the same within police and health sectors, both at the local or national level, does not exist and needs to be nurtured and developed over a period of time. Police collect large amounts of information from injury deaths and reported injuries. However, these data remain buried in records, as mechanisms to analyse and examine information in totality are not part of the system. Information on numbers, age, sex, region, type and broad causes are reported to higher levels in pre-specified formats. Further, the quality of data collected also needs 56 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

79 re-examination. The collected data is neither applied nor utilized for IPC programmes at local or national levels. Till date, health sector and hospitals have their own independent information systems. Injury related information is collected more from a police/medico legal perspective or for monitoring patient progress and management. Hence, much of the data required for developing IPC programmes are not routinely available in health or police records. Doctors in casualty / emergency rooms of hospitals (especially public sector hospitals) are overburdened with heavy caseload. Hospitals for varying reasons maintain accident register, MLC register, ER register, police intimation register and several others. For medico legal reasons doctors are compelled to fill these registers. It is possible to reduce the documentation overload with the introduction of an Emergency Trauma Care Record in ERs, which can serve all administrative and legal purposes. Extracting data from existing records has its inherent limitations, as there is no uniformity across hospitals / or ER personnel. In this scenario, the only alternative is to develop uniform Emergency Trauma Care Record as applicable to all institutions with uniformity in documentation. The present programme has attempted to initiate this process and needs to be built over a period of time. Co-operation of hospitals, doctors and police are crucial to build injury surveillance programmes. Resistance of staff at various levels is a significant problem. Training, capacity development, feedback, and data utilization needs to be promoted in a systematic way. There are several perceived and real medico legal hurdles prompting doctors not to deviate from existing systems as they are repeatedly called to legal corridors as witnesses in investigations. This has made the necessity of continuing with large numbers of registers, police intimations, documenting events and other complicated procedures. There is need to overcome these problems with appropriate changes and guidelines. Many of the health care institutions are not computerized and manual systems are still in practice. Use and applications of information technology needs to be strengthened as this will facilitate injury surveillance programmes. In major hospitals, one full time person may be required to ensure coverage and completeness of data collection. Unless institutionalized as part of the routine data collection, such initiatives are difficult to sustain. The present programme was built on an initial seed grant provided by ICMR, WHO, India country office and NIMHANS to develop a feasibility module for RTI surveillance. At the local level, it has been expanded into injury surveillance programme. Budgetary allocations should be made within the department of police or health / corporation for continuation and sustainability of the programme. Data utilization and application is more crucial and vital for injury surveillance and IPC to continue and sustain. Professionals from police, health and other sectors would not just like to collect data or extract data, if their work does not result in positive benefits to their institutions or the local community. As any integrated mechanism does not exist as of now, it needs to be created. Proper co-ordination mechanism between all the sectors and partners is crucial to develop evidence based intervention programmes. At present, such a mechanism or platform for discussing injury related issues and identifying solutions does not exist and needs to be created at local level. The city Road Safety Council has been a recommendatory body and does not have authority for implementation. This approach is very relevant for RTI / Injury surveillance programme as data needs to be applied at different levels for planning and delivery of interventions. The sustainability of RTI / Injury surveillance is far more difficult in district and rural areas as the scenario is far more complicated. The present programme has made an initial attempt at developing injury surveillance in a rural area in coordination with police, a district hospital and a medical college hospital. ICD coding is not widely used and hence retrospective identification of cases from medical records section or from police record is a major challenge (almost impossible, given NIMHANS 57

80 the huge number of cases). Prospective ICD coding systems should become part of hospital information systems. Lastly, surveillance across the world, especially in HICs has had different experiences and there are merits and demerits of this programme. It is essential to realize that vast amounts of data can be collected, analyzed, converted to graphs and figures, included in reports etc., But, data should be used for prevention and control. If this is not achieved, surveillance is like general education programmes with little impact on final expected result. Hence, along with with cost effective surveillance activity, city administrators need to act on data and implement prevention programmes. At present, multiple stake holders are not united and there is no lead agency bringing all of them together. This mechanism needs to be developed, for surveillance to become meaningful. 25. Inputs to policies and programmes A major aspect of any surveillance programme is to develop interventions based on evidence. In this direction, the Bengaluru injury/road traffic injury surveillance programme will develop mechanisms to input data into various policies and programmes. The collaborating team will jointly discuss the findings and identify areas of intervention. This would be discussed with concerned stakeholders to translate data into actionable and sustainable intervention programmes. At present, several ministries and government departments at state and national level have the responsibility of developing injury prevention programmes within their own sphere of activities. In the city of Bengaluru, the various stakeholders involved in injury/road traffic injury prevention are - police, transport, health, law and judiciary, urban and rural development, social welfare, Bengaluru Mahanagara Palike, excise, education, information and broadcasting, NGOs, media and several others (Figure 56). However, there is no established forum for developing integrated and coordinated injury prevention programmes. Over a period of time, a platform to discuss injury related issues should be developed in the city with all stakeholders, professional organizations, professionals from different backgrounds, media representatives and NGOs to focus on specific areas. Thus, there is a need for a designated agency/ organization with authority, status and budget to address injury prevention and control activities. This agency should be an independent agency free from politics and run by professionals. Figure 56: Need for an intersectoral approach Transport Health Police Law Urban Development Education Information Revenue Insurance Media Civil Society Rural Development All others 58 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

81 26. Sustainability issues For any programme to be effective, administrative support resource availability professional s wholehearted participation necessary back up services continuous feedback and data utilization / application for policies and programmes are crucial. Injury surveillance, especially for Road traffic injuries and suicides, should become an inbuilt component of injury prevention and control programmes. Sustainability, cost effectiveness and feasibility should be addressed from the beginning. Experience thus far, reveals that some crucial issues need to be considered from the early stages. Some suggestions and follow through activities as applicable to Bengaluru are provided below 1. The Chief Minister s 10 point programme for Bengaluru city has included Road safety along with improvement of traffic scenario in Bengaluru. Accident analysis and reduction programme and School safety programme are recognized as important components of this programme. Further, B-TRAC 2010 programme has also identified development of a road safety plan for accident reduction. Road traffic injury surveillance programme should be integrated under this broader programme as it provides necessary data for reducing accidents by 30 % by 2010, through engineering enforcement education and emergency care. 2. At the city level, a central agency like CCRB could take the lead along with support from local organizations in technical areas. Alternatively, an experienced unit (an injury prevention centre or Community medicine department of a medical college) can be given the responsibility of leading data collection and analysis activities. The initial focus of surveillance should be on road traffic injuries and suicides. 3. The Directorate of Health or State Health Ministry should take initiative and inform all major hospitals for introduction of Emergency trauma care record on a regular basis from 2009 onwards. Necessary administrative notifications should be sent to all partnering health institutions. 4. Injury surveillance capacity strengthening programmes for senior and mid level policy makers and training programmes for other staff from police and health sector should be held at periodical intervals. This will ensure monitoring of programme along with data inputs for other activities at different levels. 5. Training for all those involved in data gathering should be conducted (at least twice in a year) for members of all participating institutions (police at mid and junior levels and ER staff medical record division of selected participating hospitals) to elicit better cooperation. The required training manuals and training courses should be developed jointly for ensuring uniformity in training. 6. Information should be disseminated to all through reports, fact sheets, websites and other channels for sensitisation, awareness building and use of data. 7. The local decision making bodies and respective departments at higher levels should utilize and apply data for development implementation of interventions and for larger decision making process as well. The programme should be monitored continuously and evaluated once a year for further modifications and improvements. 8. No programme can be successful without the wholehearted participation of professionals. A programme of this nature will require cooperation participation support of stake holders, police and transport officials, hospital administrators, nodal officers and teams in casualty departments. Inputs to strengthen this component through training programmes, information sharing, continuous feedback, using data at individual and hospital levels, and joint collaborative programmes needs to NIMHANS 59

