Injury Surveillance

Training Manual

Participant Guide
INJURY SURVEILLANCE TRAINING MANUAL 

 

“The reason for collecting, analyzing, and disseminating information 

on a disease is to control that disease. Collection and analysis should 

not be allowed to consume resources if action does not follow.” 

William H. Foege, M.D., M.P.H., Former Director, 

Centers for Disease Control and Prevention 

In: Horan M, Mallonee S. Injury Surveillance. 

Epidemiological Reviews 2003;25:24–42.

 

 

 
The Injury Surveillance Training Manual is a publication of the National Center for

Injury Prevention and Control, part of the Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention 

Julie L. Gerberding, M.D., M.P.H.

Director

National Center for Injury Prevention and Control

Ileana Arias, Ph.D.

Director

I am grateful to a number of colleagues at the  

National Center for Injury Prevention and Control (NCIPC)

and the Division of International Health,  

Epidemiology Program Office,  

for their helpful recommendations and

assistance in producing this manual.  

Thanks to the NCIPC staff, Office of Communication Resources,  

for producing these training materials.  

Special thanks to Sue Swensen, Sandra Emrich,  

Sevena Quattlebaum, and Mary Ann Braun.

— Victoria Espitia‐Hardeman

Suggested Citation: Espitia‐Hardeman V, Paulozzi L. Injury Surveillance Training

Manual. Atlanta (GA): Centers for Disease Control and Prevention, National

Center for Injury Prevention and Control; 2005.

Injury Surveillance Training Manual 2 Introduction 
INJURY SURVEILLANCE TRAINING MANUAL 

Team Coordinator 

Victoria Espitia‐Hardeman 

Reviewers—English Version 

Ileana Arias

Carmen Clavel‐Arcas  

Alberto Concha‐Estman

Linda Dahlberg

Ann Dellinger

Martha Highsmith

Arthur Kellerman

Sue Mallonee

James Mercy  

Leonard Paulozzi  

David Sleet

David Wallace

Rick Waxweiler  

Pilot Test in Nicaragua 

Carmen Clavel‐Arcas

Fabiola Prado

Julio Rocha

Pilot Test in Brazil 

Vilma Gawriyswesky

Sonia Gesteira

Leonard Paulozzi

Eugenia Rodrigues

Development Team

Hoang Dang

Douglas Klaucke

James Mercy  

Carmen Sanchez‐Vargas

Denise Traicoff

David Wallace

Rick Waxweiler 

Public Health Students in 

Practice 

LaShawn Curtis

Nevada Wolf  

 

Pilot Test in El Salvador

Rafael Chacon

Wilfredo Chara

LaShawn Curtis

Silvia de Garcia

Roberto Florez  

Julio Rocha

Gloria Suarez

Denise Traicoff

David Wallace

Pilot Test in Honduras

Gloria Suarez‐Rangel  

Cover Photos

Jose Fernando Rios, Journalist     

Instituto Cisalva, Universidad

del Valle, Cali  

 

Editor—English Version 

Lisa Jeannotte  

Editor—Spanish Version 

Dilia Franz                                

Reviewers—Spanish Version 

Carme Clavel‐Arcas

Alberto Concha‐Eastman

Rodrigo Guerrero Velasco

Joanne Klevens

Gloria Suarez‐Rangel

Maria Isabel Gutierrez

Injury Surveillance 

Conceptual Art 

Diane Speight

Injury Surveillance Training Manual 3 Introduction 
CONTENTS 

 

Introduction 

Overview,   7

Workshop Guide,   10  

Course Outline,   14

Sessions 

Pretest 

I Understand the Conceptual Framework of Injury Prevention

II Assess Injury Data Sources and Describe the Injury Problem

III Build a Coalition to Support the Injury Surveillance System  

and Prevention Activities

IV Determine the Appropriate Methodology for the  

Surveillance System        

V Define and Develop an Analysis Plan for the Surveillance Data                     

VI Use Injury Surveillance Data to Inform Injury Prevention

VII Define  an Evaluation Plan for the Surveillance System and

Monitor Prevention Activities

Posttest 

Session evaluation 

Workshop evaluation 

Injury Surveillance Training Manual 5 Introduction 
Introduction
INTRODUCTION 

Overview 

This manual has been designed primarily for professionals who develop or operate 

surveillance systems and conduct prevention activities in less-resourced countries. It 

describes the steps needed to establish and maintain an injury surveillance system; 

provides information on designing and monitoring prevention activities; and 

provides guidance for making informed decisions about injury prevention. The 

curriculum used in this manual emphasizes the following: 

1. Basic epidemiological skills needed to conduct surveillance and 

prevention activities; 

2. Participation by different sectors and institutions in injury 

prevention and control efforts—including federal and local 

governments, health and transportation sectors, forensic 

medicine, law enforcement, justice systems, family counseling 

offices, and nongovermental organizations; and 

3. Injury surveillance and prevention activities at the local level, 

where stakeholders are closest to the injury data and can 

specifically address injury problems. 

This manual contains an overview, an introduction to the conceptual famework of 

injury prevention, and six surveillance sessions. You are encouraged to perform the 

exercises using your local injury data. 

A. Learning Objectives 

By the end of the course, participants should be able to: 

1. Understand the conceptual framework of injury prevention; 

2. Assess injury data sources and describe the injury problem; 

3. Build a coalition to support the injury surveillance system 

and prevention activities; 

4. Determine the appropriate methodology for the surveillance system; 

5. Define and develop an analysis plan for the surveillance data; 

6. Use injury surveillance data to inform injury prevention; 

7. Define an evaluation plan for the surveillance system and monitor 

prevention activities. 

Injury Surveillance Training Manual 7 Introduction 
B. Target Audience 

This manual targets public health officials who are or will be responsible for an 

injury surveillance system, including Field Epidemiology Training Program 

(FETP) trainees, epidemiologists, and health professionals. The audience must 

include stakeholders, human rights advocates, and personnel from a 

transportation office, forensic medicine, or law enforcement (police, district 

attorney, etc.). 

C. Content of Sessions 

Session I. Understand the Conceptual Framework of Injury Prevention 

Terms and key concepts about injury prevention are presented in this session, 

such as: What is an injury? What is the difference between unintentional and 

violence-related injury? What is the impact of injury on public health? Session I 

will answer these questions and will demonstrate the important role 

epidemiologists and public health officers play in addressing serious public 

health issues. This session will be sent to you at least two weeks before the 

training course because self-study is required prior to the instructor-led 

training. 

Session II. Assess Injury Data Sources and Describe the Injury Problem 

Before developing an effective injury surveillance system, public health 

professionals must understand the status, usefulness, and quality of existing 

data sources. This session addresses potential injury data sources, how to 

identify the strengths and weaknesses of each, and how to calculate basic 

indicators that describe the injury problem. 

Session III. Build a Coalition to Support the 

Injury Surveillance System and Prevention Activities 

A successful surveillance system requires the cooperation and effort of many 

individuals and organizations, which can be achieved through a coalition, an 

alliance of organizations working together to achieve a common purpose. A 

coalition can also provide intervention channels within a community (e.g., 

health care system, schools, and work sites). This session addresses how to 

identify partners and build, manage, and maintain a coalition to support an 

injury surveillance system. 

Session IV. Determine the Appropriate 

Methodology for the Surveillance System 

The events, variables, types of surveillance systems, and factors to consider 

when planning for injury data collection will be examined in this session. These 

factors include collection frequency, data collection instruments, data entry, and 

quality control of data. Key staff and positions to operate the system are 

described as well. 

Injury Surveillance Training Manual 8 Introduction 
Session V. Define and Develop an Analysis Plan for the Surveillance Data 

Data analysis is an important step in a surveillance system. Raw statistics are 

usually insufficient to fully describe a problem. Typically, the raw data is 

analyzed and interpreted to identify the most important problem areas and to 

present information in a way that is easy to understand. In this session, 

participants will calculate basic indicators such as: crude, specific and adjusted 

rates and YPLL. The session also addresses geographical analysis of events and 

etiological factors, creation of maps, calculation of public health indicators, 

development of a plan to disseminate results, and the basic contents of a 

surveillance report. 

Session VI. Use Injury Surveillance Data to Inform Injury Prevention

Public health practitioners use surveillance system data to respond effectively 

to the injury problem. Surveillance data can guide injury prevention actions 

such as the development of new policies and strategies or the improvement 

of existing ones. In this session, participants will learn how to use surveillance 

data to identify priority injuries, etiological factors, and methods to select 

appropriate prevention activities. Haddon Matrix, Ecological Model and 

Decision Matrix will be used with this purpose. 

Session VII. Define an Evaluation Plan for the 

Surveillance System and Monitor Prevention Activities 

Once the surveillance system is operational, it should be evaluated to confirm 

that it is accomplishing its purpose. In this session, you will learn to apply the 

Centers for Disease Control and Prevention (CDC) evaluation criteria when 

evaluating a surveillance system. The session also addresses how to monitor 

prevention activities using surveillance system data. 

A. Participant Prerequisites 

1. Experience in giving public presentations; 

2. Experience in report writing; 

3. Familiarity with local injury data and demographic data to be used in 

the workshop, such as: 

• Country population by age and sex; 

• Causes of death (from public health and vital statistics offices); 

• Injury deaths by intention, such as: homicide, suicide, motor 

vehicle-related, other injury deaths, domestic violence, child 

maltreatment (from police departments, forensic medicine, 

district attorneys, coroners/medical examiners, transportation 

offices, and public health offices); and 

• Nonfatal injury data (from public health offices or hospital 

discharge records, if available). 

4. Knowledge of basic principles of epidemiology; and 

5. Knowledge of basic principles of public health surveillance. 

Injury Surveillance Training Manual 9 Introduction 
B. Recommended Reading (to be completed before the course begins)

• Session I of the manual, “Understand the Conceptual 

Framework of Injury Prevention” (to be provided two weeks 

before the workshop) 

• Principles of Epidemiology—CDC course #3030 (www.phf.org) 

• World Health Organization (WHO) World Report on Violence and 

Health (www.who.org) 

• WHO World Report on Road Traffic Injury Prevention 

(www.who.org) 

• Injury Surveillance Guidelines. Geneva. World Health Organization, 

2001

• Guidelines for the Epidemiological Surveillance on Violence and 

Injuries. Pan-American Health Organization. 2001

C. Evaluation Forms 

• Learner Evaluation (Pre- and Post-Course Test):

A pretest will be administered to participants at the 

beginning of the first day to establish a baseline of 

previous knowledge. The same test will be administered 

at the end of the workshop to evaluate student progress. The 

participants will have 15 minutes to complete each test. 

• Session Evaluation:

A session evaluation form will be distributed to participants 

at the end of each session to determine if the objectives were met. 

• Workshop Evaluation:

An evaluation form will be distributed to participants at the 

end of the workshop to determine its overall success and to 

evaluate the instructor, materials, and length of sessions and 

workshop. 

Injury Surveillance Training Manual 10 Introduction 
Course Outline 

Session I. Understand the Conceptual Framework of Injury Prevention 

1. Injury Definition. 

2. Injury classification. 

3. The global burden of injuries. 

4. The cost of injuries. 

5. Conceptual models for understanding and preventing injury: 

The public health approach to injury prevention; 

The Epidemiological Triad; 

The Haddon Matrix; 

The Ecological Model. 

6. Development of an Injury Surveillance System. 

7. Ethical considerations. 

Session II. Assess Injury Data Sources and Describe the Injury Problem 

1. Identify strengths and weaknesses of injury data sources. 

2. Determine the jurisdiction, data collection method, and data flow 

used by each data source. 

 2.1 Describe data collection method and data flow. 

3. Identify the data sources to include in the surveillance system. 

4. Describe the size of the injury problem: 

4.1 Determine the frequency of the leading causes of death; 

4.2 Determine the frequency of the leading causes of injury 

deaths. 

5. Compare the frequency of injuries calculated with data from 

different sources. 

Session III. Build a Coalition to Support the Injury Surveillance System and 

 Prevention Activities 

1. Identify partners to include in the coalition. 

 1.1 Determine recruiting strategies to involve Coalition Partners 

2. Identify local, national, or international organizations working in 

injury prevention and control in the region. 

3. Determine the existing political, social, and legal framework within which the 

surveillance system and prevention strategies will be established. 

Injury Surveillance Training Manual 11 Introduction 
Session IV. Determine the Appropriate Methodology for the Surveillance System 

1. Define the events to include in the surveillance system. 

2. Determine data elements to include in the system: Variables, Case Definition, 

and Codes 

2.1 Define the variables; 

2.2 Define the codes to use in the system; 

2.3 Review the case definition. 

3. Develop data collection instruments and determine data 

collection frequency. 

4. Determine the type of surveillance system. 

5. Plan for systematization, maintenance, and data security. 

6. Describe the staff and key positions necessary to operate the system. 

 

Session V. Define and Develop an Analysis Plan for the Surveillance Data 

 1. Calculate frequency and percentage of injury deaths (homicide, suicide, 

motor vehicle-related, and other unintentional deaths): 

1.1 Calculate injury rates: How to Get Appropropriate denominators; 

1.2 Calculate crude rates for injury deaths; 

1.3 Calculate specific rates for injury deaths by age group; 

1.4 Calculate adjusted rates using direct method. 

2. Calculate years of potential life lost (YPLL). 

3. Describe the geographical analysis of data. 

4. Define a plan to disseminate and communicate the results; 

 4.1 Define the basic elements to include in an injury surveillance system report 

 4.1.1 Recipients. 

 4.1.2 Delivery method. 

 

Session VI. Use Injury Surveillance Data to Inform Injury Prevention 

1. Identify priority injuries. 

2. Identify potential etiological factors of the priority injuries in the region or city: 

2.1 Use the Haddon Matrix to help identify and organize 

potential etiological factors for unintentional injuries; 

2.2 Use the Ecological Model to identify and organize 

potential etiological factors for violence-related injuries. 

3. Review effective injury prevention strategies. 

4. Identify and select potential interventions to prevent priority injuries: 

4.1 Use the Haddon Matrix to identify possible interventions 

for unintentional injuries; 

4.2 Use the Ecological Model to organize possible interventions 

to prevent violence-related injuries. 

5. Use the Decision Matrix to identify the most appropriate intervention for the 

 injuries in your region. 

Injury Surveillance Training Manual 12 Introduction 
Session VII. Define an Evaluation Plan for the Surveillance System and 

 Monitor Prevention Activities 

1. Know the steps for evaluating an injury surveillance system: 

1.1 Engage stakeholders in the evaluation; 

 1.2 Describe the surveillance system to be evaluated; 

 1.3 Focus the evaluation design; 

1.4 Gather credible evidence about the surveillance system’s 

performance. 

1.5 Justify and state conclusions and make recommendations. 

 1.6 Use evaluation findings and share lessons learned. 

2. Review public health indicators proposed to monitor injuries 

 2.1 Basic indicators 

 2.2 Developmental indicators 

 2.3 Research indicators. 

3. Use injury surveillance data to monitor prevention activities. 

Steps to Develop and 

Maintain an 

Injury Surveillance System

7. Define an evaluation plan

 for the surveillance system

 and monitor prevention 

 activities 

Apply the criteria to evaluate 

the surveillance system and

monitor the strategies 

1. Understand the conceptual 

 framework of injury prevention 

Define and understand typology 

of unintentional and violencerelated injuries

2. Assess injury data sources 

 and describe the injury 

 problem 

Identify strengths and 

weakness of injury data 

sources and size of the 

problem 

3. Build a coalition to support 

 the injury surveillance system 

 and prevention activities 

4. Determine the appropriate

 methodology for the 

 surveillance system 

Determine events, data 

elements, type of surveillance, 

and data-collection instruments

5. Define and develop an 

 analysis plan for the 

 surveillance data 

Use data to identify preventable 

injuries, high-risk groups, and 

most appropriate interventions 

6. Use injury surveillance data 

 to inform injury prevention 

Calculate indicators, demographics, and environmental 

characteristics 

Identify partners to include 

in a coalition to support the 

injury surveillance system 

Injury Surveillance Training Manual 13 Introduction 
Appendix 1 

Pretest 

Length: 10 minutes 

City/Country: ____________________________________________ 

Date: ___ / ___ / ____ 

1. Which of the following items are components of the injury definition? 

a) Damage to a person caused by exposure to physical agents in amounts that 

exceed the threshold of human tolerance. 

b) Damage to a person caused by a sudden lack of essential agents (oxygen 

or heat). 

 c) Psychosocial trauma which results in emotional injury. 

2. For each type of injury, place a check mark under the appropriate injury classification: 

Violence-related 

injuries 

Unintentional 

injuries 

Other type of 

injuries 

Types of injuries 

Child abuse 

Assault by firearm 

Poisoning with pesticide 

Pedestrian injury 

Intimate partner violence 

Suicidal behavior 

Injury Surveillance Training Manual Appendix 1. Pretest 

 

1
3. Place the following etiological factors in the appropriate phase of the Haddon Matrix: 

Etiological factors Pre-event Event Post-event 

Impaired driving laws 

Quality of medical services 

Speed of the vehicle at impact 

Seat belt use 

Speed limit laws 

Brakes and tires of the vehicle 

involved 

Pedestrian walking in the roadway 

Recovering areas in case of 

emergency 

4. Select potential partners for a coalition that supports the injury surveillance system and 

prevention activities: 

Potential Partners YES NO 

Health 

(hospital and health center directors, ministries of health) 

Justice 

(forensic medicine, coroners/medical examiners, courts, 

prosecutors)

Security 

(police, security companies, homicide investigators) 

Transportation 

(transportation department offices or officers)

Administration 

(planning officers)

Education 

(academic directors)

Community 

(community organizations, youths, mothers) 

Private organizations 

(NGOs, human rights groups) 

Political 

(national, regional, or local authorities) 

Other 

(mention which one)

Injury Surveillance Training Manual Appendix 1. Pretest 

 

2
5. Place the following factors for intimate partner violence in the appropriate level of the 

Ecological Model: 

Factors Individual Relationship Community Societal 

Absent or rejecting 

father 

Acceptance of 

violence as a way to 

resolve conflict 

Isolation of women 

and family 

Witnessing marital 

violence as a child 

Marital conflict 

Norms related to male 

authority over women 

Injury Surveillance Training Manual Appendix 1. Pretest 

 

3
Sessions
INJURY SURVEILLANCE TRAINING MANUAL 

PARTICIPANT GUIDE 

SESSION I 

UNDERSTAND THE CONCEPTUAL FRAMEWORK OF 

INJURY PREVENTION 

Source: National Center for Injury Prevention and Control

Developed with the support of the 

National Center for Injury Prevention and Control 

 Division of International Health, Epidemiology Program Office 

 Centers for Disease Control and Prevention 

Atlanta, GA 
SESSION I 

UNDERSTAND THE CONCEPTUAL FRAMEWORK 

OF INJURY PREVENTION 

Learning Objectives 

• Understand concepts, definitions, and classification of injury. 

• Know the differences between violence-related and 

unintentional injuries. 

• Describe the global burden and cost of injuries. 

• Know the conceptual models for understanding and preventing injury. 

• Know the steps to develop an injury surveillance system. 

• Review ethical considerations. 

Introduction 

This session reviews key concepts of injury prevention. You are encouraged to review 

these concepts before the training course. The definition of injury and its varied 

classifications are reviewed in the first part of the session; the magnitude of the injury 

problem worldwide is covered in the second part. Conceptual models for 

understanding and preventing injury (Epidemiological Triad, Haddon Matrix, and 

Ecological Model) are also covered. Afterwards, the steps to develop and maintain an 

injury surveillance system are discussed. Finally, ethical considerations are mentioned. 

1. Injury Definition 

An injury is caused by acute exposure to physical agents such as mechanical energy, 

heat, electricity, chemicals, and ionizing radiation interacting with the body in 

amounts or at rates that exceed the threshold of human tolerance (Baker et al. 

referenced Gibson 1961 and Haddon 1963). In some cases (for example drowning 

and frostbite), injuries result from the sudden lack of essential agents such as oxygen 

or heat. About three-fourths of all injuries, including most vehicle crashes, falls, 

sports, and shootings, are caused by mechanical energy.1

 

“Injury” Versus “Disease” 

Some definitions of injury include a relationship between the time of exposure and 

appearance of an injury, usually classified as “short.”1 Some experts consider that the 

interval between exposure and the appearance of injury can be relatively long, such as 

in poisoning from carbon monoxide, alcohol abuse, or heavy metals. The distinction 

between injury and disease is a related issue. Consider the following examples:2

Injury Surveillance Training Manual 3 Participant Guide — Session I 
Injury Disease 

A construction worker fractures his toe while using a 

jackhammer. 

Another worker is diagnosed as having 

tendonitis of the elbow from the chronic 

vibrations of the jackhammer. 

An operator at a nuclear power plant is burned 

severely when a fuel rod breaks open. 

A fisherman develops thyroid cancer 20 

years after fallout from an aboveground 

nuclear test that blanketed his boat with 

radiation. 

A child is bitten by guard dog and requires 10 

stitches to his leg. 

A child dies of rabies after a bat bite. 

In each of the preceding examples, we would say the first victim suffered from an 

“injury,” while the second suffered from a “disease.” Acuteness is certainly a factor: 

the shorter the time from exposure to a hazard to its physical effects, the more likely 

we are to call the resulting condition an “injury” rather than a “disease.” 

Other experts have added to this discussion: “It is the acuteness of exposure 

that differentiates injury from disease. Thus, acute smoke inhalation is generally 

classified as an injury, whereas chronic damage from substances such as lead and 

cigarette smoke are excluded as injuries because toxic effects often occur slowly. 

This distinction is somewhat arbitrary and certainly not rigid, but it is conceptually 

useful for classification, research, and policy purposes.”3

 Interval from Appearance of Injury to Death 

The interval from the appearance of injury to death could be immediate, or as long 

as months or years. For instance, in the United States, a death can be linked to an 

injury at any time. It is classified as “injury sequelae” if one year or more has 

elapsed since the injury. In the Fatality Analysis Reporting System (FARS) of the 

U.S. National Highway Traffic Safety Administration, for vehicles traveling on 

public roads, all injuries resulting in the death of the victim within 30 days of the 

event are considered motor vehicle-related death. Another example is the Fatal 

Injury Surveillance System in Cali, Colombia,4 that classifies a death as 

injury-related regardless of the length of time between the injury and death. In some 

cases, this period could exceed one year. The situation in other countries may be 

different. 

 

“Injury” Versus “Accident” 

“Accident” is often used to mean an unintentional event that produces, or has 

the potential to produce, an injury. Sometimes, the word “accident” is used 

synonymously with “injury.” However, many experts in public health believe 

that widespread use of the term “accident” has not only caused semantic confusion, 

but has inhibited efforts to reduce injuries. 

Injury Surveillance Training Manual 4 Participant Guide — Session I 
This is because many people think of an “accident” as being something 

unpredictable or “an act of God” (Holder et al. referenced Haddon 1968). In 

actuality, events that injure people are not random and have identifiable risk factors.

These events involve interactions among people, vehicles, equipment, processes, 

and the physical and social environment. For these reasons, the word “accident” 

should be avoided.5

2. Injury Classification 

Injuries can be classified by the intention of the act into two groups: unintentional 

injuries and violence-related injuries (also called intentional injuries). The first 

group includes injuries related to transportation and traffic incidents, or occurring at 

home, in the workplace, in public places, and in natural disasters. The second group 

includes injuries related with interpersonal, collective, terror-related, and selfinflicted violence. 

 Unintentional Injuries 

Unintentional injury is defined as: 

1. Physical damage to the body; 

2. Damage resulting from excessive energy applied to the body (physical, 

radiant, etc.); or from exposure to external agents (e.g., poisons); or from the 

absence of essentials (warmth, oxygen); 

3. The application, exposure, or deprivation not done deliberately to oneself or 

by another person. 

Unintentional injuries occur by a number of mechanisms, including falls, road 

traffic, water hazards, fire and hot liquids, and poisonings.3 The energy that causes 

injury may be: 

• Mechanical (an impact with a moving or stationary object such as surface, 

knife, or vehicle); 

• Radiant (ultraviolet radiation); 

• Thermal (air or water that is too hot or too cold); 

• Electrical (lightning strike, electric shock); 

• Chemical (a poison or mind-altering substance such as drugs or alcohol).6

Unintentional injuries account for about two thirds of all injury deaths in the 

United States. Almost half are attributable to motor vehicle-related incidents. 

In Table 1, the mechanism of injury is matched with the place of injury occurrence. 

Shaded boxes indicate locations where the injury occurs most often. 

Injury Surveillance Training Manual 5 Participant Guide — Session I 
Table 1. Unintentional Injuries 

Place of Occurrence 

Mechanism of Injury Home Sports/ 

Leisure 

Workplaces School 

Facilities 

Public 

Places 

Burns/Scalds 

From electrical appliances, cooking mishaps, cooking 

stoves with open flame, radiators, home fires, fireworks 

Cuts/Lacerations 

Toys, sports, playgrounds, furniture, household gadgets, 

gadget blades, occupational hazards 

Drowning 

At pools and beaches or from floods, falls into ponds and 

wells, water transport 

Impact Injury 

Falls from rooftops, windows or furniture; falls related to 

agriculture, construction, recreation, sports, or transportation (automobiles, cyclists, pedestrians, motorcyclists) 

Electric Shock 

From household gadgets, toys, and substandard or 

hazardous wiring; improper use of and substandard 

electrical gadgets 

Poisoning 

From medicines, household chemicals, cooking fuels, 

seeds 

Suffocation/Asphyxia 

From infant and toddler furniture, clothes and toys, plastic 

bags, swallowing of seeds or toys 

Firearms 

Unintentional use 

Insect and Animal Bites 

From dogs, snakes, scorpions, etc. 

Adapted from: Mohan D, Romer J. Accident mortality and morbidity in developing countries. In: The 

Epidemiological Approach. New York, NY: Oxford University Press; 1998. 

 

 Violence-Related Injuries (Intentional Injuries)

The World Health Organization (WHO) defines violence as: 

The intentional use of physical force or power, threatened or actual, 

against oneself, another person, or against a group or community, that 

either results in or has a high likelihood of resulting in injury, death, 

psychological harm, maldevelopment, or deprivation.7

The three categories differentiate among violence a person inflicts upon oneself (selfdirected); interpersonal violence inflicted by another individual or by a small group 

of individuals; and violence inflicted by larger groups such as states, organized 

political groups, militia groups, and terrorist organizations. 

Each broad category is subdivided into specific types of violence. Self-directed 

violence includes suicidal behavior and self-abuse. Interpersonal violence includes 

two subcategories: violence between family members and intimate partners, and 

community violence between individuals who are unrelated (usually in a place other 

than the home). Collective violence is subdivided into social, political, and economic 

violence. The social violence category includes, for example, crimes of hate 

committed by organized groups, terrorist acts, and mob violence. Political violence 

Injury Surveillance Training Manual 6 Participant Guide — Session I 
includes war and related violent conflicts, state violence, and similar acts carried out 

by large groups. Economic violence includes attacks by large groups motivated by 

economic gain. Clearly, acts committed by large groups can have multiple motives. 

A violent act can also be classified by its nature. The four categories are physical 

violence, sexual violence, psychological violence, and violence involving 

deprivation or neglect. These four types of violent acts occur in each of the broad 

categories described above—except self-directed violence. For example, violence 

against children can include physical, sexual and psychological abuse, or neglect. 

In the World Report on Violence and Health,

7 violence is divided into three categories 

according to the person who commits the violent act and into four categories 

according to the nature of the violence. The horizontal array shows who is affected, 

and the vertical array describes how they are affected (Table 2). 

Table 2. A Typology of Violence 

Self-Directed Interpersonal 

Family/Partner Community Nature of Collective 

Violence Suicidal 

Behavior 

SelfAbuse Child Partner Elder Acquaintance Stranger Social Political Economic

Physical 

Sexual 

Psychological 

Deprivation or 

Neglect 

Adapted from: Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World Report on Violence and Health. 

Geneva: World Health Organization; 2002. 

According to WHO, an estimated 1.6 million people worldwide died in 2000 as 

a result of self-inflicted, interpersonal, or collective violence. Nearly half of these 

deaths were suicides; one third were homicides; and one fifth were war related. 

International estimates on physical and sexual assaults are lacking, as systems 

for reporting and compiling these data are absent in many countries, or are still 

being developed. There are often cultural and social pressures to keep violence 

behind closed doors or to accept it as a natural facet of human relations. Even in 

areas where surveillance systems are in place, victims may be reluctant to report 

violent experiences.7

Injury Surveillance Training Manual 7 Participant Guide — Session I 
3. The Global Burden of Injuries 

Every day around the world, almost 16,000 people die from injuries, according to 

WHO. For every person that dies, several thousand more are injured, some of them 

with permanent sequelae. Motor vehicle-related injuries are the eleventh leading 

cause of mortality worldwide (Table 3). 

