Child and adolescent injury prevention: A WHO plan of action 2006-2015 World Health Organization Geneva, Switzerland 2006
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Acknowledgementy This publication was prepared following a consultation meeting on child and adolescent injury prevention,held on 30 March-1 April 2005 at WHO Headquarters in Geneva,Switzerland.Present and contributing were N.T.An(Ministry of Health,Viet Nam);C.Branche(CDC,USA);G.Brandmayr(Safekids Intemational,Germany);K. Browne(University of Birmingham,UK):V.Chandra-Mouli(WHO,Switzerland);A.Concha-Eastman(WHO-AMRO, USA):N.Du Toit(CAPFSA,South Africa):H.Fathey El-Sayed(Suez Canal University,Egypt);S.Hussain(WHO- EMRO,Egypt);A.Ghaffar(Global Forum for Health Research,Switzerland);M.Giersing(UNICEF,Bangladesh);F. Gore(WHO,Switzerland);Z.Guang(CDC.China);L.Hesemans(Ministry of Health,Welfare and Sport, Netherlands);K.Hoffmann(USAID,USA);A.A.Hyder(International Society for Child and Adolescent Injury Prevention,USA);O.Kobusingye(WHO-AFRO,Democratic Republic of Congo);E.Krug (WHO,Switzerland);L. Laflamme(Karolinska Institutet,Sweden);H.Linnan(UNICEF,Thailand);D.Ma Fat(WHO,Switzerland):C.McCourt (Health Canada,Canada);K.McMahon(Department for Transport,United Kingdom);C.Mulholland(WHO Switzerland):P.Orpinas(University of Georgia,USA);K.Oyegbite(UNICEF,USA):J.Ozanne-Smith(Monash University Accident Research Centre,Australia);M.Peden(WHO,Switzerland);D.Peterson(The Alliance for Safe Children,Thailand):;J.Pronczuk(WHO,Switzerland);A.K.M.Rahman(Institute of Child and Mother Health, Bangladesh);I.Scott(WHO,Switzerland);D.Sethi (WHO-EURO,Italy);K.Shibuya (WHO,Switzerland);B. Strukcinskiene(Klapeda College of Social Sciences,Lithuania):E.Towner(Centre of Child and Adolescent Health United Kingdom);J.Vincenten(European Child Safety Alliance,The Netherlands);C.Voumard(UNICEF,China). The publication was finalised by: 1.Scott Technical Officer,Department of Injuries and Violence Prevention,WHO. Switzerland M.Peden Coordinator,Unintentional Injuries Prevention,Department of Injuries and Violence Prevention,WHO,Switzerland E.Krug Director,Department of Injuries and Violence Prevention,WHO,Switzerland L.Hesemans Senior Policy Officer,Nutrition.Health Protection and Prevention Department Ministry of Health,Welfare and Sport.The Netherlands C.Branche Director,Division of Unintentional Injury Prevention,National Center for Injury Prevention and Control.Centers for Disease Control and Prevention.USA H.Fathey El-Sayed Pediatrician,Suez Canal University,Egypt AA.Hyder Chair,International Society for Child and Adolescent Injury Prevention,Johns Hopkins University,USA O.Kobusingye Regional Advisor,Disability/Injury Prevention and Rehabilitation,WHO Regional Office for Africa,Democratic Republic of Congo H.Linnan Regional Consultant on Child Injury Prevention,UNICEF East Asia and Pacific Regional Office,Thailand P.Orpinas Department of Health Promotion and Behavior,University of Georgia,USA K.Oyegbite Senior Programme Officer,Planning and Coordination Health Section,UNICEF, USA J.Ozanne-Smith Professor,Monash University Accident Research Centre,Australia E.Towner Professor,Centre for Child and Adolescent Health,University of the West of England,United Kingdom WHO thanks Ann Morgan for editorial assistance,Pascale Lanvers-Casasola for administrative support,and Aleen Squires for design of the cover and graphics. The World Health Organization wishes to thank the Netherlands Ministry of Health,Welfare and Sport for their financial contribution which made the publication of this document possible. This document can be downloaded from: http://www.who.int/violence injury prevention/publications/other injury/en/index.html
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Foreword Injury and disability mar millions of young lives each year.Annually more than 875 000 children and adolescents under the age of 18 years die and tens of millions more require hospital treatment following an injury.For survivors the temporary or often times permanent impairment injuries cause and the resulting need for care and rehabilitation have far-reaching impacts on a child or young person's prospects for health,education and social inclusion as well as their parents'livelihood. Apart from the loss of these young lives with all their potential,the effect of injuries on children and adolescents is not limited to the injuries they alone may suffer-death,injury or disability to a sibling, parent or other family member can also alter their lives forever. The unequal burden of injury reinforces a need to address the problem.The burden falls most heavily on children and young people in poorer countries and on those from poorer families in all societies.More than 95%of injury deaths among children and adolescents occur in low-and middle-income countries. However,even in high-income countries,injuries are still a major cause of death for children and adolescents,accounting for about 40%of the deaths among those aged between 1 and 18 years The large and growing toll of child injury death,the significance of serious injury,and the frequent long lasting effects of injury on children and adolescents have resulted in the World Health Organization stepping up its injury prevention efforts.Fortunately,the news is good:there are ways to prevent child and adolescent injuries.The experience of many high-income countries is that a public health approach- rigorous scientific analysis of the problem,research on its causes,implementation of prevention strategies, and the broad replication of measures which have