82 be promoted. In addition, data leading to action will be a source of inspiration for all, as a method of recognizing and rewarding one s work. 9. Resources are required in the long run for continuous running of the programme. An initial investment is very much required till the programme gets established. The required funds at this stage can be provided through B-TRAC 2010 programme/ city corporation/ Directorate of health/or any other agency. 10. All programmes need direction, vision, mission and a passion. It is important to develop a city level action group with the primary mission of saving young lives from injuries. Children saved today from polio and other diseases need not be victims of road crashes, nor attempt suicide after an examination. Recommendations With research studies pointing that nearly 13-18% of total deaths are due to injuries and an estimated death of nearly 1 million people in the country, injuries are no more police, transport, social and economic problems, but significant public health problems as well. It is estimated that for every death, hospitalizations occur to an estimated level of million hospitalizations every year. The number of minor injuries is immeasurable, probably to the tune of million. Each death results in immeasurable loss, suffering and agony for the families. Any amount of compensation or findings of enquiry committees will not replace lives nor can replace broken heads and bones. The economic losses to the country are huge, probably to the tune of 3 5% of GDP, due to direct and indirect impact of injuries. This is occurring at a time when it is possible to predict and prevent injuries even with existing knowledge. There is need to build systematic programmes (both by integrating with ongoing programmes and with new programmes) and IPC activities in the coming years. For this to happen effectively, there is a need to identify the extent, burden, dimensions and impact of the problem. Reliable data are needed to provide a solid foundation for road safety planning, injury prevention and control and for decision making purposes. Making correct and scientific decisions are only possible when good quality information is available to all concerned stakeholders. Such data should drive and lead policies and programmes in transport safety, urban development, environment protection, suicide prevention, and prevention and control of other injuries. Surveillance is the first step in this direction, by bringing issues to the public domain for recognition and action by all ministries and parliamentarians, policy makers, programme managers, industry, NGO s, media and others. The present programme in Bengaluru, India, faciliated by ICMR and WHO, India Country office was conducted by NIMHANS in collaboration with Bengaluru city police, Bengaluru metropolitan transport Corporation, 25 leading hospitals (urban and rural) and few NGO s. The major objective of the programme was to develop a methodology for Injury / RTI surveillance and to examine the feasibility of implementing the same in one of the rapidly progressing city of India, Bengaluru. Starting with stake holder s consultation, number of preparatory steps and joint planning of operations, information was gathered from 4,334 injury deaths, 113 BMTC involved crashes and 68,498 hospital first contact injury contacts along with 2,152 injury patients from rural Bengaluru. The various problems encountered were jointly discussed and solutions were identified for further changes. The following recommendations are based on a situation analysis of ongoing activities in the present scenario, analysis of data, opinion of partners and recommendations of various meetings held in Bengaluru. The following recommendations are placed under 2 headings of Strengthening surveillance; and injury prevention and control activities. 60 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

83 1. Strengthening Surveillance and information systems 1. Injury surveillance is an important component of injury prevention and control and should be strengthened in a phase wise manner. The present experience in Bengaluru has shown that it is possible, feasible, sustainable and can be a cost effective way for recognizing the magnitude of problem, identifying patterns and broad determinants, prioritizing areas of interventions and in measuring the impact of interventions. Data on both fatal and non-fatal injuries should be combined to obtain total picture of injury burden and impact, with an initial focus on Road traffic injuries and suicides. 2. Instead of building new systems, the existing systems need to be recognized, limitations identified and, strengthened with additional inputs and resources. 3. At the national level, NCRB is entrusted with the responsibility of data collection. The existing systems and methods should be strengthened with a focus on collecting data that will help formulate policies and programmes. The annual reports of NCRB should stimulate action and further research. 4. A technical injury prevention wing should be constituted in SCRB and CCRB along with lead injury prevention centre/ community medicine department/ technical agency to promote injury surveillance. Help and support from technical institutions (referral institutions and community medicine departments of medical colleges) should be drawn at the initial stages to achieve competency and sustainability in the programme. 5. Information on fatal events can be obtained from a combination of police records and corporation / district authorities. Review by the present programme and previous review on injuries reveal nearly 90% of RTI and suicide deaths are captured in the system, while there is significant underreporting with regard to workplace injuries, falls, burns, poisoning and others. Police records should be used for this purpose with improvement in quality of data. a) Since information collected on deaths varies from place to place, a uniform pattern of information gathering should be put in place and all deaths registered with police should be documented in a uniform way across the state and city and its different traffic/crime divisions. b) Documenting information should move beyond medico legal concerns and should be from injury prevention and control perspective. The focus should be on identifying real characteristics, risk factors (e.g., information on alcohol, use of protective equipments like helmets and seatbelts), context and situation of injury occurrence, essentials of trauma care. The format used in Bengaluru is provided in Annexure 9 for both RTIs and other injuries. c) The amount of information to be collected on each injury death should be decided a priori. It is essential to note that surveillance aims at collecting small quantity of good quality information that is helpful for programmes and not for criminal or legal proceedings. The type of data that can be collected is discussed in section 24 d) With data flowing from various police stations, compilation, analysis and dissemination has to occur at a central level for developing and implementing injury prevention and control programmes. e) For this to happen effectively at the city level, a designated lead organization has to be identified with development of similar teams in each city/state district. Additional resources in terms of manpower, computer facilities and other resources should be provided along with capacity building of teams at NIMHANS 61

84 local level for data analysis, reporting and dissemination. f) In parallel to this aspect, there is need to strengthen vital death registration at city and state level and in systems like SRS and MCCD to supplement police information. 6. For non-fatal injuries, collecting information from health systems is the obvious choice. Since this system is in rudimentary state under the health information of India, a new approach and strategy has to be developed. Agencies like ICMR, CBHI should take a lead role in this process and should be developed in a phase wise manner with equal importance to urban and rural areas. a) Selection and inclusion of institutions should be in a phased manner with inclusion of medical college hospitals - apex / tertiary care centres and private specialty hospitals in urban areas (with more than 100 beds) and small number of major hospitals in district (with emergency care services, geographical coverage, good hospital systems with medical record departments / units). In rural areas, district hospitals and rural medical colleges are to be included in phase 1 of the programme. b) Type, amount, extent and quality of information to be collected has been reviewed earlier and a uniform Emergency Trauma Care Record should be in place. c) In each of the hospital, the casualty teams (doctors, nurses and medical records staff) should be provided brief training on importance, procedures, and usefulness of surveillance. Necessary training manuals and operational guidelines should be developed for this purpose. Manual paper versions should be changed to electronic and web based systems in future. 7. Information collected should be analyzed at local and state levels for effective decision making purposes. Areas of potential and possible interventions should be identified through systematic analysis and used for policies and programmes. 8. Brief reports on injuries (as Injury Monitor) from these centres should be disseminated to all stakeholders (police, transport, health, judiciary, economics and all other ministries at state and city levels) for initiating appropriate action. A variety of other channels like fact sheets, alerts, web based communication, stakeholders meeting should be used to disemminate collected information. This should happen for RTI and suicides to begin with and expanded to other injuries over a period of time. 9. The centres can also be developed over time with technical and financial inputs to undertake in-depth investigation and analysis of prioritized injuries based on surveillance data and also provide information for industry, product manufacturers, and different departments along with additional tasks of quality control steps. Since it is proposed to include Road Traffic Injury Surveillance under Phase 3 of Integrated Disease Surveillance Programme, Government of India, it is essential to keep in mind the issues raised in earlier parts of this report. The programme can begin in metros and selected districts of identified states in a phase wise manner. Larger pilot studies are required for further strengthening of the proposed methodology with appropriate administrative directions, training and capacity development, establishing methods for dissemination of information, to be followed by action by appropriate authorities. Information from medical colleges, city crime records bureaus and City Corporation should be brought under one roof and integrated for both deaths and injuries. This requires strengthening existing mechanisms or setting up of new agencies to develop coordinated mechanisms. 62 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

