INJURY SURVEILLANCE REPORT Injury Prevention Project Department of Health Ministry of Health Myanmar

INJURY SURVEILLANCE REPORT 2010-2013 Injury Prevention Project Department of Health Ministry of Health Myanmar

Contents Executive summary Executive summary table of trauma from 5 sentinel hospitals Acknowledgement Introduction 1 Objectives 3 Methodology 3 Results 5 Results of data analysis from transport injuries 10 Results of data analysis on injuries from assault 13 Results of data analysis on childhood injuries 14 Results of data analysis on falls 15 First aid treatment and Emergency Medical Service 16 Situation analysis 18 Recommendations 18 Trends in severe motorcycle accidents in Magway Divisional Hospital 19 Deaths and injuries during Myanmar Thingyan water festival ( Yangon & Nay Pyi Taw) 23 References 24

Executive Summary Background In 2005 survey on injuries took place at Yangon General Hospital and in 2007 another survey was done in 27 townships. Afterwards Injury Surveillance System was designed to provide data that identifies areas for improvement within the acute trauma care, pre-hospital and referral care system and also providing information for major prevention. The hospital-based sentinel surveillance system started collecting data on 1 st July 2009, on all cases attending at the ER (Emergency Rooms) at five sentinel hospitals (Yangon General Hospital, Mandalay General Hospital, Nay Pyi Taw 1000 bedded hospital, Magway Divisional General Hospital & North Okkalapa General Hospital). The data were collected by the doctors, interns, nurses and medical recorders depending on the hospital using IS forms. The reporting criteria includes all cases presented at ER of the 5 sentinel hospitals. Results Starting from 2010, there were total 24781 injured patients and increased to 33767 in 2013 reported by the 5 sentinel sites. Number of deaths from all injuries increased from 189 in 2010 to 485 in 2013. The findings showed the transport was the most common in Myanmar (ranged from 30.9 % 35.7%). Among the road users most of the injured cases were motorcyclists (both the riders and pillions) ranging from 37.8% - 46.5%. The second most common cause of reported by all sentinel hospitals was falls ( 24.3% - 28.9%) followed by assault ( ranged from 14.5% - 19.1%). The most common characteristics among motorcycle cases were alcohol related driving and non-helmet use. Alcohol-related driving was found in 60.5% and non-helmet use was found in 89% among the injured motorcyclists in Magway region. The highest number and proportion of all kinds of were found in Yangon General Hospital which is the biggest hospital followed by Nay Pyi taw and Mandalay General Hospital. Commonest type of still is the transport though falls were also common especially in children and elderly. Males is larger in proportion than females with a ratio of 7:3 among injured and 2.3:1 among deaths. Fifteen to twenty year old group constitute the largest proportion among the injured patients (39.4% - 40.2%). Alcohol consumption was found about 12.5% in injured patients and 16.5% in the counterparts. Childhood is a growing global public health problem and also in Myanmar. The majority of the injuries were unintentional due to falls and transport, amid assaults were alarmingly increasing. The most common place of occurrence was in the home and home area ( apart from road traffic where the most common place is on streets and high ways). Only 1.1% were dead before arrival to the hospital and only 6.3% were brought to hospitals by ambulance (Emergency Medical Services EMS). Seventy eight per cent of the injured who were brought to the sentinel hospitals did not get first-aid/ necessary care on site or during transportation and among those who got initial care did not get proper first aid treatment. Discussion and recommendations It is found that the road traffic injuries are the most common where deaths from the motorcycle crashes accounted for the largest proportion of all the injured patients that died. Basic safety education in all schools and parents, law enforcement and promotion of helmet wearing and anti-alcohol drinking are the most vital intervention for reducing morbidity and mortality due to transport injuries. It is also important to support the expansion of acute trauma care provided to pre-hospital care services and development of Emergency Medicine in health care settings. Collaboration is needed among the relevant government and non-governmental services, departments and agencies in order to solve the trauma care and to plan National Strategy to prevent care and disability..

Table of trauma from 5 sentinel hospitals 2010 2011 2012 2013 No.of casualty Male (%) 69.5% 69.2% 69.5% 69.5% Female (%) 30.%% 30.8% 30.5% 30.5% Age (%) 0 _ 14 4143 16.5% 5096 16.2% 5082 15.0% 4597 15.0% 15 _ 29 9894 39.4% 12173 38.7% 13445 40.0% 12338 40.2% 30 _ 44 6307 25.1% 7975 25.4% 8705 25.8% 7731 25.2% 45 _ 60 3175 12.6% 4219 13.4% 4416 13.1% 4074 13.3% > 60 1612 6.4% 1982 6.3% 2135 6.3% 1927 6.3% No. of traffic 7658 30.9% 11126 31.9% 11237 34.4% 12065 35.7% No. of non traffic 17123 69.1% 23751 68.1% 21402 65.6% 21702 64.3% No. of falls 6807 27.5% 9359 26.8% 9448 28.9% 8215 24.3% Self deliberate harm 236 1.0% 168 0.5% 143 0.4% 183 0.5% Assault 4721 19.1% 5681 16.3% 6057 18.6% 4904 14.5% Hospital information Admission 8301 11717 12945 14106 Out-patient 14791 19323 20535 16361 Referral 402 146 65 57 % of admission <15 2319 10.0% 3014 9.7% 3001 9.0% 2432 8.0% >15 12472 54.0% 16309 52.5% 17534 52.4% 13929 45.7% % of out-patient <15 1542 6.8% 2040 6.6% 2061 6.2% 2151 7.1% >15 6759 29.2% 9677 31.2% 10834 32.4% 11955 39.2% Road Users Motorcyclists 2657 37.8% 3947 41.0% 5204 46.0% 5166 46.5% Pedestrians 1333 19.0% 2170 22.5% 2496 22.1% 2691 24.2% Passengers (Public 1483 21.1% 1847 19.2% 1870 16.5% 1671 15.0% transport) Trishaw/ bicyclists 879 12.5% 1057 11.0% 1081 10.0% 774 7.0% Bus driver 520 7.4% 518 5.4% 520 4.6% 578 5.2% Others 154 2.2% 106 1.1% 144 1.3% 239 2.1% Source: Myanmar National Sentinel IS system (from 5 sentinel hospitals)

Acknowledgement The Injury Surveillance Report has been developed by the Emergency Department at Sentinel site hospitals (Yangon General Hospital, North Okkalapa General Hospital, Mandalay General Hospital, Magway Divisional General Hospital and Nay Pyi Taw 1000 bedded Hospital). We gratefully acknowledge the contributors, doctors, nurses and staffs from the aforementioned sentinel hospitals for their hard work and assistance to develop this report.