proven to be effective-has lead to substantial reductions.These include interventions on seat-belts,child restraints,helmets,flame resistant clothing and fencing around areas of water,and,to prevent violence-related injuries,they include home visitation programmes,family counselling,substance abuse programs and separate locked storage of firearms and ammunition. This document Child and adolescent injury prevention:a WHO plan of action presents a framework for the World Health Organization's approach to child and adolescent injury prevention,to guide its efforts at country,regional and global levels to reduce fatal and non-fatal injuries among children and young people. The plan results from an extensive process of consultation with organizations and individuals concerned with child health,and with child injury prevention in particular.It focuses on the main areas where WHO has added value in relation to injury prevention for children and adolescents,including surveillance, research,prevention,capacity development and advocacy. The World Health Organization could not take on this task alone,and will work in partnership across sectors to implement this plan.The work will involve a wide range of partners including:child and adolescent injury prevention organizations;WHO collaborating centres for injury and violence prevention; nongovernmental organizations;groups concerned with disability and rehabilitation;organisations representing persons affected by injury and violence and govemment representatives. I invite you to join us in our efforts to prevent these tragic and avoidable deaths and injuries of children and young people around the world. Dr Etienne Krug Director,Department of Injuries and Violence Prevention World Health Organization
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Table ofContents Acknowledgements Foreword Part I.How children are injured 1 1. Introduction 1 Global concern for the health and welfare of children and adolescents 2 Child and adolescent injury prevention in context 2. What are the prevalence,risk factors and impacts of injury? 4 Definitions and classifications 4 Risk factors 7 Economic and social costs 8 Are child and adolescent injuries preventable? 9 4. What are the challenges? 11 Data limitations 11 Research 12 Prevention 12 Capacity development 12 Advocacy 13 WHO's role 13 6. The role of other agencies 14 Part Il The WHO plan of action 15 Data and measurement 16 2 Research 17 Prevention 18 4. Services for children affected by injury and violence 19 6 Capacity development 20 6 Advocacy 7. Conclusion 2 References 23 Annex 1. WHO child and adolescent injury prevention plan at a glance 25
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Part I How childrenare injured 1.Introduction Injury is a major killer of children and adolescents throughout the world,responsible for over 875 000 deaths in children and young people under the age of 18 years each year(1).Tens of millions more require hospital care for non-fatal injuries,many of whom are left with some form of disability,which all too often has lifelong consequences. The burden of injury is unequal in that it falls most heavily on the poor,that is to say,the burden is greatest Child and adolescent injury deaths on children and adolescents in the poorer countries of Injury deathsa Injury death rate the world and within any given country,on those from (of all (per100000 low-income families.Overall,more than 95%of all injury deaths) population) deaths in children and adolescents occur in low-and High-income countries 41 7.7 middle-income countries.Although the child injury death Low-and middle-income rate is much lower among children and adolescents countries 13 37.2 from high-income countries,injuries are still a major cause of death,accounting for about 40%of all child aData refer to persons aged 1-14 years. Source:WHO Global Burden of Disease project,2002,version 5 and adolescent deaths in these countries (see facing table). Disconcertingly,as data collection systems improve,it has become increasingly LEADING CAUSES OF obvious that both the absolute numbers and rates of child and adolescent injury and OLESCEUS AED ONE death are rising in the low-and middle-income countries,in tandem with growing levels TO 15 YEARS,2002,by rank of urbanization and motorization.The combination of increasing incidence and recent successes in reducing other causes of death,particularly infectious disease,means Lower respiratory infections that the significance of injury is growing such that it now figures prominently among the Childhood cluster diseases list of leading causes of death in children and adolescents(see chart). Diarrhoeal diseases These trends can,however,be reversed.The experience of many high-income HIV/AIDS countries shows that through careful analysis and appropriate action,child and Malaria adolescent injuries can be prevented.Among the member countries of the Organisation Road traffic可juries for Economic Co-operation and Development(OECD),for example,the number of Drowning injury deaths among children under the age of 15 years fell by half between 1970 and Perinatal conditions 1995(2).This reduction has been attributed to a combination of research,data system development,the introduction of specific prevention measures,changes in the local Protein-energy malnutrition environment,legislation,public education,improvements in the level and quality of Congential anomalies 10 emergency assistance and trauma care,and project evaluation.Regrettably,until Fire-related burns 11 relatively recently,little or no attention has been paid to the issue of injuries in the low- Tuberculosis and middle-income countries.The lack of awareness and understanding of the problem Meningitis and given the particular circumstances that these countries face-has meant that appropriate interventions for injury prevention have not been implemented to the same Leukaemia extent as they have been in the high-income countries. Poisonings 1