Table 3. Leading Causes of Mortality Worldwide, Both Sexes — 2002 

Rank Causes Percentage of Total 

 1. Ischemic Heart Disease 12.6 

 2. Cerebrovascular Disease 9.6 

 3. Lower Respiratory Infections 6.6 

 4. HIV/AIDS 4.9 

 5. Chronic Obstructive Pulmonary Disease 4.8 

 6. Perinatal Conditions 4.3 

 7. Diarrheal Diseases 3.1 

 8. Tuberculosis 2.8 

 9. Trachea, Bronchus, Lung Cancers 2.2 

10. Malaria 2.1 

11. Road Traffic Injuries 2.1 

12. Diabetes Mellitus 1.7 

Source: Peden M, Scurfield R, Sleet D, et al. World Report on Road Traffic Injury Prevention. Geneva: World 

Health Organization; 2004. 

In 1998, road traffic injuries were the leading cause of unintentional injury deaths in 

the world. Suicides were the leading cause of violence-related injury deaths and the 

third leading cause of injury overall (Table 4). 

Table 4. Injury-Related Mortality Worldwide — 1998 

Injury Deaths Number of Deaths Mortality Rate (per 100,000) Percentage 

Unintentional

Road Traffic Injuries 1,170,694 19.9 20.3 

Drowning 495,463 8.4 8.5 

Falls 315,633 5.4 5.4 

Burning 282,178 4.8 4.8 

Poisoning 251,881 4.3 4.3 

Other Unintentional Deaths 977,259 16.6 16.9 

Violence-Related 

Suicide 947,697 16.1 16.4 

Homicide 735,972 12.5 12.7 

War 588,050 10.0 10.2 

Total 5,764,825 97.9 100.0 

Source: Krug E, ed. Injury: A Leading Cause of the Global Burden of Disease. Geneva: World Health 

Organization; 1999. 

 

Injury Surveillance Training Manual 8 Participant Guide — Session I 
Age and Sex of Victims 

According to WHO, an estimated 520,000 homicides occurred in 2000, with an 

adjusted rate of 8.9 per 100,000 population. Nearly 80% of the homicides were males, 

with a rate of 13.6 per 100,000, three times higher than for females, for 

which the rate was 4.0 per 100,000. Males aged 15 to 29 years had the highest rates 

of homicide of all age groups (19.4 per 100,000)7 (Table 5). 

Table 5. Estimated Global Homicide and Suicide Rates 

by Age Group and Sex — 2000 

Homicide Rate* Suicide Rate* Age Group (years) Males Females Males Females 

0–4 5.8 4.8 0.0 0.0 

5–14 2.1 2.0 1.7 2.0 

15–29 19.4 4.4 15.6 12.2 

30–44 18.7 4.3 21.5 12.4 

45–59 14.8 4.5 28.4 12.6 

60+ 13.0 4.5 44.9 22.1 

Total ** 13.6 4.0 18.9 10.6 

* Rates per 100,000 population 

** Age standardized 

Source: WHO Global Burden of Disease Project for 2000. Version 1. In: Krug E, Dahlberg L, Mercy J, Zwi A, 

Lozano R, eds. World Report on Violence and Health. Geneva: World Health Organization; 2002. 

 High- Versus Low-Income Countries 

Analysis of mortality causes by region reveals important characteristics (Table 6). In 

high-income countries, self-inflicted injuries are the twelfth leading cause of injury 

mortality, and road traffic injuries are the fourteenth leading cause. In low-income 

countries, road traffic injuries are the tenth leading cause of death.8

Table 6. Leading Causes of Mortality in High- and Low-Income 

Countries, Both Sexes — 2002 

High-Income Countries 

Rank Causes 

Percentage 

of Total 

Low-Income Countries 

Rank Causes 

Percentage 

of Total 

 1. Ischemic heart disease 17.0 1. Ischaemic heart disease 11.8 

 2. Cerebrovascular disease 9.8 2. Cerebrovascular disease 9.6 

 3. Trachea/bronchus/lung cancers 5.8 3. Lower respiratory infections 7.0 

 4. Lower respiratory infections 4.4 4. HIV/AIDS 5.7 

 5. Chronic obstructive pulmonary 

 disease 

 3.9 5. Chronic obstructive pulmonary 

 disease 

 5.0 

 6. Colon/rectum cancers 3.3 6. Perinatal conditions 5.0 

 7. Alzheimer and other dementias 2.7 7. Diarrheal diseases 3.6 

 8. Diabetes mellitus 2.6 8. Tuberculosis 3.2 

 9. Breast cancers 1.9 9. Malaria 2.5 

10. Stomach cancer 1.8 10. Road traffic injuries 2.2 

11. Hypertensive heart disease 1.6 11.Trachea/bronchus/lung cancers 1.6 

12. Self-inflicted injuries 1.6 12. Hypertensive heart disease 1.6 

Source: Peden M, Scurfield R, Sleet D, et al. World Report on Road Traffic Injury Prevention. Geneva: World 

Health Organization; 2004. 

Injury Surveillance Training Manual 9 Participant Guide — Session I 
Unintentional Injuries 

The major types of unintentional injury have similar rates in most countries. 

However, the nature and extent of injury varies widely by geographic, cultural, 

urban/rural, and other factors. In Table 7, the major causes of severe injury in highincome countries are compared with those of low-income countries. Once the 

differences are understood, appropriate data can be gathered and effective 

preventive measures can be instituted. 

Table 7. Major Causes of Severe Unintentional Injuries in 

High- and Low-Income Countries 

Low-Income Countries 

(causes not ranked) 

High-Income Countries 

(causes not ranked) 

Fire and Burns 

Fires in slums and squatter housing House fires in private dwellings, especially in 

slum housing and mobile homes 

Scalds from boiling water Scalds from hot tap water, cooking gas, boiling water 

Ignition of clothing from cooking on open fires, 

with kerosene lamps, or on pressurized stoves 

Ignition of clothing by cigarettes, outdoor fires, 

portable heaters 

Children falling into open cooking fires Occupational burns from molten metals, 

gasoline-powered appliances/vehicles 

Drowning 

Children falling into open wells Children falling into home swimming pools 

Floods Leisure boat incidents 

Public transport on waterways Intoxicated persons near any body of water 

Falls 

Workers falling from high trees 

(e.g., palm or coconut trees) Construction workers 

Children falling from rooftops, farm animals, or 

low trees (e.g., fruit trees) Children falling from apartment windows 

Home construction and repair Children or elderly falling down stairs 

Incidents involving baby walker devices 

Motor Vehicle-Related 

Vulnerable road users (pedestrians, bicyclists, etc.) 

struck by motor vehicles 

Occupants of private automobiles involved in single- and 

multiple-vehicle crashes 

Motorcycle crashes Motorcycle crashes 

People falling off transport vehicles; crashes of public 

transport vehicles (buses and trains) 

Pedestrians (especially children and elderly) 

struck by cars 

Truck drivers killed in crashes Farm tractor rollovers 

Laborers falling from open truck beds Young people falling from recreational 

 all-terrain vehicles (ATVs) 

Adapted from: Berger L, Mohan D. A Global View, Injury Control. Delhi: Oxford University Press; 1996. 

 

Injury Surveillance Training Manual 10 Participant Guide — Session I 
Violence-Related Injuries (Intentional Injuries) 

Most violence-related deaths occur in low- to middle-income countries. Less than 

10% of all violence-related deaths occur in high-income countries.7 (See Figure 1.) 

Figure 1. Proportion of Violence-Related Deaths 

Low- and MiddleIncome Countries 

High-Income

Countries 9%

91%

Source: Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World Report on Violence 

and Health. Geneva: World Health Organization; 2002. 

 The Injury Pyramid 

Mortality data are a powerful injury indicator, but deaths from injury comprise just 

a fraction of the impact of injuries on a population. For each death from injury, 

many more result in hospitalization, emergency department or general practitioner 

treatment, or treatment that does not involve formal medical care. 

 

According to WHO, in the world’s high-income countries, for every person killed 

by injury, 30 people are hospitalized, and 300 are treated in emergency rooms; even 

more are treated in other health care facilities. This does not reflect the situation in 

developing countries, which have fewer resources for prevention, treatment, and 

rehabilitation of injuries. In all countries, people of low income are especially prone 

to injury and are less likely to survive or recover from disability.7

The injury pyramid shown in Figure 2 helps illustrate this fact. The pyramid top is 

composed of deaths, which are fewer in number, but more visible. Following deaths 

are severe injuries resulting in hospitalization and disability, usually classified by 

health sector, public or private. The third category is less-severe injuries, requiring 

emergency treatment. Next are injuries treated in basic health facilities. At the 

bottom of the pyramid are injuries which do not receive attention in a health 

institution. Estimates of these injuries can only be obtained through surveys or 

special research. For instance, a survey conducted in Nicaragua of 10,000 

households showed that only 1 in 10 injured persons visited a local hospital for 

treatment.9

Injury Surveillance Training Manual 11 Participant Guide — Session I 
In addition to the severity of an injury, a host of cultural and economic factors 

determine the level of treatment an injury victim receives. As a result, injury 

pyramids cannot be compared across countries and are thus provided here for 

illustrative purposes only. 

Figure 2. The Injury Pyramid 

Fatal 

 injuries

Injuries requiring 

hospitalization 

or that result in disability 

Injuries requiring

emergency treatment

Injuries resulting in

primary care treatment

Injuries that do not receive attention in a health institution

Injury Surveillance Training Manual 12 Participant Guide — Session I 
4. The Cost of Injuries 

The reliability and validity of estimated costs of various injuries are greatly affected 

by the completeness and detail of epidemiologic surveillance. Accurate reporting of 

death rates, hospitalization, and disability from specific injuries by age and sex 

provides a foundation for estimating the economic impact. If rates for a wide range 

of injury events and outcomes are not available, it is difficult to calculate injury 

costs.10 

In 1992, direct and indirect annual costs due to gunshot wounds in the United States 

were estimated at $126 billion, with an additional $51 billion due to cutting or stab 

wounds.10 In New Brunswick, Canada, the mean total cost estimate per suicide was 

over $849,000.11 In Latin America, the Inter-American Development Bank sponsored 

studies of the impact of violence in six countries between 1996 and 1997. These 

studies found that the cost of violence, expressed as a percentage of the gross 

domestic product (GDP) was 1.9% of the GDP in Brazil, 5.0% in Colombia, 

4.3% in Peru, and 0.3% in Venezuela.12

Although direct costs such as hospital and physician charges, medications, and 

transportation are the most easily measured, acquiring data on such costs can be 

difficult. The list of direct costs is extensive and the information is not always in a 

useable form (Table 8). 

Table 8. Partial List of Direct Costs of Injuries 

Emergency Services: Ambulance, emergency room, personnel 

(Emergency Medical Technicians/Paramedics, Physicians, Nurses, etc.) 

Hospital Inpatient Costs: Physicians, operating room, drugs 

Hospital Outpatient Services: Medications, appliances 

Office-Based Services: Physicians, Nurses 

Rehabilitation: Physical, occupational, speech and hearing therapy, prosthesis 

Long-Term Care: Custodial care, modification of home environment (e.g., wheelchair ramps) 

Home-Health Services: Nurses, Aides, Caregivers 

Administrative Costs: Insurance companies, government medical agencies, 

vehicle, barrier, and other property damage 

Legal Fees and Court Costs

Law Enforcement and Judicial Costs 

Welfare and Human Services Costs: Social Workers, Medical Social Workers, support payments 

Funeral and Medical Examiner Costs 

Costs for Other Affected Persons: Witnesses time in court, family members 

Adapted from: Berger L, Dinesh M. A Global View, Injury Control. Delhi: Oxford University Press; 1996. 

Injury Surveillance Training Manual 13 Participant Guide — Session I 
5. Conceptual Models for Understanding and Preventing Injury 

The Public Health Approach to Injury Prevention 

The public health model to prevention has been applied to a wide range of 

noninfectious and infectious public health problems, with a remarkable record 

of success.13 Although many scientific disciplines have advanced the understanding 

of injury, public health brings something that has been missing to this field: a 

multidisciplinary scientific approach that is explicitly directed toward identifying 

effective methods of prevention. 

This model is based on the following principles: 

a. Emphasis on primary prevention; 

b. Multidisciplinary in nature; 

c. Science-based; 

d. Population-based. 

The public health approach begins by defining the problem through surveillance 

systems, surveys, and other sources. The second step is to identify associated risks 

and causes through research. The third step is to develop and evaluate 

interventions. The last step is to widely implement interventions that show promise. 

Although Figure 3 illustrates a linear progression through these four steps, in 

reality, many of these steps are likely to occur simultaneously. 

Figure 3. Public Health Approach to Injury Prevention 

Source: National Center for Injury Prevention and Control

Injury Surveillance Training Manual 14 Participant Guide — Session I 
 The Epidemiological Triad 

William Haddon, the former director of the United States National Highway Traffic 

Safety Administration and the Insurance Institute for Highway Safety, played a 

leading role in bringing epidemiological principles to injury research and intervention programs. Haddon maintained that injuries could be easily examined from 

an epidemiological framework. In its classic sense, epidemiology considers the 

interaction of three factors in the development of disease: the host, the agent, and the 

environment, which is called the epidemiological triad (Figure 4). 

Figure 4. Epidemiological Triad 

Host 

Agent Environment 

 

 The Haddon Matrix 

Haddon applied the epidemiological triad primarily to unintentional injuries, and 

most often to injuries from motor vehicle crashes. As diagrammed in Figure 4, the 

host is the human being whose behavior is operation of the vehicle. Physical energy 

is the agent in injury events. For motor vehicle events, this translates into the 

physical energy involved with motor vehicles. The environment is the milieu in 

which the vehicle and the human interact—the type of road, the weather conditions 

involved, and so forth.14

Haddon extended the epidemiological triad even further to consider how these 

factors relate to the crash sequence. The crash sequence can be examined in terms of 

three elements: the circumstances surrounding the event prior to the crash; the 

circumstances of the crash; and those that follow the crash. The crash sequence 

interacts with human, environmental, and vehicular factors to define the frequency 

and severity of injury. Table 9 shows examples of the risk factors related to the 

likelihood of injury in motor vehicle crashes within the framework of the 

epidemiological triad and the Haddon Matrix. 

Injury Surveillance Training Manual 15 Participant Guide — Session I 
Table 9. Factors Related to the Likelihood of Crash Injury: The Haddon Matrix 

Factors 

Phases 

Human Vehicle Physical and Social 

Environment 

Pre-Crash 

Alcohol intoxication; 

Fatigue; 

Experience and 

judgment; 

Driver vision; 

Amount of travel 

Brakes, tires; 

Center of gravity; 

Jackknife tendency; 

Ease of control; 

Load weight; 

Speed capability 

Laws related to alcohol and driving; 

Visibility of hazards; 

Road curvature and gradient; 

Surface coefficient of friction; 

Divided highways, one-way streets, 

intersections, access control; 

Signalization; 

Speed limits 

Crash 

Seat belt use; 

Age; 

Sex; 

Speed at impact; 

Vehicle size; 

Automatic restraints; 

Hardness and sharpness 

of contact surfaces; 

Load containment 

Recovery areas; 

Guardrails; 

Characteristic of fixed objects; 

Median barriers; 

Roadside embankments 

Post-Crash 

Age; 

Physical condition; 

Disabilities 

Fuel system integrity 

Emergency communication and 

transport systems; 

Distance to and quality of medical 

services; 

Rehabilitation programs 

Adapted from: Baker S, O’Neill B, Ginsburg M, Li G. The Injury Fact Book. 2nd ed. New York, NY: Oxford 

University Press; 1992. 

The Haddon Matrix changed how injuries are viewed and provided a framework 

for the development of injury control interventions. Haddon demonstrated that an 

appropriate understanding of the factors affecting injuries in each cell of the matrix 

could lead to more effective interventions. By identifying which factors are 

important and their location in the crash sequence, it will be possible to understand 

where interventions may be most appropriate.14

Haddon identified the pre-injury phase as the period when primary prevention 

approaches, such as divided highways and speed limit enforcement, could be 

implemented. The injury phase focuses on secondary prevention such as the 

deployment of airbags or the installment of breakaway signposts. The post-injury

phase emphasizes tertiary prevention such as effective emergency medical services 

and trauma rehabilitation. Haddon applied this matrix to several other unintentional injuries and to those from motor vehicle crashes. Barss et al. compared the 

application of these epidemiological methods to diseases and to injuries, with 

attention to the host, agent, and environment,3 as shown in Table 10. This table also 

shows that equipment factors and activity at the time of the incident are essential 

considerations. 

Injury Surveillance Training Manual 16 Participant Guide — Session I 
Table 10. Comparative Epidemiology of Disease and Injury: 

 Malaria Versus Brain Damage to Motorcyclist 

Health Condition Variable 

Disease Injury 

Pathology Malaria Brain damage 

Incident Mosquito bite Crash into tree 

Agent Plasmodium parasite Kinetic energy 

Vector/Vehicle Anopheles mosquito Motorcycle 

Activity Sleeping Motorcycle travel 

Personal/Host Factors Low immunity — young child Alcohol intoxication; youth; male sex; 

inexperience; fatigue 

Equipment Factors Mosquito net; insect screening Motorcycle helmet; guardrail 

Environment Factors Unscreened home near 

swamps; rain 

Unprotected curve near tree; unsafe 

surface and incline; rain 

Time/Visibility Factors Night/Darkness Night/Darkness 

Source: Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International Perspective (Epidemiology, 

Surveillance and Policy). New York, NY: Oxford University Press; 1998. 

 The Ecological Model 

In the same way that the Haddon Matrix has been valuable for addressing prevention of unintentional injuries, there is also a model for understanding the 

prevention of violence. The Ecological Model examines the complex interplay of 

individual, relational, social, cultural, and environmental factors that increase or 

decrease the risk for violence.7 This model was first introduced in the 1970s and was 

initially applied to child abuse.15 Subsequently it was applied to youth violence and, 

most recently, researchers have used it to understand intimate partner violence and 

abuse of the elderly16 (Figure 5). 

Figure 5. Ecological Model for Understanding Violence 

Societal Community Relationship Individual

Source: Krug E, Dahlberg L, Mercy J, Zwi A, Lozano R. World Report on Violence and Health. Geneva: World 

Health Organization; 2002. 

Injury Surveillance Training Manual 17 Participant Guide — Session I 
The ecological model posits that (1) health and well-being are affected by a dynamic 

interaction among biology, behavior, and the environment, and that (2) this 

interaction changes over the life course. 

 

Individual Factors: Characteristics of the individual that increase the likelihood of 

being a victim or a perpetrator of violence, such as: 

• Impulsivity; 

• Low educational attainment; 

• Substance abuse (alcohol, drugs); 

• Prior history of aggression and abuse. 

Relationship Factors: Proximal social relationship (i.e., with peers or within family 

environments) that increase the risk for violent victimization and perpetration. 

Examples of relationship factors include: 

• Harsh parenting practice; 

• Association with peers involved in delinquent activities; 

• Poor parental supervision. 

Community Factors: Characteristics of context in which social relationships are 

embedded that are associated with being victims or perpetrators of violence, such as: 

• Residential mobility; 

• High-population density; 

• Drug trafficking; 

• High levels of unemployment; 

• Social isolation; 

• Few institutional supports. 

Societal Factors: Factors that create an acceptable climate for violence, reduce the 

inhibitions against violence, and create and sustain gaps among different segments 

of society or tensions among different groups or countries. Examples of such factors 

include: 

• Cultural norms that support violence as an acceptable way to 

resolve conflicts; 

• Attitudes that regard suicide as a matter of individual choice 

instead of a preventable act of violence; 

• Norms that give priority to parental rights over child welfare; 

• Norms that entrench male dominance over women and children; 

• Norms that support the use of excessive force by police against citizens; 

Injury Surveillance Training Manual 18 Participant Guide — Session I 
• Access to health care; 

• Educational inequality; 

• Economic and social policies; 

• High levels of economic or social inequality within groups or countries.7

6. Development of an Injury Surveillance System 

Injuries have been shown to account for a significant health burden on populations, 

regardless of gender, age, income, or geographic region. The historical neglect of 

injuries as accidents or random events is fading with the growing understanding 

that injuries are a preventable health threat that affect us all. The role of the 

epidemiologist is fundamental in this evolution. By conscientiously providing the 

public and policy makers with a steady stream of effectively gathered and correctly 

analyzed and interpreted surveillance data, epidemiologists can significantly 

contribute to effectively addressing this previously overlooked health issue. 

Currently, surveillance for injury is similar to that for infectious or chronic diseases. 

However, some circumstances are unique to injury, such as the role of institutions 

outside the health sector, including police departments, district attorneys, forensic 

medicine, coroners and medical examiners, and transportation offices. Ethical 

considerations also come into play more often in violence-related injury, especially 

when the injury results from crime (e.g., homicide). 

Injury surveillance is defined as: 

“...the ongoing systematic collection, analysis, and interpretation 

of injury data, for use in planning, implementation and evaluation 

of prevention activities. Injury prevention programs use 

surveillance data to assess the need for new policies or programs 

and to evaluate the effectiveness of those that already exist.”17

The steps for developing and maintaining an injury surveillance system follow. 

Notice that the process is considered cyclical; when you evaluate the system you will 

probably revisit the steps you completed earlier to make adjust-ments and to 

continually improve the quality of the system. For example, circumstances change, 

and the coalition members or operations team may need to be adjusted, or you may 

find you need to change your indicators. In addition, it is very likely that some of 

these steps occur simultaneously or in a different order. The first step is to know the 

conceptual framework of injury prevention, which is basic to developing the 

subsequent steps. The second step is to describe the size of the injury problem and 

the data sources. In the third step, some considerations about the coalition necessary 

to support the injury surveillance and prevention activities are described. The fourth 

and fifth steps specify the technical skills necessary to develop the surveillance 

system. Discussions of the methodology and analysis plans are also covered in 

Injury Surveillance Training Manual 19 Participant Guide — Session I 
these sessions. The sixth step focuses on translating surveillance data into 

prevention activities. The last step involves defining an evaluation plan and monitoring activities. These steps draw upon other important documents and reports 

such as the Injury Surveillance Guidelines.

5, 18

Steps to Develop and 

Maintain an 

Injury Surveillance System

7. Define an evaluation plan

 for the surveillance system

 and monitor prevention 

 activities 

Apply the criteria to evaluate 

the surveillance system and

monitor the strategies 

1. Understand the conceptual 

 framework of injury prevention 

Definition and typology of 

unintentional and violencerelated injuries

2. Assess injury data sources 

 and describe the injury 

 problem 

Identifying strengths and 

weakness of injury data 

sources and size of the 

problem 

3. Build a coalition to support 

 the injury surveillance system 

 and prevention activities 

Identify the partners to include 

in a coalition to support the 

injury surveillance system 

4. Determine the appropriate

 Methodology for the 

 surveillance system 

Determine events, data 

elements, type of surveillance, 

and data collection instruments

5. Define and develop an 

 analysis plan for the 

 surveillance data 

Use data to identify preventable 

injuries, high-risk groups, and 

most appropriate, interventions 

6. Use injury surveillance data 

 to inform injury prevention 

Calculate indicators, demographic, and environmental 

characteristics 

 

7. Ethical Considerations 

Effective public health activities, including public health surveillance, depend on a 

trusting relationship between public health practitioners and the society they need 

to help.19 Epidemiologists should consider any known or potential risks that individuals or populations may encounter as a result of their participation in surveillance activities. Consideration should be given not only to physical risks, but also 

to psychological, economic, legal, and social risks. Surveillance practitioners should 

be sensitive to the possible stigmatization of groups as a result of categorization in 

surveillance data.20

Injury Surveillance Training Manual 20 Participant Guide — Session I 
 Protecting Confidentiality and Privacy 

Privacy refers to the right of individuals to refuse to provide information about 

themselves. Confidentiality refers to the obligation of parties receiving such information to restrict access to it as stipulated by the individual in question. Except 

under unusual circumstances (e.g., when there is a need for follow-up counseling 

or treatment, or when release of information is mandated by a court of law), 

information obtained about participants in a surveillance project should be kept 

confidential. Protection of confidentiality is not only required by the ethical principle 

of respecting people (autonomy), but also because the disclosure of certain 

information to third parties or subsequent use of the data for a purpose other than 

that which motivated its initial collection may cause harm to an individual, such as 

discrimination in employment, housing, or health insurance coverage.21

A successful reporting system will have clear policies that protect the privacy and 

confidentiality of information. Policies and procedures also need to protect sensitive 

or personally-identifying information from being disclosed. For instance, law 

enforcement agencies may be reluctant to divulge information that could even 

remotely compromise pending investigations. Law enforcement may be particularly 

sensitive about “legal” homicides or deaths that occur in the course of duty. The 

privacy rights of living suspects and alleged perpetrators associated with violent 

deaths include the right to be free from defamation. The duty of law enforcement 

agencies to thoroughly investigate homicides and to apprehend perpetrators 

requires agencies to protect information from disclosure in many open or pending 

cases. Protection of information on juveniles is even stronger: state statutes almost 

universally protect such information, based on the philosophy that juveniles should 

receive rehabilitation and services as opposed to punishment.22

8. Summary 

Now that you have completed this session, you should be able to: 

• Understand concepts, definitions, and classification of injury; 

• Know the differences between violence-related and unintentional injuries; 

• Describe the global burden and cost of injuries; 

• Know the conceptual models for understanding and preventing injury; 

• Know the steps to develop an injury surveillance system; 

• Review ethical considerations. 

 

Session II addresses the next step, assessing injury data sources and describing the 

injury problem. 

Injury Surveillance Training Manual 21 Participant Guide — Session I 
REFERENCES 

 1. Baker S, O’Neill B, Ginsburg MJ, Li G. The Injury Fact Book. 2nd ed. New York, NY: 

Oxford University Press; 1992. 

 2. Berger L, Mohan D. Injury Control: A Global View. Delhi: Oxford University Press; 

 1996. 

 3. Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International Perspective 

(Epidemiology, Surveillance and Policy). New York, NY: Oxford University Press; 1998. 

 4. Espitia V, Guerrero R, Gutierrez M, et al. Ten years of a Fatal Injury Surveillance 

System Using Linkage Data. Cali, Colombia. 1993–2002. Paper presented at: 7th 

World Injury Conference; June 2004; Vienna, Austria. 

 5. Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O, eds. Injury 

Surveillance Guidelines. Geneva: World Health Organization; 2001. 

6. The National Committee for Injury Prevention and Control. Injury Prevention: 

Meeting the Challenge. New York, NY: Oxford University Press: 1989. 

 7. Krug E, Dahlberg L, Mercy JA, Zwi A, Lozano R. World Report on Violence and Health.

Geneva: World Health Organization; 2002. 

 8. Peden M, Scurfield R, Sleet D, et al. World Report on Road Traffic Injury Prevention.

Geneva: World Health Organization; 2004. 

 9. Rocha J. Lesiones en el municipio de León, Nicaragua: Vigilancia, Análisis y 

Evaluación de un Sistema de Vigilancia a nivel local. Leon, Nicaragua: 2000. Thesis 

to Master Degree in Public Health. Universidad Nacional Autonoma de Nicaragua, 

Facultad de Ciencias Medicas. 

10. Miller TR, Cohen MA. Costs of gunshots and cut/stab wounds in the United States, 

with some Canadian comparisons. Accident Analysis and Prevention, 1997;29: 

329–341. Cited by: Krug E, Dahlberg L, Mercy JA, Zwi A, Lozano R. World Report on 

Violence and Health. Geneva: World Health Organization; 2002. 

11. Clayton D, Barcel A. The cost of suicide mortality in New Brunswick, 1996. Chronic 

Diseases in Canada. 1999;20:89–95. In: World Report on Violence and Health. World 

Health Organization. 2002:20. 

12. Bunivic M, Morrison A. Violence as an Obstacle to Development. Washington, DC: 

Inter-American Development Bank; 1999. Cited by: Krug E, Dahlberg L, Mercy JA, 

Zwi A, Lozano R. World Report on Violence and Health. Geneva: World Health 

Organization; 2002. 

Injury Surveillance Training Manual 22 Participant Guide — Session I 
13. Mercy J, Rosenberg M, Powell K, Broome C, Roper W. Public health policy for 

preventing violence.9 Health Affairs. 1993:4(12); 7–29. 

14. Garbarino J. Adolescent Development: An Ecological Perspective. Columbus, Ohio: 

Charles E. Merrill Publishing Co.; 1985. 