Injury Surveillance Report Myanmar 2010 2013 1. Introduction Injuries, unintentional or intentional, constitute a major public health problem, killing more than 5 million people worldwide each year and causing many more cases of disability. Historically, the problem has been neglected, largely because injuries were viewed as accidents or random events. People from all economic groups suffer fatal injuries, but death rates due to tend to be higher those in the lower income groups. Public health surveillance system, when properly implemented, have shown to be effective in providing reliable data for program planning, monitoring and evaluation. Surveillance is the ongoing systematic collection, analysis, interpretation and dissemination of data in order to plan, implement and evaluate public health interventions. Currently, prevention has tended to be an issue only in high income countries, however deaths and disability due to are found in LMIC. To develop effective prevention strategies, most countries need better information. In particular, countries need to know more about the numbers and types of injuries that occur and about the circumstances in which those injuries occur. Such information will help to prioritize and indicate the problem, that prevention measures are most urgently needed. Myanmar, with a population of about 60 millions, injuries stood second leading cause of deaths and first leading cause of morbidity among all diseases (2010 Health Statistics). The Injury Prevention Program is part of the strategic area of non-communicable diseases in the National Health Plan 2006-2011. National Injury Surveillance system started in July 2009 in five sentinel hospitals, in Myanmar (Yangon General Hospital, North Okkalapa General Hospital, Nay Pyi taw 1000 bedded hospital, Mandalay General Hospital and Magway Divisional General Hospital). 2. Objectives a. Table 1: Distribution of YLL among SEAR Table 2: Distribution of YLL by causes in WHO region 2008 region - 2008 1

Injury prevention is a very cost-effective public health strategy the costs of intervention are usually much lower than the cost of consequences of. Data on and its determinants are essential for identifying priority issues and high-risk groups, and also understanding the underlying causes of. Over the last decade many countries have focused on the Millennium Goal Development and much funding has been provided to address infectious disease. The magnitude, risk factors and preventability of injuries are not widely appreciated at all levels, from policy makers and donors to the local community. This lack of understanding means that the resources required are not being allocated to preventive efforts and the political and organizational structures that are needed are not being put in place. 2

2. Objectives a. General Objective:- To illustrate the epidemiology of mortality and morbidity from injuries and assess surveillance and recommend prevention strategies. b. Specific Objectives: 1. To review the situation of surveillance system and its linkages with other related departments 2. To share information about the ongoing work of prevention and rehabilitation 3. To develop an surveillance system that would facilitate prevention and control at both local and national levels 4. To strengthen national capacity for trauma care and rehabilitation through human resource and infrastructure development 3. Methodology Setting up Injury Surveillance System - Reviewed related literature, study data systems of various departments and organizations and documents - Held work shop at Nay Pyi Taw for accidents and injuries experts from Universities, Public Health, NGOs and International Organizations for development of surveillance system, guidelines, structure, model and responsible persons - Drafted surveillance record forms, data collection manual with definitions and meaning of terms - Improved the record forms and manual for data recording - Training and usage of SPSS version 17 was developed - Review of data collection and evaluation of surveillance system at all five sentinel hospitals workshop held in Mandalay Reporting criteria for the surveillance system - All injured patients (both outpatients and in-patients) having following causes must be reported. a. Those who have been injured within 7 days, by any of the following external causes; 1.1 Transport accidents (V01 V99) Land transport accidents Water transport accidents Air and space transport accidents 1.2 Other external causes of accidental injuries Falls (W20 W49) Exposure to inanimate mechanical forces (W50 W64) Exposure to animate mechanical forces (W65 W74) Accidental drowning and submersion (W75 W84) Other accidental threats to breathing (W75 W84) 3

Exposure to electric current, radiation and extreme ambient air temperature and pressure (W85 W99) Exposure to smoke, fire and flames (X00 X09) Contact with heat and hot substances (X10 X19) Contact with venomous animals and plants (X20 X29) Exposure to forces of nature (X30 X39) Accidental poisoning by and exposure to noxious substances (X40 X49) Overexertion, travel and privation (X50 X57) Accidental exposure to other and unspecified factors (X58 X59) 1.3 Suicide, intentional self-harm, assaults, event of undetermined intent and legal intervention and operation of wars (X60 Y36) 1.4 Blood pressure, pulse rate, respiratory rate and GCS must be recorded Methods 1. IS reports from 2010 to 2013 from five sentinel hospitals were collected a. Tools for data collection - the surveillance record form b. Target group of patients the injured and dead due to external causes 2. Data transfer the sentinel hospitals have to submit monthly data and data entry and data editing using SPSS version 17 was done in Yangon office 3. Descriptive method was used to illustrate the results 4. Quality control of Injury Surveillance Data - the supervision procedures include sampling of data recording forms for verification of correctness in filling in formation, coding and data which already been entered in a computer was done in Mandalay in 2013. 4