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Global concern for the health and welfare of children and adolescents The central objective of the World Health Organization (WHO),namely,"the atfainment by all peoples of the highest possible leve/of health",by definition embraces children and adolescents.Specific concern for the lives,health and well-being of children and young people is,however,voiced in a series of separate international agreements and initiatives.These agreements,which are briefly described below,reflect not only this broader collective concemn but also the intemational consensus on what needs to be done. Convention on the Rights of the Child(CRC) Parties to the CRC agree to 'tale all appropriate The human rights of children and the standards to which all governments must aspire legislattve,administrattve, in realizing these rights,are concisely articulated in the Convention on the Rights of the Child (3).This United Nations convention was drafted as part of a global socialand educational measures to protect the child consultation process,spanning a 10-year period,and was adopted during a United from all forms of phiysicalor Nations General Assembly session in November 1989.The Convention affirms that mentalviolence,fnfury or each child has the right to the highest attainable level of health and the right to a safe abuse,neglect or negligent environment. treatment,maltreatment or exploitation,including sexual As the majority of United Nations Member States have ratified the Convention,it abuse"(3). represents a powerful statement of the collective views on the responsibilities towards children.At present,however,there is some concern that the intentions of the Article 19 of the Convention on the Rights of the Child Convention are not being fully implemented in practice and that a more concerted effort is required to fulfil its commitments. Millennium Development Goals In September 2000,the General Assembly of the United Nations adopted a series of Millennium Development Goals.One of these goals,the fourth,is the reduction,by two thirds,of the mortality rate in the under-fives between 1990 and 2015(4).Because of the large number of deaths from infectious diseases and neonatal causes in children under the age of 1 year,injury only represents between 1.5% and 2.0%of deaths in this age group.However,for children aged between 1 and 4 years,injuries are a more significant cause of death,accounting for just over 6%of all deaths. United Nations Member States are committed to meeting all eight Millennium Development Goals by 2015. However,recent reports and meetings have expressed concem over the current pace of progress towards meeting these goals and,as in the case of the CRC,greater efforts are called for in order to remedy the situation. A world fit for children In May 2002.the United Nations General Assembly held a Special Session on children.The outcome was a document entitled"A world fit for children",which sets out a series of goals for children and adolescents One of the goals in the plan of action prescribed in this document is specific to injuries and calls upon all Member States to reduce child injuries due to accidents or other causes through the development and implementation of appropriate preventive measures(5). 2
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More recently,the intemational focus on children has resulted in a concerted effort to examine in more detail the factors that influence child survival.Of "Millions of chilaren will particular note is a series of papers published in the Lancet in 2003(6).The continue to die Bellagio papers,as they since have become known,provide new estimates unnecessarily every year, of the numbers and causes of child deaths(including injuries),and suggest unless there are mafor that two thirds of the nearly 11 million annual deaths among children under shifts in policy and funding the age of 5 years can be prevented by universally implementing just 23 at international and cost-effective interventions. country level.We can It is clear from the above discussion that child survival has become an wait no longer.Knowledge must be franslated into important issue globally,forming part of a growing broader collective concer for the health and well-being of children and young people.Indeed,child practice"(6). survival has been described by some as "the most pressing moral dilemma of the new millennium"(7).As a leading cause of death and disability among children and adolescents worldwide,child injury prevention is of particular relevance to this wider issue and is thus central to any intemational effort to improve the health of children and adolescents. Child and adolescent injury prevention in context On the basis of cause of death data reported by its Member States,WHO estimates that at least 875 000 children and adolescents under the age of 18 At least 875 00o chilaren years die as a result of either an unintentional injury ("accident")or an and adolescents under the intentional injury (i.e.violence or self-harm)each year.This is equivalent to age of 18 years die as a 40 deaths per 100 000 children.However,community surveys being result of tnfury each year, undertaken