85 10. The programme can be expanded systematically to cover larger number of institutions in a phased manner across the state. The breadth of data collection systems should be complemented with trauma registries, focussed risk factor studies and multidisciplinary crash investigations over a period of time. 2. Strengthening Injury Prevention and Control 1. There is need for a central coordinating and regulatory authority to be set up at national level and corresponding bodies at state/city level with specific goals of reducing injury deaths, morbidity, disabilities and socio-economic losses. The body should be independent, managed by technical experts, with adequate financial and technical resources and powers. This body should be entrusted with responsibilities of guiding, coordinating, integrating, supervising, developing guidelines and standards, monitoring and evaluating activities with the primary objectives of injury prevention and control. Examples already exist like National Disaster Management Authority, National Pollution Control Board, National Aids Control Organisation and a recently proposed Directorate for Road safety (22). A similar body should be established for Injury prevention and Control and Road safety at all levels. 2. An Injury Prevention and control policy with focus on prioritized injuries like Road traffic injuries, suicides and occupational injuries should be developed. The policy should set forth guidelines and mechanisms for programmes and plan of action with attainable short term, medium term and long term objectives. 3. An Implementable action plan of short term, medium term and long term activities with specified (achievable and sustainable) activities should be developed, specifying roles and responsibilities of stake holders along with mode of implementation. 4. Capacity strengthening of professionals, policy makers and others should be undertaken for IPC. These programmes should be interdisciplinary and multisectoral in nature leading to shared responsibilities. 5. A description of all known and proven interventions for different injuries is beyond the scope of this report. However, a list of proven and sustainable ones is given in Annexure 5 as an example. These should be implemented in a uniform, visible manner immediately, as these are proven to work and will decrease burden of injuries. It is crucial to note that even some of the proven interventions have not been implemented in totality in India. Laws and regulations on paper and concern for injuries alone are not enough but require action at ground level. 6. A safety wing should be established within police department with trained manpower as they are primarily entrusted with the responsibility of preventing traffic injuries, managing violence, responding to threats, investigating suicides, probe into work related injuries, investigation and reporting of injuries. This team should have trained and skilled manpower to undertake these activities. 7. All these activities should be driven by data - evidence and research and not by adhoc decisions. Injury surveillance, crash investigations and analysis, product related research, research into related areas of human behaviour, and others should be part of this decision making process. Surveillance is the first step in this direction. 8. Health sector should take lead role in surveillance and research, advocacy, capacity development and monitoring changes along with measuring the impact of interventions. The real change over a period of time should be in actual reduction in deaths, injuries and disabilities. NIMHANS 63

86 The way forward The programme was initiated in January 2007, with analysis, reporting, and dissemination continuing in The report, fact sheets and public health alerts will be shared with stakeholders and opinion sought on continuation of activities. The data from BMTC involved crashes has already been submitted to authorities and activities are strengthened for the current year. The methodology needs to be strengthened from 2009 onwards as a regular activity, with focus on building next phase of activities. RTIs and Suicides should be the focus of surveillance and expanded subsequently. In the coming months, the first Bengaluru Injury surveillance collaborators group will meet to outline further activities. The need for evidence-based programmes, which would result in a noticeable reduction in deaths and hospitalizations, has been acutely felt. It is hoped this joint partnership programme with leading institutions and organizations in the city of Bengaluru would pave the way to formulate effective injury prevention policies and programmes in the coming years. 64 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

87 References 1. Gururaj G. Injuries in India: A National Perspective. In: Burden of disease in India. National Commission on Macroeconomics & Health. Ministry of Health & Family Welfare. Government of India, 2005a, World report on road traffic injury prevention. (eds). Peden M, Scurfield R, Sleet D, Mohan D, Hyder AA, Jarawan E, et al. World Health Organization, Geneva, cause of death in rural India mortality data from the Andhra Pradesh Rural Health Initiative. International Journal of Epidemiology 2006; 35: Gajalakshmi V and Peto R. Suicide rates in rural Tamil Nadu, South India: Verbal autopsy of deaths in International Journal of Epidemiology 2007 Feb 14; [Epub ahead of print]. 3. World Report on Violence and Health. World Health Organization, Gururaj G. Road traffic Injury Prevention in India. National Institute of Mental Health and Neuro sciences, Publication no. 56, Bengaluru. 5. Dandona R, Mishra A. Deaths due to road traffic crashes in Hyderabad City in India: Need for strengthening surveillance. National Medical Journal of India, 2004; 17: Singh RB, Singh V, Kulshrestha SK, Singh S, Gupta P, Kumar R et al. Social class and all-cause mortality in an urban population of North India. Acta Cardiology 2005; 60(6): Gururaj G, Aeron Thomas A, Reddi MN. Underreporting of road traffic injuries in Bengaluru. Implications for road safety policies and programmes. Proceedings of the 5th world conference on injury prevention and control. New Delhi: Macmillan India Ltd, 2000b. 6. Mohan D. The road ahead: Traffic injuries and fatalities in India. Transportation Research and Injury Prevention Programme. Indian Institute of Technology, Delhi, Indian Council of Medical Research. Development of a feasibility module for road traffic injury surveillance, Gururaj G. Suicide prevention. Current scenario and strategies for interventions (in print), National Crime Records Bureau. Accidental deaths and suicides in India. Ministry of Home Affairs, New Delhi, Government of India, Krug E(ed). Injury: A leading cause of the global burden of disease. Geneva: World health Organization: World Health Organization. International Classification of Diseases. 10 th Edition, World Health Organization. ICECI Guidelines for counting and classifying external causes of injuries for prevention and control. Report No. 208, April Varghese M, Mohan D. Transportation injuries in rural Haryana, North India. Proceedings of the international conference on traffic safety. New Delhi: Macmillan India Ltd., 2003; World Health Organization. Injury surveillance guidelines (eds.). Holder Y, Peden M, Gururaj G. Geneva, Vital Statistics Division, Bengaluru Mahanagara Palike, Planning Commission: Report of the Working Group on Road Accidents, Injury Prevention and Control. Planning Commission, Government of India, July Sunder Committee Report. Report of the committee on road safety and traffic management (Report submitted to the Ministry of transport & Highways, Govt of India). 23. Gururaj G and Benegal V. Final report of the project: Drinking and driving under the Influence of Alcohol, (unpublished report). National Institute of Mental Health and Neuro Sciences, Bangalore, Haddon Jr W. The changing approach to the epidemiology, prevention and amelioration of trauma: the transition to approaches etiologically rather than descriptively. American Journal of Public Health 1968; 58: Joshi R, Cardona M, Iyengar S, Sukumar A, Ravi Raju C, Ramaraju K et.al. Chronic diseases now a leading 24. Gururaj G, Shastry KVR, Chandramouli AB, Subbakrishna DK, Kraus JF. Traumatic brain injury. National Institute of Mental Health and NeuroSciences, Bangalore. Publication No. 61, Gururaj G and Isaac MK. Epidemiology of Suicides in Bangalore. National Institute of Mental Health & Neuro Sciences, Bangalore, Publication No. 43, NIMHANS 65