4. Results 1. Demographic data Year Injury Total Dead Total % % % dead dead dead Male Female Male Female Male Female Male Female 2010 17465 7668 25133 133 56 189 0.8% 69.5% 30.5% 70.4% 29.6% 2011 21747 9698 31445 244 66 310 0.9% 69.2% 30.8% 78.7% 21.3% 2012 23484 10299 33,783 298 80 378 1.1% 69.5% 30.5% 78.8% 21.2% 2013 21305 9362 30667 393 92 485 1.6% 69.5% 30.5% 81.0% 19.0% Table 3: Injuries and fatalities by gender (2010 2013) Year 0 _ 15 15 _ 29 30 _ 44 45 _ 59 60 Injury Dead Injury Dead Injury Dead Injury Dead Injury Dead 2010 4143 15 9894 60 6307 52 3175 42 1612 20 2011 5096 22 12173 106 7975 87 4219 51 1982 24 2012 5082 21 13445 139 8705 117 4416 70 2135 31 2013 4597 28 12338 280 7731 161 4074 78 1927 38 Table 4: Number of injuries and deaths by age distribution 2010 2011 2012 2013 Causes of Number % Causes of Number % Causes of Number % Causes of Number % Transport 570 42 Transport 788 35.7 Transport 790 36.9 Transport 825 32.7 Assault 256 18.9 Assault 461 20.9 Assault 470 21.9 Assault 586 23.2 Falls 179 13.2 Falls 335 15.2 Falls 273 12.7 Falls 400 15.5 Animal bite 130 9.6 Animal bite 224 10.1 Animal 265 12.3 Animal bite 281 11.1 bite Inani.Mech.force 69 5 Inani.Mech,force 88 4 Machinery 61 2.8 Inani.Mech. forces 120 4.8 Others 154 11.3 Others 143 6.5 Others 241 11.3 Others 314 12.4 Total 1358 Total 2210 Total 2142 Total 2526 Table 5: The first 5 causes of in Magway Divisional Hospital (2010 2013) 2010 2011 2012 2013 Causes of Number % Causes of Number % Causes of Number % Causes of Number % Transpo 2610 45.2 Transport 3442 52.1 Transport 3812 53.6 Transport 3093 53.4 rt Assault 973 16.9 Falls 1149 17.4 Falls 1199 16.8 Falls 1032 17.8 Falls 871 15.1 Assault 965 14.6 Assault 757 10.6 Machiner 659 11.4 y Machiner 305 5.3 Machinery 562 8.5 Machiner 743 10.4 Assault 643 11.1 y y Inani.Me ch.forces 134 2.3 Inani.Mec h.forces 210 3.2 Inani.Mec h.forces 276 3.9 Inani.Me ch.forces 294 5.1 Others 827 14.3 Others 263 4.0 Others 311 4.4 Others 237 4.1 Total 5769 Total 6611 Total 7117 Total 5796 Table 6: The first 5 causes of in Mandalay General Hospital (2010 2013) 5

2010 2011 2012 2013 Causes of Numbe % Causes of Numbe % Causes of Number % Causes of Number % r r Transport 3880 26.9 Falls 6324 32.2 Falls 5989 31.1 Transport 5225 32.2 Falls 3873 26.8 Transport 5675 29.0 Transport 5626 30.0 Falls 4975 30.6 Assault 3076 21.3 Assault 4047 20.6 Assault 4081 21.2 Assault 3212 19.8 Inani.Mech 402 2.8 Inani.Mech 517 2.6 Inani.Mech 480 2.5 Machinery 375 2.3.forces.forces.forces Machinery 338 2.3 Machinery 388 2.0 Machinery 336 1.7 Inani.Mech. 351 2.2 forces Others 2399 14.3 Others 2595 13.2 Others 2718 14.1 Others 2113 13.0 Total 14413 Total 19614 Total 19272 Total 16251 Table 7: The first 5 causes of in Yangon General Hospital (2010 2013) 2010 2011 2012 2013 Causes of Number % Causes of Number % Causes of Number % Causes of Numbe % r Transport 766 34.3 Transport 1048 46.2 Transport 1820 50.2 Transport 2534 53.6 Falls 731 32.7 Falls 703 31.0 Falls 792 21.8 Falls 739 15.6 Assault 164 7.3 Inani.Me 124 5.5 Assault 343 9.5 Assault 580 12.3 ch.forces Inani.Mec 149 6.7 Machiner 111 5.0 Inani.Mec 198 5.5 Inani.Mech 333 7.5 h.forces y h.forces.forces Machiner 111 5.0 Assault 76 3.3 Animal 93 2.6 Animal bite 195 4.1 y bite Others 317 14.2 Others 207 9.1 Others 312 8.6 Others 345 7.3 Total 2234 Total 2269 Total 3629 Total 4731 Table 8: The first 5 causes of in Nay Pyi Taw General Hospital (2010 2013) 2010 2011 2012 2013 Causes of Number % Causes of Number % Causes of Number % Causes of Number % Falls 370 27.2 Falls 208 25.7 Assault 290 23.4 Assault 169 30.0 Transport 282 20.8 Transport 171 21.1 Transport 274 22.1 Transport 160 20.8 Assault 252 18.6 Assault 123 15.2 Falls 234 18.9 Falls 149 19.4 Machinery 93 6.9 Machiner 64 7.9 Inani.Mec 86 6.9 Machinery 67 8.7 y h.force Inani.Mec 36 2.7 Inani.Me 48 5.9 Machiner 81 6.5 Inani.Mech. 33 4.3 h.force ch.force y force Others 324 23.9 Others 195 24.1 Others 274 22.1 Others 174 22.6 Total 1357 Total 809 Total 1239 Total 769 Table 9: The first 5 causes of in North Okkalapa General Hospital (2010 2013) 6

5% 13% 1% 0% 0% 0% 0% 1% 10% 18% 3% 3% Male 9% 37% Transport Injury Fall from < 10' Fall from > 10' Fall of Object Assault Burns/ Scald Gunshot Drowning Poisoning Animal bite Fall on ground Machine Injury Blast Others Fig 1: Types of among the males 23% 2% 1% 0% 0% 0% 0% 8% 2% 16% 2% Female 1% 35% 10% Transport Injury Fall from < 10' Fall from > 10' Fall of Object Assault Burns/ Scald Gunshot Drowning Poisoning Animal bite Fall on ground Machine Injury Blast Others Fig 2: Types of among females 7