15. Garbarino J, Crouter A. Defining the community context for parent-child relations: 

the correlates of child maltreatment. Child Development. 1978;49:604–616. 

16. Schiamberg LB, Gans D. An ecological framework for contextual risk factors in elder 

abuse by adult children. Journal of Elder Abuse and Neglect. 1999;11:79–103. 

17. Safe States Working Group. SAFE STATES: Five components of a Model State Injury 

Prevention Program and Three Phases of Program Development. Oklahoma City, 

Oklahoma: State and Territorial Injury Prevention Directors Association; 1977. 

18. Concha-Eastman A, Villaveces A. Guidelines for the Design, Implementation and 

Evaluation of Epidemiological Surveillance Systems on Violence and Injuries. Washington, 

DC: Pan American Health Organization; 2001. 

19. Coughlin SS, Beauchamp TL. Ethics and epidemiology. New York, NY: Oxford 

University Press; 1996. Cited by: Snider DS, Stroup DF. Ethical issues. In: Teutsch S, 

Churchill RE. Principles and Practice of Public Health Surveillance. 2nd ed. New York, 

NY: Oxford University Press; 2000. 

20. Teutsch S, Churchill RE. Principles and Practice of Public Health Surveillance. 2nd ed. 

New York, NY: Oxford University Press; 2000. 

21. Seltzer W. Population statistics, the Holocaust, and the Nuremberg Trials. Population 

and Development Review. 1998;47:1147-53. Cited by: Snider DS, Stroup DF. Ethical 

issues. In: Teutsch S, Churchill RE. Principles and Practice of Public Health Surveillance. 

2nd ed. New York, NY: Oxford University Press; 2000. 

22. Centers for Disease Control and Prevention (CDC). National Violent Death 

Reporting System. Implementation Manual. [Online]. (2003). National Center for 

Injury Prevention and Control (producer). Available from: www.cdc.gov/injury. 

Injury Surveillance Training Manual 23 Participant Guide — Session I 
INJURY SURVEILLANCE TRAINING MANUAL 

PARTICIPANT GUIDE 

SESSION II

ASSESS INJURY DATA SOURCES AND 

DESCRIBE THE INJURY PROBLEM 

Developed with the support of the 

National Center for Injury Prevention and Control 

Division of International Health, Epidemiology Program Office 

Centers for Disease Control and Prevention 

Atlanta, GA 
SESSION II

ASSESS INJURY DATA SOURCES AND 

DESCRIBE THE INJURY PROBLEM 

Learning Objectives 

• Identify injury data sources and the strengths and weaknesses of each. 

• Identify available data sources that can provide information to the 

surveillance system. 

• Describe the size of the injury problem. 

• Compare the frequency of injuries calculated with data from 

different sources. 

Introduction 

Data sources in an injury surveillance system may come from the health sector, law 

enforcement, and other sectors. Death certificates, one of the most important 

documents for fatal events, are usually filled out by physicians, medical examiners, 

coroners, pathologists, or in some rural areas, by lay people. Death certificates 

provide an accurate death count; however in some countries, death certificates do 

not contain information on underlying cause of death, victim’s occupation, or the 

context where death occurred. In such cases, the police report is more accurate for 

collecting information related to the context or circumstances and the aggressor. 

In some developing countries, health information systems are not sufficient to cover 

all regions of the country. These systems often lack reliable data on the local 

incidence of health conditions or even on the leading causes of death. The 

magnitude of the problem of injuries is inadequately documented in such countries 

except by special surveys or data sources outside the health sector. Sometimes the 

only deaths recorded are those that occur in hospitals and for which a death 

certificate is completed. Most deaths that occur at home in rural areas are 

unreported. Even the records of deaths that occur in hospitals may be relatively 

useless for public health purposes and coding may be inadequate.1 

An adequate investigation of the external cause and circumstances of injury deaths 

that occur in communities involves police, coroners, pathologists, the national 

statistical office, and the transportation office. Poor communications infrastructure, 

underreporting of deaths, long delays before reported deaths are investigated, staff 

shortages, inadequate laboratory tests, and lack of transportation to remote areas all 

hinder the investigation of injury deaths and reduce the reliability and validity of 

injury mortality. 

Injury Surveillance Training Manual 3 Participant Guide — Session II 
Police reports are also a potential source of information about injuries, especially 

road traffic injuries and violence-related injuries. Often the police have an office 

in charge of investigating the circumstances surrounding violent deaths. This 

information can be very useful for determining the context in which the injury 

occurs. 

Records of occupational injuries are sometimes available from sources such as 

departments of labor or occupational hygienists working in industrial settings. 

Local newspaper accounts of deaths and injuries are also potentially valuable 

sources of information. Newspaper accounts often include details about the age and 

sex of victim and the cause and agent of injuries. For certain types of unintentional 

injuries, such as drowning and fires, these stories can be relatively complete and 

contain more useful details about preventable factors for injury deaths than do 

coroners’ reports.

The utility of existing data can be enhanced significantly by establishing data 

linkages across jurisdictions. Such linkages can overcome the limitations of separate 

databases and aid in the development of comprehensive information about an 

event, its circumstances, the occurrence and severity of the injury, the type and cost 

of treatment received, the outcome in terms of both mortality and morbidity, and 

the administrative or legal outcome. 

Linking disparate data sources is a good strategy for assessing the true magnitude 

of the injury problem. However, significant barriers may be encountered when 

establishing linkages: 

1. Limited access to databases (in some cases, relevant data are collected but not 

computerized and, if computerized, are not readily available because of data 

release policies, concerns about confidentiality, and interagency politics); 

2. High costs and limited resources for developing and maintaining databases; 

3. Technical difficulties. 

When the databases to be linked use similar unique identifiers, linkage is relatively 

easy. However, most databases have been stripped of unique identifiers to protect 

confidentiality. To address this barrier, probabilistic matching software has been 

developed and used to link data-bases when unique identifiers are not available and 

to deal with the inevitable discrepancies related to spelling, data entry errors, or 

similar problems.

In the United States, for example, the National Highway Traffic Safety 

Administration (NHTSA) has fostered development of linked databases by funding 

several states to develop Crash Outcome Data Evaluation Systems (CODES). 

CODES were initially designed to develop comprehensive data for determining the 

impact of seat belt and motorcycle helmet use on the incidence and severity of 

Injury Surveillance Training Manual 4 Participant Guide — Session II 
injuries, health care costs, and outcome. The implementation of CODES required the 

linkage of police crash reports with death certificates or medical examiner data and 

health care data (including emergency medical service data, emergency department 

data, hospital discharge data, and occasionally data from insurance claims). The 

CODES database is now being used to address a variety of motor vehicle injury 

research and evaluation questions at the local, state, and national levels. Similar 

linkages are needed for other types of injuries.2 

The U.S. National Violent Death Reporting System (NVDRS), implemented by 

Centers for Disease Control and Prevention (CDC) in 2000, was developed to 

provide a census of violent deaths that occur in the United States. Information 

documented by coroners and medical examiners, vital records registries, law 

enforcement, and crime laboratories for violent deaths is gathered at the local level, 

linked in a standardized database, stripped of individual identifiers, and forwarded 

to the national database.3 

In Colombia, the use of linkage data has been implemented in the Fatal Injury 

Surveillance System, which is in operation in Cali and Bogotá. Data from 

different sources are linked in a database to support prevention strategies.4

This session emphasizes the use of injury information from multiple data sources. 

The exercises and examples will be performed using mortality data. Morbidity data, 

such as hospitalizations, visits to emergency departments, or admissions to rehabilitation facilities, can be used if they are available. Such data provide information on 

the frequency and the severity of nonfatal injuries. In this session, you will learn to 

identify injury data sources in your region, calculate and compare basic indicators 

using data from different sources, describe the size of the injury problem, and define 

the most appropriate data sources for providing information to the surveillance 

system. 

1. Identify Strengths and Weaknesses of Injury Data Sources 

Each institution collects injury mortality data that supports its mission, which may 

vary from country to country. However, there are some commonalities. The health 

sector maintains information on injuries and deaths collected by health institutions. 

This focus is often on the injury itself more so than the circumstances surrounding it. 

Medical providers in emergency rooms, for example, have more interest in saving 

the life of the victim than in knowing if the injury was unintentional or violence 

related. The health sector uses the International Classification of Diseases (ICD) to 

assign a code for each disease or cause of death. 

For instance, police generally record their findings about road traffic crashes and 

injuries in collision or accident reports. The police definition of what constitutes a 

traffic injury can have a major impact on traffic injury data. Studies have shown 

that the completeness and accuracy of police reporting is adequate for deaths, 

moderately useful for serious injuries, and usually poor for less-severe injuries. 

Injury Surveillance Training Manual 5 Participant Guide — Session II 
Additionally, police are more likely to misreport serious injuries as slight injuries 

when the occurence involves vulnerable road users rather than vehicles.2 

Example: 

The data sources used in the Fatal Injury Surveillance System in Cali, Colombia, are 

presented in Figure 1. Data are linked manually to a common database, through a 

weekly meeting to compare and standardize the information.5

District Attorney

Attends all cases of injury deaths 

and collects information on the 

victim and circumstances. 

Provides the case definition. 

Forensic Medicine

Conducts the autopsy in all 

injury deaths and defines the 

cause of death, and identifies 

the victim. Also it contributes in 

the case definition. 

Transportation Office 

Collects information related 

to type of victim, vehicle 

involved, and circumstances 

of the event. 

Government Secretary 

Produces weekly official statistics 

on injury deaths in the city. 

Maintains linked database to 

support prevention strategies. 

Represents the mayor’s office in 

the meeting. 

Police Department 

Attends all cases of injury 

deaths and collects information 

on the victim, circumstances, 

and place of occurrence for 

the event. 

Police Investigation Office 

Collects information about 

homicide investigations such as 

circumstances, perpetrator, 

record of victim, and type of 

weapon. 

Cisalva Institute

An Academic Center which 

analyzes the data and produces 

periodic bulletins to be disseminated through mass media. 

Maintains a linked database for 

research and policy use. 

Compare and 

standardize data in a 

weekly meeting. 

Manually link data.

Figure 1. Data Sources for the Fatal Injury Surveillance System 

 Cali, Colombia 

Exercise: Discuss the strengths and weaknesses of data sources in your 

region. 

Injury Surveillance Training Manual 6 Participant Guide — Session II 
2. Determine the Jurisdiction, Data Collection Method, and 

 Data Flow Used by Each Data Source 

In an injury surveillance system using different data sources, the reported data 

may correspond to different geographical areas, which may cause differences in the 

registries. 

For road traffic injury, for example, the victim could die at the site, on the way to 

the hospital, or in the hospital. At the hospital the victim could die that day or many 

days later. Police records usually contain information about the victims who die in 

the street, but not always. The transportation office often reports the event, but 

usually only when an official is at the scene. Also, the time of the event collected by 

each data source could vary. Even in the hospital, if the injured person is admitted, 

there may be a discrepancy between the initial and final diagnoses. 

The health sector maintains records of deaths occurring in the hospitals. If the 

victims die at the scene and do not reach the hospital, their deaths are not registered 

by the hospital. For instance in San Salvador (El Salvador), only 25% of the 

homicides that occurred in the city in 2002 were registered in the public hospitals.6 

Vital statistics offices often collect information from the death certificates. If the 

death certificates are incomplete or underreported, the result will be statistically 

unreliable. The data published by these offices are classified by place of residence, 

which is helpful in calculating rates by residence. However, records of deaths by 

place of occurrence are necessary for developing prevention strategies. 

Example: 

A comparison was made using data from forensic medicine offices and police 

departments for some cities in Colombia. For all municipalities, the number of cases 

reported by forensic medicine was higher than those reported by police. 

An analysis of the discrepancy in numbers indicated that data from forensic 

medicine offices are administrative in nature and reflect the number of necropsies 

done on homicides in each municipality, regardless of the event’s place of 

occurrence. 

In contrast, data from the police department indicate the number of homicides in 

each city classified by place of occurrence. This example shows how published data 

can sometimes be misleading (Table 1). 

Injury Surveillance Training Manual 7 Participant Guide — Session II 
Table 1. Number of Homicides in Cities of Colombia — 1999 

City Forensic Medicine Police Department 

Palmira 185 95 

Buga 106 81 

Tulua 166 87 

Cartago 210 83 

Buenaventura 312 131 

Roldanillo 94 85 

Zarzal 65 63 

Source: Forensic Data for Life, National Police Bulletin. Prepared by: Espitia V., Espinosa R., 

and Vergara M. for the Office of the State Public Health Secretary’s Sivivi Project, 2000. 

a. Where must the death certificate be filed? 

b. Where should the investigation about the 

perpetrator and circumstances be conducted? 

c. Where must the case be counted? 

Exercise: Answer the following questions. 

 If one person is hospitalized because of an injury and later dies in 

another hospital in another city or state: 

2.1 Describe Data Collection Method and Data Flow 

Data collection methods vary among institutions because each uses its own 

forms to collect information at the scene. This information is entered into 

databases and analyzed to produce periodical reports. For example, the police 

usually prepare reports of cases known to them (some are restricted, but most 

are public); forensic medicine and public health officials frequently prepare 

annual reports of cases they treat. Data collection methods and data flow can 

vary among institutions depending on the human and techonological resources 

available in each place. 

In the United States, for instance, when a death occurs, the funeral director 

obtains information from the family about the decedent’s education, 

occupation, birthplace, racial identity, etc. The local coroner/medical examiner 

(C/ME) supplies cause-of-death and basic information about the context of 

death. The certificate is then filed with the local or state health department. In 

most states, a nosologist at the state health department registry of vital records 

assigns the ICD cause-of-death codes, usually with software assistance. There 

are three types of state death certificate data: 

Injury Surveillance Training Manual 8 Participant Guide — Session II 
1. Death certificate—usually available within a few weeks after the death; 

includes cause of death and nature of injury, but not necessarily in coded 

format. 

2. Preliminary electronic data—either in electronic form or a hard copy 

printout; sometimes these preliminary electronic data are available within 

weeks of the certificate being filed. 

3. Final death certificate data—cleaned and fully coded; this level of data may 

not be available for a long time, as much as a year and half after the close of 

a data year.3

C/MEs are responsible for investigating violent or sudden deaths and for providing 

an official determination of the cause of death. They are in charge of (a) determining 

the circumstances surrounding the death; (b) investigating the scene; (c) arranging 

for or conducting postmortem exams or autopsies; (d) toxicology testing; and (e) 

certifying the cause of death. Twenty percent of deaths in the United States, 

typically those due to homicide, suicide, or unintentional injury, are investigated by 

C/ME offices.3

 

The process of investigating an injury death in Cali, Colombia is shown in Figure 2. 

Police officers patrolling the streets are the first authority present on the scene. They 

send data about injuries and crimes by radio or fax to their central office and to the 

district attorney’s office. The police officer in charge of the investigation attends the 

scene with the district attorney, who collects information related to the victim, 

circumstances, and possible aggressor. They investigate homicide, suicide, other 

unintentional deaths, and motor vehicle-related deaths. Pathologists in the forensic 

office await the body, which is transported by the district attorney and police. The 

forensic medicine office collects information on a specially designed form, the 

necropsy report. All data about the body of the victim is registered on this form. 

The death certificate, which contains information on cause, nature of death, and 

identification of victim, is filed. The public health office receives and systematizes 

the death certificate and sends it to the National Statistics Office.5 

Injury Surveillance Training Manual 9 Participant Guide — Session II 
Figure 2. Injury Death Investigation Process in Cali, Colombia 

Victim in Scene 

Exercise: Draw on the board the process to follow when an injury death occurs in a city. 

Answer the following questions: 

 1. What do the police do? 

 2. What does the forensic medicine office do? 

 3. What does the health sector do? 

 4. What does the district attorney do? 

 5. What does the coroner/medical examiner do? 

 6. What do the relatives do? 

Victim in scene 

of death 

Victim in forensic 

medicine office 

A public health office receives and systematizes 

the death certificate and assigns the ICD codes. 

After two months, the certificates are sent to the 

National Statistics Office. This office also prepares 

the burial license for the relatives. 

 National Statistics Office receives and 

 systematizes all death certificates and 

 reviews the previous ICD codes. 

 

Victim is buried by 

family and relatives 

Pathologist in forensic medicine 

conducts the necropsy, determines the 

cause of death and nature, identifies the 

victim, and prepares the death 

certificate. 

District attorney and police 

investigates the circumstances, cause 

of death, victim, and aggressor or 

counterpart in motor vehicle-related 

incident. 

Police are the first authority on 

the scene; they call other 

related entities and collect 

preliminary data about 

circumstances.

Injury Surveillance Training Manual 10 Participant Guide — Session II 
3. Identify the Data Sources to Include in the Surveillance System 

The injury events that will be included in a surveillance system determine which 

data sources are necessary to provide information to the surveillance system. The 

availability and quality of data are important criteria when selecting data sources. 

Table 2 shows possible data sources for a surveillance system according to event 

and availability of data. The shaded boxes indicate the best data source for a given 

type of information. This is only an example, however, and the availability of data 

and sources may vary in each country. 

 Table 2. Probable Data Sources in an Injury Surveillance System 

Data Sources 

Events District 

Attorney 

Police 

Office 

Forensic 

Medicine 

Public 

Health 

Transport 

Office 

Family 

Community 

Nongovernment 

Offices 

Media 

Fatal Injuries 

Homicide 

Suicide 

Transport - 

Related deaths 

Other 

Unintentional 

Deaths 

Nonfatal Injuries 

Homicide 

Attempt 

Suicide 

Attempt 

TransportRelated 

Injuries 

Other 

Unintentional 

Injuries 

Domestic 

Violence 

Child 

Maltreatment 

Elderly Abuse 

Exercise: Identify a data source for each event in Table 2. One group will work with 

fatal injuries; the other group will work with nonfatal injuries. 

Injury Surveillance Training Manual 11 Participant Guide — Session II 
4. Describe the Size of the Injury Problem 

The availability of reliable health statistics generally reflects a country’s level of 

development. In some countries, reliable data on the local status of health 

conditions, or even on the leading causes of death, are not available. Preliminary 

estimates of basic indicators like number and percentage of injuries will begin to 

give you an idea about the problem of injuries in the region. 

The purpose of this part is to guide participants in reviewing mortality data such as 

the frequency of the twenty leading causes of death by cause and frequency of 

injury deaths by intention. If morbidity data are available (such as hospital 

discharge data by cause), these data can be used to broaden the understanding of 

the problem. 

4.1 Determine the Frequency of the Leading Causes of Death 

Deaths are commonly used to describe and compare public health problems, 

in part, because deaths are well defined and detailed mortality data are often 

available. Data on fatalities (particularly homicide, suicide, and war-related 

deaths) and on motor vehicle and other unintentional injuries can provide an 

indication of the extent of the injury problem in a particular community or 

country. These data can also be used for monitoring changes over time in 

injury rates, identifying groups and communities at high risk of injury, and 

making comparisons within and among countries. These data are also useful 

for motivating stakeholders to support injury prevention and to build a 

coalition. Knowing the leading causes of death makes it possible to rank 

injuries by frequency. 

In Table 3, for instance, the 15 leading causes of death in the United States 

are shown. Unintentional deaths, suicide, and homicide were among the 15 

leading causes of death in 2000. 

 

Injury Surveillance Training Manual 12 Participant Guide — Session II 
Table 3. Total Deaths for the 15 Leading Causes of Death, 

U.S. Population — 2000 

Rank Cause of Death (Based on ICD-10 Revision, 1992) Frequency 

 1 Heart Disease 710,760 

 2 Malignant Neoplasms 553,092 

 3 Cerebrovascular Diseases 167,661 

 4 Chronic Lower Respiratory Diseases 122,009 

 5 Unintentional Injuries 97,902 

 6 Diabetes Mellitus 69,301 

 7 Influenza and Pneumonia 65,313 

 8 Alzheimer’s Disease 49,558 

 9 Nephritis, Nephritic Syndrome, and Nephrosis 37,251 

10 Septicemia 31,224 

11 Suicide 29,350 

12 Chronic Liver Disease and Cirrhosis 26,552 

13 Essential (primary) Hypertension and 

Hypertensive Renal Disease 16,073 

14 Homicide 16,765 

15 Pneumonitis due to solids and liquids 16,636 

All other causes 391,904 

Total 2,403,351 

Adapted from: National Vital Statistics Report, Vol. 50, No 15; September 16, 2002. 

Exercise: Using local data, develop a table showing the frequency of the 10 or 15 

leading causes of death (similar to Table 3). 

4.2 Determine the Frequency of the Leading Causes of Injury Deaths 

After the leading causes of death are known, the next step is to determine the 

leading causes of injury deaths. The following examples can be used to initiate 

discussion about the characteristics of injury death by intention. 

Example 1: 

In the United States, 148,209 people died of injuries in 2000. Of these deaths, 

97,900 were classified as unintentional and 46,474 as violence-related (Table 4). 

Death certificates provided the data for these figures, and the information was 

obtained through CDC’s Web-based Injury Statistics Query and Reporting 

System (WISQARS) (www.cdc.gov/ncipc/wisqars/default.htm). 

Injury Surveillance Training Manual 13 Participant Guide — Session II 
Table 4. Injury Deaths Among U.S. Residents — 2000 

All Races, Both Sexes, All Ages 

Intent Cause of Injury Deaths Frequency 

Overall Motor Vehicle 43,354 Unintentional Deaths 

(97,900 Total) Other Unintentional Deaths 54,546 

Homicide 16,765 

Suicide 29,350 

Violence-related Deaths 

(46,474 Total) 

Legal Intervention-Related 359 

Undetermined Intent 3,819 

Total 148,209*

* Includes 16 deaths associated with operations of war and its sequelae (ICD codes Y36–Y89.1). Source: 

Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System 

(WISQARS) [Online]. (2002). National Center for Injury Prevention and Control, Centers for Disease 

Control and Prevention (producer). Available from: URL: www.cdc.gov/ncipc/wisqars. [2003 May 15]. 

Example 2: 

In Cali, Colombia, over a 10-year period (1993–2002), a total of 19,479 homicides, 

1,106 suicides, 4,403 motor vehicle-related deaths, and 1,269 other unintentional 

deaths were registered by the Fatal Injury Surveillance System5 (Table 5). 

Table 5. Frequency of Injury Deaths in Cali, Colombia, 1993–2002 

Intent Cause of Injury Deaths Frequency 

Unintentional Deaths Motor Vehicle-Related 4,403 

(5,672 Total) Other Unintentional Deaths 1,269 

Violence-Related Deaths Homicides (includes legal intervention) 19,479 

(20,585 Total) Suicides 1,106 

Total (not including undetermined intent) 26,257 

Source: Fatal Injury Surveillance System. Data from: Police department, forensic medicine, district 

 attorney, transportation office. 

 

Exercise: Compare injury deaths in the United States and Cali. Answer the 

following questions: 

1. Are there differences in injury mortality characteristics? 

2. Are the data comparable? 

3. Which indicator(s) will you use to compare these data? 

Injury Surveillance Training Manual 14 Participant Guide — Session II 
5. Compare the Frequency of Injuries Calculated with 

Data from Different Sources 

Injury data are commonly collected for different purposes according to the mission 

of each institution. Identifying the goal behind each and comparing the goals with 

the objectives of the surveillance system will help explain the differences in the 

numbers. 

For instance, in Nicaragua, when a suicide mortality comparison was performed 

among three different data sources, the Ministry of Health (minsa), the police 

(policia), and forensic medicine (medicina), differences were found among the data 

sources. Forensic medicine only reported data for deaths occurring in Managua, the 

capital city. The police did not investigate all cases of suicide, and the health sector 

provided information from hospital deaths and death certificates in the country7

(Figure 3). 

 

Figure 3. Suicide Reported by Different Data Sources in Nicaragua, 

1999–2002 

Years 1999 2000 2001 2002 

 Source: Prado F, Rocha J. Injury Surveillance Workshop, 2003. 

Another comparison among injury data sources was conducted in El Salvador. The 

absence of information seen in some categories reflected the lack of interest or 

timely data for specific types of death. For instance, suicides and other unintentional 

deaths are not reported by the police, since their interest is in homicides and motor 

vehicle-related deaths. Forensic medicine reports data for all injury deaths. More 

motor vehicle-related deaths and homicides are recorded by forensic medicine than 

by the police. Public health collects data on homicide and suicide, but the frequency 

is lower than the previous two sources because public health only reports hospital 

deaths8 (Table 6). 

Injury Surveillance Training Manual 15 Participant Guide — Session II 
Table 6. Total Cases of Injury Mortality Reported by 

Different Data Sources in El Salvador — 2001 

Type of Injury Forensic Medicine Police Department Public Health 

Frequency of Unintentional Injuries 

Motor Vehicle-Related 

Deaths 1,629 886 No data 

Other Unintentional 

Deaths 933 No data No data 

Frequency of Violence-Related Injuries 

Homicide 2,696 2,341 543 

Suicide 815 No data 222 

Source: Forensic medicine, police department, and public health. Injury Surveillance Workshop; 2002. 

Exercise: Calculate injury frequency using local death data. Summarize the data by 

the major injury categories (i.e., homicide, suicide, motor vehicle-related, and other 

unintentional deaths). Compare the different indicators and discuss, keeping in 

mind the following topics: 

1. Are there some differences among the data from different sources? 

2. Which events have more discrepancies? 

3. If discrepancies are found, explain why there may be differences. 

6. Summary 

Now that you have completed this session, you should be able to: 

• Identify injury data sources and the strengths and weaknesses of each; 

• Identify available data sources that can provide information to the 

surveillance system; 

• Describe the size of the injury problem; 

• Compare the frequency of injuries calculated with data from different 

sources. 

Session III addresses the next step, which is to build a coalition to support the injury 

surveillance system and prevention activities. 

 

Injury Surveillance Training Manual 16 Participant Guide — Session II 
REFERENCES 

 1. Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International Perspective 

(Epidemiology, Surveillance and Policy). New York, NY: Oxford University Press; 

1998:28. 

 2. National Highway Safety Administration (NHTSA) website. Available at: 

www.nhtsa.dot.gov. Accessed June 2004. 

 3. Centers for Disease Control and Prevention. National Violent Death Reporting System 

(NVDRS) Implementation Manual [online]. 2003. National Center for Injury Prevention 

and Control, Centers for Disease Control and Prevention (producer). Available at: 

www.cdc.gov/injury. 

 4. Sistema Unificado de Violencia y Delincuencia. Bogota, Colombia. Available at: 

www.suivd.gov.co. Accessed June 2004. Fatal Injury Surveillance System of Cali, 

Colombia. Available at: http://cisalva.univalle.edu.co. Accessed June 2004. 

 5. Espitia V, Guerrero R, Gutierrez M, Concha-Eastman A, Rafael E. Ten years of a fatal 

injury surveillance system using linkage data. Cali, Colombia. 1993–2002. Paper 

presented at: 7th World Injury Conference; June 2004; Vienna, Austria. 

 6. Molina F. Injuries in San Salvador. In: Workshop “Injury Surveillance System in San 

Salvador.” San Salvador, El Salvador: Centers for Disease Control and Prevention, 

Ministry of Health of El Salvador; 2004. 

 7. Rocha J, Prado F. Magnitude of the injury problem in Nicaragua. In: Workshop 

“Injury Surveillance Systems in Nicaragua.” Managua, Nicaragua: Centers for 

Disease Control and Prevention, Ministry of Health of Nicaragua; 2003. 

 8. Chacon R, Moran S. Magnitude of the Injury Problem in El Salvador. In: Workshop 

“Injury Surveillance System in San Salvador.” San Salvador, El Salvador: Centers for 

Disease Control and Prevention, Ministry of Health of El Salvador; 2002. 

Injury Surveillance Training Manual 17 Participant Guide — Session II 
INJURY SURVEILLANCE TRAINING MANUAL 

PARTICIPANT GUIDE 

SESSION III

BUILD A COALITION TO SUPPORT THE 

INJURY SURVEILLANCE SYSTEM AND 

PREVENTION ACTIVITIES 

Developed with the support of the 

National Center for Injury Prevention and Control 

Division of International Health, Epidemiology Program Office 

Centers for Disease Control and Prevention 

Atlanta, GA 
SESSION III

BUILD A COALITION TO SUPPORT THE 

INJURY SURVEILLANCE SYSTEM AND 

PREVENTION ACTIVITIES 

Learning Objectives 

• Identify partners to include in the coalition and recruiting strategies for 

involving them. 

• Identify local, national, and international organizations working 

in injury prevention and control in the region. 

• Define the existing social, legal, and political framework in which an 

 injury surveillance system and prevention activities may be established. 