88 26. Gururaj G. Crash Reporting and Analysis of Fatal Bus Crashes 2007 (unpublished report). 27. Gururaj G, Girish N, Isaac MK, Subbakrishna DK. Final report of the project Health behavior survillence submitted to the Ministry of Health and Family Welfare, Government of India; Gururaj G, Isaac MK, Subbakrishna DK, Ranjani R. Risk factors for completed suicides: A case control study. Journal of Injury Prevention & Safety Promotion 2005b; 11: World Health Organization. Fact sheets on Burns, Gururaj G. Sateesh VL. Assessment of facilities at casualty and emergency services in hospitals at Bangalore. Journal of Academy of Hospital Administration, 1999; 11(1):9-10. Is possible and feasible. Injury prevention and control Requires establishment of an independent safety agency with authority, status and resources to guide develop coordinate implement and evaluate safety aspects. Needs political commitment, policy maker s cooperation, professional s participation, and public involvement along with media contribution. Is an intersectoral activity with combined inputs and joint efforts from all partners like health, transport, police, social welfare, education, information, media and several others. Is dependent on development of institutional mechanisms for understanding problems and priorities and for joint coordinated activities with independent monitoring and supervision of research, policies and programmes. Should be developed and implemented on a public health approach of identifying the problem, delineating risk factors, implementing right interventions and evaluating them for cost effectiveness - sustainability - culture specificity and measured by actual reduction of deaths and injuries. Is an integrated activity as multiple interventions need to be combined and implemented to get maximum benefits and greater success within each intervention. Is based on combined approaches of education, engineering, enforcement, emergency care and evaluation. Requires implementation of more and more passive countermeasures as these are more beneficial given the limitations of human behaviour. Requires increased resources that need to be invested in prevention and control at the primary level to see that society has safe people, safe vehicles, safe environments with adequate support and care for injured. Activities should be based on programmes developed on local, regional and national analysis of data collected through well-designed information systems. Is not possible if unspecific, adhoc, knee jerk reactions and populist measures are promoted. 66 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

89 Annexure - 1 Sl. No. The cases of Injured and Killed in India for various causes, 2007 Causes Bengaluru Injured Killed Karnataka Injured Killed India Injured Killed A Unintentional injuries I Air-Crash II Collapse of Structure (Total) House Building Dam Bridge Others III Drowning (Total) Boat Capsize Other Cases IV Electrocution V Explosion (Total) Bomb Explosion Others (Boilers, Gas Cyld. etc.) VI Fall (Total) From Height Into Pit/Manhole VII Factory Machine Accidents Mines or Quarry Disaster VIII Fire (Total) Fireworks/Crackers Short-Circuit Cooking Gas Cylinder/Stove Burst Other Fire Accidents IX Fire-Arms X Killed by Animals XII Poisoning (Total) Food/Accidental intake of Insect. etc Spurious/Poisonous liquor Leakage of gases etc Snake Bite/Animal Bite Other XIII Stampede XIV Traffic Accidents (Total) Road Accidents Rail-Road Accidents Other Railway Accidents XV Other Causes XVI Causes Not Known Total of unintentional injuries B Intentional injuries XVII Intentional Injury Deaths 1 Homicides Dowry deaths Suicides XVIII Other Intentional Injuries 1 Attempt to commit murder Rape Kidnapping and abduction Molestation Sexual harassment Cruelty by husband and relatives Other IPC crimes Others Total of intentional injuries Grand Total (A+B) Ratio of Killed:Injured 1:6 1:5 1:6 Source: NCRB report 2007 NIMHANS 67

90 Annexure - 2a Police Information System Witness /100 Accident Spot 10% General Police Station Hospital Telephone/Wireless Traffic Police Station 90% Annexure - 2b Flow of information from traffic police stations to City Crime Records Bureau Traffic police station Visits accident spot Visits reporting hospital Complaint + Preliminary enquiry Complaint registered Complaints not registered FIR (3 copies) + Investigation mahajar Court ACP (for information) DCP Traffic police Weekly & monthly consolidated report State Crime Record Bureau 3 - Commissionorate unit 27 - District unit 1 - Railway unit 31 - Units National Crime Record Bureau 68 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

91 Annexure - 3 Injury related deaths in Bengaluru (10% rise) % underreporting B'lore Police RTIs Other road Falls Drowning Poisoning Burns Hanging Fall of objects Fall from height Homicides 28 Mechanical injuries 36 Causes not known Others Other accidental causes Total Accidental & Suicidal deaths in Karnataka & Bengaluru Accidental Karnataka Suicidal RTIs Other road Falls Drowning Poisoning Fire (burns) Hanging Fall of objects Fall from height Below moving vehicle Homicides 0 0 Mechanical injuries Causes not known Others Other accidental causes Total Total Bengaluru Accidental Suicidal Total NIMHANS 69

92 Annexure - 4 Date Details of the training programmes held for Police personnel Training Programme Place of training No. Of Participants 12th April 2007 Writers of Traffic Police stations NIMHANS 26 26th June 2007 Writers of Traffic Police stations NIMHANS 37 11th July 2007 Writers of Law and Order Police stations NIMHANS th September 2007 Writers of Law and Order Police stations NIMHANS th September 2007 Writers of Traffic Police stations NIMHANS 42 20th November 2007 Writers of Traffic Police stations NIMHANS 38 22nd November 2007 Writers of Law and Order Police stations NIMHANS 118 No. Date Details of the training programmes held for personnel in partner hospitals Training Programme Place of training No. of Participants 1 3rd March 2007 Training programme for Nodal Officers (All partner institutions) NIMHANS th March 2007 Training programme for doctors and staff Jayanagar General Hospital th March 2007 Training programme for doctors and staff Bowring and Lady Curzon Hospital th March 2007 Training programme for doctors and staff (All partner institutions) NIMHANS th March 2007 Training programme for doctors and staff Siddhartha Medical College, Tumkur th April 2007 Orientation on Injury prevention Sanjay Gandhi Accident Hospital and Research Centre th April 2007 Training programme for writers of various police stations NIMHANS th April 2007 Training programme for Doctors and staff District Hospital, Tumkur th April 2007 Training programme for Nurses District Hospital, Tumkur th April 2007 Training programme for Nurses District Hospital, Tumkur th April 2007 Training programme for Doctors and CMOs District Hospital, Tumkur th July 2007 Training programme for Nurses NIMHANS st July 2007 Training programme for CMOs and staff nurses in M S Ramaiah hospital M S Ramaiah hospital th august 2007 Training programme for staff and students of medicine department in Victoria hospital Victoria hospital th August 2007 Training programme for staff and students of Orthopedics, general surgery departments in Victoria hospital Victoria hospital thaugust 2007 Training programmes for MOs and staff pf CHC and PHC in Tumkur Tumkur rd September 2007 Training programmes for MOs and staff nurses of DG hospital D G Hospital nd September 2007 Training programmes for doctors, nurses, medical record officers in KIMS hospital KIMS hospital Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