According to the Injury Surveillance report from 5 sentinel hospitals 2010-2013, there were 121028 injuries and 1362 deaths. The highest number of injuries and deaths were from Yangon General Hospital, which is the biggest hospital in the country, indicating the heaviest service load in Myanmar. Transport injuries were still the cause of the highest number of injuries and deaths throughout the year 2010-2013. The ratio of injuries and deaths from road crashes in all sentinel sites (21 54%). There were more male patients than female with the ratio of 7:3. Fig 3: Increasing trend in road traffic deaths, source: Myanmar Police Force Sex 30% 70% Male Female Fig 4: Male to female ratio among the injured patients The most frequently found next to the transport were falls, assaults and inanimate mechanical forces (e.g. from falling objects, cuts, burns, etc.). Falls were found to be the second most frequent cause in Yangon General Hospital and North Okkalapa General Hospital and interpersonal violence (assaults) were the third common type of in all sentinel hospitals. Animal bites were found to be common in Magway Divisional General Hospital (9.6% - 11.1%) which was the 4 th common cause after RTA, falls and assault and also in Nay Pyi Taw 1000 bed hospital (2.6% - 4.1%). These two areas put snake bites among animal bites in their data and also it is a common public health issue in central Myanmar. 8

Most of the injuries took place on streets and highways followed by domestic area. Injuries at school and sports ground were high for the children under 15 years of age. Among the injuries and deaths 15-29 age group were the most common age group (40%) followed by 30-44 age group (25%). Groups Place of Total Home School Street/ Highway Sports ground Office Market Industrial Agriculture Others < 15 M 6199 787 4602 374 51 77 149 241 466 12946 F 3070 200 2362 32 11 32 44 49 123 5923 Total 9269 987 6962 406 62 109 593 390 589 18869 >15 M 15400 356 43682 755 1023 1273 4079 1635 2799 71002 F 11323 226 17164 99 209 445 433 356 840 31095 Total 26732 582 60846 854 1232 1718 4512 1991 3639 102097 Table 10: Place of by gender and age 1% 2% 4% 2% 3% 1% 30% home school 56% 1% street and highway sport ground office place Fig 5: Diagram showing percentage of places of Injury and dead by age (2010 2013) Dead 2010 2011 2012 2013 0 _ 14 15 22 21 28 15 _ 29 60 106 139 180 30 _ 44 52 87 117 161 45 _ 59 42 51 70 78 60 20 24 31 38 Injury 2010 2011 2012 2013 0 _ 14 4143 5096 5082 4597 15 _ 29 9894 12173 13445 12338 30 _ 44 6307 7975 8705 7731 45 _ 59 3175 4219 4416 4074 60 1612 1982 2135 1927 Table 11: Number of injuries and deaths by age group 9

Results of data analysis from Transport Injuries Transport injuries are still the cause of highest number of injuries and deaths throughout the years 2010-2013. The ratio of injuries and deaths from this cause was highest in every hospital ( 121028) of the injured patients. Mandalay General Hospital, and Nay Pyi Taw 1000 bed hospital had the highest ratio of injuries from transport injuries (53.6%) with Magway Divisional General Hospital as runner-up with 42%. 10

Injury (RTA) Traffic causes Non-traffic causes Dead (RTA) Traffic causes Non-traffic causes 2010 7658 30.9% 17123 69.1% 2010 94 49.7% 95 50.3% 2011 11126 31.9% 23751 68.1% 2011 149 51.4% 141 48.6% 2012 12357 36.6% 21402 63.4% 2013 12065 35.7% 21702 64.3% 2012 242 64.0% 136 36.0% 2013 320 66.0% 165 34.0% Table 12: The number of injuries and deaths among RTA and non-rta injuries in 5 sentinel hospitals The demographic characteristics of transport did not differ from year to year, where males were more injured than the females with a ratio of 7:3.Those in the 15 29 years age group were the highest number injured at every hospital of all the injured patients. Fatal injuries were more common in road traffic injuries compared to non-traffic injuries. Motorcyclists constituted the highest ratio ( 54 %) of the injured patients and (34 %) of deaths from all kinds of vehicles. Helmet wearing rate among the motorcyclists were very low with only 11% among the injured motorcycle riders. Five sentinel sites/ Type of Vehicle Injury Small car 4% 0% 1% 3% 2% 1% 0% 1% 0% 32% Truck Motorcycle Bicycle Train Plane Bus Htaw la gyi Tri-cycle 51% 5% ship Cart Other Fig 6: Diagram showing type of vehicles Types of Vehicle 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2010 2011 2012 2013 Fig 7: Chart showing types of vehicles according to the year Other Cart Ship Tri-cycle Htaw la gyi Bus Plane Train Bicycle Motorcycle Truck Small car 11

36% 18% Road User Category 2010,2011,2012,2013 6% 9% 2% 24% 5% Road User Category Pedestrian Road User Category Driver Road User Category Trishaw/ Bicyclist Road User Category Passenger Road User Category Motorcycle rider Fig 8: Diagram showing road user category in 5 sentinel hospitals Among the road user categories, motorcyclists found to be increased (32.9% - 42.9%) and pedestrians (17.0% - 22.3%) year by year. Fig 9: Diagram showing road user category. Source ; Myanmar Police Force Alcohol drinking rate among the injured patients were 7.8% and in the counterparts were 7.7%, whereas non-consuming rate was 73% in patients and 33.5% in the counterparts. Blood alcohol concentration was tested only for those drivers involved in the road crashes and not every patient was tested for BAC. In some areas breath analyzers were used to detect alcohol intoxication. Most of the road crashes took place at 12:00 18:00 hours and 18:00 24:00 hours. 12