by the United Nations Children's Fund(UNICEF)indicate that the putting unintentional annual death toll might be even higher than this(8). injury firmly among the leading causes of death in A study conducted in 2001 by the UNICEF Innocenti Research Centre ranked 26 of the world's richest countries according to their rates of injury this age group. death among children aged 1-14 years(2).The study showed that in all 26 industrialized countries surveyed,injury was the leading cause of death for children and that mortality is only the tip of the injury burden iceberg.On the plus side,in many of the countries examined the risk of a child dying from injury had halved across a 20-year period,a finding that was attributed to concerted and skilled prevention efforts.The study further concluded that for "..a child born into the developed world today,the chances of death by injury before the age of 15 are approximately 1 in 750-less than half the level of 30 years ago"(2).The league table revealed substantial differences between countries in the level of child injury death;for instance,there is a five-fold difference in child injury death rates between the top and bottom countries,with the group of countries at the bottom having at least twice the rate of child injury death as the group at the top.The magnitude of the range of death rates is particularly significant, indicating just how many additional lives could be saved if countries in the bottom half of the rankings achieved injury death rates that were on a par with those at the top. From a global perspective,the variation in the significance of injury as a cause of death and ill-health is even greater.The percentage that injury represents of all deaths varies markedly across world regions (see map on page 4),and also by country,age,gender and level of income.Injury deaths as a percentage of all deaths ranges from just 2%in those under 1 year of age in low-and middle-income countries to nearly 50%in 10-14 year-olds from high-income countries.Global data on non-fatal injuries are incomplete,especially in relation to the medium-and long-term health effects,including disability.Data of this nature are particularly sparse for the low-and middle-income countries.However,available data for high-income countries suggest that non-fatal injuries are hugely important,not just because of the demand placed on health resources but also in terms of their associated social and economic costs,factors which, 3
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when taken together,mean that non-fatal injuries are likely to make a substantial contribution to the overall burden of injury.For instance,according the Innocenti study,in the OECD nations alone annually there are 50 million accident and emergency department visits and 4 million children hospitalized for injuries(2). In sum,while absolute numbers,proportions and rates vary,it is clear that injury is a universally significant cause of death and hospitalization among children and adolescents throughout the world. REGIONAL DISTRIBUTION OF CHILD AND ADOLESCENT INJURY MORTALITY RATES,2002 (under 15 years) Injury mortality rate per 100 000 population ■5.0-9.9 ■10.0-19.9 ■20.0-29.9 ■30+ WHO 97440 2. Injury:prevalence,risk factors and impacts Definitions and classifications Age groups There is no universally agreed definition as to what constitutes a child or an adolescent.The defined age range of a child or adolescent can,however,have important implications;for example,it can govem the age at which young people enter the formal workforce and/or acquire the legal right to drive a vehicle or to drink alcohol.It is interesting to note that a"child"in one setting may be a"worker"in another. For the purpose of this document a child Definitions in current use tend to have evolved either through common practice,as a result or adolescent is a of legal issues or simply from convenience.Some definitions are linked to changes in development and ability.As children age,grow and develop,their physical and cognitive person under the age abilities,their degree of dependence,the activities they undertake and their risk behaviours of 18 years. change substantially.Often it is these factors that are found to be associated with variations in the incidence and patter of injury and death
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This document follows the practice of the UN Convention on the Rights of the Child,which stipulates that a 'child'means every human being below the age of 18 years(3).When referring to the problem of injury in children and adolescents,however,the focus of attention is primarily on those aged 1-17 years(injury being a less significant cause of death for infants under the age of 1 year). Injury classification Injuries can be classified in a number of ways,either according to Classification of injuries whether or not they are deliberately inflicted (and by whom),and/or according to the mechanism of the injury(see adjacent box).In most WHO,following the International cases,the classification of injury by intent is fairly straightforward. Classification of Disease(ICD-10),uses the However,in relation to children,it is more likely that there will be following classification scheme for injuries some"grey"area.For example,a child losing their balance and falling 9: into a fire clearly constitutes an unintentional injury,but if the fall Unintentional(i.e."accidental"),for example: occurs when the child has been left unsupervised for long periods or road traffic crashes, after the child has been struck,then the question of