Introduction 

Exercise: Answer the following questions: 

1. What does “coalition” mean to you? 

2. What are some other names for coalition? 

3. Do you think it is important to have a coalition to 

support the injury surveillance and prevention activities? 

A coalition is an alliance of organizations working together to achieve a common purpose. 

A successful injury surveillance system requires the cooperation and effort of many 

individuals from different sectors. The expertise of professionals from multiple 

disciplines must be integrated to develop the most effective and efficient solutions 

for specific injury problems. For certain types of injuries, such as traffic injuries, 

drownings, or sports injuries, departments or organizations other than those 

involved with public health may be more efficient in coordinating prevention 

activities by multiple organizations. Public health epidemiologists can provide 

technical assistance to these groups in the development of surveillance and research. 

Injury Surveillance Training Manual 3 Particpant Guide — Session III 
Although circumstances vary from one community to the next, these issues 

must be addressed to ensure that the coalition will include the necessary partners, 

address pertinent health issues, and implement one or more successful programs 

or interventions. Some of these keys to success include:1 

• Commitment of lead agency; 

• Effective core planning group; 

• Planned recruitment of coalition members; 

• Functional coalition structure; 

• Clearly defined staff roles; 

• Formally accepted mission and goals; 

• Respected leadership; 

• In-depth education of coalition members; 

• Ownership and commitment by coalition members; 

• Successful implementation of a pilot project; 

• Recognition of coalition members. 

1. Identify Partners to Include in the Coalition 

In addition to helping define prevention strategies, a coalition can provide the 

surveillance system with political and financial support. The stakeholders, 

authorities, data sources, communities, religious groups, nongovernment offices 

(NGOs), and other community groups organized around prevention should be 

represented in this group. 

Also involve authorities that approve funding, lead programs and projects, and 

launch control laws. Health personnel are especially sensitive about prevention 

issues because they are directly affected by the consequences. Justice and security 

officials also have a vested interest because they attend to victims as well. Personnel 

in transportation offices who respond to traffic accidents may also want to 

participate in the coalition. Elementary and high school teachers are important to 

involve in this process because they face violence-related problems every day. 

Involving community organizations and mass media will be helpful in the 

development of prevention strategies and the dissemination of information. 

 

Example:

Table 1 identifies potential partners to include in an intersectorial coalition for 

creation of an injury surveillance system (guidelines for the epidemiological 

surveillance of violence and injuries2). At least 10 sectors have been identified, along 

with the institutions and participants’ profiles. 

Injury Surveillance Training Manual 4 Particpant Guide — Session III 
Table 1. Potential Partners in an Intersectorial Coalition for 

Creation of an Injury Surveillance System 

Sector Institutions Participants 

Health 

Ministry of Health 

Hospitals 

Health Centers 

Health Posts 

Epidemiologists, doctors, nurses, 

health educators, health promoters, 

paramedics, and other health workers 

Justice 

Forensic Medicine Offices 

(Coroner/Medical Examiner) 

Courts 

Public Defenders’ Offices 

Prosecutors’ Offices 

Family Services or Counseling 

Forensic pathologists, judges, public 

defenders, prosecutors or their 

assistants, directors or professional staff 

of family services or family counseling 

Security Police (Homicide Investigation Office) 

Security Companies 

Regional or local police chiefs, 

statistical officers 

Transportation Transportation Departments and Offices Department directors or traffic police, 

statistical officers 

Administration 

Planning Departments 

National and Provincial Statistical 

Departments 

Statisticians, geographers 

Education 

Universities 

Colleges 

Schools 

Researchers, professors, and 

student leaders 

Community Community Organizations 

Youth and Mothers’ Organizations 

Community leaders, youth leaders, 

community groups 

Private 

Organizations 

Nongovernmental Organizations 

Human Rights Groups 

Insurance Aagencies 

Spokespersons and leaders of private 

organizations, statisticians 

Political National, Regional, and Local 

Authorities 

Staff in the president’s, governor’s, or 

mayor’s offices 

Media Television, Radio, Newspapers Journalists and personnel working in 

mass media 

Source: Concha-Eastman A, Villaveces A. Guidelines for the Design, Implementation, and 

Evaluation of Epidemiological Surveillance Systems on Violence and Injuries. Washington, DC: 

Pan American Health Organization; 2001. 

1.1 Determine Recruiting Strategies to Involve Coalition Partners 

A good strategy to begin the recruiting process is to hold a meeting with stakeholders and potential partners to involve in the coalition. The meeting may be held 

before or at the initiation of the surveillance system to promote support among 

participating agencies, to recruit expertise, and to address objections and concerns 

that stakeholders may have before these become obstacles (e.g., why they should be 

interested in the surveillance system and how it will benefit them or the 

community). The stakeholder informational meeting can occur in a variety of 

settings. For example, it could be part of a larger conference about violence or could 

be a dedicated meeting. A neutral location for the meeting, such as a local college or 

hotel conference room, is a good idea. Potential investors must be included in this 

meeting as well. All attendees should be provided with injury data showing the big 

Injury Surveillance Training Manual 5 Particpant Guide — Session III 
picture: the lives that can be be saved and the social and economic costs that can be 

avoided. Provide concrete examples from a local community and ask the question, 

“Could this personal tragedy have been avoided?” Suggest the steps to develop an 

injury surveillance system and the prevention activities.3

Aside from government staff, invite knowledgeable people who are interested in 

recommended data sources and injury issues (e.g., law enforcement, criminal justice, 

health, and mental health). They can become valuable advocates for the surveillance 

system. A possible agenda for this meeting may be developed from the discussion 

topics which follow: 

• Describe what is known and not known about the problem of 

injuries in your city or community. Use the injury data prepared 

in Session II to show the problem’s magnitude. 

• Discuss the opportunities an injury surveillance system offers to 

combat myths and misunderstandings, to learn about the size of 

the problem, and to develop, define, and monitor prevention strategies. 

• Describe potential challenges, obstacles to success, and 

key contacts and resources. 

• Establish a list of next steps for participants, including the development of an advisory board.4

Each participant in the coalition must have a clear role on the team. Politicians are 

often involved in funding for prevention programs and must approve legislation on 

prevention. Because politicians are usually not epidemiologists or public health 

officers, they are often driven more by economic pressures than by the human health 

issues and suffering that motivate health professionals. Thus, health and other sectors 

should collaborate with economists to clearly and forcefully document the short- and 

long-term economic impact of injuries. This will involve analysis of the direct and 

indirect costs of premature mortality and morbidity, including temporary and 

permanent disabilities. 

Success Story: 

In 1987, in Oklahoma City, the State Department of Health launched surveillance of 

burn injuries. The absence of a functional smoke alarm was identified as a major risk 

factor for fire fatalities. A partnership was formed among a number of community 

agencies and volunteers, including the state and local health departments, the local 

chapter of the American Red Cross, and the Oklahoma City Fire Department. The 

Lifesavers Program was established in 1990. Free smoke alarms were distributed in 

the area. Fire-related injury rates decreased 81% in the target population.4 Some 

recruitment strategies used to involve the partners follow: 

• Identification of institutions or organizations with similar goals that were 

working in the target community. For instance, the Red Cross gives 

temporary shelter to people who have lost their homes; consequently, it is 

important that the Red Cross participate in prevention activities. 

Injury Surveillance Training Manual 6 Particpant Guide — Session III 
• Preparation of an educational plan for partners based on statistical data, 

including what steps can be followed to prevent fire fatalities. 

• Identification of opinion leaders (e.g., clerics, actors, and professional 

athletes) who can motivate community participation in the program. 

2. Identify Local, National, or International Organizations Working in 

 Injury Prevention and Control in the Region 

Since injury prevention is often most successful at the local level, where specific 

injury problems can be addressed, coalition building at all levels, including the local 

level, is crucial to strengthening the response to the injury problem. Financial and 

technical assistance is needed from federal and state government agencies and from 

the private for-profit and nonprofit sectors.5 Injury prevention is a goal that offers 

common ground for parties who might not otherwise agree about issues involving 

injuries, especially firearm violence or motor vehicle-related injuries. 

There may be organizations working at the local level in injury prevention such as 

health care providers, police, educators, social workers, employers, and government 

officials. Small-scale pilot programs and research projects are usually developed at 

the local level to try out new ideas.5 

At the national level, a variety of government ministries—not just those concerned 

with law enforcement, social services, and health, but others as well—can make 

important contributions to preventing injury. Education ministries, for instance, are 

an obvious partner, given the importance of intervention in schools. Religious 

leaders and organizations have a role to play through their pastoral work and, in 

appropriate cases, can mediate problems.6 

At the global level, a variety of international donors, bilateral programs, nongovernmental organizations, and religious organizations are already involved in violence 

prevention activities around the world. These include the World Health 

Organization, United Nations, World Bank, Interamerican Development Bank, 

High Commissioner for Refugees, the United Nations Children’s Fund, and others.5 

Success Story: 

In the United States, a successful local community organization effort in injury 

control is the Injury-Free Coalition for Kids initiative, which started with the Harlem 

Hospital Injury Prevention Program in New York City. In the mid-1980s, injury 

surveillance was used to identify the causes of injury to children and adolescents 

living in the low-income neighborhoods surrounding Harlem Hospital. In response 

to compelling evidence of an injury problem, a multidisciplinary lay-professional 

coalition was formed to develop and implement prevention programs. 

Injury Surveillance Training Manual 7 Particpant Guide — Session III 
The coalition included health professionals, parents, and community members. 

Strategies included development of safe play areas and provision of supervised 

activities for children. From 1983 to 1995, hospital admissions due to injury 

decreased by 55% overall (46% for pedestrian injuries; 50% for playground injuries; 

46% for violence-related injuries).7

Exercise: Answer the following questions: 

1. What institutions in your region are working in injury prevention 

 and control? 

 2. What kinds of programs or projects do they have? 

3. Determine the Existing Political, Social, and Legal Framework 

Within Which the Surveillance System and Prevention Strategies 

Will be Established 

To establish an injury surveillance system or an injury prevention program, political 

considerations such as the importance of the problem to the authorities, the political 

situation in the country or region, and the timing of elections must be considered. 

These factors could positively or negatively influence the establishment of a 

surveillance system. It is important to know the legal framework. For example, are 

helmet and seat belt laws and drinking and driving bans needed in the region prior 

to initiating the surveillance system or the prevention program? Finally, it is 

important to understand the social norms in the area where the surveillance system 

will be established, like knowing if is socially acceptable for a person to drive a car 

after drinking alcohol. If it is acceptable, then the measure of blood alcohol 

concentration (BAC) levels of injured persons may be an important element to 

include in the surveillance system. 

Exercise: Identify aspects of the political, legal, and social environment that can 

affect the ability to establish the injury surveillance system and injury prevention 

acrivities. 

1. Is it socially acceptable for a husband to hit his wife? 

2. What is the relationship between the mayor and the health authorities, 

security authorities, and communities? 

3. Are motorcyclists and cyclists required to wear helmets? 

4. How is drunk driving viewed? 

5. Is there a regulation that applies to gun ownership? 

6. Are authorities interested in establishing an injury 

surveillance system in their jurisdiction? 

7. In which category would you include this photo? Why would someone 

display this bumper sticker? 

Injury Surveillance Training Manual 8 Particpant Guide — Session III 
4. Summary 

Now that you have completed this session, you should be able to: 

• Identify partners to include in the coalition and recruiting strategies for 

involving them; 

• Identify local, national, and international organizations working in 

injury prevention and control in the region; 

• Define the existing social, legal, and political framework in which an 

injury surveillance system and prevention strategies may be established. 

The next step, in Session IV, will be to determine the appropriate methodology for 

developing and maintaining the surveillance system. 

Injury Surveillance Training Manual 9 Particpant Guide — Session III 
REFERENCES 

1. Brownson R, Remington P, Davis J, eds. Chronic Disease Epidemiology and Control. 

Washington, DC: American Public Health Association; 1993. 

2. Concha-Eastman A, Villaveces A. Guidelines for the Epidemiological Surveillance 

on Violence and Injuries. Washington, DC: Pan American Health Organization; 2001. 

3. Centers for Disease Control and Prevention. National Violent Death Reporting System 

(NVDRS) Implementation Manual [online]. 2003. National Center for Injury Prevention 

and Control, Centers for Disease Control and Prevention (producer). Available at: 

www.cdc.gov/injury. 

4. State and Territorial Injury Prevention Directors Association. Safe States, 2003 Edition. 

Atlanta, GA: State and Territorial Injury prevention Directors Association; 2003. 

5. Bonnie RJ, Fulco CE, Liverman CT, eds. Reducing the Burden of Injury: Advancing 

Prevention and Treatment. Washington, DC: National Academy Press; 1999. 

6. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World Report on Violence and 

Health. Geneva: World Health Organization; 2002.

7. Gielen AC, Sleet D. Application of behavior-change theories and methods to injury 

prevention. Epidemiologic Reviews. 2003;25:70. 

Injury Surveillance Training Manual 10 Particpant Guide — Session III 
INJURY SURVEILLANCE TRAINING MANUAL 

PARTICIPANT GUIDE 

SESSION IV

DETERMINE THE APPROPRIATE METHODOLOGY 

FOR THE SURVEILLANCE SYSTEM 

Developed with the support of the 

National Center for Injury Prevention and Control 

Division of International Health, Epidemiology Program Office 

Centers for Disease Control and Prevention 

Atlanta, GA 
SESSION IV

DETERMINE THE APPROPRIATE METHODOLOGY 

FOR THE SURVEILLANCE SYSTEM 

Learning Objectives 

• Define the injury events and data elements (variables, case definition, 

and codes) to be included in the system. 

• Develop data collection instruments and determine data collection 

frequency. 

• Determine the type of surveillance system. 

• Plan for systematization, maintenance, and security of the data. 

• Describe the staff and key positions necessary to operate the system. 

Introduction 

When selecting a methodology for an injury surveillance system, several factors 

must be taken into account, including data needs and existing resources. The key 

elements that must be addressed include injury events, variables, instruments, 

systematization of data, and required staff. All are described in this session. 

The following criteria can help you select the appropriate methodology for your 

surveillance system:1

Objective: Clearly define what you want to accomplish with the surveillance system 

by considering questions such as: 

• Why do you and other stakeholders want an injury surveillance system? 

• Should the surveillance system be comprehensive (i.e., cover all types 

of injuries)? Should it also or solely focus on particular injuries? 

Size and Type of Injury Problem: The magnitude and type of injury problem is one 

key element to determining which injury events to monitor. Basic indicators, as 

calculated in Session II, should be used to determine the size of the problem. 

Available Data Sources: You must identify the source of information for the 

surveillance system. In the previous session, you developed the skills to identify 

such data sources. 

Feasibility of Getting Information: Consider how feasible it is to get needed data. 

Which institutions are collecting these data? For instance, if you want to include 

Injury Surveillance Training Manual 3 Participant Guide — Session IV 
child maltreatment in the surveillance system, but none of the identified institutions 

collect this information, you may decide to exclude this outcome or include another 

data source in the system. 

Political Priorities: Involving stakeholders and authorities in the development of 

the surveillance system will keep them informed and will help you understand their 

priorities. 

Potential for Defining Interventions: The ultimate goal of an injury surveillance 

system is to identify appropriate interventions, based on the data analysis. Data 

collection and analysis should not be allowed to consume resources if action does 

not follow.2

1. Define the Events to Include in the Surveillance System

Because different data sources will be used in the surveillance system, one of the 

first steps is to establish cooperative and mutually-beneficial relationships with data 

providers and organizations that will serve as data sources. Once contact is made, 

set up a meeting either in person or over the phone to discuss the type of injury 

events and data elements needed, how data confidentiality will be protected, how 

the data can be collaboratively used, and the form in which the data are available 

(electronic files or hard copy reports). Sharing a list of required injury events and 

data elements with the data sources in advance will help them determine if they will 

collect their data on a standardized form, or just provide their data to the 

surveillance system on their own forms. 

Some data sources may not have a database designed to collect information. They 

may only have counts on spreadsheets. Offering assistance in creating a database to 

collect the information may motivate some sources to participate in the surveillance 

system. However, some data sources, for instance, police departments and district 

attorneys, may want to include other events in the system, such as robbery or 

kidnapping, even if no one was injured. In this case, you should get an agreement 

over the key events and data elements to include in the surveillance system. For this 

reason, it may be appropriate to include more than the minimum variables needed 

for injury surveillance. 

Identifying multiple-victim incidents is a problem in many injury surveillance 

systems. Linking victims who die in a multiple-victim incident is a challenge since 

most data sources are victim-based, and not incident-based. There are several ways 

to link cases, none of which are foolproof. In some cases, the police report collects 

the information indicating if the victim died in a single- or multiple-victim incident. 

Linkage is more difficult when only electronic data are available from data sources. 

Querying the data for cases that occur in the same city on the same day can 

sometimes reveal missed linkages.3 

Injury Surveillance Training Manual 4 Participant Guide — Session IV 
Other additional criteria can guide selection of the types of injury events to include 

in an injury surveillance system: 

• Based on the intentionality: violence-related injuries or 

unintentional injuries; 

• Based on the result: fatal injuries, nonfatal injuries, or disabilities; 

• Based on the nature: physical, sexual, psychological, 

deprivation, or neglect. 

Example: 

In the United States, there are 12 state health departments that voluntarily 

participate in a new surveillance effort. These health departments use the 

six categories listed below to monitor injury events. The process of selecting these 

events was based on the availability of data sources and their willingness to share 

the information. In this model, the states are collecting nonfatal, fatal, unintentional, 

violence-related, and self-reported injuries:4 

1. All injury hospitalization; 

2. Traumatic brain injury; 

3. Motor vehicle crashes; 

4. Self-reported motor vehicle crashes; 

5. Drowning; 

6. Fire-related injuries and deaths. 

2. Determine Data Elements to Include in the System: 

Variables, Case Definition, and Codes 

Data elements are the variables needed for each event, such as demographic variables 

(name, age, sex, education level, employment, alcohol consumption); 

time variables (date, time of event occurrence, time of death); place variables 

(where the event occurred, residence of victim, and where the victim died); 

circumstance variables (relationship between victim/aggressor, mechanism used 

[type of weapon], context surrounding the event, and criminal history of victim). 

The case definition and codes are included as data elements as well. 

 2.1 Define the Variables 

Frequently, the injury surveillance system collects variables related to: (1) the 

person who has a fatal or nonfatal injury; (2) the time and place where the 

event ocurred; and (3) the characteristics or context surrounding the event. 

Injury Surveillance Training Manual 5 Participant Guide — Session IV 
Demographic Variables 

Name: Some injury surveillance systems do not collect the name of the 

injured person, just an identifier, which is necessary if the data are linked. 

In some cases (i.e., a pedestrian is injured by a hit and run driver), the 

identity of the person is unknown. 

Age and sex: These are variables frequently included in the surveillance 

system and for which the information is usually available. 

Race or ethnic group: In some places or regions, defining this variable is 

difficult. Race/ethnic group are not collected frequently. 

Education level: This variable is not often collected. 

Employment: It is an important variable, especially for occupation relatedinjuries. 

Blood alcohol concentration (BAC) : Although very important, a BAC test 

result is rarely available because either the test is not taken or the result is 

not timely. BAC testing of the aggressor is critical, especially in 

transportation-related injuries; however, it is difficult to get as well. 

Collection of this variable has several limitations: cost related with having 

the test available for all cases; authorization to conduct the test; and legal 

implications of test results. 

Place of residence of the injured person: This variable is considered as 

demographic if the purpose is to know the socioeconomic status of the 

person according to the place where he or she lives. Traditionally, 

epidemiologic studies use the victim’s place of residence, while 

criminological studies use the place of occurrence.3 This variable could be 

included with the purpose of performing geographical analysis or 

distribution of the case. 

Time-related Variables 

Date and time of event, of health care (if provided), and of death (if it 

occurs): These moments could be different, and usually data sources 

register just one, according to their interest. 

Place-related Variables 

Date and time of the event, of health care (if provided), of death (if it 

occurs), and of residence. The place where the event occurs could be 

considered in two dimensions: one is the place where the person was at the 

moment of injury (i.e., home, street, school); the other dimension is the 

Injury Surveillance Training Manual 6 Participant Guide — Session IV 
exact address, which is useful to perform geographical analysis. On the 

other hand, the place of death could be different from the place of 

occurrence or the scene where health care was practiced. Some deaths are 

investigated at the scene, whereas others are investigated where the victim 

lives. Information about the place of occurrence is needed to define 

prevention activities. 

Variables Related to Event Circumstances (Characteristics) 

Relationship victim/aggressor: This variable is useful for the analysis and 

for defining prevention activities, especially instances of domestic violence 

or child maltreatment. However, this information is difficult to collect, even 

with information from law enforcement. 

Mechanism: This variable is usually collected by the injury surveillance 

system, and it indicates the method or instrument that caused the injury. 

Context: If possible, the collection of this variable is key to defining 

prevention activities. Police are often able to collect this information. 

Criminal history of victim and aggressor: Although these variables are 

important to understanding the problem, seldom are criminal histories 

available. To obtain this information, it may be necessary to use other 

methods (surveys or special research). 

Other variables included in the injury surveillance systems are the nature, 

severity, and result of the injury. These variables may be collected in hospitalbased systems. 

Example: 

The World Health Organization’s (WHO) Injury Surveillance Guidelines1

propose two types of variables. The first group is called the “core set” and the 

second group the “optional data set. 

Guidelines from the Pan American Health Organization (PAHO)5 are in the form of 

a table that depicts the relationships between variables, definitions, type of 

measurement, sources, and usefulness. 

 

The fatal injury surveillance system in Cali, Colombia,6 includes 12 similar 

variables. 

Injury Surveillance Training Manual 7 Participant Guide — Session IV 
These three proposals are shown in Table 1. Shaded boxes indicate the 

common variables among the three examples. 

Table 1. Variables Included in Injury Surveillance Systems 

WHO Guidelines 

Core Optional 

PAHO Guidelines Fatal Injury Surveillance System 

Cali, Colombia 

DEMOGRAPHIC VARIABLES 

Identifier Name 

Age Age Age 

Sex Sex Sex 

Marital status 

Activity Employment Employment (only in cases of suicide 

and other unintentional deaths) 

Socioeconomic status (SES) SES 

Education level 

Other psychoactive 

substances 

Alcohol level Alcohol level 

Race/Ethnicity 

TIME VARIABLES 

Date of injury Date of act Date of event 

Time of injury Time of occurrence 

PLACE VARIABLES 

Neighborhood Place of occurrence – 

Neighborhood and SES 

Place of occurrence Place of residence Location of the act Place of residence – 

Neighborhood and SES 

CHARACTERISTICS 

Mechanism of injury Type of weapon Mechanism of injury 

Motive for the act Context 

Relationship victim/aggressor Aggressor known / unknown 

Special category of people or 

risk group 

Special category of people or 

risk group 

Intention Intention (homicide, suicide, transportrelated, other unintentional deaths) 

Nature of injury ICD codes, 

Severity, 

Disposition 

For motor vehicle-related injuries: 

mode of transport, type of victim, and 

vehicle involved 

 

Injury Surveillance Training Manual 8 Participant Guide — Session IV 
2.2 Define the Codes to Use in the System 

Standard codes are required to accurately compare state, local, or international 

data to assess the magnitude and distribution of injuries as a public health 

problem. In Public Health Sector, mortality data on death certificates are coded 

using the International Classification of Diseases (ICD) codes. In 1999, the tenth 

revision of ICD codes (ICD-10) replaced the ninth revision (ICD-9), which had 

been the standard since 1979. In the ICD-9, external causes of death were 

coded with a supplementary set of codes (commonly known as E-codes). 

E-codes indicated the mechanism causing death (e.g., a motor vehicle traffic 

crash) and the injuries resulting from the external causes (e.g., fractures, 

open wounds), both of which were listed as contributing causes on the 

death certificate. In the ICD-10, external causes are classified under a series 

of alphanumeric codes, V01–Y98.7 (For a list of ICD-10 codes, see: 

Ftp://Ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10/). 

When a death or injury is the result of an external cause, the assigned ICD-10 

or ICD-9 external cause code is defined as a combination of the manner of the 

death or injury and the mechanism of the event. Manner of death is classified 

as unintentional or accidental, suicide or self-inflicted, homicide or assault, 

intent not determined, legal intervention, or act of war. Examples of the 

mechanism of the event would be firearm injury or motor vehicle crash. 

The primary difference between the assignment of codes for mortality and 

morbidity is that for mortality, the external cause is the underlying cause of 

death (the event that led to the chain of events resulting in death) and for 

morbidity, the external cause of the injury is the event that was related to the 

patient’s admission to the hospital.7 

 In the United States, CDC’s National Center for Health Statistics (NCHS) 

 formed the Ad Hoc Workgroup on the Classification of Death and Injury 

 Resulting from Terrorism. Based on the efforts of this group, NCHS has 

 developed a set of new codes within the framework of the ICD-10 and ICD-9 

 that will allow the identification of deaths from terrorism reported on death 

 certificates through the National Vital Statistics System and injuries and 

 illnesses from terrorism reported on medical records used for statistical 

 purposes and for reimbursement.8 Recognizing that investigation and track-

 ing of terrorism is in the domain of the U.S. Federal Bureau of Investigation 

 (FBI), the Ad Hoc Workgroup agreed to use the FBI definition of terrorism: 

“Injuries resulting from the unlawful use of force or violence against 

person or property to intimidate or coerce a government, the 

civilian population, or any segment thereof, in furtherance of 

political or social objectives.”8 

Injury Surveillance Training Manual 9 Participant Guide — Session IV 
 “U-codes” have been adopted to classify injuries related to terrorism. For 

 instance, the classification for mortality is *U01 Assault (homicide), which 

 includes assault-related injuries resulting from the unlawful use of force or 

 violence against persons or property to intimidate or coerce a government, 

 the civilian population, or any segment thereof, in furtherance of political 

 or social objectives. 

 *U02 Sequelae of Terrorism 

 *U03 Intentional Self-harm (Suicide) 

 The classification for morbidity related to terrorism follows: 

 E 979—Terrorism includes injuries resulting from the unlawful use 

 of force or violence against persons or property to intimidate or 

 coerce a government, the civilian population, or any segment thereof, 

 in furtherance of political or social objectives. 

 E 999—Late effect of injury due to war operations and terrorism 

 E 999.0—Late effect of injury due to war operations 

 E 999.1—Late effect of injury due to terrorism 

 Example: 

WHO’s World Report on Violence and Health presents a typology of violence, based 

on the victim/aggressor relationship and nature of violence. The cells in Table 2 

have been filled out with the appropriate ICD-10 codes categories from Chapters 

V, XIX, and XX. Other data sources must be used to complete the boxes. 

Table 2. A Typology of Violence Using ICD-10 Codes 

Interpersonal Self-Directed Family/Partner Community Nature of Collective 

Violence Suicidal 

Behavior Self-Abuse Child Partner Elder Acquaintance Stranger Social Political Economic

Physical 

F10–F19 

Mental and 

behavioral 

disorders due to 

psychoactive 

substance use 

X60–X84 

Intentional 

self-harm; 

Y87.0 

Sequelae of 

intentional 

self-harm 

Y07 

Other 

maltreatment 

syndromes 

P04.2–4 

Y07.0 

Other 

maltreatment 

syndromes 

Y07 

Other 

maltreatment 

syndromes 

X85–Y09 Assault; 

Y87.1 Sequelae of 

assault; 

Y08 Assault by other 

specified means; 

Y09 Assault by 

unspecified means 

Y35-Y36 Legal intervention 

and operations of war 

Sexual 

Y07 

Other 

maltreatment 

syndromes 

Y05 

Sexual 

assault by 

bodily force 

Y07 

Other 

maltreatment 

syndromes 

Y05 Sexual assault by 

bodily force. Includes 

rape (attempted), 

sodomy (attempted) 

Psychological 

F10–F19 

Mental and 

behavioral 

disorders 

due to 

psychoactive 

substance 

use 

Y07 

Other 

maltreatment 

syndromes 

Y07 

Other 

maltreatment 

syndromes 

Y07 

Other 

maltreatment 

syndromes 

Deprivation or 

Neglect 

Y06 Neglect and abandonment: By spouse or partner, by parent, by 

acquaintance or friend, by other specified persons, by unspecified person 

Injury Surveillance Training Manual 10 Participant Guide — Session IV 
In addition to ICD-10, other tools exist in the public health sector to classify the 

circumstances in which injuries occur. One such tool is the International Classification 

of External Causes of Injury (ICECI). It is a Related Classification in the World Health 

Organization’s Family of International Classification of Diseases and Related Health 

Problems (www.who.int/classifications/icd/adaptations/iceci/en/index.html). It 

complements Chapter XX, External Causes of Morbidity and Mortality of ICD-10. 