93 Annexure - 5 List of interventions Selected Violence and Injury Prevention Interventions, by Cause, Effectiveness and Health Sector Role Intervention Effectiveness Road traffic injuries Unintentional injuries Increasing the legal age of motorcyclists and drivers from 16 to 18 years Effective Introducing and enforcing laws on blood alcohol concentration limits Effective Graduated driver licensing systems Effective Traffic-calming measures Daytime running lights on motorcycles Introducing and enforcing seat-belt laws Child-passenger restraints Introducing and enforcing motorcycle helmet laws Speed-introduction measures Effective Effective Effective Effective Effective Effective Fires Electrification of housing Promising Banning the manufacture and sale of fireworks Reducing storage of flammable substances in households Smoke alarms and detectors Improving building standards Modifying products - for example, kerosene stoves, cooking vessels and candle holders Promoting use of cold water for first aid of burns Promising Promising Promising Promising Promising Effective Poisoning Child-resistant containers Effective Poison-control centres Effective Better methods of storage, relating both to the nature of storage vessels and where they are placed Effective The use of warning labels Restricting availability of most hazardous pesticides Promising Effective Drowning Use of personal floatation devices Effective Falls Introduction and enforcing laws on pool fencing Teaching how to swim Covering bodies of water, such as wells Safety standards for swimming pools Clear and simple signage Properly trained and equipped lifeguards Ensuring availability of weather reports to fishermen and others working on rivers and seas Safety mechanisms on windows, such as window bars in high-rise buildings Stair gates Impact-resistant surfacing material on playgrounds Safety standards for playground equipment Muscle-strengthening exercises and balance training for older adults Checking and if necessary modifying potential hazards in the home, where there are individuals at high risk Educational programmes encouraging safety devices to prevent falls Encouragement/ evolution of safer working techniques and harnesses for construction workers and window cleaners who work at heights and tree climbers Effective Effective Effective Promising Promising Promising Promising Effective Effective Effective Promising Promising Promising Promising Promising NIMHANS 71

94 Intervention Effectiveness Intentional and unintentional injuries Reducing the availability of alcohol during high-risk periods Reducing economic inequalities Stand-alone education programmes focusing only on changing risky behaviors Strengthening social security systems Promising Promising Ineffective Unclear Intentional injuries Suicides Early recognition and management of individuals with suicidal Promising ideations and behaviour Improved care for those with history of attempted suicides, Promising violent behaviors and alcohol problems Training of health care personnel Expansion of mental health services (including counseling) Life skills programmes in all institutions Limiting the availability of lethal products (manufacture and sale) Establishing social and crisis support mechanisms Parental supervision and guidance for at risk children. Better media reporting practices Improving trauma care practices Promising Promising Promising Promising Promising Promising Promising Promising Child maltreatment Home visitation programmes Effective Training programmes for parents Effective Improving the quality of and access to prenatal and postnatal carepromising Preventing unintended pregnancies Training health-care providers to detect child maltreatment Promising Unclear Youth violence Life skills training programmes Effective Preschool enrichment, to strengthen bonds to school, raise achievement and improve self-esteem Effective Intimate partner & sexual violence Family therapy for children and adolescents at high risk Educational incentives for at-risk high-school students Home-school partnership programmes promoting the involvement of parents Peer mediation and counseling Education on the dangers of drug use School-based programmes to prevent violence in dating relationships, Training health care providers to detect intimate partner violence and to refer cases Teaching women survival tactics Promoting gender and social equality both through social and educational policies Effective Effective Promising Ineffective Ineffective Effective Unclear Unclear Promising Elder abuse Building social networks of older people Promising Training older people to serve as visitors and companions to individuals at high risk of victimization Promising Developing policies an'd programmes to improve the organizational, social and physical environment of residential institutions for the elderly Promising Self-inflicted violence Restricting access to the means of self-inflicting violence - such as to pesticides, medications and unprotected heights Preventing and treating depression, alcohol and substance abuse School-based interventions focusing on crisis management, the enhancement of self-esteem, and coping skills Phone in help lines or hotlines for crisis management Effective Effective Promising Effective All types of violence Reducing demand for and the availability of firearms Promising Sustained, multimedia prevention campaigns aimed at changing cultural norms Promising Source: WHO 2006; Mohan D, 2004; Gururaj G, NIMHANS Series Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

95 Annexure - 6 Harrison's Story (Reproduced with permission from - Injury Issues Monitor, No. 38, January 2007.) The Use of Emergency Department Injury Surveillance Data to Effect Change in the Community I d like to start with a brief history of QISU and an explanation of the data we hold. The Queensland Injury Surveillance Unit collects data on injury from patients who present to an emergency department for treatment of that injury. QISU is a small unit housed in the Mater Children s Hospital in Brisbane. We have two clerks, a parttime statistician/data analyst, a media manager, myself as manager and 3 emergency medicine specialists. We currently collect data from 16 hospitals around Queensland. These hospitals include urban, regional and rural and remote campuses the information we collect paints a very good picture of injury in Queensland. Our data is Level 2 NDS-1S, which means we collect specifics about products and activities (down to rugby union for example instead of just sport ). At the moment we have eight hospitals that collect information from a paper-based system where the information is sent through to us in Brisbane and trained coders code and enter that data. In the bigger hospitals that have EDIS software, the triage nurse collects and enters the information when the patient is being assessed. This data is then sent to QISU to be cleaned and then analysed. Now I d like to tell you a bit of a story. The photos on the next pages are of a wee boy called Harrison. Al the time this all started he was a typical busy, exuberant toddler and the youngest of five children. One day, just before Christmas in 2004 Lisa, Harrison s mum, went to put a video on for his five year old sister. In the couple of minutes that it took to put the video in and turn on the television, she heard Harrison screech from the kitchen. When she raced back to the kitchen she was horrified to see Harrison sitting on the floor screaming with blood coming from his mouth. She rang the ambulance, grabbed the container of dishwasher powder he had taken a swallow from and finally, they arrived at the Mater Hospital Emergency Department. Dr Barker, an emergency department (ED) specialist, who also works with QISU, was waiting for Harrison. She stabilised him and sent him oft to theatre. At that point there was doubt about whether or not Harrison would even survive. The dishwasher powder he d ingested was obviously highly caustic and, while it was burning his oesophagus, it was also causing swelling to his airways and making it difficult for him to breathe. Dr Barker arrived in the QISU unit after having transferred Harrison to theatre and explained what she had just seen. We were particularly concerned that it was so easy for Harrison to gain access to such a caustic substance. These issues were identified: the 2-click mechanism of the child resistant closure; ph of dishwashing powder; and the scheduling of dishwashing powder compared to dishwasher gel or liquid. The first thing we did was look at the issues surrounding Harrison s poisoning. The bottle itself was a concern. The cap looked like a child resistant closure. This instilled confidence in NIMHANS 73