neglect or abuse falls, arises.In terms of the intention to harm,the gradient ranges from burns,flame,scalds, actively intending to hurt or harm a child at one end of the spectrum drowning, through to neglect,where a child is injured through lack of reasonable poisoning, care or failure to protect.at the other. animal bites. Intentional (i.e.deliberate),for example: interpersonal violence(e.g. Patterns of injury homicide,sexual violence), self-harm(e.g.attempted suicide, Overall,the leading causes of injury death among children and self-mutilation). adolescents are road traffic crashes,drowning,fire-related burns, Legal interventions self-harm and violence (see figure below).It is important to note that War,civil insurrection the pattern of non-fatal injuries is very different to that of injury deaths. Undetermined intent For example,falls are commonly a leading cause of injury but not necessarily a leading cause of injury death. INJURY DEATHS IN CHILDREN AND ADOLESCENTS UNDER THE AGE OF 15 YEARS,BY CAUSE, 2002 Other*28% Road Traffic 26% Self-inflicted 2% Violence 4% Drowning 20% Poisons 5% Falls 5%- Burns 10% *"Other"includes deaths due to smothering,choking,venomous animals,electrocution,firearm incidents and war. Source:WHO Global Burden of Disease project for 2002,version5. 5
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Child injury as a life-cycle issue Injuries are responsible for close to 3%of the nearly 11 million deaths that occur annually in children under the age of 5 years.Although in the case of infants under 1 year,injury only represents 1-1.5%of all deaths,for those aged 1-4 years,the proportion rises to 6%.As a cause of death,injury continues to increase in significance as children age:for children aged 5-9 years injury is associated with 25%of deaths,and for those aged 10-14 years,injury accounts for almost a third of deaths(31%).The proportion of deaths due to injury for those aged 15-17 years is likely to be the same as,or higher than,that for those aged between 10 and 14 years(1).On average,for children in the age group 5-14 years,injury accounts for more than a quarter(27%)of all deaths worldwide. The finding that injury prevalence is highly associated with age and stage of development is not surprising. In fact,the rate of injuries rises the moment babies start to move and explore their world.This is because children inhabit a world built for adults but interact and deal with the world differently to adults.Their size mass,bodily proportions and surface-to-mass ratio are all factors that contribute to increasing their risk of dying from a specific type of injury.For example,a hot liquid scald of a given size is likely to be more dangerous to a child than to an adult because of the greater proportion of skin affected;likewise,the toxic dose of a poisonous substance is lower for children because of their smaller mass.Exploration of their surroundings is an essential part of a child's development but it is this very exploration-combined with their lack of understanding of hazards and the nature of their immediate environment-that places them at risk:a baby explores its world by putting things in its mouth oblivious to any harm that might accrue from so doing or steps onto water not understanding that it is not solid.The ability to judge hazards takes time to develop and in very young children its absence further increases their risk of injury. The stage of development of a child,how a child interacts with the world and the different activities it undertakes as it matures all help to explain the strong association between life-stage and the rate and type of injury.For instance,among those aged under 1 year,fires,road traffic crashes,drowning and falls are the leading causes of injury death.In the 1-4 year age group,as children start to move more independently,drowning becomes the leading cause of injury-related death followed by road traffic crashes and fires,all three of which combined account for two thirds of injury deaths.Similarly,most injury deaths in young children can be categorized as unintentional,but as children age the proportion of intentional injury begins to rise.Whereas in children under 10 years of age intentional injury only accounts for around 5%of injury deaths,in those aged 10-14 years,the percentage rises to about 15%.Above 15 years of age,as many as one third of injury deaths are classified as intentional. Child injury and gender Injury and injury death are also highly associated with gender.In the under fifteens,there are,on average, 25%more injury deaths among boys than there are among girls(1).A number of factors contribute to the male excess in injury mortality,including differences in exposure to hazards,behaviour and socialization as well as differences in social treatment. The gender difference varies by the type of injury and also by age.The number of male deaths exceeds that of females in nearly all categories of injury,with the exception of fire-related bums(see figure on page 7).The female excess in fire-related bums is particularly noticeable in certain parts of the world,where female adolescent deaths can exceed males by more than 50%(1).In the low-income countries of the Easter Mediterranean Region,for example,flame death rates for females aged 10-14 years are 60% higher than those for males (1).a finding which can be attributed,at least in part,to the fact that the responsibility for cooking-mainly on open fires-falls to young girls and women,many of whom wear traditional-style,flammable clothing 6
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