The ICD-10 Framework: External Cause of Injury Mortality Matrix 

(www.cdc.gov/nhcs/about/otheract/ice/matrix10.htm) has been adopted to 

bridge ICECI and ICD-10, making it possible to compare aggregated injury data 

classified according to either system. 

Another classification is the ICD-9-CM, which is a clinical modification of WHO’s 

Manual of the International Classification of Diseases, Injuries, and Causes of Death, 9th 

Revision (ICD-9). ICD-9-CM codes are widly used to code external causes of injury 

for visits in hospitals, emergency departments, and ambulatory care settings across 

the United States. However, within the next few years, the ICD-9-CM classification 

system will be replaced with the 10th revision of the clinical modification of the ICD 

classification system, which is currently under development. The National Center 

for Health Statistics (NCHS), is coordinating the effort to develop an ICD-10-CM 

coding system, including expansion of external-cause-of injury codes. When 

implemented, ICD-10-CM will allow for more detailed coding of the external cause 

of injury based on information in the medical record about injury circumstances 

(e.g., intentionality, mechanism, place of occurrence, and activity at the time of 

injury). 

 

 Exercise: Describe how to classify and code the following examples. 

If a person falls down the stairs and strikes his head on a metal door: 

1. What is the principal diagnosis and the reason for admission at the 

hospital? 

2. If a person falls, as in the previous example, but dies as a result of the 

fall, what is the immediate cause of the injury and the underlying cause 

of death? 

 

2.3 Review the Case Definition 

How do you define “a case”? It depends on the objectives of your surveillance 

system. For instance, if the objective is to monitor the burden of care on a given 

service, then a “case” will be any visit (first or repeat) to that service by an 

injured person or by a person who only suspects that he/she was injured. If the 

objective is to monitor the incidence of different types of injury, then a “case” 

will be an injury presented by one person for the first time. In this instance, 

repeat visits for treatment of the same injury will not count as separate cases; 

Injury Surveillance Training Manual 11 Participant Guide — Session IV 
otherwise, you would be counting the same injury more than once. Noninjuries, such as suspected but not actual concussion or bone fracture, do not 

count as cases. If one person has dual or multiple injuries, each injury counts as 

a case. If the objective is to monitor the incidence of injured persons, then a 

“case” will be the first visit of one person, irrespective of whether that person 

has one injury or multiple injuries. Repeat visits and visits by non-injured 

persons do not count as cases.1

 Determining a case definition is not always as simple as it seems. For example, 

 from a legal standpoint, a case in which a criminal dies as a result of police 

 action during a robbery can be differentiated from a case in which the robber 

 himself kills a policeman. The first case will be classified as a legal intervention, 

 and the second case as homicide, even though in both cases the intent of the 

 action is the same, to kill the opponent.5 

In some injury surveillance systems, the “gold standard” for defining the cause 

of death is the death certificate. Because almost all death certificates need a 

registration, using the state’s vital records office to identify cases is one way to 

ensure that intentional deaths are captured. However, as was mentioned 

earlier, in some countries not all deaths have death certificates, especially those 

occurring in rural areas. 

In selecting a case definition for the injury surveillance system, you could use 

ICD-10 codes, which are used by public health sector. If you decide to include 

other data sources, for example law enforcement, you must keep in mind that 

these sources use different definitions. In the case of motor-vehicle related 

injury, the transportation office often uses its own definitions as well. 

A comparison between ICD codes and codes used by U.S. law enforcement 

show that in the ICD-10, homicides are called “assault,” whereas the FBI uses 

the term “criminal homicide.” ICD-10 mentions only the mechanism and does 

not specify when a homicide is legal intervention. 

Using the FBI definitions, “justifiable homicide” is similar to legal intervention, 

but no “operations of war” counterpart exits. Manslaughter by negligence, 

using the FBI definition, could be considered similar to “Neglect and 

Abandonment Y06” in ICD-10.“Aggravated assault” could be considered 

similar to “Assault (X85–Y09) in ICD-10” (Table 3).

Injury Surveillance Training Manual 12 Participant Guide — Session IV 
Table 3. Case Definition for Violence-Related Injuries: 

 Public Health versus Law Enforcement 

Public Health (ICD-10)* Law Enforcement** 

Assault (X85–Y09): 

Includes homicide and injuries inflicted by another person 

with intent to injure or kill, by any means. 

Excludes: Legal intervention and operations of war. 

Assaults are classified by mechanism; a four-digit code is 

used for place of occurrence of the event and for activity 

of the victim. 

 

Criminal Homicide: 

 Murder and no negligent manslaughter: the willful killing of 

 one human being by another. 

Aggravated Assault: 

 An unlawful attack by one person upon another for the 

 purpose of inflicting severe or aggravated bodily injury. 

 This type of assault is usually accompanied by the use 

 of a weapon or by means likely to provide death or great 

 bodily harm. 

Other Assaults: 

 Assaults and attempted assaults in which no weapons are 

 used and do not result in serious or aggravated 

 injury to the victim. 

Legal Intervention (Y35): 

Includes legal intervention according to the mechanism: 

Involves firearm discharge, explosives, gas, blunt 

object, sharp objects, legal execution, other means, 

and unspecified. 

Justifiable Homicide (Not a Crime): 

 Killing of a felon by a law enforcement officer in the 

 line of duty. 

 The killing of a felon, during the commission of a 

 felony, by a private citizen. 

Neglect and Abandonment (Y06): 

Classified according to the perpetrator: 

 Spouse or partner, parent, acquaintance or friend, 

 other specified persons, unspecified person. 

Manslaughter by Negligence: 

 The killing of another person through gross negligence. 

Operations of War (Y36): 

Includes: injuries to military personnel and civilians 

caused by war and civil insurrection and injuries due to 

operations of war occurring after cessation of hostilities 

(for instance, injuries by explosion of bombs or mines 

placed in the course of operation of war are classified as 

Y36.8). 

 * International Statistical Classification of Diseases and Related Health Problems (ICD-10) 

** National Incident-Based Reporting System Volume 1: Data Collection Guidelines (Uniform Crime 

Reporting—FBI), available at: www.fbi.gov/ucr/nibrs/manuals/v1all.pdf. 

Injury Surveillance Training Manual 13 Participant Guide — Session IV 
 Examples: 

1. At an injury surveillance system workshop held in Nicaragua in 2002, 

participants (who represented the health sector, police, forensic medicine, 

department of transportation, and government authorities) identified at 

least five different classifications for homicide based on police data: 

• Assassination; 

• Homicide; 

• Parricide; 

• Infanticide; 

• Manslaughter. 

This classification is based on several criteria: (1) the relationship between 

the victim and the aggressor (parricide, infanticide); (2) the intention 

(homicide versus manslaughter); and (3) the context (assassination), which 

is taken into account when the homicide was premeditated. According to 

the law in this country, each category has a different sentence. All 

categories are considered to be homicide or assault according to ICD-10. 

2. In the fatal injury surveillance system of Cali, Colombia, the case definition 

for violence-related injuries is given by the district attorney and forensic 

medicine. For motor vehicle-related injuries, transportation office case 

definitions are used, which causes some differences among the data 

sources. For instance, when a vehicle driver dies, the district attorney 

classifies it as unintentional injury. In contrast, if the passenger dies, this 

office classifies it as intentional injury. The transportation office classifies all 

such deaths as vehicle occupant death, categorized as driver or passenger 

deaths. 

3. Develop Data Collection Instruments and 

 Determine Data Collection Frequency 

Develop or Select Data Collection Instruments: Once you have decided which 

data elements to include in the surveillance system, the next step is to develop or 

select the data collection instruments or forms. 

Whether you decide to built on an existing system or establish a new system, WHO 

guidelines1 recommend some steps to take in creating the collection forms: 

• Seek input from all stakeholders and staff who will actually be 

filling out the forms once the surveillance system is in place. Their 

experience of handling injury cases and extracting information from 

patients will be invaluable. 

Injury Surveillance Training Manual 14 Participant Guide — Session IV 
• Seek advice from a statistician, if possible. A statistician can help with 

form design and ensure that the information obtained is as easy as 

possible to collate and process. 

• Make the form easy on the eye, easy to understand, and, above all, 

easy to complete. 

• Decide whether or not to precode the forms. It is usually better to 

precode, in which case it is best to have as few opportunities as 

possible to enter “other” or “unknown” or to answer questions with 

unique words or phrases. There are, however, situations where it 

may be preferable to leave questions open-ended, allow staff to fill 

in whatever words seem appropriate to them, and then extract and 

code the information afterwards. 

Wherever possible, use numbers rather than letters or symbols to 

code information (i.e., numeric codes rather than character codes). 

Numbers are easier to process and less prone to entry errors. 

• Test the form(s) before adopting them for general use. Arrange for 

the staff that will be filling out the forms regularly to use them on a 

trial basis. Note any difficulties that staff may have in understanding 

questions or recording responses, and be prepared to revise the forms, 

if necessary. 

In the health sector, surveillance forms are completed while patients are being 

interviewed about their injury, either during triage, registration, or treatment. Every 

effort should be made to avoid duplication of work and to avoid asking patients to 

answer the same questions several times. Ideally, a member of the medical staff 

(e.g., a doctor, nurse, or paramedic) treating an injury case should complete the 

injury surveillance form, one copy of which becomes part of the patient’s medical 

record, while another is used for surveillance purposes. A second option could be to 

designate a trained person, e.g., a triage officer, nurse, or psychologist. A third 

option is self-administration. However, this requires a high level of literacy and an 

understanding of the mechanism of injury, and is applicable in cases when the 

patient is concious.1 

Example: 

The forms to collect the data proposed in the WHO guidelines are especially useful 

for injury surveillance systems in health facilities such as emergency departments 

and hospitals, because these are the only institutions that collect information about 

the nature of the injury. 1 Table 4 shows a form that was adapted on the basis of 

WHO guidelines. Some variables like the address and context were added. 

Injury Surveillance Training Manual 15 Participant Guide — Session IV 
Table 4. Form to Collect Minimum Data for an Injury Surveillance System 

Name or Identification Number: 

Age: Sex: Male Female Unknown 

Address where the injury occurred: 

# Street: City: State: Zip Code:

Place where the injury occurred: 1. Home __ 2. School __ 3. Sport __ 4. Other __ 5. Unknown ___ 

Time and date when the injury occurred: 

Mechanism (how the injury was inflicted): 

 1. Traffic injury 2. Sexual assault 3. Fall 

 4. Other blunt force 5. Stab/cut 6. Gunshot 

 7. Fire, heat 8. Choking/hanging 9. Drowning 

10. Poisoning 98. Other (specify) 99. Unknown 

Intent: 

1. Unintentional 2. Intentional (self-inflicted) 3. Intentional (assault) 4. Unknown 

Context in which the injury occurred: 

Nature of injury (hospital injury surveillance): 

1. Fracture 2. Sprain/strain 3. Cut, bite, open wound 

4. Bruise 5. Burn 6. Concussion 

7. Organs system injury 8. Other (specify) 9. Unknown 

Motor vehicle related: Mode of transport Type of victim Vehicle involved 

Adapted from: Holder Y, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O, eds. Injury Surveillance

Guidelines. Geneva: World Health Organization; 2001.

Example: 

In the injury surveillance system used in emergency rooms in Central America and 

Colombia, the variables necessary for the system were included in the clinical record 

(Questionnaire #1). This method avoids the duplication of data. This document is 

used for both the records in the hospital and for the injury surveillance system.9 

A similar questionnaire was used in Argentina to assess the incidence of acute 

injuries through a surveillance system, based mainly in emergency departments 

(Questionnaire #2). This instrument is completed manually and then entered into 

a Web-based database that is sponsored by the Argentina Ministry of Health.10 The 

questionnaires used in these systems are at the end of this session and also in the 

CD-ROM. The titles of the questionnaires are: 

Questionnaire #1: Injury Surveillance System in Emergency Room 

 Clinical Report 

Questionnaire #2: Ministerio de Salud de la Nación, Republica de Argentina 

Injury Surveillance Training Manual 16 Participant Guide — Session IV 
 Exercise: Answer the following questions about emergency room-based data 

 collection instruments for injury surveillance systems in Central America 

 and Argentina: 

1. Are enough variables included in these forms for the 

Injury Surveillance System? 

2. Are there any questions that interviewees may be reluctant 

to answer? 

3. Is it possible to fill out this form in emergency rooms? 

 

Frequency of Data Collection: 

The criteria that you used in the development of the surveillance system will 

determine the appropriate frequency of data collection. The criteria may include 

items such as resources (economic, human, and physical), purpose of the system, 

and requirements of the stakeholders and recipients of the information. Another 

very important criterion is the magnitude of the injury problem in your region. For 

example, if you have no more than 20 injury deaths per month in your region, 

monthly data collection may be adequate; but if you have a larger number of cases, 

the data may need to be collected more frequently. The type of surveillance system 

is another relevant criterion. For instance, if the injury surveillance system is 

population-based, the data could be collected daily; but if it is based on surveys, the 

frequency will depend on when you are planning to conduct the survey. 

One other consideration which may influence the frequency of data collection is the 

concept of active versus passive surveillance, which is addressed in WHO’s Injury 

Surveillance Guidelines.1

Active Collection: 

In this approach, injury cases are sought out and investigated and injured people 

are interviewed, with follow up. Active surveillance of child abuse cases, for 

example, would involve identifying and locating cases through a variety of sources 

such as police reports, social service agencies, and educational authorities. The next 

step might be to seek out the abused children, their parents or guardians, or 

appropriate authorities to conduct initial and follow-up interviews. Active 

surveillance usually requires large expenditures of human and financial resources. 

Passive Collection: 

In this approach, relevant information is collected in the course of doing other 

routine tasks. That is, the generation of data is not necessarily the primary function 

of the system that yields the data. For example, doctors are routinely required to fill 

out death certificates for legal purposes, but it is possible to extract information 

entered on those certificates to obtain data on death from injuries. Similarly, forms 

filled out by doctors or nurses for medical insurance purposes can serve a dual 

function, as the medical information entered on insurance forms can also be used 

for surveillance purposes. 

Injury Surveillance Training Manual 17 Participant Guide — Session IV 
4. Determine the Type of Surveillance System 

Guidelines for the epidemiological surveillance of violence and injuries from 

PAHO5 describe several ways of setting up injury surveillance depending on the 

coverage needed; the objective to be met; the budgetary, human, and organizational 

resources of the locality; and the interest of government or nongovernment agencies. 

The six types of surveillance are mentioned below. 

Surveillance Definitions: 

1. Universal surveillance: The total number of cases occurring within a 

defined population is included in the system. This population-based 

surveillance accounts for all cases that occur. This is the preferred method of 

monitoring the occurrence of fatal injuries because rates of injuries and injury 

risk factors can be calculated and generalized to the population. 

2. Surveillance based on samples of cases: The information is obtained from 

a portion of the total number of cases or events. The sample must be 

representative so that inferences can be made regarding all possible 

cases occurring in the population. This method can be used to collect 

information about nonfatal injuries. 

3. Surveillance based on a review of institutional registries: Institutional 

registries are reviewed periodically to analyze and identify variables of 

interest. When using this method, it is important to properly identify the 

institutions and the sources within institutions, such as clinical and 

emergency records, hospital discharges, or complaints filed with police or 

family welfare institutions. It is useful for monitoring specific injuries, such 

as eye injuries. 

4. Survey-based surveillance: Information is obtained through questionnaires 

focused on a specific topic, within a predefined period of time, and at 

predefined intervals. In the United States, for example, self-reported seat 

belt and safety seat use is measured at the state level by household surveys 

conducted for the Behavioral Risk Factor Surveillance System (BRFSS), by 

school-based surveys conducted for the Youth Risk Behavior Surveillance 

System (YRBSS), and by direct observation of passenger vehicle occupants for 

the National Occupant Protection Use Survey.11

5. Sentinel surveillance: One or more institutions are chosen to monitor 

trends, target surveillance activities, and suggest preventive interventions. 

In general, surveillance systems of this type are not representative of the 

population, but are useful for calling special attention to risk situations and thus fulfill a key function for injury prevention decision-making. 

One example of this type of surveillance is the approach taken by child 

death review teams, which gather and analyze data on the circumstances 

surrounding all causes of child deaths. Sentinel surveillance systems 

complement other sources of information for injury prevention. 

Injury Surveillance Training Manual 18 Participant Guide — Session IV 
6. Others: Laboratory surveillance can collect information from, for example, 

blood alcohol levels in victims of injuries or homicides, or toxicological 

information in case of suicides or injuries. Crime labs can provide information about weapons used in violent injuries. 

Examples: 

• The fatal injury surveillance systems in Cali and Bogota, Colombia,12 

are population-based because all cases of injury death are included 

in the system. 

• The surveillance projects in Central America and Colombia are 

sentinel-type surveillance systems because in each city, one or two 

hospitals have been selected to monitor the injuries in emergency rooms. 9 

• In Cali in 1995, the Injury Surveillance System in Emergency Rooms13 

was implemented. This system was based on samples of injury victims 

taken on special weekends when event occurrences were expected to be 

higher than on other weekends. 

5. Plan for Systematization, Maintenance, and Data Security 

The next step is to develop an electronic database for inputting and managing 

surveillance information. If you have possibilities to collect data using Internet 

resources, the information will be timely and the process easy, but it can be 

expensive. Alternatively, you can use free software to build the database, for 

example, CDC’s Epi Info 2002 program created by CDC (available at 

www.cdc.gov/epiinfo). Epi Info is IBM-compatible software that is available in the 

public domain. It includes a word processor, database manager, and data analysis 

tools. A statistician, epidemiologist, or programmer may be able to help you build 

the database. Remember to devise a way to present and analyze the information. 

Data maintenance, the next step, should focus on the following activities: 

1. Reducing errors that are introduced through flaws in design 

and changes in content (e.g., changes in the list of notifiable 

conditions). 

2. Improving the system’s scope and services through routine 

maintenance, emergency maintenance, and fulfillment of 

requests for special reports, and system improvements. An 

effective maintenance program includes the following steps: 

• Back up data and system files according to an 

established schedule; maintain records in a secure 

environment. 

• Require that requests for emergency maintenance 

be made in writing and entered into a log. 

• Assign priorities to special requests on the basis of 

urgency of need and time and resources required. 

Injury Surveillance Training Manual 19 Participant Guide — Session IV 
• Institutionalize routine maintenance such as procedures 

associated with changing to a new reporting year. 

• Document maintenance as it is conducted. 

To maintain the integrity of a computer system, only one person should have the 

authority to access the system and to assign and change the password. This same 

rule must apply to accessing the physical computer files. If possible, a second 

computer should be available for testing changes to the system so that the computer 

used for the surveillance information system can be reserved for production only. 

The second computer could also serve as a backup computer, should the primary 

computer fail. The numerous risks to the security of a database include mechanical 

failure, human carelessness, malicious damage, crime, and invasion of privacy. 

Therefore, backup copies of the database should be kept securely off-site to ensure 

that the system cannot be deliberately or unintentionally destroyed. Updating of the 

off-site copies should be done on a routine basis, and new diskettes or other storage 

media should be used to make backup copies at least once each year. If a valid copy 

of the current system is available, a monthly total-system back up is recommended. 

Data files that are changed during the day should be backed up at the end of the 

day. Protection against computer viruses should also be implemented, as these have 

become a threat to database and computer-system security.14

Successful surveillance projects will have clearly written procedures for securing 

physical and electronic records and for controlling access to and production of 

records. Procedures may include limiting access to those involved in data collection 

and analysis. Rules for data storage can be as basic as locking cabinets containing 

records, instituting a sign-out sheet for researchers who are using case files, using 

password protection for computer files, or regularly backing up computer database 

files.14

Example: 

The system back up of the Cali, Colombia, database for fatal injury surveillance is 

performed every Monday. Each month, the database is cleaned to detect 

inconsistencies. 12

Injury Surveillance Training Manual 20 Participant Guide — Session IV 
6. Describe the Staff and Key Positions Necessary to Operate the System 

Ideally, a surveillance system would have a core staff (part time or full time). This 

group could include a program manager, data manager, research analyst, and 

coordinator. The composition of the core staff will vary from system to system. In 

some cases, one or more staff members may perform a variety of duties. At a 

minimum, the core staff should include two people: the program manager, who will 

coordinate system activities and establish contact with the stakeholders and data 

sources, and the data manager, whose responsibility is data entry, quality control, 

analysis, and preparation of the reports. For research analysis, it might be possible 

to collaborate with an academic center or university in your region. 

The program manager is responsible for organization, supervision of the process, 

and management of data collection. The program manager also serves as the 

spokesperson and interacts with the coalition team, mass media, authorities, and 

community members. If possible, an epidemiologist or public health officer should 

be in this position. The program manager is also responsible for selecting the other 

members of the core staff, those who will be responsible for collecting the 

information, analysis, and report preparation. 

An advisory board or advisory group may offer technical advice, strategic planning, 

and support for the reporting system’s success. The goal of an advisory board is to 

advise about the establishment and scientific integrity of a injury reporting system, 

act as a vehicle for disseminating information, and help to leverage the support of 

new organizations and resources. 

Advisory board members should include people who are associated with and 

knowledgeable about the data sources, are interested in using/analyzing the 

information, have expertise in data collection, are willing to come to meetings, 

represent local/state agencies, and can influence agency decisions and 

cooperation (or effectively report system concerns back to the decision makers). 

Ideally, the advisory board should include leaders from the following domains: 

• Law Enforcement; 

• Coroners/Medical Examiners; 

• Vital Registrars; 

• Health Care; 

• Policy Makers and Advocacy Groups; 

• Business; 

• Community Organizations; 

• Researchers/Educators. 

Injury Surveillance Training Manual 21 Participant Guide — Session IV 
The advisory board may: 

• Provide the data necessary for the injury surveillance 

system; 

• Review and advise on policies and procedures for 

data collection, linkage, publication, and mechanisms 

for implementation of the reporting system; 

• Provide technical advice; 

• Identify the best uses of the data; 

• Strategize about how to remove obstacles and 

inefficiencies—whether political, legal, or technical; 

• Provide speaking opportunities with professional 

organizations; 

• Obtain or sign data-sharing agreements; 

• Serve as evidence of broad, high-level support for the 

system.3

The stakeholders include government officials, public health authorities, law 

enforcement authorities, transportation officials, etc. These stakeholders typically 

define the activities and strategies to prevent injuries. 

Exercise: Define the criteria to establish a fatal injury surveillance system in 

your region, as follows: 

Group 1: Variables 

 Codes and case definition 

Group 2: Data collection instruments and frequency 

 Type of surveillance system 

 Personnel necessary to operate the system 

Injury Surveillance Training Manual 22 Participant Guide — Session IV 
7. Summary 

Now that you have completed this session, you should be able to: 

• Define the injury events and data elements (variables, case 

definition, and codes) to be included in the system; 

• Develop data collection instruments and determine data collection 

frequency; 

• Determine the type of surveillance system; 

• Plan for systematization, maintenance, and security of the data; 

• Describe the staff and key positions necessary to operate the system. 

 

The next step, which will be addressed in Session V, is to define and develop the 

analysis plan for the injury surveillance data. 

Injury Surveillance Training Manual 23 Participant Guide — Session IV 
REFERENCES 

 1. Holder Y, Peden M, Krug E, Luna J, Gururaj G, Kobusingye O, eds. Injury 

Surveillance Guidelines. Geneva: World Health Organization; 2001. 

 2. Horan MJ, Mallonee S. Injury surveillance. Epidemiological Reviews. 2003;25:35. 

 3. Centers for Disease Control and Prevention. National Violent Death Reporting System 

(NVDRS) Implementation Manual [online]. 2003. National Center for Injury Prevention 

and Control, Centers for Disease Control and Prevention (producer). Available at: 

www.cdc.gov/injury. 

 4. Davies M, Connolly A, Horan J. State Injury Indicators Report. Atlanta, GA: Centers 

for Disease Control and Prevention, National Center for Injury Prevention and 

Control; 2001. 

 5. Concha-Eastman A, Villaveces A. Guidelines for the Epidemiological Surveillance 

on Violence and Injuries. Washington, DC: Pan American Health Organization; 2001. 

 6. Concha-Eastman A, Espitia V, Espinosa R. La Epidemiologia de los homicidios en 

Cali, 1993–1998: seis años de un modelo poblacional. Pan American Journal of Public 

Health. 2002;12(4):230–239. 

 7. Centers for Disease Control and Prevention. Classifications of Diseases and Functioning 

and Disability. Baltimore, MD: Centers for Disease Control and Prevention, National 

Center for Health Statistics; 1999. 

 8. Centers for Disease Control and Prevention. Terrorism in the United States. Baltimore, 

MD: Centers for Disease Control and Prevention, National Center for Health 

Statistics; 1999. Available at: 

www.cdc.gov/nchs/about/otheract/icd9/appendix1.htm. 

 9. Clavel-Arcas C., Rocha J, Torres S, Anderson M, Amador J, Quintanilla M. Lesson 

Learned: Developing an Injury Surveillance System in Nicaragua. Paper presented at: 6th 

World Conference on Injury Prevention and Safety Promotion; May 12–15, 2002; 

Montreal, Canada 

10. Coronado V, Vaccino M, Zein, O. Sistema de vigilancia de lesiones de causa externa. 

Buenos Aires, Argentina: Ministerio de Salud de la Nación; 2003. 

11. Consensus Recommendations for Injury Surveillance in State Health Departments. Report 

from the Planning Comprehensive Injury Surveillance in State Health Departments 

Workgroup. Marietta, GA: State and Territorial Injury Prevention Directors 

Association (STIPDA); September 1999. 

Injury Surveillance Training Manual 24 Participant Guide — Session IV 
12. Sistema Unificado de Violencia y Delincuencia. Secretaria de Gobierno de Bogota, 

Alcaldía Mayor de Bogota, Colombia; 2003. Disponible en : www.suivd.gov.co. 

 Observatorio Social de Cali, Secretaria de Gobierno, Alcaldía de Cali, Colombia, 

2005. Disponible en: www.cali.gov.co/observatorio 

13. Espinosa R, Concha-Eastman A. Injury Surveillance Systems in Emergency Rooms. 

Cali, Colombia, 1995 [master’s thesis]. Cali, Colombia: Public Health School, 

Universidad del Valle; 1996. 

14. Teutsch S, Churchill RE. Principles and Practice of Public Health Surveillance. 2nd ed. 

New York, NY: Oxford University Press; 2000. 

Injury Surveillance Training Manual 25 Participant Guide — Session IV 
INJURY SURVEILLANCE TRAINING MANUAL 

PARTICIPANT GUIDE 

SESSION V

DEFINE AND DEVELOP AN ANALYSIS PLAN 

FOR THE SURVEILLANCE DATA 

Developed with the support 

of the National Center for Injury Prevention and Control 

Division of International Health, Epidemiology Program Office 

Centers for Disease Control and Prevention 

Atlanta, GA 
SESSION V

DEFINE AND DEVELOP AN ANALYSIS PLAN 

FOR THE SURVEILLANCE DATA 

Learning Objectives 

• Calculate injury indicators such as frequencies, percentages, and 

crude, specific, and adjusted rates. 

• Calculate years of potential life lost (YPLL). 

• Describe the geographical analysis of the data. 

• Define a plan to disseminate and communicate the results. 

Introduction 

The analysis and interpretation of surveillance data establishes the foundation for 

many observational studies, placing surveillance at the forefront of the spectrum 

of descriptive epidemiology. Surveillance has a myriad of uses such as: to detect 

epidemics, to suggest hypotheses, to characterize trends in disease or injury, to 

evaluate prevention programs, or to predict future public health needs. Data from 

surveillance must be analyzed carefully and interpreted prudently. Data from 

surveillance systems do not come from a designed study or a randomized trial. 

Moreover, the analysis (and subsequent interpretation) proceeds from the specific 

elements of the process in which the assembly of individual units eventually 

produces a more general picture of health-related conditions in a population. 

Analysis should be implemented as part of a routine surveillance program. 

You should keep in mind the following recommendations when analyzing 

surveillance data:1

• It is tempting to immediately examine trends over time using surveillance 

data. However, gaining an intimate knowledge of the day-to-day 

strengths and weaknesses of the data collection methods and the 

reporting process can provide a “real-world” sense of the trends that 

emerge. 

• Although surveillance data are collected individually, one part of the 

analysis is to have a global image of the problems under surveillance. 