96 Lisa that her children couldn t access the contents of the bottle. What she didn t realise was that the lid required 2 clicks to engage the child resistant mechanism. When she put the bottle in the cupboard she thought it was closed safely, but the child resistant feature of the bottle cap hadn t been engaged. There was no warning or instruction anywhere on the bottle to suggest that there were varying levels of closure. The ph of the powder in the bottle was 13.4! This is highly caustic. The ph of liquid Drano is more like 12 we all accept that it is dangerous and treat it with extreme caution. The dishwashing powder Harrison accessed was On a logarithmic scale this is a huge difference. Next, we did a data search to find out if Harrison s was a one-off case or whether this sort of poisoning was common. We learned that 4% of all nonmedicinal ingestions were from dishwasher detergents, and many of these were severe. Triage nurses assign a category from 5 to 1 to indicate how quickly a person requires treat-ment when they arrive in the ED. Anything less than 3 means a person needs treatment in less than half an hour. 1 indicates that the person requires immediate treatment or death is likely. In our database there were 19 children under 5 who arrived in the ED having been poisoned with a non-medicinal substance who were categorized as a 1. Three of these children had ingested dishwasher powder. Now that we knew that dishwasher detergent ingestions were a real problem for Queensland toddlers, we were able to move on and see what we could do to change this. I rang the manufacturer and spoke to their product safety officer. He was horrified to hear about Harrison s injuries, but was also very careful to explain that the product complied with all legal requirements. When I gave him more details about the number of toddlers in our database who had had similar experiences to Harrison s, he agreed that something had to be done and promised to get back to me with some strategies. (Now keep in mind, they ve not done anything technically wrong here... they were within the law in their packaging and labelling and the closures were far from unique to this particular brand.) Within a couple of months there were warning labels on all the packages saying that it required 2 clicks to close the caps on the powder containers, and then the entire bottle was redesigned to incorporate a flow limiter on the bottle and a 1-click mechanism on the cap. This meant that one, product was safer, but there were still shelves full of dishwasher powder in the supermarket, many of which were no more than a cardboard box with a spout. The next step was to draw in some partners who understood the issues and had a vested interest in seeing a reduction in ingestions of this kind. A working parly was formed and included members of Kidssafe Queensland, the Department of Fair Trading s Product Safety Unit, Queensland Health s Environment and Poisons Unit and the Queensland Poisons Information centre. The beauty of this group was that each of us were keen to see the laws surrounding dishwasher powder changed, but we each came from different organisations with varying expertise and perspectives. Queensland Health had people who sat on committees within the Therapeutic Goods Administration (TGA) who could advise us about which procedures we should follow in trying to effect change. Staff of the Poisons Information Centre was able to supplement our data with their own. The Department of Fair Trading could lobby from the perspective of its requirement to provide safe products to consumers. Kid safe has a key role to play in lobbying for injury reduction in children and in the education of parents and caregivers about the potential for injury with dishwashing powders. Poisons are scheduled by the TGA. Dishwasher detergents were included in a Schedule 5 if they had a ph of greater than This meant they had to have a child-resistant closure and very specific warnings on the labels. BUT, somewhere along the line, it was decided that children were unlikely to drink powders because they were so unpalatable, so powders were exempted from this schedule. The working group decided to put in a formal submission to the TGA via the National Drugs and Poisons Scheduling Committee (NDPSC) asking to 74 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

97 have the powders re-scheduled and a limit placed on the availability of such caustic products for the domestic market. We also decided to approach Standards Australia to have the standard for child resistant closures reviewed so that this 2-click mechanism couldn t be included as a compliant closure, but also to ensure that if something appeared to be a child resistant closure, it had to function as such. The aim was to remove any ambiguity for a consumer as to the safety of any container available in the marketplace. Rather than make these submissions as one working group, we each did so from our own organisation, using our own perspective to support the argument for change. We implemented a public awareness campaign. We embarked on this campaign by alerting the public to the problem. Lisa was very keen to ensure that this never happened to another family so was happy to appear and speak about what had happened to her son Harrison, and she was very passionate and eloquent. We also engaged professional associations to raise awareness through their networks and newsletters. At this point Lisa was able to say that, while Harrison had been discharged from the Intensive Care Unit and was finally home after 7 weeks in hospital, he was having to go into hospital every fortnight to have his oesophagus dilated so he could swallow his own saliva. He had to be fed from a tube directly into his stomach because of the scar tissue, and the fact that his epiglottis had been burned away meant that he would run the risk of aspiration if he ate normally. As you can imagine, this reality hit home to lots of people! Because the media outlets had a face to attach to the story, it was picked up locally, and on a state and national level (Choice and the Today Show). So what happened? The TGA accepted the statistics and submissions and, as of 1 September, all powders with a ph of > 11.5 will have to be packaged in the same way as liquids and gels with warning labels and child resistant closures. If any dishwashing detergent has a ph of > 12.5, it is no longer available for the domestic market. This is great, because manufacturers are moving toward using oxygen bleaches and enzymes, so all the products will be safer. Standards Australia have been less easy. Initially they couldn t reconvene the HE-016 committee because there was no project officer, so a new project officer was appointed. Correspondence was sent to members of the committee and now the project officer has left and we re waiting for a replacement to be appointed to further the issue. Harrison turned three in June. He s a gorgeous boy with mischief in his eyes. He and his mother call into the Unit regularly when he has to come to the Mater Hospital for treatment, and I always demand and get a hug hello and a kiss goodbye. He s still having fortnightly dilations and is fed through a tube. Doctors are optimistic that eventually he won t have to be 100% tube fed, but it s not a given. The good news is that, with the changes we ve seen, this soil of severe damage from dishwasher detergents is unlikely to happen to any other toddlers. In summary, change was brought about because of clinical concern that could be supported with sound evidence. With this sound evidence base we were able to form partnerships and, through these partnerships, make a tangible difference for the community. Debbie Scott (debbie.scott@qut.edu.au) NIMHANS 75

98 Annexure - 7 Data Capture format for injury deaths (Police) 1. Police Station name: 2. FIR No./Cr. No.: 3. Date of registration (DD/MM/YY): 4. Time of registration (HH:MM): 5. Date of Occurrence of Injury: 6. Time of Occurrence of Injury: am / pm 7. Date of death (DD/MM/YY): 8. Time of death (HH:MM): am / pm 9. Name of deceased: 10. Age (years): 11. Sex (M/F): 12. Place of residence: 1. Urban Bengaluru 2. Rural Bengaluru 3. Others, specify 13. Address: 14. * Education (in completed years): 15. * Occupation: 1. Unemployed 3. Student 5. Skilled 7. Business 9. Others 2. Retired 4. Homemaker 6. Unskilled 8. Professional 10. Unknown 16. Cause of death: 1. Road accident 4. Poisoning 7. Drowning 10. Mechanical injury 13. Others, specify 2. Assault 5. Burns 8. Self inflicted cuts/stabs 11. Sports injury 3. Fall 6. Hanging 9. Fall of object 12. Disaster, specify 17. Place of Injury Occurrence: 1. Road 6. Residential area 11. Industry 2. Home 7. Construction site 12. Unknown 3. Workplace 8. Railway 13. Others, specify 4. School/college 9. Playground/play site 5. Public place 10. Agricultural field 18. Object/Product causing injury: 19. Activity at time of Injury: 1. Traveling in vehicle 7. Crossing 2. Walking 8. Playing 3. Standing on road 9. Sleeping 4. Working 10. Unspecified 5. Going/Coming from school 11. Others, specify 6. Doing household work 20. Intent: 1. Unintentional (accidental) 3. Intentional (assault/violence) 2. Suicidal 4. Unknown 21. Alcohol consumption by: 1. Injured 3. Both 5. Unknown 2. Counterpart 4. Not applicable 6. No A. ROAD TRAFFIC INJURY: 22. Road User category of the deceased: 1. Pedestrian 6. Three-wheeler occupant 11. Other 4-wheeler driver (maxi cab, tempo, etc) 2. Pedal cyclist 7. Car driver 12. Other 4-weeler occupant 3. Two-wheeler rider 8. Car occupant 13. Others, specify 4. Two-wheeler pillion 9. Bus / truck driver 14. Unknown 5. Three-wheeler driver 10. Bus / truck occupant 23. Crash Type: 1. Hit & Run 5. Hit a fixed object 9. Fall from moving vehicle 2. Head on collision 6. Run off the road 10. Pedestrian run-over 3. Hit from the back 7. Overturn 11. Others, specify 4. Hit from the side 8. Skid & fall 24. Place of crash: 1. City roads 3. State Highway 2. National Highway 4. Rural Roads 25. Crash location name: 76 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