Results of data analysis on injuries from assault According to the data from Injury Surveillance reports from five sentinel hospital there were 19714 patients injured in assaults. Each hospital reported (834 14416) cases injured from assault ( 5.5% - 23.2% of injured patients from all causes in each hospital). The patients in this category ranked 3 rd leading cause of in all sentinel hospitals and in 2012-2013 it ranked first leading cause of cases in North Okkalapa General Hospital. Injury Age & Sex <15 Male Female Total >15 Male Female Total Intent of Injury Unintentional Intentional Deliberate self harm Others 11515 5221 16736 52790 22324 75114 642 258 900 13563 5251 18814 28 33 61 483 186 669 26 12 38 151 119 270 Total 12211 5524 17735 66987 27880 94867 Table 13: Types of according to age & sex The epidemiological pattern of from assaults indicated that men were more injured than women with a ratio of 2.07:1. The majority were teenagers and those in the working age group. The age group was reported with the highest proportion was 15 29 year old. The highest proportion of patients from assaults was found in Yangon General Hospital 23.0%, followed by Magway Divisional Hospital 21.5%, North Okkalapa General Hospital 20%, Mandalay General Hospital 13.2% and Nay Pyi Taw 9.0%. According to the data from Yangon General Hospital assault stood sixth common cause of and it is a growing problem. 13

It was found that in all hospitals the frequent means of assault was the use of blunt objects 47% in the injured from assaults. Home and its compound were the places where assaults occurred most frequently and the second most frequent place of assaults was on street or highways. The time took place most frequently was between late evenings 18:00 24:00 hours. It was found that more than half (56%) that the most frequent means of assaults was the use of blunt objects. Bodily force was reported to have 25% and sharp object with 15% of all assaults. As for alcohol consumption among the injured patients which could be have high correlation with assault patients found % among the patients. A major limitation in an effort to characterize due to interpersonal violence and thereby, plan prevention effort is lack of accurate data. Results of data analysis on Childhood Injury Trauma remains the common cause of death in children and young adults and is responsible for more productive years of life lost than cancer, stroke and heart diseases combined. The road traffic injuries are still in increasing trend, more than 13.5% children and adolescents were injured in traffic accidents. Road crashes are a significant cause of disease burden among children. In 2004, road crashes resulted in more than 260,000 deaths in children and youth aged 0-19 years which accounted for 21% of all road traffic related deaths worldwide. Although road traffic deaths decreased in some highincome countries, by 2030 it is predicted that they will be the 5 th leading cause of death worldwide. Descriptive and time trend analysis of demographic data as well as causes, severity and place of was conducted form the IS data. Nearly ( 34.1%) of them were between 5-9 years of age, with 1.1 males for every female. Among the injured pedestrians were the most common while the second most commonly injured were passengers. The majority had minor injuries, but notably higher proportions with moderate to severe injuries were found to be increasing. Most common non-fatal injuries include head injuries and fractured limbs. The children were at risk for road traffic injuries because roads were shared space for playing, walking, working, cycling and driving. Also the helmet wearing rate was low and the correct use of helmets was a significant risk for head injuries in road crashes. Compared to adults, children and adolescents run a considerably higher risk of suffering unintentional injuries. Most accidents (51.3%) occur at home or during leisure time activities. Boys suffer more frequently than girls and they show higher rates in adolescence than during childhood. While among children injuries mostly happen at home amid road traffic and sports injuries increase in occurrence during adolescent. 14

In most countries around the region, drowning ranks among top three causes of death from unintentional, but drowning and submersion were reportedly low in the sentinel hospitals. Childhood injuries in Nay Pyi Yaw 1000 bedded hospital Data collection and reported by Medical Record Department, Nay Pyi Taw In the year 2013 there were 5468 patients attended to trauma emergency, and among the injured 741 were children (under 15 years) which constitute about 13.6%. Falls were the commonest among the injured patients (37.1%0 followed by road traffic injuries (33.1%). S/No Causes Male Female Total % 1 Falls 192 83 275 37.1 2 Transport accidents 164 81 245 33.1 3 Exposure to inanimate mechanical forces 76 31 107 14.4 4 Exposure to animate mechanical forces 28 19 47 6.3 5 Assault 10 8 18 2.4 6 Others 38 11 49 6.6 Total 508 233 741 100 Table 14: Mechanism of among children at Nay Pyi Taw 1000 bedded hospital 2013 Place of Sex Total % Male Female Home 203 114 317 42.8 Street and highway 206 94 300 40.5 School 25 10 35 4.7 Sports ground 23 2 25 3.4 Agricultural area 19 5 25 3.4 Industrial place 8 2 10 1.3 Market place 4 1 5 0.8 Trade & service area 3-3 0.4 Others 17 4 21 2.8 Total 508 233 741 100.0 Table 15: Place of among the children at Nay Pyi Taw 1000 bedded hospital - 2013 Most of the injuries took place at home (domestic ) 42.8% and on street and high ways 40.5%. There were 14 deaths and 9 were due to road traffic accidents. Results of data analysis on Falls Nationwide systematic collection of data regarding falls within health-care facilities is still lacking in Myanmar. Falls in the elderly are a major source of resulting in disability and hospitalization. The total fall for all age group was 37027 (30.6%) of the injured patients. Falls comprise a leading type of resulting in hospitalization, emergency room attendance or restricting activity, which was found commonly in Yangon General Hospital and North Okkalapa General Hospital. 15

Age group < 1 1-4 5-9 10-14 15-19 20-30 31-40 41-50 51-60 >60 Total Mechanism of Fall < 10 Fall > 10 509 2210 3368 2781 2035 5290 4011 3430 3069 4238 30941 1.6% 7.1% 10.9% 9.0% 6.6% 17.1% 13.0% 11.1% 9.9% 13.7% 19 69 151 204 317 855 544 375 236 118 2888 0.7% 2.4% 5.2% 7.1% 11.0% 29.6% 18.8% 13.0% 8.2% 4.1% Total 528 2279 3519 2985 2352 6145 4555 3805 3305 4356 33829 Table 16: Falls according to age groups and mechanism The majority of fall-related deaths and injuries were among adults, amid falls account for 35.2% among the children and it was more vulnerable in 5-9 years aged group with 10.9%. Falls in the elderly >60 years of age account for13.7% with more than 75% fell on the level ground. Falls in the elderly are a major source of resulting in disability and hospitalization. The fall risk was considered for elderly with two thirds of all being affected in and around home while it was associated with limited mobility, cognitive impairment, recent history of falls and old age. Elderly patients should routinely be screened for relevant risk factors and if need, an individually targeted fall program should be compiled. Fall from height more than 10 feet were found to be highest in the 20-30 aged group (29.6%) and most of them were at the work site (occupational ). Despite the slight variance, the trend of the rates remains largely stable. If specific fall risks can be determined, preventive measures can be applied in a more personalized manner and care can be improved. Home hazard reduction strategies, exercise programs combined with other fall prevention approaches will effectively reduce the falls and related injuries. First aid treatment and Emergency Medical Service The majority of the patients were brought to the hospital from the site of accident by their relatives or bystanders. Only a few were brought in by ambulance (government, private, rescue foundation, well wishers etc.). 16