• Proceed from the simplest to the most complex analyses. Begin 

with questions such as: How many cases were reported by week, 

month, or year? How many cases were reported by sex? How 

many cases were reported by age group? These questions must 

be answered using the surveillance data.1

Injury Surveillance Training Manual 3 Participant Guide — Session V 
In this session you will learn to determine the most common types of analysis for 

surveillance data. The following indicators will be calculated: 

• Frequency and percentage; 

• Crude, specific and adjusted rates; 

• Years of potential life lost (YPLL). 

Injury mortality data will be used to calculate measures of frequency and indicators. 

An introduction to geographical analysis of surveillance data and a plan to 

disseminate the results are included in this session. 

 

1. Calculate Frequency and Percentage of Injury Deaths 

 (Homicide, Suicide, Motor Vehicle-Related, and 

 Other Unintentional Deaths) 

Determining frequencies is the first step in the analysis process. The number and 

percentage of events allow one to describe the size of the problem. The second step 

is to calculate other kinds of indicators, such as rates, in which the frequency of the 

event and the affected population are used as well. Rates are presented using a 

standard denominator, for example, deaths per 100,000 persons, and for a standard 

time period, often one year. In small populations, several years of deaths may be 

pooled as the numerator for the rate and person-years of exposure used as the 

denominator; such rates are often referred to as incident density. 

Data from an injury surveillance system provide information about the number of 

cases in a given event. For instance, in El Salvador 2,696 homicides occurred in 

2000.2 In Cali, Colombia, in 2002, 1,961 homicides occurred.3 These data represent 

just one aspect of the size of the problem. 

A comparison between these two numbers indicates that the magnitude of the 

homicide problem is higher in El Salvador than in Cali. The percentage is the 

proportion of the cases of the total. For instance, in El Salvador, homicides 

accounted for 44.3% of the total injury deaths. In Cali this proportion was 74.9% 

(Table 1). 

Table 1. Injury Mortality in El Salvador and Cali — 2000 

El Salvador* Cali** Cause of Death

Number Percentage Number Percentage 

Unintentional Deaths 

 Motor Vehicle-Related 1,629 26.8 % 467 17.9 % 

 Other Unintentional Deaths 933 15.4 % 104 3.9 % 

Violence-Related Deaths 

 Homicides 2,696 44.3 % 1,961 74.9 % 

 Suicides 815 13.5 % 85 3.3 % 

Total 6,073 100 % 2,617 100 % 

 * Injury Surveillance Workshop in El Salvador—2003. Data from forensic medicine. 

** Fatal Injury Surveillance System in Cali. Data from forensic medicine, district attorney, police department, 

and transportation office. 

Injury Surveillance Training Manual 4 Participant Guide — Session V 
If we have only this information, all we can say is that the number of injury deaths 

in El Salvador is 2.3 times higher than in Cali, and the percentage of injury deaths 

due to homicide in Cali is higher than in El Salvador (74.9% vs. 44.3%). Motor 

vehicle-related deaths and suicides appear to be a bigger problem in El Salvador 

than in Cali. However, percentages can be deceiving. Comparisons between a city 

and a country also are not appropriate. The next step is to calculate the rates. 

Exercise: Calculate frequency and percentage of injuries using local injury data. 

The first group will calculate frequency and percentage for violence-related deaths 

(homicide and suicide). The second group will calculate the same indicators for 

unintentional deaths (motor vehicle-related and other unintentional deaths). 

 

1.1 Calculate Injury Rates: How to Get Appropriate Denominators 

Rates enable one to make more appropriate, informative comparisons of 

occurrence in a population over time, among different subpopulations, or 

among different populations at the same time, since the size of the 

population and the period of time are accounted for in the calculation of 

rates. Calculating and analyzing rates is critical in epidemiologic 

investigations, not only for formulating and testing hypotheses about 

causes, but also for identifying risk factors for disease and injuries. To 

determine rates, one must have reliable numerator and denominator data; 

however, the latter is generally more difficult to obtain in most 

epidemiologic investigations.1

 A rate measures the frequency of an event in a population. A crucial 

 aspect of a rate is the specification of the time period under consideration. 

 An optional component is a multiplier, such as a power of 10, that is used 

 to convert awkward fractions to more workable numbers. The general 

 form of a rate is shown below: 

 

Number of people injured in a specific period 

Rate = Average or mid-interval population 

at risk of the event 

x 10 n

 The denominator represents the size of the population during the specified 

 time period in which the events occur. The size of “n” usually ranges from 

 2 to 6 (i.e., the number at risk varies between 100 and 1,000,000). The 

 selection of “n” depends on the incidence or prevalence of the event. Many 

 different rates are employed in standard public health practice. These 

 measures are calculated in many ways and may have different 

 connotations. 

Injury Surveillance Training Manual 5 Participant Guide — Session V 
Special distinction should be made among the terms rate, ratio, and 

proportion. A ratio is any quotient obtained by dividing one quantity by 

another. The numerator and denominator are generally distinct quantities, 

neither of which has to be a subset of the other. No restrictions exist on the 

value or dimension of a ratio. A proportion is a special type of ratio for 

which the numerator is a subset of the denominator population. Although 

all rates are ratios, in epidemiology, a rate may be a proportion (e.g., 

prevalence rate).1

Denominators in Motor Vehicle-Related Injuries 

To calculate rates for motor vehicle-related injuries, the most common 

denominator to use is the population affected—for city, region, or country. 

However, other types of denominators can also be useful, such as number 

of vehicles or number of vehicle miles traveled. The best denominator to 

use depends on the situation. For instance, to calculate rates of injuries to 

motorcyclists, the best denominator would be the number of motorcyclists 

exposed. This is more difficult to obtain than the overall population, but 

one number that might be available is the number of motorcycles registered 

in the transportation office. One potential problem with this approach, 

however, is that the numerator may include injured motorcyclists who are 

registered in surrounding cities, and thus are not reflected in the 

denominator. Obtaining an appropriate denominator when you have 

pedestrians in the numerator is more difficult because statistics on the 

number of people who walk rather than drive are usually not available. 

As a nation’s economy grows, the number of motor vehicles increases. This 

means death and injury from road traffic is likely to increase as well, 

especially if measures are not taken to mitigate the problem.4 In Table 2, a 

comparison of the different indicators for motor vehicle-related injuries is 

shown. Notice how the choice of denominators affects the international 

comparison. Information about the number of vehicles by country, traveled 

miles, etc., may be found by visiting www.worldroadstatistics.org. 

Table 2. Indicators for Motor Vehicle-Related Deaths Using 

Different Denominators 

Country 

Vehicles/1,000 

Inhabitants 

Injuries/100,000 

Population 

Deaths/100,000 

Population 

Deaths/10,000 

Vehicles 

Bangladesh 3.8 2.7 1.7 44.0 

Bhutan 19.6 2.0 0.8 4.0 

India 31.2 32.5 6.3 20.0 

Pakistan 18.0 6.7 3.2 17.0 

Sri Lanka 42.0 91.9 10.5 25.0 

United Kingdom 408.0 538.8 6.1 1.2 

United States 787.0 1,281.3 14.8 1.9 

 Source: Estimating Global Road Fatalities. World Bank, Department for International Development; 2000. 

Injury Surveillance Training Manual 6 Participant Guide — Session V 
Denominators in Cases of Suicides 

When calculating rates for suicides, the denominator will usually include 

the total population. However, some experts believe that children less than 

5 years old should be excluded from the denominator because they are not 

believed capable of understanding the concept of taking one’s own life and, 

therefore, are not capable of committing suicide. 

Denominators in Cases of Violence-Related Injuries 

Crude rates often are calculated using the total number of deaths or injuries in 

the numerator and the affected population in the denominator. Sometimes 

you will encounter difficulties with available denominator data. For example: 

• If you are using mortality data from a country, the denominator will be 

the population of this country. However, in some countries population 

estimates are not available for intercensal years. 

• In some areas, it is difficult to match the geographic area for which injury 

data is available with the geographic area for which population estimates 

are available. 

• If you are using injury data from a hospital emergency room, the 

population in the numerator and denominator could be different. For 

instance, a trauma hospital may receive cases referred from other 

hospitals and other cities. Also, residents of the city may go to other 

hospitals for care. For the denominator, use the population of the city 

where the trauma hospital is located (if most cases come from the same 

city). Or, use the city population but exclude nonresidents from the 

numerator. If most patients are from other cities, try using 

denominators such as total number of visits to the emergency room for 

all causes. Then, the indicator will be a proportion, not a rate. 

 1.2 Calculate Crude Rates for Injury Deaths 

 Computation of crude rates is the initial step in analysis because 

information about entire populations must be obtained and compared. (See 

Table 3 to calculate crude rates.) 

• Number of events, in this case, injury deaths in El Salvador. 

• Population at risk, in this case, the population of El Salvador. 

• Ratio, calculated by dividing Column 1 by Column 2. 

• Quotient, calculated by dividing Column 1 by Column 2. 

• Constant used to multiply each result of the fraction; in this case the 

constant is 100,000. 

• The rate is the final result. It is expressed using “per,” for instance, 25.9 

per 100,000 population, which means that for every 100,000 inhabitants 

in El Salvador, an average of 25.9 persons have died in motor vehiclerelated events. 

Injury Surveillance Training Manual 7 Participant Guide — Session V 
Table 3. Steps to Calculate Crude Rates Using El Salvador Data 

Cause of Death El Salvador* 

Unintentional Deaths 

Number 

(1) 

Population 

(2) 

Ratio 

(3) 

[(1) / (2)] 

Quotient 

(4) 

Constant 

(5) 

Rate per 100,000 

(6) 

[(4) x (5)] 

 Motor Vehicle-Related 1,629 6,276,037 1,629 / 

6,276,037 0.0002595 100,000 25.9 

 

 Other Unintentional Deaths 

 

933 6,276,037 

933 / 

6,276,037 0.0001486 100,000 14.9 

Violent Deaths 

 

 Homicides 2,696 6,276,037 2,696 / 

6,276,037 0.0004295 100,000 42.9 

 

 Suicides 

 

815 6,276,037 

815 / 

6,276,037 0.0001298 100,000 13.0 

Total 6,073 6,276,037 6,073 / 

6,276,037 0.0009676 100,000 96.8 

* Source: Injury Surveillance Workshop in El Salvador—2003. Data from forensic medicine. 

These data indicate that homicides in El Salvador are the leading cause of 

injury death. Motor vehicle-related deaths are the second place. The crude 

world rate for homicide in 1998 was 12.5, the rate in El Salvador is almost 4 

times higher. The rate of motor vehicle deaths in the world was 19.9; the rate in 

El Salvador is clearly higher. Other unintentional deaths in El Salvador have a 

rate higher than the world rate, which is 7.9 (Table 4). 

Table 4. Number, Percentage, and Crude Rates of Injury Mortality 

 in El Salvador (2000) and Worldwide (1998) 

Cause of Death El Salvador* World** 

Unintentional Deaths Number Percentage Rate per 100,000 

Population 

Rate per 100,000 

Population 

 Motor Vehicle-Related 1,629 26.8 % 25.9 19.9 

 Other Unintentional Deaths 933 15.4 % 14.9 7.9 

(approximately) 

Violent Deaths 

 Homicides 2,696 44.3 % 42.9 12.5 

 Suicides 815 13.5 % 12.9 16.1 

Total 6,073 100 % 96.8 97.9 

 * Injury Surveillance Workshop in El Salvador—2003. Data from forensic medicine. 

** Krug E, ed. Injury: A Leading Cause of the Global Burden of Disease. Geneva: World Health Organization; 1999. 

Injury Surveillance Training Manual 8 Participant Guide — Session V 
Exercise: Using local injury data calculate crude rates for homicide, 

 suicide, and motor vehicle-related and other unintentional deaths. 

 

 

 1.3 Calculate Specific Rates for Injury Deaths by Age Group 

 The rate at which a particular health event occurs may not be constant 

throughout the entire population. For example, suicides are not considered 

to affect children under 5 years of age. The risk of dying in motor vehicle 

crashes increases for teenagers when they are first starting to drive. To 

examine the differences, the population is partitioned into relevant specific 

subpopulations, and a specific rate is calculated for each subset. For 

example, if one calculates death rates by age group, the resulting rates are 

termed age-specific death rates. Variation of rates among population 

subgroups results from several factors: natural history of the health 

problem, differential distribution of susceptibility or causes, and genetic 

differences among subpopulations. For example, in the United States, injury 

mortality rates are generally higher among men than women and higher 

among Blacks than whites. The distribution of subgroups within the 

population may also be so disparate that the overall rate may not convey 

useful information. Therefore, the magnitude of an overall rate depends on 

the magnitude of the rates of the subpopulations as well as on the 

demographics of the entire population. These variations in rates across a 

population would remain unknown if only overall rates were calculated.1

Death rates from injuries vary considerably by age and sex. Awareness of 

such differences can guide development of programs for prevention among 

groups at increased risk. For this reason, it is important to have available 

age- and sex-specific mortality rates for specific injuries. However, the 

calculation of age- and sex-specific rates requires reasonably accurate 

information about the composition by age of the population and not just 

the total number of people at risk. Census data are used to obtain the 

numbers of individuals in different age and sex groups or strata of the 

population. Such data may not be available at all or may be available only 

for selected study populations. In developing countries adult males of 

working age tend to be at high risk, often because of exposure to environmental (including road traffic) and occupational hazards and, in some 

countries, to violence. In most countries, the elderly have high mortality 

rates from non-motor vehicle unintentional injuries and, in some countries, 

from suicide. Young adult females are at high risk of suicide in the rural 

areas of some developing countries.5

Injury Surveillance Training Manual 9 Participant Guide — Session V 
The steps necessary to calculate specific rates are shown, using homicide 

data from Cali, in Table 5: 

 1. Age groups: distribution by 5-year age groups. 

 2. Number of homicides in each age group: number of homicides by 

 age group in Cali in 2000. 

 3. Population in each age group: Cali population distribution by 

 5-year age groups. 

 4. Ratio (obtained by dividing Column 2 [number of homicides in 

 each age group] by Column 3 [population in each age group]). 

 5. Quotient (obtained by dividing Column 2 by Column 3). 

 6. Constant used to multiply each result (in this case, 100,000). 

 7. The rate is the final result, which means in this case that there were 

 189.3 or 190 homicides in the group of 20–24 year olds per each 

 100,000 population in this group. Another way to express this 

 result is to say that about 2 out of every 1,000 persons in this age 

 group died by homicide in Cali in 2000. 

 Table 5. Specific Rates of Homicide by Age Group in Cali — 2000 

Age Group 

(1) 

Number of 

Homicides 

(2) 

Population in 

Each Group 

(3) 

Ratio 

[(2) / (3)] 

(4) 

Quotient 

(5) 

Constant 

(6) 

Rate per 100,000 

Population 

[(5) / (6)] 

(7) 

< 5 1 208,525 1/208,525 0.0000047 100,000 0.5 

05–09 9 214,316 9/214,316 0.0000419 100,000 4.2 

10–14 19 197,137 19/197,137 0.0000963 100,000 9.6 

15–19 326 211,893 326/211,893 0.001538 100,000 153.9 

20–24 426 224,986 426/224,986 0.001893 100,000 189.3 

25–29 340 193,138 340/193,138 0.001760 100,000 176.0 

30–34 252 158,849 252/158,849 0.001586 100,000 158.6 

35–39 208 133,422 208/133,422 0.001558 100,000 155.9 

40–44 146 96,238 146/96,238 0.001517 100,000 151.7 

45–49 107 77,190 107/77,190 0.001386 100,000 138.6 

50–54 53 66,829 53/66,829 0.0007930 100,000 79.3 

55–59 31 50,994 31/50,994 0.0006079 100,000 60.8 

60–64 17 39,753 17/39,753 0.0004276 100,000 42.8 

65+ 26 72,725 26/72,725 0.0003575 100,000 35.8 

Total 1,961 1,945,995 1,961/1,945,995 0.001007 100,000 100.8 

Source: Fatal Injury Surveillance Sytem in Cali, Colombia. Data from forensic medicine, district 

attorney, police department. 

 

Injury Surveillance Training Manual 10 Participant Guide — Session V 
Example: 

Specific rates by age group and sex have been calculated using Cali’s homicide 

data for three different years: 1994, 1997, and 2002. In these three years, the specific 

rates for men have been higher than for women. The age group with highest rates 

is 20–29 years of age. Even when the rates decreased, these age groups continued 

to be the most affected (Figure 1). 

Figure 1. Homicide Specific Rates by Age and Sex 

 Cali, 1994, 1997, and 2002 

Crude rate per 100.000 population

< 5

5-9

10-1415-1920-24

25-29

30-34

35-39

40-4445-4950-5455-5960-64

>65

0

100

200

300

400

500



< 5

5-9

10-14

20-24

25-2930-3435-3940-4445-4950-5455-5960-64

>65

0

100

200

300

400

500

HOMICIDE ESPECIFIC RATES BY AGE AND SEX. CALI. 1994-1997-2002

1994 1997

2002

< 55-9

10-1415-1920-2425-29

30-34

35-3940-4445-4950-5455-5960-64

>65

0

100

200

300

400

500

MALE

MALE

MALE

FEMALE

FEMALE

FEMALE

20-24

Crude rate per 100.000 population

< 5

5-9

10-1415-1920-24

25-29

30-34

35-39

40-4445-4950-5455-5960-64

>65

0

100

200

300

400

500



< 5

5-9

10-14

20-24

25-2930-3435-3940-4445-4950-5455-5960-64

>65

0

100

200

300

400

500

HOMICIDE ESPECIFIC RATES BY AGE AND SEX. CALI. 1994-1997-2002

1994 1997

2002

< 55-9

10-1415-1920-2425-29

30-34

35-3940-4445-4950-5455-5960-64

>65

0

100

200

300

400

500

MALE

MALE

MALE

FEMALE

FEMALE

FEMALE

20-24

Rate per 100,000 Population 

Source: Fatal Injury Surveillance System in Cali, Colombia. Data from: Police, Forensic Medicine,

District Attorney, Transportation Office.

Injury Surveillance Training Manual 11 Participant Guide — Session V 
 1.4 Calculate Adjusted Rates Using Direct Method 

An important use of mortality data is to compare your data with data from 

other countries or regions. The mortality figures could be different solely 

because of differences in the distribution of the population by age or other 

demographic characteristics (e.g., race/ethnicity). Therefore, methods have 

been developed for comparing mortality in such populations while 

effectively holding constant characteristics such as age. 

Two methods of adjustment exist. One method is the direct method of 

adjustment, whereby a “standard population” is created, and then the 

study population’s mortality rates are applied to it, stratified by the 

demographic characteristic(s) of interest (most commonly age). By using a 

single standard population, we eliminate any possibility that observed 

differences in rates could be a result of age differences in the two 

populations. By applying each age-specific mortality rate from the study 

population to the population in each age group of the standard population, 

we derive the expected number of deaths that would have occurred in the 

standard population had those rates been applied. By dividing the total 

expected numbers of deaths by the size of the standard population, we can 

calculate the expected mortality rate for the standard population if the 

study population’s age-specific rates have been applied. 

This adjusted rate represents what the crude rate would have been in the 

study population if that population had the same distribution as the 

standard population with respect to the variable(s) for which the 

adjustment or standardization was carried out. 

 

The other method is an indirect adjustment in which the Standardized 

Mortality Ratio (SMR) is calculated by totaling the observed number of 

deaths and dividing by the expected number of deaths. Multiplication by 

100 is often done to yield results without decimals. The SMR is commonly 

used in occupational studies. 

In this manual, adjusted rates are calculated using the direct method of 

adjustment. The following data must be available to use direct adjustment: 

1. Specific rates for the study population; 

2. Distribution for the selected standard population across the 

same strata as those used in determining the specific rates.1

 The steps necessary to calculate adjusted rates are shown in Table 6, 

 using data on homicides in Cali: 

1. Age groups; 

2. Number of homicides in each age group; 

3. Cali population in each age group; 

Injury Surveillance Training Manual 12 Participant Guide — Session V 
4. Quotient of number of homicides divided in the population, 

for each age group; 

5. Standard population (this example uses the standard 

population for the United States in 2000); 

6. Expected deaths in each age group, obtained by multiplying the 

quotient in Column 4 by the standard population in each age group; 

7. Adjusted rate is the result of dividing the total of expected deaths 

by the total of standard population. 

 Table 6. Adjusted Rates for Homicides in Cali — 2000 

Age Group 

(1) 

Number of 

Homicides 

(2) 

Cali Population 

by Age Group 

(3) 

Quotient 

[(2) / (3)] 

(4) 

Standard 

Population 

(U.S. 2000) 

(5) 

Expected 

Deaths 

[(4) x (5)] 

(6) 

< 5 1 208,525 0.000005 18,987,000 91 

05–14 28 411,453 0.000068 39,977,000 2,720 

15–24 752 436,879 0.001721 38,077,000 65,542 

25–34 592 351,987 0.001682 37,233,000 62,621 

Adjusted Rate 

for Cali 

Homicides 

[Total (6) / Total 

(5)] per 100,000 

35–44 354 229,660 0.001541 44,659,000 68,838 

45–54 107 144,019 0.000743 37,233,000 27,663 

55–64 48 90,747 0.000529 23,961,000 12,674 

65+ 26 72,725 0.000358 34,710,000 12,409 

Total 1,961 1,945,995 0.001008 274,837,000 252,558 91.96 

Source: Fatal Injury Surveillance System in Cali, Colombia. Data from forensic medicine, district attorney, 

police department, and transportation office. 

 In this example, the adjusted rate is lower than crude rate, because the age 

 distribution of Cali’s population is different from that of the standard population. 

 Cali has fewer elderly people than the United States. The lower homicide rates 

 among the elderly take on more weight when Cali’s rate is adjusted to this older 

 population. 

Exercise: Calculate adjusted rates using injury local data. You will need a 

standard population, and the population distribution by age group. 

 

2. Calculate Years of Potential Life Lost (YPLL) 

YPLL is a measure of the impact of premature mortality on a population. Because of 

the way in which YPLL is calculated, this measure gives more weight to deaths that 

occur at younger ages. A specific age is selected as an upper limit. The upper limit is 

usually the life expectancy in the country, but is sometimes the age at retirement or 

the age of 75 years. 

Injury Surveillance Training Manual 13 Participant Guide — Session V 
The steps to calculate YPLL before 65 years are shown in Table 7 using data from Cali: 

1. Distribution by age group of Cali population. 

2. Midpoint in each age group, which is obtained by adding the 

first number in the category plus the second number and 

dividing by two. For instance, in the age group 25–34, the 

midpoint is: 25 + 34 = 59/2 = 29.5. (Some methods add 1 to the first part to 

make the numbers more manageable.) 

3. The upper limit in this example is 65, minus the midpoint in 

each age group. 

4. This column shows the number of homicides in each age group. 

5. YPLL is calculated by multiplying the number of homicides in 

each age group (Column 4) by the result in Column 3. 

Table 7. YPLL by Homicides in Cali, Colombia — 2000 

Age Group 

(1) 

Midpoint 

[Low + High / (2)] 

(2) 

Life Expectancy (65) 

Minus Midpoint 

(3) 

Homicides 

(4) 

YPLL 

[(3) x (4)] 

(5) 

1–4 2.5 65 – 2.5 = 62.5 1 62.5 

5–14 9.5 65 – 9.5 = 55.5 28 1,554.0 

15–24 19.5 65 – 19.5 = 45.5 752 34,216.0 

25–34 29.5 65 – 29.5 = 35.5 592 21,016.0 

35–44 39.5 65 – 39.5 = 25.5 354 9,027.0 

45–54 49.5 65 – 49.5 = 15.5 107 1,658.0 

55–64 59.5 65 – 59.5 = 5.5 48 264.0 

65–74 NA NA 

75–84 NA NA 

85+ NA NA 26 

Total 1,961 67,797.5 

Adapted from: Establishing an Injury Surveillance System. Instructor’s Guide. CDC/Epidemiologic Intelligence 

Service; 2000. Data from: Fatal Injury Surveillance System; Instituto Cisalva, Univalle; Cali, Colombia. 

The results indicate that in Cali in 2000, homicides accounted for 67,797.5 YPLL. The 

highest number of YPLL, 34,216, was in the group of 15–24 year olds. 

 Exercise: Calculate YPLL using injury local data. 

 

3. Describe the Geographical Analysis of Data 

Maps can be used to graphically depict data using location and geographic 

coordinates. A map provides a clear, quick method for grasping data and is 

particularly effective for readers who are familiar with the physical area being 

portrayed. A few popular types of maps that depict incidence or distribution 

of health conditions are described below.5 Currently, there are several different 

Injury Surveillance Training Manual 14 Participant Guide — Session V 
software packages that can be used to create maps. Some are free, like Epi Map, 

which is part of the Epi Info software package (www.cdc.gov/epiinfo). 

However if you do not have the necessary equipment, you can at least prepare a 

spot map, locating each case on a printed map. Another possibility is to prepare an 

area map, which uses frequency, percentages, or rates. The following are the most 

common type of maps: 

Spot Maps 

 A spot map is produced by placing a dot or other symbol on the 

map where the injury occurred. Different symbols can be used for 

multiple events at a single location. Although a spot map is beneficial for displaying geographic distribution of an event, it does not 

provide a measure of risk, since population size is not taken into account. 

Area or Chloropleth Map 

 An area map, also called a shaded or chloropleth map, is a frequently 

used statistical map involving different types of shading, hatching, or 

coloring to portray range-graded values. Chloropleth maps are useful 

for depicting rates of injury in specific areas. These maps are actually 

superior to spot maps because the rates of risk are depicted. 

Black Spots 

 To assess road traffic hazards, traffic engineers examine the location 

and other details of individual crashes. In the aggregate, this information helps to pinpoint specific hazards that can often be corrected in 

a cost-effective manner by straightforward engineering changes. Such 

data are increasingly being computerized by traffic authorities. In addition, 

printed crash maps that use colored pins to denote individual events are 

often maintained to locate “black spots,” locations with higher than 

expected crash rates. Unfortunately, studies of black spots are based upon 

the use of crash data, and these may be subject to a high degree of 

underreporting. In developing countries, black spots analyses may be 

especially valuable to address the problem of injuries and deaths involving vehicle occupants, pedestrians, motorcyclists, and bicyclists. In 

Colombia, for instance, one strategy of the Fondo de Prevencion Vial (NGO) 

has been to draw a black/yellow star in the street where most pedestrian 

deaths occur.6

Injury Surveillance Training Manual 15 Participant Guide — Session V 
Example: 

In the geographical distribution of homicides in Cali for 2001, shown in Figure 2, 

each dot represents one homicide and marks the place where it occurred. Homicide 

clusters with specific characteristics in particular areas of the city are highlighted. 

COLOMBIA 

40-44

– 2001

-

A higher proportion 

of homicides against 

women 

100% of 

homicides due 

to firearms 

High proportion 

of homicides 

among youth using 

firearms 

Source: Fatal Injury Surveillance System. Cali 

High proportion 

of homicides from 

stabbing among 

nonresidents 

Figure 2. Homicides in Cali — 2001 

 Exercise: Identify each type of map each and the information needed to 

prepare such a map. 

 

Injury Surveillance Training Manual 16 Participant Guide — Session V 
4. Define a Plan to Disseminate and Communicate the Results 

Surveillance and communication are processes that provide “information for 

action.” Surveillance data must be presented in a manner that facilitates its 

use for public health action. Effective communication of public health surveillance 

results presents a critical link in the translation of scientific information into public 

health practices and policies. Information from the surveillance system must be 

disseminated to help decision makers understand the implications of the results 

and to facilitate implementation of public health action. It is important to present 

the information clearly and to know the intended audience.1 Surveillance data is 

not presented in the same way to the general public as it is presented to public 

health professionals. 

Dissemination of the results is a one-way process through which information is 

conveyed from one point to another. Communication is a collaborative process 

involving at least one sender and recipient. Steps in controlling and directing 

information dissemination follow:1

1. Develop the message;

2. Define the audience; 

3. Select the channel; 

4. Market the message; 

5. Evaluate the impact. 

Following are some suggestions for making the data presentation useful to the 

public:7

• Present data to the public in an appealing format. 

• Use language the public understands (professional versus public 

language). 

• Keep it simple: provide only the most important facts. 

4.1 Define the Basic Elements to Include in an 

Injury Surveillance System Report 

A report is the means by which the results of surveillance are conveyed to all 

stakeholders. The needs of stakeholders should be considered when making 

decisions about report design and production frequency.8 Below is a sample 

outline you can use to prepare a report of the surveillance system: 

Injury Surveillance Training Manual 17 Participant Guide — Session V 
Sample Outline for an Injury Surveillance System Report: 

I. Introduction: Brief description of the injury surveillance system, the 

purpose, related prevention activities, and the objective of the report. 