99 26. Crash location details: i. T-junction iv. Cross road vii. Sudden narrowing x. Others, specify ii. Y-junction v. Round about viii. Curves iii. Straight road vi. Bridge/culvert ix. Road hump/rumble strips 27. Lane type: i. Single lane with one way iii. Double separated ii. Single lane with two ways iv. More than 3 lanes 28. Deceased Hit by: 29. Position of the deceased (for car, bus, lorry, HCVs): 1. Front passenger seat 3. Open space 2. Back passenger seat 4. Passenger seat area 30. USE OF HELMET (if Two-wheeler rider/pillion): 1. Yes 2. No 3. Not known 31. USE OF SEAT BELT (if Car driver/occupant): 1. Yes 2. No 3. Not known B. ASSAULT: 32. Nature of assault/violence: 1. Individual 2. Family 3. Group 4. Communal 33. Perpetrator (relationship): 34. Major cause: C. SUICIDE: 35. Situation of committing suicide: 1. Alone at home 2. In presence of others 3. Outside house 36. Suicide Method: 1. Fall from height, goto D 4. Drowning, goto G 7. Others, specify 2. Poisoning, goto E 5. Self inflicted cut/stab, goto H 3. Self-immolation, goto F 6. Hanging 39. Name of the product: D. FALL: 40. Height of Fall: 41. Nature of landing surface: 1. Soft 2. Hard3. Rock 4. Not known E. POISONING: 41. Name of the product: 42. Product availability: 1. Available at home 2. Brought from outside F. BURNS: 43. Extent of burns (in %): 44. Product causing burn: 1. Kerosene/Petrol 3. Hot water 5. Cylinder burst 7. Others, specify 2. Hot Oil 4. Electricity 6. Stove burst G. DROWNING: 45. Place of drowning: 1. Bath tub 3. Well 5. Canal 4. Sea 2. Swimming pool 4. Lake/pond 6. River H. SELF INFLICTED CUT / STAB INJURY: 46. Product used for cut/stab: 1. Blade 2. Knife 3. Glass 4. Scissors 5. Wire I. PREHOSPITAL CARE: 47. Any FIRST-AID given before death: 1. Yes 2. No 3. Not known * If Q47 is yes WHERE was First Aid given: 1. At injury site 3. Nearby Pvt. Hospital / Nursing home 5. Others, specify 2. Nearby Clinic 4. Nearby Govt. hospital WHO gave first-aid: 1. Health worker 3. Nurse 5. Public 7. Others, specify 2. Doctor 4. Police 6. Self medication 48. NUMBER of hospital/s visited before registering death: 49. Place of death: 1. At injury site 3. In the hospital, name; 2. During transport to hospital 4. After discharge * Optional items NIMHANS 77

100 Annexure - 8 EMERGENCY TRAUMA CARE RECORD 1. Name of the hospital: 2. Hospital Id. No.: 3. Police Id. No.: 4. Date of registration (DD/MM/YY): 5. Time of registration (HH:MM): am / pm 6. Information provided by: 1. Family member 2. Known person 3. Police 4. Not known 5. Self 7. Date of injury (DD/MM/YY): 8. Time of injury (HH:MM): am / pm 9. Place of injury: 1. Within Bengaluru 2. Outside Bengaluru 10. Name of injured: 11. * Education (in completed years): 12. * Occupation: 1. Unemployed 3. Student 5. Skilled 7. Business 9. Others 2. Retired 4. Homemaker 6. Unskilled 8. Professional 10. Unknown 13. How was the person Injured: 1. Road accident 5. Burns 9. Sports 13. Disaster, specify 2. Fall 6. Poisoning 10. Animal bites 14. Others, specify 3. Assault 7. Drowning 11. Fall of object 4. Self inflicted cuts/stabs 8. Hanging 12. Mechanical injury 14. Location of injury: 1. Road 6. Residential area 11. Industry 2. Home 7. Construction site 12. Unknown 3. Workplace 8. Railway 13. Others, specify 4. School/college 9. Playground/play site 5. Public place 10. Agricultural field 15. Object/Product causing injury: 16. Activity at time of Injury: 1. Traveling in vehicle 4. Working 7. Playing 10. Others, specify 2. Walking 5. Going/Coming from school 8. Sleeping 3. Standing on road 6. Doing household work 9. Unspecified 17. Intent: 1. Unintentional 2. Suicidal 3. Intentional (assault) 4. Unknown 18. Alcohol consumption by: 1. Injured 3. Both 5. Unknown 2. Counterpart 4. Not applicable 6. No 19. Place of occurrence: 1. City roads 2. National highway 3. State highway 4. Rural roads 20. Road User category of the injured: 1. Pedestrian 6. Three-wheeler occupant 11. Other 4-wheeler driver (maxi cab, tempo, etc) 2. Pedal cyclist 7. Car driver 12. Other 4-weeler occupant 3. Two-wheeler rider 8. Car occupant 13. Others, specify 4. Two-wheeler pillion 9. Bus / truck driver 14. Unknown 5. Three-wheeler driver 10. Bus / truck occupant 21. Crash Type: 1. Hit & Run 5. Hit a fixed object 9. Fall from moving vehicle 2. Head on collision 6. Run off the road 10. Pedestrian run-over 3. Hit from the back 7. Overturn 11. Others, specify 4. Hit from the side 8. Skid & fall 22. Injured person Hit by: 78 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