78% of the patients brought to the hospital from the scene of accident did not receive first-aid care, and only 9% got necessary care at the site of accident. Most of the cases that got initial care (81%) was at the nearby hospital and clinics. The care that tended to be neglected was temporary splintage or POP slab and assist in breathing problems. Department of Medical Science commences the Emergency Medicine course in 2012 with diploma degree and in 2015 Master course will be conducted. Injury Prevention project also gave trainings to the service and non-service doctors on Injury Prevention and Care. 17

Situation Analysis - Transport injuries are still the most common cause of and death. Characteristics among this risk group did not differ much within these years and motorcyclists constituted the highest ratio for road traffic injuries. Helmet wearing rate among the motorcyclists were still very low and drink driving problems are alarming issue. - Deaths from falls, assaults and self deliberate harm were most frequent next to road accidents, with inter-personnel violence showing a tendency to increase. - Access to emergency medical service did not differ much from the previous years - Data collection, data entry and data analysis were not well organized. Recommendations: - The Ministry of Health should have a Trauma Unit coordinating with related departments and organizations ( The office of the President, Ministry of Home Affairs, Ministry of Education, Ministry of Information, Ministry of Social Welfare, Myanmar Red Cross Society etc.) - The Ministry of Health should step up in effort to develop Emergency Medical Service and Ambulance system - To develop trauma registry in all State and Regional hospitals and health service should take more role in coordinating while improving quality care to the injured patients - Strengthening of existing Injury Surveillance System by training medical professionals, providing materials and staffing - Strengthening of trauma care by means of integrated trauma care services, improved notification methods, rapid transport of victims and suitable referral protocols. - Seek cooperation from the public sector and the mass media - Enactment of the laws should be supervised at both the National and Regional level - Injury epidemiology, prevention and care curriculum should be put in basic education schools as well as in higher education institutions - Integrating childhood surveillance into existing primary health care service 18

Trends in severe motorcycle injuries in Magway Divisional Hospital Rate of helmet wearing, alcohol consuming and pattern of injuries Motorcycles including mopeds are popular in developed countries as a transportation measure and also as a leisure activity. However, the vehicles cause many deaths and non-fatal injuries, especially among young riders and passengers. Traffic accidents have been an interesting issue as they have been one of the top causes of death among Myanmar people and caused substantially immense economic and social loss. The district that is in the study site (Magway district with a population of 1,418,466) is one of the districts with the prosperous economy of the country and traffic and death rendered it great loss. Therefore, reducing efficiently the rate of and death due to motorcycle injuries must be done based on not only epidemiological views, which deals with traffic accidents but also a concept that reflects social problems, which are increasingly severe and bring about health problems and social violence. Recent economic changes, the rapid increase of motor vehicle use, the affordability of motorcycles over public transportation, the lack of adequate public transportation policies and other insufficient measures to improve safety explain these trends. The study, trends in fatal motorcycle injuries in the Magway district, 2012-2013, shows that motorcycle injuries/deaths in the region increased, from 3,209 in 2012 to 10,505 in 2013. Men are the most frequent motorcycle users in Magway, and those aged 15 to 29 years were the most common victims of crashes. According to the study, men face a 2.42 times higher risk of death from motorcycle crashes than women. Age - groups Sex male female Total 0 _ 4 17 13 30 5 _ 14 59 41 100 15 _ 29 686 245 931 30 _ 44 332 138 470 45 _ 59 138 64 202 60 _ 70 45 23 68 71 > 11 8 19 Total 1288 532 1820 Table 17: Distribution of age and sex among motorcycle injuries M:F 7:3 Fig. 1: Sex ratio among motorcycle accidents 19

In Magway district the total number of registered vehicles are 52373 with 48284 motorcycles which constitute about 92.2%. Motorcyclists are especially vulnerable to injuries due to the high speeds they can achieve and the small size of motorcycles, which offer little protection and are less visible in traffic. Motorcyclists involved in collisions have a higher risk of death or serious and suffer a high frequency of injuries to the head, chest and legs. There are rules and regulations for helmet wearing, requiring the use of helmets by all passengers, of all ages, on any motorized two-wheel vehicle, on all roads, and with helmets that fulfill specific safety standards. Use of Helmet Yes No Total Age _ Groups 0 _ 4 0 10 10 5 _ 14 5 41 46 15 _ 29 46 433 479 30 _ 44 35 205 240 45 _ 59 7 89 96 60 _ 70 5 20 25 71 > 1 7 8 Total 99 805 904 Table 18: Use of helmet among the motorcycle users Helmet wearing rate in Magway From survey From Injury Surveillance report Motorcyclists on the road - 26.2% injured motorcyclists - 11% From the survey, 30% of motorcyclists gave history of helmet wearing with chin straps firmly fastened. Risk taking behavior among motorcycle riders was found that only 11% of the injured patients wear helmets, inspite of helmet wearing law was enforced. Regarding with the alcohol consumption, 60.5% had reported that they were under the influence of alcohol at the time of accident (this data was from the study in Magway General Hospital 2012-2013). Many studies in other countries indicated that motorcyclists who reported having consumed alcohol within 12 hours were at higher risk. There are motorcycles imported from neighbouring countries and some local manufactured ones. The motorcycles that were manufactured locally did not meet the standard norm and some people removed the protective gears from the motorcycles. 20