II. Leading causes of deaths, frequency and proportion, and rank 

of injuries among all causes of death. 

III. Leading causes of injury mortality, frequency, proportion, 

and crude rates, emphasizing the highest indicators. 

IV. Leading causes of injury morbidity, if the information is available. 

V. Years of potential life lost (YPLL). 

VI. Cost of injuries, comparing local data if available. If not, 

you could use data from studies in other places. 

VII. Priority injuries identified in the region, summarizing those 

with the highest number, percentage, rate, costs, and YPLL. 

VIII. Recommendations for prevention strategies. This is the most 

important step, because it helps stakeholders decide what 

actions to take. 

Examples: 

The injury surveillance system in Bogotá publishes a monthly bulletin with data 

analysis results, recommendations, and evaluation of strategies already 

implemented. This bulletin is available at www.suivd.gov.co. 

Cisalva Institute prepares a report every three months based on data from the 

fatal injury surveillance system. This report is sent to mass media contacts and 

stakeholders in the city; it is available at: 

www.prevencionviolencia.org.co/sistemas/vigilesiones.htm

The injury surveillance system in emergency rooms in El Salvador produces a 

weekly bulletin of the system: www.hospitalbloom.gob.sv. 

In Nicaragua, the injury surveillance system in emergency rooms has published 

articles on injury data on its website: www.minsa.gob.ni. 

4.1.1 Recipients 

Recipients of the surveillance report could include decision makers. Decision 

makers include institutions, particularly those providing data to the surveillance 

system. Recipients of the report could also include: 

• Stakeholders: Government authorities, Law Enforcement 

Directors, Public Health Directors, Education Institutions 

Directors, etc.; 

• Forensic Medicine Offices; 

• District attorney offices; 

Injury Surveillance Training Manual 18 Participant Guide — Session V 
• Hospitals and emergency departments; 

• Health professionals in the scientific community; 

• Personnel working with the surveillance system; 

• Scientific/academic researchers; 

• Grassroots organizations; 

• Mass media directors. 

4.1.2 Delivery Method 

The means of delivering reports depends on available resources and 

equipment. One channel is via a website; however, only people with a 

computer and Internet access will be able to reach it. The following are some 

other means you can use to deliver your injury surveillance system report: 

• Health department newsletters; 

• Public service announcements (PSAs); 

• Press releases; 

• Scientific journal articles; 

• Flyers; 

• Periodicals or annual reports; 

• Presentations and exhibits at scientific and 

 stakeholder meetings; 

• Newspapers; 

• Websites. 

The mass media are important partners for dissemination of injury surveillance 

data. Information about injuries is always important news in the city. By 

establishing an appropriate partnership with the mass media, you may be able to 

publish your results in the newspaper. This can also be a way to get the community 

involved. The mass media can also benefit from this relationship because the 

surveillance team can serve as a valuable ongoing local resource, not only for data, 

but also for opinions on interventions and political implications. 

 Exercise: Answer the following questions: 

1. Which information is most important to present to 

stakeholders? 

2. Which indicators would best show the size of the problem? 

3. Do you think cost data is important to stakeholders? 

4. Should you include recommendations about prevention 

strategies in your surveillance reports? 

 

Injury Surveillance Training Manual 19 Participant Guide — Session V 
5. Summary 

Now that you have completed this session, you should be able to do the following: 

• Calculate injury indicators such as frequency, percentages, and 

crude, specific, and adjusted rates; 

• Calculate years of potential life lost (YPLL); 

• Describe the geographical analysis of the data; 

• Define a plan to disseminate and communicate the results. 

The next step, using injury surveillance data to inform injury prevention, is 

addressed in Section VI. 

Injury Surveillance Training Manual 20 Participant Guide — Session V 
6. Developing and maintaining and injury surveillance system 

REFERENCES 

1. Teutsch S, Churchill RE. Principles and Practice of Public Health Surveillance. 2nd ed. 

New York, NY: Oxford University Press; 2000. 

2. Chacon R, Moran S. Magnitude of the Injury Problem in El Salvador. In: Workshop 

“Injury Surveillance System in San Salvador.” San Salvador, El Salvador: Centers for 

Disease Control and Prevention, Ministry of Health of El Salvador; 2004. 

3. Espitia V, Guerrero R, Gutierrez Maria, Concha-Eastman A, Espinosa R. Ten years 

of a fatal injury surveillance system using linkage data. Cali, Colombia. 1993–2002. 

Paper presented at: 7th World Injury Conference; June 2004; Vienna, Austria.

4. World Bank. Road Safety: A Development Challenge for South Asia [brochure for World 

Health Day]. 2004. 

5. Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International Perspective 

(Epidemiology, Surveillance and Policy). New York, NY: Oxford University Press; 1998. 

6. Fondo de Prevencion Vial, Colombia. Estrellas negras (black stars). Available at : 

www.fonprevial.org.co. Accessed January 31, 2005. 

 

7. Frazier L Jr. Overview of the Injury Data Dissemination: Finding Common Ground 

Workshop. Summary of breakout group discussion. August 20–21, 1998; Hickory 

Knob, SC. 

8. Holder Y, Peden M, Krug E, Luna J, Gururaj G, Kobusingye O, eds. Injury 

Surveillance Guidelines. Geneva: World Health Organization; 2001. 

Injury Surveillance Training Manual 21 Participant Guide — Session V 
INJURY SURVEILLANCE TRAINING T MANUAL 

PARTICIPANT GUIDE 

SESSION VI

USE INJURY SURVEILLANCE DATA TO 

INFORM INJURY PREVENTION

 

Developed with the support of the 

National Center for Injury Prevention and Control 

Division of International Health, Epidemiology Program Office 

Centers for Disease Control and Prevention 

Atlanta, GA
SESSION VI

USE INJURY SURVEILLANCE DATA 

TO INFORM INJURY PREVENTION 

Learning Objectives 

• Use surveillance data to identify priority injuries in your region.

• Identify potential etiological factors of priority injuries.

• Review successful interventions for injury prevention.

• Identify the most appropriate interventions for the injuries in your region.

Introduction 

An important aspect of prevention is to document the existence and magnitude of a 

health condition and the extent to which its burden is increasing or decreasing. In 

addition, to implement primary prevention, factors that contribute to the problem must 

be identified.1

Establishing injury priorities is a necessary and increasingly difficult task. Public health 

administrators and managers are often faced with an increasing range of pressing 

problems and decreasing resources. To define injury priorities, you need 

to keep in mind factors such as the magnitude of the problem, the disability that it 

causes, the direct and indirect costs, and the available resources for injury prevention. 

Once you have defined the injury priorities in the population, you should identify 

some strategies to address them. In this session, you will learn to define injury 

priorities, to identify etiological factors for these injury priorities, and to identify 

potential interventions after reviewing successful experiences from other places. 

Public health professionals play an important role in these aspects of prevention 

because they generally have received special training in methods for measuring the 

extent of disease and injuries; for identifying the associated circumstances, including 

underlying causes and high-risk groups; and for evaluating the effectiveness of 

prevention programs.1

Injury Surveillance Training Manual 3 Participant Guide — Session VI 
1. Identify Priority Injuries 

Various methods are available for prioritizing health events; typically, these methods 

include the following criteria:2,3,4

• Magnitude of the problem—Generally defined by injury mortality and 

morbidity indicators such as crude, specific, and adjusted rates for variables 

sucha as age, sex, place, and mechanism. 

• Severity of the problem—Often determined by indicators of admitted rate, 

disability rate, and lethality for the group overall and for special groups. One 

criteria of severity could be the affected population (i.e., youth). 

• Disability Adjusted Life Years (DALYs)—An indicator of the magnitude and 

severity that combines years of potential life lost due to premature mortalty 

with years of productive life lost due to disability. Instructions for calculating 

this indicator may be found at the WHO website (www.who.org). 

• Trend of the event—Useful criteria for defining the problem’s magnitude; for 

instance, events for which the trend increases over a period of at least 5 years 

must have a higher priority than those events with a decreasing or stable trend. 

• Control possibilities or vulnerability—Relates to potential control with existing 

resources. Problems which can be prevented or controlled more easily or with 

less cost should be assigned a higher priority than those in which control and 

prevention is more difficult and expensive. 

• Local interest and importance of the problem for the community and 

stakeholders—Information from community leaders and authorities that can be 

acquired in varied ways (i.e., meetings, surveys). 

• Interests of international, national, and local organizations working in the 

prevention and control of the injury events—Areas in which international, 

national, or local cooperation is neccesary. 

• Cost—Defined in two ways: (1) direct and indirect costs associated with patient 

care in health institutions and relatives of the injured person, and (2) 

intervention cost to prevent and control the problem, including research to 

ensure the efficacy and effectiveness. 

Injury Surveillance Training Manual 4 Participant Guide — Session VI 
Criteria to prioritize Health Events 

Event Importance (magnitude, severity, trend, cost)

HIGH LOW 

HIGH 

High importance and good control and 

prevention capacity = High priority for 

prevention and control 

Low importance and good 

control and prevention capacity 

= Low priority for prevention 

and control 

Prevention 

and Control 

Capacity 

(possibilities for 

controlling, local 

interests, and 

other sectors’ 

interests) LOW 

High importance and low control and 

prevention capacity = High priority for 

research 

Low importance and low control 

and prevention capacity = Not a 

priority 

 

To apply this criteria, the following information must be on hand: 

1. General information 

• Leading causes of death; 

• Number, proportion, and crude and adjusted injury rates; 

• Years of potential life lost (YPLL) from injuries by intention; 

• Trend of injuries (minimum of 5 years data). 

2. Specific information 

• Homicides (crude and adjusted rates by age group); 

• Motor vehicle-related deaths (crude and adjusted rates by age group); 

• Leading causes of injury morbidity (crude rates, lethality rates, admission 

rates, disability rates, etc.). 

3. Costs 

• Direct cost expended for patient care (i.e., hospital, health personnel, 

medicine, and transportation); 

• Indirect cost (i.e., guards; environmental changes such as protective 

fencing or adding sidewalks to accommodate handicaps and pedestrians; 

insurance; lawyers and judges); 

• Economic and human cost payable to relatives (i.e., job loss, maintenance).

4. DALYs, if available.

5. Activities to prevent and control injuries at local, national, and international 

levels.

Injury Surveillance Training Manual 5 Participant Guide — Session VI 
Exercise: Using local injury local data, apply the prioritization criteria: The first 

group should focus on unintentional injuries; The second group should focus on 

violence-related injuries. 

 1. General information

 a. Leading causes of death (frequency and crude rates), as prepared in 

Session II, Item 4. 

b. Frequency, proportion, and crude rates of injury deaths by intention 

(i.e., homicide, suicide, motor vehicle-related, and other unintentional 

deaths). These were calculated in Session V, Item 1. 

 c. Trend of injury crude rates (minimum of 5 years data) 

 

 2. Specific information

 a. Homicides: Specific rates by age group and sex (see Session V, Item 1.3). 

b. Motor vehicle-related deaths: Rates by type of victim (pedestrian, vehicle 

occupant, motorcyclist, and bicyclist) and rates by age group and sex. 

 c. Trend of injury specific rates (minimum of 5 years data) 

3. Leading causes of injury morbidity (if the information is available): injuries by 

age group and sex, intention, nature, etc. Lethality, admission and disability 

rates. 

 4. Costs and DALYs, if available. 

 5. Local, national, and international interests in injury prevention and control. 

2. Identify Potential Etiological factors of the Priority Injuries in the Region 

 or City 

The Haddon Matrix and Ecological Model are used to help identify and to organize 

etiological factors for priority injuries. Although both models can be used for either 

intentional or unintentional injuries, the Haddon Matrix typically is used for 

unintentional injuries, whereas the Ecological Model is generally applied to violencerelated injuries in which there is a chain of events instead of one unexpected event. 

 

2.1 Use the Haddon Matrix to Help Identify and Organize Potential 

Etiological Factors for Unintentional Injuries 

 William Haddon, Jr. made numerous contributions to the field of injury 

 control through his research on various injury topics and his leadership 

 of the National Highway Traffic Safety Administration and later, the 

 Insurance Institute for Highway Safety. He is most well known for developing 

 two complementary conceptual frameworks for understanding how injuries 

Injury Surveillance Training Manual 6 Participant Guide — Session VI 
 occur and for developing intervention strategies. The first conceptual frame-

 work is known as the Haddon Matrix, and the second is his articulation of 

 10 countermeasure strategies for reducing injuries.5 (Note: the 10 

 countermeasures are not reviewed in this manual.) 

The Haddon Matrix is built using columns and rows. In the columns, Haddon 

identifies the following: 

• Host (person affected by the injury); 

• Agent, which he defines in terms of energy transferred to the host by either 

an inanimate vehicle (e.g., a firearm or automobile) or an animate vector 

(e.g., an assailant); 

• Environment, consisting of both the physical and social environment. 

o The physical environment consists of those elements of the physical 

surroundings that contribute to the occurrence of potentially injuryproducing events or to injury (e.g., the physical characteristics of the 

roadway, building, playground, athletic field, or factory). 

o The social environment refers to the sociopolitical milieu affecting the 

process, which could include cultural norms or mores (e.g., tolerance of 

corporal punishment or alcohol consumption); the political environment 

(e.g., willingness to adopt regulatory interventions that restrict the 

freedom of motorcyclists or gun owners); and the legal environment 

(e.g., the presence or absence of seat belt usage laws or prosecution of 

perpetrators of domestic violence or child abuse). 

By filling in the cells of the matrix, one can identify a range of potential risk and 

protective factors or strategies for prevention that are directed at each of the factors 

(the columns) and have an influence during various phases (the rows).5 The rows of 

the Haddon Matrix relate to the circumstances occurring before the event, during 

the event, and after the event. These circumstances interact with human, 

environmental, and vehicular factors to define the frequency and severity of injury. 

Primary prevention approaches can be implemented during the pre-event phase; 

secondary prevention focuses on the event phase, and tertiary prevention focuses on 

the post-event phase. 

 

Example: 

The Haddon Matrix has been used both to conceptualize etiological factors and to 

identify potential preventive strategies, making it a useful tool not only for guiding 

epidemiologic research, but also for developing interventions. In Table 1, an 

example of applying the matrix to identify factors related to motor vehicle crash 

injury is shown. 

Injury Surveillance Training Manual 7 Participant Guide — Session VI 
Table 1. Factors Related to the Likelihood of Crash Injury — The Haddon Matrix 

Factors Phases 

Host (Human) Agent (Vehicle) Physical and Social Environment

Pre-Crash 

Alcohol intoxication 

Fatigue 

Experience and judgment 

Driver vision 

Amount of travel 

Brakes, tires 

Center of gravity 

Jackknife tendency 

Ease of control 

Load weight 

Speed capability 

Laws related to alcohol and driving 

Visibility of hazards 

Road curvature and gradient 

Surface coefficient of friction 

Divided highways, one-way streets, 

 intersections, access control 

Signalization 

Speed limits 

Crash 

Seat belt use 

Age 

Sex 

Osteoporosis 

Speed at impact 

Vehicle size 

Automatic restraints 

Hardness and sharpness 

 of contact surfaces 

Load containment 

Recovery areas 

Guardrails 

Characteristic of fixed objects 

Median barriers 

Roadside embankments 

Post-Crash 

Age 

Physical condition Fuel system integrity 

Emergency communication and 

 transport systems 

Distance to and quality of 

 medical services 

Rehabilitation programs 

Source: Baker S, O’Neill B, Ginsburg MJ, Li G. The Injury Fact Book. 2nd ed. New York, NY: 

Oxford University Press; 1992. 

Exercise A: Using a blank Haddon matrix and Post-it note, place each of the 

statements related to Pedestrian Injuries. After each statement is placed in the 

matrix, ask the participants to discuss the statement’s most appropriate placement. 

The statements follow: 

 1. No crosswalks on the roadway 

 2. No laws related to alcohol and driving 

 3. Children crossing the street without supervision 

 4. Age, sex, and physical condition of the pedestrian 

 5. Size and shape of the vehicle involved 

 6. Speed of the vehicle involved at impact 

 7. Quality of emergency communications 

 8. Quality and availability of medical services 

 9. Preexisting pathologies in the injured person (i.e., osteoporosis, 

disabilities, diabetes) 

 10. Brakes and tires of the vehicle 

Exercise B: Working in two or more groups and using the Haddon Matrix, 

define the etiological factors for the unintentional injuries identified as 

priorities in the first part of this session, using the Haddon Matrix. You may 

refert to the previous matrix to present the results. 

Injury Surveillance Training Manual 8 Participant Guide — Session VI 
2.2 Use the Ecological Model to Identify and Organize Potential 

Etiological Factors for Violence-Related Injuries 

 

 The Ecological Model helps to identify and organize the multiple levels of 

 influence that affect behavior. Violence is considered the product of the 

 interaction between these multiple levels. The strength of the model lies in its 

 ability to distinguish among the multitude of influences on violence while at 

 the same time providing a framework for understanding the interaction. 

Individual. The first level of the Ecological Model focuses on the characteristics of 

an individual that increase the likelihood of being a victim or a perpetrator of 

violence (i.e., low level of education, substance abuse). 

Relationship. The second level of the Ecological Model explores how proximal 

social relationships such as relations with peers, intimate partners, and family 

members can increase the risk for violent victimization and perpetration of 

violence. For example, in cases of interpersonal violence among youth, research 

shows they are much more likely to engage in negative activities when those 

behaviors are encouraged and approved by their peers. 

 Community. The third level of the Ecological Model examines the community 

 contexts in which social relationships are embedded—such as schools, work-

 places, and neighborhoods—and seeks to identify the characteristics of these 

 settings that are associated with being victims or perpetrators of violence. 

 For instance, a high level of residential mobility, heterogeneity and high 

 population density, drug trafficking, high levels of unemployment, and 

 widespread social isolation are associated with some forms of violence. 

Societal. The final level of the Ecological Model examines the larger societal factors 

that influence rates of violence. Included here are those factors that create an 

acceptable climate for violence, those that reduce inhibitions against violence, and 

those that create and sustain gaps among different segments of society or tensions 

between different groups or countries.6

Example: 

For the Ecological Model applied to intimate partner violence, consider etiological 

factors at the individual level, either perpetrator or victim, and factors in each of the 

other levels. 

Injury Surveillance Training Manual 9 Participant Guide — Session VI 
Table 2. Ecological Model of Factors Associated with Intimate Partner Violence7 

Level Etiological Factors 

Individual Perpetrator 

Individual Victim8

Being male; witnessing marital violence as a child; absent or rejecting father; 

being abused as a child; alcohol or drug use 

Being female; lack of full-time employment; physical abuse after report of 

earlier abuse 

Relationship Marital conflict; male control of wealth and decision-making in the family 

Community Poverty; low socioeconomic status; unemployment; isolation of women 

and family 

Society Norms granting men control over female behavior; acceptance of violence as a 

way to resolve conflict; rigid gender roles; inadequate legal protections 

Exercise A: Using a blank Ecological Model matrix and Post-it note, place each of 

the statements related to Youth Violence. After each statement is placed in the 

matrix, ask the participants to discuss the statement’s most appropriate placement. 

Statements:6

1. Inequalities of gender, economics, access to health care, or education 

2. Concentration of poverty 

3. Peers involved in crime 

4. Psychological and personality factors 

5. Impulsiveness 

6. Poor parenting practices 

7. Local illicit drug trade 

8. Weak police/criminal justice systems 

Exercise B: Working in two or more groups and using the Ecological Model, 

define the etiological factors for the violence-related injuries identified as 

priorities in the first part of this session, using the Ecological Model. You may 

refer to the previous matrix to present the results. 

Injury Surveillance Training Manual 10 Participant Guide — Session VI 
3. Review Effective Injury Prevention Strategies 

Once the injury priorities and the potential etiological factors have been identified, 

the next step is to identify potentially effective prevention strategies. It would 

be valuable to look at local, national, and international examples: 

a. Review of strategies applied to prevent injuries in your local 

communities, nongovernmental offices (NGOs), or government; 

b. National and international experiences applied in other cities of 

your country. You could find examples on the Internet or with the 

help of academic centers. 

A compilation of recommendations to reduce injuries to motor vehicle occupants was 

published9 and is included as an example in Table 3. These recommendations are the 

work of an independent, nonfederal Task Force on Community Preventive Services. 

The Task Force developed the Guide to Community Preventive Services (the Community 

Guide) with the support of the U.S. Department of Health and Human Services (HHS) 

and in collaboration with public and private partners. The Centers for Disease Control 

and Prevention (CDC) provided staff support to the Task Force for development of the 

Community Guide. 

The Community Guide addresses the effectiveness of three community-based 

intervention strategies to prevent motor vehicle occupant injuries: 

1. Increase proper use of child safety seats; 

2. Increase the use of safety belts; 

3. Reduce alcohol-impaired driving. 

Remember, “insufficient evidence to determine effectiveness” does not mean that the 

intervention does not work, but instead indicates that additional research is needed to 

determine whether the intervention is effective. 

Decision makers should consider these evidence-based recommendations in light of 

local needs, goals, and constraints when choosing interventions to implement 

(Table 3). 

Injury Surveillance Training Manual 11 Participant Guide — Session VI 
Table 3. Proven or Promising Strategies to Prevent Road-Traffic Injuries 

Intervention Recommendation 

Interventions to Increase the Use of Child Safety Seats 

Child safety seat use laws Recommended (Strong evidence) 

Community-wide information and enhanced 

 enforcement campaigns Recommended (Sufficient evidence) 

Distribution and education programs Recommended (Strong evidence) 

Incentive and education programs Recommended (Sufficient evidence) 

Education-only programs Insufficient evidence of effectiveness 

Interventions to Increase the Use of Seat Belts 

Seat belt use laws Recommended (Strong evidence) 

Primary enforcement laws 

 (versus secondary enforcement laws) Recommended (Strong evidence) 

Enhanced enforcement programs Recommended (Strong evidence) 

Interventions to Reduce Alcohol-Impaired Driving 

0.08% blood alcohol concentration (BAC) laws Recommended (Strong evidence) 

Lower BAC laws for young or inexperienced drivers Recommended (Sufficient evidence) 

Minimum legal drinking age laws Recommended (Strong evidence) 

Sobriety checkpoints Recommended (Strong evidence) 

Server intervention training programs 

 (face-to-face instruction with management support) Recommended (Sufficient evidence) 

Table 4 shows a compilation of prevention strategies to reduce violence-related injuries 

and to address youth and intimate partner violence and child abuse. This information 

was published in the World Report on Violence and Health.6

Table 4. Proven and Promising Violence Preventing Programs 

Intervention Recommendation 

To Reduce Child Abuse and Neglect 

Home visits to new mothers Promising strategy. 

It appears that visits by nurses are most effective. 

School-based programs to prevent 

 child sexual abuse 

One recent meta-analysis concluded that programs to prevent 

victimization were fairly effective in teaching children concepts 

and skills related to protection against sexual abuse.10

To Reduce Antisocial and Aggressive Behavior in Children and Adolescents 

Improving competency and social 

 skills with peers 

Promoting positive, friendly, and 

 cooperative behavior 

Demonstrated to be effective in reducing youth violence or risk 

factors for youth violence. 

Warm and supportive relationship 

 with a positive adult role model 

Mentoring Programs 

Is thought to be a protective factor for youth violence. 

To Reduce Abuse between Intimate Partners 

Training health workers to identify and 

 respond to abuse between intimate 

 partners 

Active screening for abuse and questioning patients about their 

possible histories of suffering violence by intimate partners is 

generally considered good practice in this field. However, little 

systematic evaluation has been carried out on whether 

screening for abuse can improve the safety of women.11

Injury Surveillance Training Manual 12 Participant Guide — Session VI 
Table 5 shows examples of prevention strategies classified by sector. Although not all 

strategies have been evaluated, such examples can provide a foundation for 

developing a prevention program. 

Table 5. Strategies to Prevent Violence Classified by Sector12

Sector Preventive Actions 

Education 

Carry out cognitive interventions (anger management, cognitive self control, moral reasoning, 

social perspective-taking) 

Improve school climate (properly handling students in classrooms, establishing school policies 

and rules, ensuring school safety, reducing bullying) 

Implement technical education or vocational programs to help reduce school dropout rates and 

provide improved opportunities for students entering the labor market 

Health Provide greater access to reproductive health care services and to programs that reduce drug 

and alcohol abuse 

Justice 

Create decentralized alternative dispute-resolution centers 

Incorporate violence prevention activities into sectoral judicial reform projects 

Enact laws or regulations to restrict the sale of alcohol at certain times of day and 

on certain days 

Police 

Implement community policing and/or problem-oriented policing 

Provide police training, including domestic violence and human rights components 

Organize voluntary programs for taking guns out of the hands of the civilian population 

Solve and prosecute more cases in an attempt to reduce impunity for the 

perpetrators of crime 

Improve information gathering, record keeping, and reporting of crimes 

Social Services 

Conduct workshops for couples on how to resolve conflicts in a nonviolent way 

Establish high-quality day care centers 

Organize mentoring programs for high-risk teens 

Create parenting programs (including setting limits for children’s behavior, 

mediation, and nonviolent conflict resolution) 

Media 

Mount information campaigns to change norms regarding violence 

Reduce violence in TV programming, especially in children’s programs 

Train journalist on how to report crime 

Provide media training programs on domestic and social violence 

Housing and 

Urban 

Development 

Incorporate safety issues in housing construction programs and neighborhood 

improvement programs (street lights, spatial configuration, parks, etc.) 

Build sports and recreational facilities 

Build facilities for neighborhood organizations 

Civil Society 

Provide training to nongovernment organizations to bring about greater cooperation with 

and monitoring of police reform efforts 

Generate private sector support of violence prevention initiatives 

Subsidize/fund nongovernmental organizations to provide early childhood development 

programs 

Implement programs for at-risk youth 

Involve the church and other community groups in efforts to change prevailing attitudes and 

socially acceptable norms regarding violence 

Source: Adapted from Technical Note #5. Inter‐American Development Bank. 

In February 2005, the American Journal of Preventive Medicine published a 

supplement devoted to a systematic review of interventions to Reduce Injury and 

Death from Violence. The Journal presents findings from the Task Force on 

Community Preventive Services evaluation of three interventions: firearm laws, 

early childhood visitations, and therapeutic foster care.13

Injury Surveillance Training Manual 13 Participant Guide — Session VI 
Example: 

A multifaceted injury prevention strategy was applied in Bogotá, Colombia, from 

1995 to 1997. During this period, 130 million (3.7%) of the city’s budget was 

invested. The objective was to strengthen self-regulation of collective and 

individual behaviors by closing gaps between these types of behavior and legal 

repercussions. This strategy was based on the premise that the three systems 

regulating human behavior—law, culture (on a collective level), and morals 

(individual behavior)—were disconnected. During the same period, a reduction in 

the homicide rate was observed from 72 to 51 per 100,000 inhabitants. Table 6 

presents the strategies and results.14

Table 6. Multifaceted Injury Prevention Strategy; Bogotá, Colombia 

Strategies Results 

Voluntary disarmament with the collaboration of the 

church 

2,538 weapons were turned in and melted down to 

make baby spoons under the voluntary disarmament 

campaign. Over the following three months common 

homicides dropped 23% to 30%. 

Community workshops (semilleros) attended by 

citizens to raise consciousness about rules of civil 

coexistence and receive input for proposals to 

amend the city of Bogota’s code of police behavior 

Nearly 18,000 people participated in the community 

workshops (semilleros) and offered nearly 30,000 

proposals that were summarized in a “Civil Charter” 

(Carta de Civilidad). 

Restrictions placed on the use of fireworks The number of children injured by fireworks at 

Christmastime was reduced to fewer than one third 

of the figure from previous years. 

Education on the use of alcohol and the enactment 

of the dry law (ley zanahoria) which mandated that 

establishments serving alcoholic beverages close at 

1:00 AM 

A 9.5% reduction in the number of homicide victims 

who had alcohol in their blood was experienced 

during the first year of the program; a 26.7% 

reduction was experienced during the second year. 

Source: Adapted from Technical Note #5. Inter‐American Development Bank.

Example: 

The Development, Safety, and Peace Program (Programa de Desarrollo, Seguridad y Paz), 

known by its Spanish acronym “DESEPAZ,”was developed in Cali, Colombia, in 1992, 

by initiative of the mayor, a public health professional. The program’s objective was to 

decrease the high level of violence. During a period of 4 years, homicide rates in the city 

were reduced 30% (600 fewer homicides), from 124 homicides in 1994 to 86 homicides in 

1997. Following are some of the strategies implemented in Cali: 15,,6

• Develop an injury surveillance system. Identify groups at risk and risk 

areas to inform prevention activities. 