101 23. USE OF HELMET (if Two-wheeler rider/pillion): 1. Yes 2. No 3. Not known 24. USE OF SEAT BELT (if Car driver/occupant): 1. Yes 2. No 3. Not known 25. FIRST-AID given before reaching this hospital: 1. Yes 2. No 3. Not known * If Q25 is Yes, WHERE was First Aid given:1. At injury site 4. Medical college 2. Nearby Govt. hospital 5. Private Clinic 3. Nearby Pvt. Hospital / Nursing home 6. Police 7. Others, specify * If Q25 is Yes, WHO gave the first aid: 1. Health worker 4. Police 7. Others, specify 2. Doctor 5. Public 3. Nurse 6. Self medication 26. Source of REFERRAL: 1. Directly on their own 3. Govt. Hospital 2. Clinic 4. Pvt. Hospital / Nursing Home 27. NUMBER of hospital/s visited before reaching this hospital: 28. MODE of transportation: 1. Ambulance 4. Autorikshaw (3-wheeler) 7. Others, specify 2. Private vehicle (personal car/taxi) 5. Police vehicle 3. Public transport (bus/truck/train) 6. Walking 29. STATUS of the injured at the time of entry: 1. Brought dead 2. Unconscious 3. Conscious 30. Type of injury: 1. Mild 2. Moderate 3. Severe 31. PART OF THE BODY injured (tick the appropriate part/s of the body): Head Face Neck Chest Abdomen Spine & vert. column Upper limbs Lower limbs GroinUpper back 32. * NATURE OF INJURY (tick the appropriate nature of injury): Abrasion Brain injury Cut or open wound Laceration Fracture Burns (indicate %) Contusion Injury to internal organ Blunt injury Sprain Haematoma Crush injury 33. Treatment: 1. Treated in emergency room & sent home 2. Admitted for medical / surgical care 3. Treated in emergency room & referred to another hospital 34. Outcome (at the end of casualty stay): 1. Improved 2. Not improved 3. Referred to 4. Dead 35. If referred, place of referral: EXAMINATION / FINDINGS* (all injuries should be documented in total) (OPTIONAL) TREATMENT GIVEN* PATIENT IDENTIFICATION* SIGNATURE * Optional items NIMHANS 79

102 80 Bengaluru Injury / Road Traffic Injury Surveillance Programme: A feasibility study

103 Select resource materials available from Department of Epidemiology, WHO Collaborating centre for Injury Prevention and safety Promotion, NIMHANS. (more details available from McMahon K, Gururaj G, Stevenson M. Chapter 2 : Road traffic Injuries. In : Peden M, Oyebgite K, Ozanne Smith J, et al, eds. World Report on Child Injury Prevention. Geneva, World Health organization and UNICEF, Gururaj G. Road traffic deaths, injuries and disabilities in India: Current scenario. National Medical Journal of India Vol 21, No, 2008, Norton R, Hyder A & Gururaj G: Injuries - An international Perspective. In: International Public Health: Disease, Program, Systems and Policies. (eds) Merson MH, Black RE and Mills AG. Second Edition. Jones and Bartlett Publishers, Boston, Gururaj G: Road Traffic Injury Prevention in India, NIMHANS Publication No. 56, Bangalore Gururaj G: Head injuries and Helmets: Helmet Legislation and Enforcement in Karnataka and India, NIMHANS Publication No. 62, Bangalore, India, Gururaj G, Girish N, Benegal V: Alcohol use and abuse in South East Asia: gaining less or losing more, South East Asia Regional Office, World Health Organisation, New Delhi, Gururaj G, Girish N, Benegal V: Burden and Socio-economic impact of alcohol: The Bangalore study, South East Asia Regional Office, World Health Organisation, New Delhi, Gururaj G, Kolluri S, Chandramouli BA, Subbakrishna DK and Kraus JF. Traumatic Brain Injury. National Institute of Mental Health and Neuro Sciences, Publication No. 61, Gururaj G. Injuries in India: A national perspective. In: Burden of Disease in India; Equitable development - Healthy future. National Commission on Macroeconomics and Health. Ministry of health and family welfare, Government of India. New Delhi, 2005, Gururaj G: Road safety in India: Role of community health professionals and institutions. Proceedings of the 31st Annual Conference of Indian association of preventive and social medicine, Chandigarh, Jan Gururaj G: Final report of the project Profile and Characteristics of violence prevention programmes in Bangalore city, World Health Organization, Geneva, October Gururaj G. Alcohol and road traffic injuries in South Asia: Challenges for prevention. Journal of College of Physicians and Surgeons of Pakistan, 14(2), 2004, Gururaj G, Das BS, Channabasavanna SM. The effect of Alcohol on Incidence, Severity and Outcome from Traumatic Brain Injury. Journal of Indian Medical Association, 102 (03), March 2004, Gururaj G, Isaac MK, Subbakrishna DK and Ranjani R. Case Control Study of completed suicides in Bangalore, India. Injury Control and Safety Promotion, 11(3), 2004, Gururaj G. Developing Safe Communities in South East Asian Countries: Challenges and Opportunities. In: Proceedings of the Second Asian Conference on Safe Communities, Dhaka, Aeron Thomas A, Jacobs GD, Sexton B, Gururaj G and Rahman F. The involvement and impact of road crashes on the poor - India and Bangladesh case studies. Transport Research Laboratory, PR/INT/275/2004. Gururaj G et al. Injuries in South East Asia: Cause for concern and call for action. Report submitted to Division of Injury and Disability Prevention, Word Health Organization, South East Asia Regional Office, Gururaj G, Isaac MK. Suicide Prevention: Information for Women and Child Development Organizations; NIMHANS/ EPI/SUI.Prevn/Women & Child Gururaj G, Isaac MK. Suicide Prevention: Information for Non-Governmental Organizations; NIMHANS/EPI/ SUI.Prevn/NGO Gururaj G, Isaac MK. Suicide Prevention: Information for Educational Institutions; NIMHANS/EPI/SUI.Prevn/ Education Gururaj G, Isaac MK. Suicide Prevention: Information for Police Personnel; NIMHANS/EPI/SUI.Prevn/Police Gururaj G, Isaac MK. Suicide Prevention: Information for Family Physicans; NIMHANS/EPI/SUI.Prevn/Family Gururaj G, Isaac MK. Suicide Prevention: Information for Health Professionals; NIMHANS/EPI/SUI.Prevn/Health Gururaj G, Isaac MK. Suicide Prevention: Information for Media Professionals; NIMHANS/EPI/SUI.Prevn/Media Davis A, Quinbly A, Odero W, Gururaj G and Hijar M. Improving Road Safety by reducing impaired driving in developing countries: A scoping study (Unpublished document PR/INT/724/03). Gururaj G. Epidemiology of Traumatic Brain Injuries: Indian Scenario, Neurological Research, 24, 1-5, 2002 Gururaj G, Ahsan N, Isaac MK, Lateif MA, Abeyasinghe R and Tantipiwatanaskul P. Suicide Prevention- Emerging from darkness. World Health Organization, South East Asian Regional Office, World Health Organization. Injury surveillance Guidelines (eds) Holder Y, Peden M, Krug E, Lund J, Gururaj G and Kobusingye O Gururaj G and Isaac MK: Epidemiology of Suicides in Bangalore. NIMHANS Publication 44, Gururaj G and Isaac MK: Suicides - Beyond Numbers. NIMHANS Publication 43, Gururaj G, Das BS, Kaliaperumal VG - The status and impact of prehospital care on outcome and survival of head injured persons in Bangalore. Journal of Academy of Hosp. Adm., 11(1), 1999, 7-8. Gururaj G, Sateesh VL - Assessment of facilities at casusalty and emergency services in hospitals at Bangalore. Journal of Academy of Hosp. Adm., 11(1), 1999, Gururaj G, Peek Asa C, Kraus JF: Epidemiologic features of facial injuries among motorcyclists. Annals of Emergency Medicine 32: 4, 1998, Gururaj G: Need and scope of rehabilitation services for traumatic brain injury survivors. ACTIONAID Disability News, 9(1), Jan, 1998,

104 Bangalore City Traffic Police Bengaluru Injury / Road Traffic Injury Surveillance Programme BANGALORE ESTD 1980 Sagar Hospitals World Health Organization, New Delhi In Collaboration with Indian Council of Medical Research, New Delhi Ministry of Health & Family Welfare, New Delhi