Types of Motorcycle Imported (specify ) Local manufacture Others Total Age _ Groups 0 _ 4 2 1 1 4 5 _ 14 6 17 0 23 15 _ 29 93 72 16 181 30 _ 44 54 28 7 89 45 _ 59 22 9 1 32 60 _ 70 13 3 1 17 71 > 1 2 1 4 Total 191 132 27 350 Table 19: Types of motorcycle injuries according to age group There needed measures that could help halt or reverse these trends include the development and enforcement of standard motorcycle safety norms; laws that require helmet use by all passengers; exclusive motorcycle lanes; better enforcement of speed limits, quality, and safety of motorcycles; and policies that encourage the use of public transportation. Cause of Injury Car to Motorcycle to Motorcycle to Motorcycle to Motorcycle Motorcycle Motorcycle Motorcycle pedestrian moving vehicles to object turnover Total Age _ Groups 0 _ 4 1 5 8 2 4 5 25 5 _ 14 4 23 35 1 8 10 81 15 _ 29 89 346 61 82 56 172 806 30 _ 44 26 149 47 40 24 155 441 45 _ 59 14 68 17 23 6 57 185 60 _ 70 5 21 21 4 2 12 65 71 > 1 6 7 1 0 2 17 Total 140 618 196 153 100 413 1620 Table 20: Causes of motorcycle injuries according to age group 21

Cause of Injury 900 800 700 600 500 400 300 Motorcycle turnover Motorcycle to object Motorcycle to moving vehicles Motorcycle to pedestrian Motorcycle to Motorcycle Car to Motorcycle 200 100 0 0 _ 4 5 _ 14 15 _ 29 30 _ 44 45 _ 59 60 _ 70 71 > Fig : Bar diagram showing causes of motorcycle injuries according to age group Anatomical Region Head Neck Arm Forearm Hand Chest Abdo Pelvic Thigh Knee Leg Foot Other Total Age _ Groups 0 _ 4 15 0 3 2 0 0 0 0 3 0 1 2 1 27 5 _ 14 45 1 3 5 4 2 3 2 2 4 11 6 4 92 15 _ 29 397 12 66 45 53 18 9 9 29 44 99 73 35 889 30 _ 44 226 11 24 18 25 13 5 8 8 13 51 20 21 443 45 _ 59 78 3 16 14 9 9 3 7 6 7 29 9 10 200 60 _ 70 27 1 5 6 1 3 1 1 3 3 7 1 3 62 71 > 5 0 0 2 3 0 0 1 1 0 2 1 1 16 Total 793 28 117 92 95 45 21 28 52 71 200 112 75 1279 Table 21: Injuries according to the anatomical region in motorcycle accidents Injury Pattern Penetrating Abrasions Bruises Laceration wound Fracture Sprain Dislocation Total Age _ Groups 0 _ 4 10 4 5 0 1 0 0 20 5 _ 14 48 6 14 0 8 0 0 76 15 _ 29 368 57 152 1 84 0 2 664 30 _ 44 146 30 74 3 62 1 7 323 45 _ 59 68 15 25 0 34 2 1 145 60 _ 70 19 3 4 0 15 0 2 43 71 > 5 0 4 0 5 0 0 14 Total 664 115 278 4 209 3 12 1285 Table 22: Injury patterns in motorcycle injuries 22

Most of the motorcycle accidents happened in the latter part of the day (12:00 noon 12:00 mid night). Mechanism of motorcycle accidents were found to be mostly motorcycle turnover and motorcycle to motorcycle collisions (66%), the most vulnerable are the motorcycle riders (86.3%) and the number of persons (two or more)on the motorcycle found to be 33.1% The most common anatomical part of the body being injured are head injuries ( 62% ) followed by lower limbs (34%), and the most common pattern of injuries are soft tissue injuries (82%) followed by fractures (16.3%). Fig ; Map of Magway Region 23

Deaths and Injuries during Myanmar Thingyan water festival (Yangon & Nay Pyi Taw) Injury surveillance system started in July 2009 collecting data on patients from accidents, poisonings, assault and intentional self-harms who seek medical treatment at tertiary hospitals in Yangon and Nay Pyi Taw. The aim is to develop medical services for and referrals of the injured patients and plan to prevent and solve accidents and other injuries during special events such as Thingyan Water Festival. Thingyan water festival, which celebrates the Myanmar New Year started from 12 to 17 of April. This is during the hottest season and people pay homage to the elders and do merits at the monasteries and pagodas. Young people throw water to each other and in big cities like Nay Pyi Taw, Yangon and Mandalay people drive in cars gathered at pandals and enjoyed dances. At that time young people take alcohols and many injuries happened due to car crashes, falls and assault. Injury RTA Assault Others Total Year 2012 178 32 19 229 2013 188 52 41 281 2014 165 45 39 249 Table 23: Morbidity & Mortality in external cause of at Nay Pyi Taw Hospital 2012 2014 Thingyan Water Festival Injury RTA Assault Others Total Year 2011 169 131 114 414 2012 230 170 142 542 2013 185 136 194 515 2014 290 152 252 694 Table 24: Injury and death due to RTA & other cause of at Yangon General Hospital (2011-2014) Thingyan Water Festival In Nay Pyi Taw, RTA contribute about 66% while Yangon General Hospital constitute about 40% (range 35.9 42.4%) among the injuries. Death due to RTA in Nay Pyi Taw is 73.7% and in Yangon (40-100%). Males were injured more than females with a ratio of about 4:1 in Nay Pyi Taw, where male to female ratio in Yangon was 5:1. Most common in Nay Pyi Taw was found to be RTA where motorcycle accidents constitute the majority. Helmet wearing rate during the festival was very low and deaths were due to head. In Yangon motorcycles are not allowed and most of the RTA were due to car to car, car to pedestrians and fell off from cars. 24

References -1. World report on child prevention World Health Organization -2. Injury Surveillance Report, Thailand 1995-1998 Epidemiology Division, Ministry of Public Health, Thailand -3. National Injury Surveillance Annual Report 2010, Department of Health, Myanmar -4. Second Global Status Report on Road Safety 2012-5. Thirteen years anniversary trauma registry (1997-2009) Khon Kaen Regional Hospital, Thailand -6. Injury Prevention and Care in the South East Asia region, Nonthaburi, Thailand, 2007-7. World report on road traffic prevention, Geneva, Switzerland, WHO 2004-8. The bi-regional workshop on Injury Surveillance, Chiang Mai, Thailand, WHO 2006-9. Fatal surveillance in mortuaries and hospitals: a manual for practitioners, WHO 2012-10. Trauma Quality Improvement program, Khon Kaen hospital, Thailand, 2011 25

INJURY SURVEILLANCE FORM ( MYANMAR 2010 ) (Old form) Name of Hospital Nay Pyi Taw General Hospital 1000 Bedded I. Patient Particular Name of patient Age Sex male II. INJURY PATTERN 1. Place of Injury home school street & highway sport ground Office place Industrial Area Agricultural Area Others Date of Registration female D M Y Time of Registation Residence Town 2. Date of Injury 3. Mechanism of Injury 4. Time of Injury 00:01 06:00 Hr 5. Intent of Injury 06:01 12:00 Hr 12:01 18:00 Hr 18:01 24:00 Hr Unintentional Intentional assault Deliberated Self-harm Other III. IF TRANSPORT INJURY ( ROAD TRAFFIC INJURY ) 1. Road User Category 2. Types of Vehicle Pedestrian Small car Driver Truck Trishaw/ Bicyclist Motorcycle Passenger Bicycle Motorcycle rider Cart Motorcycle pillion Train Other Transport Injury Fall from < 10' Fall from > 10' Falling of Object Assault Burns/ Scald Gunshot Drowning Poisoning Animal Bite Fall on ground Machine Injury Blast Injury ( Mine ) Plane Bus Htw Lay Gyi Three wheels motor cycle Boat/Ship Other ---------------- IV IF ASSAULT 1. Weapon Used Blunt Object Sharp Object Pointed Object Person Gun Other V INJURY RELATED TO ALCOHOL Alcohol consumption by patient Yes No Don't Know Alcohol consumption by Counterpart VI PRE-HOSPITAL MANAGEMENT 1. First Aid Before Hospital Yes No Don't know 2. If yes, Where? ----------------------------- Other Yes No Don't Know Site of Accident Near by Clinic Near by Hospital Police Station Other 3. If yes, Who? Near by person Health worker Nurse Doctor Police Other ---------- Village 4. Transport Hospital VII HOSPITAL MANAGEMENT 1. Condition of the patient on arrival 2. If Death 3. If alive treat as Dead Brought Death Out Patient Referral Alive Death on Arrival Admission 4. BP /mmhg HR /min RR /min Injury Severity Score ( ) Ambulance Private Car Boat Trishaw Taxi Cart Hwe La Gyi Htam Sin 26

Injury Surveillance Record Form (Revised) Injury Surveillance Record No. ------------------------------------------ Province ---------- Township ---------- Patient First name ----------------------Last name ---------------------------------------------------HN ------------------------ Sex Male Female Date of Birth -------------------- or Age -------Yr-----month. of Approximately --------- Yr Occupation Govt. Officials Police/Soldiers Govt. enterprise Private company employees unskilled labour self employed business Agriculture Students Others (Specify ) ------------------------ Present address -------------------------------------------------------------------------------------------------------------------------- Date Occurred -------------------------------- Time occurred -------------------------------------- Intention Date arrived at hospital -------------------- Time arrived at hospital -------------------------- Location : District ------------------------ Province------------------------------------------ Accidental Home Residential institution School, Public admin area Self-harm Sport, athletics area Street & highway Trade & service area Assault Industrial and construction area Farms Others Unknown External causes of Risk behaviors 1. Transport accidents 1.1 Type of injured person Used Pedestrian Driver Passenger Unknown Not used 1.2 Vehicle of the injured Unknown Bi/Tricycle Motor cycle Motor-tri cycle Car Pick up/van Heavy truck Bus Other specified ------------------------------------------------------------------------------------------ 1.3 Injured due to Used(Specified) Fall from vehicle Vehicle overturned Collision with -------------------------- Others (specified) ------------------------------------------------------------------------------------- Not used 2. Other causes of Injury ( Specify ) Unknown -------------------------------------------------------------------------------------------------------------- 3. Unknown External causes of code -------------------------------------------------------------------- Transportation of the injured to hospital 1. From injured site or others Person who transport No Not known Breathing care EMS Yes appropriate Charitable foundation volunteers Yes not appropriate Police Not needed Others No 2. From health facility : Name --------------------------- Province ----------------------------- Splint/ Slab 2.1 By Ambulance Not Ambulance Yes appropriate with person to take care (Specify professional ) ------------------------------------ Yes not appropriate Not person taking care Not needed 2.2 With referral letters Yes No No Seen at ER. (Record only patients who are to be Observed at ER, Admit, dead, refer) VITAL SIGNS BP-----------------------mmHg, PR --------------/min, RR -------------/ min History of consciousness since occurred ---------------------------------------------------- Coma scale ------------------------------------------------------------------------------------------ In this province Occupational Injury Yes No Unknown 1. Alcohol 3. Seat belt Yes No Unknown 2. Drugs/Medications 4. Helmet Used ------------------------ Not used Unknown Not In this province Unknown First aid/ cares while transport Bleeding care Yes appropriate Yes not appropriate Not needed No IV Fluid Yes appropriate Yes not appropriate Not needed No Type of Injury cause Blunt Penetrating Blunt and Penetrating Others Date disposition from E,R. -------------------------------------------------------------------------- Time ---------------------------------------------------------- By DBA D/C Refer Against Advice Absconded Dead at ER Observed or Admitted to --------------------- Final Diagnosis ( Specify organ and in detail) If admitted, do not fill at E.R ICD Code 1. ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- 2. ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- 3. ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- 4. ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- 5. ------------------------------------------------------------------------------------------------------------------------------------------ ------------------------- Date discharge from ward -------------------------------------------------------------------------------------------------------------------------------------------- Outcome Improve refer against advice absconded dead Ask to go back to die at home Recorders name 1. ----------------------------------------------------------------- 2. -------------------------------------------------------------------- Supervised by 27