• Improve policing. Provide education on civil rights and create community 

policing efforts. 

• Improve the criminal justice system. Implement “Houses of Justice” (“Casas 

de Justicia”), an experiment to bring the criminal justice system closer to the 

citizen and thus improve efficiency and public perception of the courts. As 

yet, no formal evaluations of this experiment have been conducted; 

nevertheless, an increase in the number of cases handled by service 

providers has been reported. 

Injury Surveillance Training Manual 14 Participant Guide — Session VI 
• Educate citizens about creating a culture of nonviolence. Work has 

commenced to modify behavior through community-based education 

programs and a media campaign called “el vivo-bobo.” 

• Restrict sale of alcoholic beverages. In an effort to reduce crime and trafficrelated injuries, this strategy curfewed sales of alcohol between 1:00 AM and 

2:00 AM. As yet, no formal evaluations have been conducted; nevertheless, a 

decrease in injuries, particularly those related to motor vehicles, has been 

observed. 

• Initiate gun control. An evaluation showed a 14% reduction in the homicide 

rate when this strategy was applied.16 

The following documents contain information related to injury prevention: 

1. World Report on Violence and Health (WHO, 2002) 

2. World Report on Violence and Health (Summary)(WHO, 2002) 

3. Handbook for the Documentation of Interpersonal Violence 

Prevention Programs (WHO, 2004) 

4. The Economic Dimensions of Interpersonal Violence (WHO, 2004) 

5. World Report on Road Traffic Injury Prevention (WHO, World Bank, 2004) 

6. Guia Didactica para Municipios: Prevencion de la Delincuencia y la Violencia a 

Nivel Comunitario en las Ciudades de America Latina (World Bank, 2003) 

7. Violence in Latin America and the Caribbean: A framework for Action IADB, 1999

8. Violence Against Women: The Health Sector Responds (PAHO, 2003)7 

The following websites present information related to injury prevention: 

www.prevencionviolencia.org.co

www.cdc.gov/ncipc

 www.surgeongeneral.gov/library/youthviolence 

www.thecommunityguide.org

www.cdc.gov/mmwr

www.hwysafety.org

http://depts.washington.edu/hiprc

 www.cpsc.gov 

www.aap.org/family/tippmain.htm

www.alaska-ipc.org/

www.iadb.org

www.suicideinfo.org

www.nhtsa.dot.gov

www.madd.org 

Injury Surveillance Training Manual 15 Participant Guide — Session VI 
4. Identify and Select Potential Interventions to Prevent Priority Injuries 

To identify and select potential interventions, have the following information at hand: 

a. Priority injuries (require urgent attention, as identified previously). To define 

risk groups and characteristics, you will need the following: 

• Homicides: crude and specific rates by age group and 

sex, and mechanism; 

• Motor vehicle-related deaths: crude and specific rates by 

age group, sex, and road user (pedestrian, vehicle occupant, 

motorcyclist, or cyclist); 

• Leading causes of injury morbidity: crude rates by age group and 

sex, nature of injury, lethality rate, admission rate, and disability. 

b. Potential etiological factors for those priority injuries. The Haddon Matrix 

and Ecological Model were used to help identify and to organize etiological 

factors for priority injuries. Besides that, there are two statistics measures to 

identify the impact of a given intervention: (1) atributable risk, which 

measures the amount of disease or injury that would be eliminated if a risk 

factor was removed from a defined population; and (2) the prevented 

fraction (PF), which is the rate of injury occurrence in a population averted 

due to a protective risk factor or public health intervention. PF measures the 

impact of the intervention by comparing the incidence of the injury event in 

the population with and without intervention. More information about these 

statistics measures maybe found in this reference.2 

c. Recommendations about proven and promising injury prevention strategies. 

(Some recommendations were reviewed in the third part of this session.) 

The Haddon Matrix and Ecological Model will be used again to determine potential 

interventions for those injuries identified as high priority in your region.

4.1 Use the Haddon Matrix to Identify 

 Possible Interventions for Unintentional Injuries 

In this step, the Haddon Matrix will be filled with ideas about strategies for 

prevention that are directed at each of the factors (the columns) and have an 

influence during the different phases (the rows). 

 

Example: 

 Here, the Haddon Matrix has been applied to identify prevention strategies 

 for childhood injuries caused by dog bites. 

Injury Surveillance Training Manual 16 Participant Guide — Session VI 
Table 7. Haddon Matrix to Identify Strategies to 

Prevent Chilhood Injuries Caused by Dog Bites 

Host (Human) Agent (Dog) Physical 

Environment Social Environment 

Pre-Event 

Teach kids about dogs: 

Don’t go near a dog’s food, 

unknown dogs, dogs in yards, 

mother dog with new 

puppies, etc. 

Teach children, parents, and 

caregivers how to respond in 

case of aggression 

Teach dogs 

appropriate and 

acceptable behavior 

(socialization 

 training) 

Spay and neuter 

dogs 

Maintain dogs in fenced 

yards or enclosures or 

by 

electronic “invisible” 

means 

Use gate alarms to 

indicate when gate is 

opened 

Increase community 

awareness of the problem and 

solutions 

Pass leash laws 

Pass of dangerous dog 

laws/ordinances (e.g., 

requiring impoundment, 

evaluation, and destruction, if 

necessary) 

Initiate and support animal 

control programs (i.e., 

evaluate reports of dangerous 

dogs and pick up 

strays/unleashed dogs) 

Establish spay/neuter and 

vaccination programs 

Event Don’t run from dogs 

Stand still and yell for help 

Position bike, bag, or other 

obstacle between you and the 

dog. If knocked to the ground, 

protect head, neck and face 

Identify risk situations 

before biting occurs 

(e.g., watch for signs 

of aggression like 

growling, hair raised, 

etc.) 

Muzzle dangerous 

dogs 

Respond to alarm 

system sounding 

indicating gate is 

opened or dog has 

escaped 

Apply consequences of 

dangerous dog 

laws/ordinances 

Enforce laws requiring 

impoundment of dangerous 

dogs 

Post-Event 

Provide first aid/trauma care 

and rabies vaccine if 

appropriate 

Provide psychological support if 

it is necessary 

Evaluate dangerous 

dogs and destroy 

them if appropriate 

Impound dogs; 

observe for rabies 

Use emergency medical 

service (EMS) systems, 

medical care system, 

and rehabilitation 

programs 

Maintain community 

surveillance for dog bites 

Report dog bite incidents 

Repeat dog bite prevention 

messages 

Adapted from: (a) AVMA Task Force on Canine Aggression and Human‐Canine Interactions.  A community approach to

dog bite prevention. JAVMA 2001; 218:1732‐1749. (b) Wallace LJD. National Center for Injury Prevention and Control

(NCIPC), CDC [Personal communication] 2005.

Injury Surveillance Training Manual 17 Participant Guide — Session VI 
Exercise A: Using a blank Haddon Matrix and Post-it note, place each of the 

statements related to Bicycle-related Injury Prevention. After each statement is placed 

in the matrix, ask the participants to discuss the statement’s most appropriate 

placement. The following are the statements to be placed in the Haddon Matrix: 

 1. Separate bicyclists from other forms of traffic 

 2. Equip bike with lights, reflectors, and a horn or bell 

 3. Reduce size and weight of motor vehicles to decrease injury severity 

 4. Modify vehicle front ends to decrease injury severity 

 5. Teach safe bicycling practices, including use of a bicycle helmet 

 6. Control traffic with engineering 

 7. Enforce speed limits and limits on alcohol use while bicycling and driving 

 8. Wear bicycle helmet 

 9. Wear riding gloves 

10. Use horns or bells when unable to stop 

11. Maintain mechanical condition of bike 

12. Teach cyclist to carry identification 

13. Encourage use of reflective clothing 

14. Provide emergency care 

15. Provide adequate EMS 

16. Penalize road users who broke the law 

17. Inspect bicycle for safety problems 

Exercise B: Working in two or more groups, define appropriate prevention 

strategies for local unintentional injuries, based on previously identified 

etiological factors, using the Haddon Matrix. You may refer to the previous 

matrix to present the results. 

 

4.2 Use the Ecological Model to Organize Possible Interventions to 

 Prevent Violence-Related Injuries 

Example: 

 During the course of a person’s life, behavior patterns may change—including 

those associated with violence. Adolescence and young adulthood are periods 

when violence and other types of risky behaviors are often more expressive. 

Understanding these conditions and behaviors can help to identify appropriate 

Injury Surveillance Training Manual 18 Participant Guide — Session VI 
interventions and policies. In the following example, the Ecological Model has 

been used to identify strategies for preventing youth violence.6

Table 8. Potential Interventions to Prevent Youth Violence6

Level Potential Interventions 

Individual 

Programs to increase access to prenatal and postnatal care 

Preschool enrichment programs 

Perpetrator programs 

Victim care and support 

Building of social skills 

Relationship 

Home visitation 

Skill training programs on parenting 

Supportive relationship with a positive adult role model 

Home-school partnership programs to promote parental involvement 

Peer mediation of students helping other students resolve disputes 

Community 

Extracurricular activities 

Gang prevention programs 

Reducing the availability of alcohol 

Society 

Reducing income inequality 

Reducing media violence 

Having laws prohibiting illegal transfers of guns to adolescents 

Reforming educational system 

Strengthening and improving police and judicial systems 

Exercise A: Using a blank Ecological Model matrix and Post-it note, place each 

of the statements related to Intimate Partner Violence Prevention. After each 

statement is placed in the matrix, prepare to discuss the statement’s most 

appropriate placement. Following are the statements: 

1. Women’s crisis center and battered-women shelters 

2. Criminalizing physical, sexual, and psychological abuse 

by intimate partners 

3. Laws requiring mandatory arrest for domestic violence 

4. Treatment programs for perpetrators of intimate partner violence 

5. Training health workers to identify and respond to abuse 

6. Outreach workers visiting victims of violence in their 

homes and communities 

7. Efforts to reform the response of institutions 

8. Family and social networks to support battered women 

9. Inter-agency coordinating council 

Exercise B: Working in two or more groups, define appropriate prevention 

strategies for local violence-related injuries, based on previously identified 

etiological factors, using the Ecological Model. You may refer to the previous 

matrix to present the results. 

Injury Surveillance Training Manual 19 Participant Guide — Session VI 
5. Use the Decision Matrix to Identify the most appropriate intervention 

 for the Injuries in your region 

 

 The Intervention Decision Matrix 18 is a tool designed to help people identify and 

choose among intervention options. This matrix can also help identify long-term goals 

and intervention options, which must be considered together. This tool is applied after 

the priority injury problems have been identified. The original Decision Matrix has 

seven elements. For the purposes of this manual, the matrix has been adapted to 

include five elements, to make it more workable. The elements are: 

1. Effectiveness, 

2. Cost, 

3. Sustainability, 

4. Social and political acceptability, 

5. Possible unintended consequences. 

Table 9. Decision Matrix — Elements and Score 

Elements Score 

1. Effectiveness 1. Not proven effective 2. Moderately effective 3. Highly effective 

2. Cost 1. High cost 2. Medium cost 3. Low cost 

3. Sustainability 1. Low sustainability 2. Medium sustainability 3. High sustainability 

4. Social and 

political 

acceptability 

1. Low acceptability 2. Medium acceptability 3. High acceptability 

5. Possible 

unintended 

consequences 

1. Known consequences 2. Unknown or unclear 

 whether there are 

 consequences 

3. No consequences 

The scoring ranges from 1 for low, 2 for medium, and 3 for high. However, for some 

elements, the score must be applied in reverse order (see Table 9). Finally, the scores 

are summed. The strategy with the highest score should be the most viable. 

Injury Surveillance Training Manual 20 Participant Guide — Session VI 
Completed Decision Matrix 

Elements Examples 

1. Effectiveness 

 Is the intervention useful to preventing injuries? 

 Has it been evaluated? 

Child safety seats, when correctly installed and 

used, reduce the risk of death by 71% for infants 

and 54% for toddlers aged 1–4 years. 

2. Cost 

 Is the proposal affordable? 

 Are there enough resources to develop 

 the proposal? 

 Is the investment justifiable? 

Building a special path for pedestrians and 

bicyclists next to a high-traffic road is an effective 

strategy to reduce injuries in those groups; 

however, the cost could be high. 

3. Sustainability 

 How long will the intervention be applied 

 after its implementation? 

Seat belt laws could have a long-term impact in the 

reduction of injuries. 

 

4. Social and Political Acceptability 

 What is the current political context in which 

 to develop the prevention strategy? 

 Is the strategy accepted by communities 

 and leaders? 

A ban on riding in the back of a truck may not be 

accepted by the community. 

 Exercise: Working in two groups, select one or several interventions to 

 prioritize injuries identified in the previous exercise (4.1) and to assign a score 

 to each identifying the most appropriate one. Identify the intervention idea that 

 best represents a good balance of decision matrix elements. 

Injury Surveillance Training Manual 21 Participant Guide — Session VI 
6. Summary 

Now that you have completed this session, you should be able to: 

• Use surveillance data to identify priority injuries 

 in your region; 

• Identify potential etiological factors of priority injuries; 

• Review successful interventions for injury prevention; 

• Identify the most appropriate interventions for the 

injuries in your region. 

The next step, defining an evaluation plan for the injury surveillance system and 

monitoring prevention activities, will be addressed in Session VII. 

Injury Surveillance Training Manual 22 Participant Guide — Session VI 
REFERENCES 

1. Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International Perspective 

(Epidemiology, Surveillance and Policy). New York, NY: Oxford University Press; 1998. 

2. Stroup D, Teutsch S. Statistics in public health. Quantitative Approaches to public 

health problems. New York, NY: Oxford University Press; 1998. 

3. Administracion y Practica de Salud Publica. Hanlon y Ticket. Collage publishing. 

4. Manual del Enfoque de Riesgo en la Atencion de Salud. Washington, DC:OPS/OMS; 

1984. 

5. Runyan CW. Introduction: back to the future—Revisiting Haddon’s 

conceptualization of injury epidemiology and prevention. Epidemiologic Reviews. 

2003;25:60–61. 

6. Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World Report on Violence and 

Health. Geneva: World Health Organization; 2002. 

7. Velzeboer M, Ellsberg M, Clavel-Arcas C, Garcia-Moreno C. Violence Against Women: 

The Health Sector Responds. Washington, DC: Pan American Health Organization; 

2003. 

8. Black DA, Schumacher JA, Smith Slep AM, Herman RE. Review of partner physical 

aggression. In: CM Allen, ed. Risk factors for partner abuse and child maltreatment: a 

review of literature [CYFERNet website]. Available at: 

www.nnh.org/risk/chap2_RiskFactorsforMale.html. Accessed May 2, 2005. 

9. Task Force on Community Preventive Services. Recommendations to Reduce Injuries 

to Motor Vehicle Occupants. Increasing Child Safety Seat Use, Increasing Safety Belt 

Use, and Reducing Alcohol-Impaired Driving. American Journal of Preventive Medicine. 

2001;21(4s):16–22. 

10. Rispens J, Aleman A, Goudena PP. Prevention of child sexual abuse victimization: a 

meta-analysis of school programs. Child Abuse and Neglect. 1997;21:975–987. Cited in: 

Krug EG, Dahlberg LL, Mercy JA, Zwi A, Lozano R, eds. World Report on Violence and 

Health. Geneva: World Health Organization; 2002. 

11. Friedman LS, Samet JH, Roberts MS, Hudling M, Hans P. Inquiry about victimization 

experiences: a survey of patient preferences and physicians practices. Archives of 

Internal Medicine 1992;152:1186–1190. Cited in: Krug EG, Dahlberg LL, Mercy JA, Zwi 

A, Lozano R, eds. World Report on Violence and Health. Geneva: World Health 

Organization; 2002. 

Injury Surveillance Training Manual 23 Participant Guide — Session VI 
12. Mayra B, Andrew M. Technical Note #5: Preventing Violence. Washington, DC:

Inter‐American Development Bank; 1999.

13. Hahn R., Bilukha O., Mercy J. The Guide to Community Preventive Services.

Interventions to Reduce Injury and Death from Violence. Systematic Reviews of

Evidence, Recommendations from the Task Force on Community Preventive Services,

and Expert Commentary. American Journal of Preventive Medicine. Supplement 1 to

American Journal of Preventive Medicine. February 2005.

14.    Mockus A. “Armonizar Ley, Moral Y Cultura.” Draft prepared for the Inter –  

        American Development Bank (IDB). In: Mayra B, Morrison A. Technical Note #5:

        Preventing Violence. Washington, DC: Inter‐American Development Bank; 1999.

15. Guerrero R. Violence Control at the Municipal Level. Technical Note #8: Preventing  

        Violence. Washington, DC: Inter‐American Development Bank; 1999.

16. Villaveces A, Cummings P, Espitia V, Koepsell T, McKnight B, Kellermann A. Effect

of a ban on carrying firearms on homicide rates in 2 Colombian cities. JAMA.

2000;283:1205–1209.

17. Peden M, Scurfield R, Sleet D, et al. World Report on Road Traffic Injury Prevention. 

 Geneva: World Health Organization; 2004. 

18. Dannenberg AL, Fowler CJ. Evaluation of interventions to prevent injuries: an

overview. Injury Prevention. 1998;4:141–147.   

Injury Surveillance Training Manual 24 Participant Guide — Session VI 
INJURY SURVEILLANCE TRAINING MANUAL 

PARTICIPANT GUIDE 

SESSION VII 

DEFINE AN EVALUATION PLAN FOR THE 

SURVEILLANCE SYSTEM AND 

MONITOR PREVENTION ACTIVITIES 

Developed with the support of the 

National Center for Injury Prevention and Control 

Division of International Health, Epidemiology Program Office 

Centers for Disease Control and Prevention 

Atlanta, GA 
SESSION VII

DEFINE AN EVALUATION PLAN FOR THE 

SURVEILLANCE SYSTEM AND 

MONITOR PREVENTION ACTIVITIES 

Learning Objectives 

• Know the steps to evaluating an injury surveillance system. 

• Review public health indicators proposed for monitoring injuries. 

• Use surveillance data to monitor prevention activities. 

Introduction 

Evaluation has been defined as systematic investigation of the merit, worth, or 

significance of an object.1 It is an essential organizational practice in public health; 

however, it is not practiced consistently across program areas, nor is it sufficiently 

well-integrated into the day-to-day management of most programs. 

The highest-priority public health events should be monitored closely, and 

surveillance systems should meet their objectives as efficiently as possible. The 

overall purpose of evaluating public health surveillance is to obtain feedback about 

the operation of the system and to promote the most effective use of health 

resources. Performance of a surveillance system can be assessed using specific 

criteria and standards of performance. The evaluation of an operating surveillance 

system for a high-priority health event aims to increase the system’s utility and 

efficiency. An evaluation may also compare two or more systems that involve the 

same health event. But, most importantly, an evaluation will determine whether the 

system is meeting its objectives, serving a useful public health function, and 

operating as efficiently as possible.2 

In 1988, CDC published the Guidelines for Evaluating Surveillance Systems to promote 

the best use of public health resources through the development of efficient and 

effective public health surveillance systems. In 2001, updated guidelines were 

published in the MMWR.3 The steps proposed in those guidelines are being 

followed in this session. 

Injury Surveillance Training Manual 3 Participant Guide — Session VII 
1. Know the Steps for Evaluating an Injury Surveillance System 

 1.1 Engage Stakeholders in the Evaluation 

As mentioned in Session III, coalition partners and other stakeholders are 

the most important users of the injury surveillance results. These users, which 

includes local government, public health officers, representatives of affected 

communities, nongovernment offices (NGOs), mass media, and others, should be 

involved in the evaluation process. They can provide input to ensure that the 

evaluation of the injury surveillance system addresses appropriate questions and 

assesses pertinent attributes and that its findings will be seen as useful. They 

may help to define questions, and this can subsequently increase their ability to 

use the findings. 

Example: In the first six months of the fatal injury surveillance system in Cali, 

Colombia, an evaluation was performed every month. A meeting with 

stakeholders and the operation team of the injury surveillance system was held 

to evaluate how well the system was working. This evaluation addressed the 

data collection process, the variables and categories, the presentation of the 

results, and other aspects of the system. During these months, some variables 

were dropped and others were added.4

 1.2. Describe the Surveillance System to be Evaluated 

The second step in the evaluation process is to fully describe the surveillance 

system to be evaluated. 

Activities: Describe the public health importance of the injury event under 

surveillance using measures such as indices of frequency, number, incidence, 

and mortality rates; years of potential life lost (YPLL); indices of severity; 

disparities or inequities associated with the health-related event; associated costs; 

preventability; and public interest (most of these measures were reviewed and 

calculated in Sessions II and V). Describe the purpose and operation of the 

system: list its objectives; describe the planned uses of system data; and describe 

the event under surveillance—including the case definition; describe the context 

in which the system evaluation is to be done; draw a flow chart of the system; 

and describe the system components. Also describe the resources used to operate 

the system, including personnel cost and financial resources. 

Example: 

An evaluation of the injury surveillance system in Central America was conducted 

in 2004. The flow chart in Figure 1 depicts the evaluation process. Note that the first 

step was to involve stakeholders in the process.5

Injury Surveillance Training Manual 4 Participant Guide — Session VII 
Figure 1. Evaluation Process of the Injury Surveillance System 

in Emergency Rooms; El Salvador — 2004 

4. Collect data obtained by 

the epidemiology office 

in the emergency room 

 

1. Involve decision makers 

 in the process 

2. Train key persons 

 in the process 

 (operations team) 

3. Collect data obtained 

 by the physician in 

 the emergency room 

5. At the epidemiology office, 

 review the quality of 

 information 

6. At the epidemiology 

 office, complete the 

 data entry 

7. Conduct the data 

analysis and 

disseminate findings 

to decision makers 

and operations team 

Injury Surveillance Training Manual 5 Participant Guide — Session VII 
1.3 Focus the Evaluation Design 

 The process of the evaluation must be planned to ensure that time and 

 resources are used efficiently. This process involves stating the purpose 

 of the evaluation; identifying stakeholders who will receive the results of 

 the evaluation; stating what questions will be answered by the evaluation 

 and how the results will be used; and defining the standards that will be 

 used to assess the system. 

 1.4 Gather Credible Evidence about the Surveillance System’s Performance 

 Indicate if the actions taken because of analysis and interpretation of the data 

 have been useful in controlling the public health problem under surveillance. 

 Each one of the following attributes must be described: 

a. Simplicity: This refers to both the structure of the system and ease 

of operation. Surveillance systems should be as simple as possible 

while still meeting their objectives. A chart depicting the flow of 

data and the lines of response in a surveillance system can help 

assess the simplicity or complexity of the system. Simplicity is 

closely related to timeliness. Simplicity also affects the level 

of resources required to operate the system. 

b. Flexibility: A flexible surveillance system can adapt to changing 

information needs and can accommodate changes in case definitions 

or technology and variations in funding or reporting sources. Flexibility 

is probably best evaluated retrospectively by observing how a system 

has responded to a new demand. 

c. Data Quality: This reflects the completeness and validity of the data 

recorded in the public health surveillance system. Examining the 

percentage of “unknown” or “blank” responses to items is an easy 

measure of data quality. Data of high quality will have low percentages 

of such responses. 

d. Acceptability: This measure reflects the willingness of people and 

organizations to participate in the surveillance system. To assess 

acceptability, the points of interaction between the system and its 

participants must be considered. The following criteria may be used 

to measure acceptability: subject or agency participation rate; interview completion rates and question refusal rates (if relevant); 

completeness of report forms; data source reporting rate; and timeline 

of data reporting. 

Injury Surveillance Training Manual 6 Participant Guide — Session VII 
e. Sensitivity: The sensitivity of a system can be considered on 

two levels. First, at the level of case reporting, sensitivity refers to 

the proportion of cases of a disease (or other health-related event) 

detected by the surveillance system. Second, sensitivity can refer to 

the ability to detect outbreaks or the ability to monitor changes in the 

number of cases over time. The primary emphasis in assessing 

sensitivity (assuming that most reported cases are correctly classified) is 

on estimating the proportion of the total number of cases in the 

population under surveillance being detected by the system, 

represented in Table 1 by A/(A+C). 

Table 1. Calculation of the Sensitivity of a Surveillance System 

Sensitivity = A / (A+C) 

Injury Patients Detected by “Gold Standard” Injury Patients 

Detected by the 

Surveillance 

System Yes No 

Yes 

True Positive 

Injury patients correctly 

registered by the 

Surveillance System 

A 

False Positive 

Patients incorrectly 

registered by the 

Surveillance System as 

injury patients 

B 

A+B 

No 

False Negative 

Injury patients incorrectly not 

registered by the 

Surveillance System 

C 

True Negative 

Patients correctly not 

registered by the system, 

because the cause was 

different than injury 

D 

C+D 

A+C B+D 

A+B+C+D 

Total patients for all 

causes 

 The measurement of the sensitivity of a surveillance system requires 

collection of or access to data that are usually external to the system, to 

determine the true frequency of the condition in the population under 

surveillance, and linkage of surveillance system cases with true cases, to 

determine if the surveillance system cases are true positives. 

f. Predictive Value Positive (PVP): This is the proportion of reported 

cases that actually have the health-related event under surveillance. In 

assessing PVP, the primary emphasis is to confirm cases reported 

through the surveillance system. To assess the PVP of the system 

adequately, calculating more than one measurement of PVP might be 

necessary. For example, PVP could also be determined for the system’s 

individual data fields, for each data source or combination of data 

sources, or for specific health-related events (e.g., hospitalization for the 

condition). In Table 2, PVP is represented by A/(A+B). 

Injury Surveillance Training Manual 7 Participant Guide — Session VII 
Table 2. Calculation of Predictive Value Positive for a Surveillance System 

Predictive Value Positive = A / (A+B) 

Injury Patients Detected by “Gold Standard” Injury Patients 

Detected by the 

Surveillance 

System Yes No 

Yes 

True Positive 

Injury patients correctly 

registered by the 

Surveillance System 

A 

False Positive 

Patients incorrectly 

registered by the 

Surveillance System as 

injury patients 

B 

A+B 

No 

False Negative 

Injury patients incorrectly 

not registered by the 

Surveillance System 

C 

True Negative 

Patients correctly not 

registered by the system, 

because the cause was 

different than injury 

D 

C+D 

A+C B+D 

A+B+C+D 

Total patients for all 

causes 

Example: 

A hypothetical example (Table 3) compares data from a hospital statistics office 

(used as the gold standard) with data from an injury surveillance system based 

in the emergency rooms of the same hospital. 

The statistics office in the hospital reported a total of 97,482 patients attended by 

all causes in emergency department in 2000. Of those, 28,311 were classified as 

injury patients. 

 

The injury surveillance system reported 27,482 injury patients in the same year. 

Of those, 491 were incorrectly included as injury patients, and 1,320 injury 

patients were not registered by the system. 

Injury Surveillance Training Manual 8 Participant Guide — Session VII 
Table 3. Calculation of Sensitivity and Predictive Value Positive for a 

Surveillance System for Injury Visits to Emergency Rooms — 2002 

Injury Patients Detected by “Gold Standard” Injury Patients 

Detected by the 

Surveillance System Yes No 

Yes 

True Positive 

26,991 

Injury patients correctly 

registered by the Surveillance 

System 

A 

False Positive 

491 

Patients incorrectly 

registered by the Surveillance 

System as injury patients

B 

A+B 

27,482 

No 

False Negative 

1,320 

Injury patients incorrectly not 

registered by the Surveillance 

System 

C 

True Negative 

68,680 

Patients correctly not 

registered by the system, 

because the cause was 

different than injury 

D 

C+D 

70,000 

A+C B+D 

A+B+C+D 

97,482 

Total patients 

for all causes

Sensitivity = A/(A+C): 26,991/28,311 = 95.33 

Predictive Value Positive = A/(A+B): 26,991/27,482 = 98.21 

g. Representativeness: A public health surveillance system that has good 

representativeness is one that accurately describes the occurrence of a 

health-related event over time and its distribution in the population by 

place and person. Representativeness is assessed by comparing the 

characteristics of reported events to all such actual events. It could be 

examined through special studies that seek to identify a sample of all 

true cases and to compare these samples with reported cases. A system 

with 100% sensitivity is highly representative. 

h. Timeliness: This measure reflects the speed between steps in a public 

health surveillance system. The interval usually considered first is the 

amount of time between the onset of a health-related event and the 

reporting of that event to the public health agency responsible for 

instituting control and prevention measures. The timeliness of a public 

health surveillance system should be evaluated in terms of availability 

of information for control of a health-related event. The need for rapid 

response in a surveillance system depends on the nature of the healthrelated event under surveillance and the objectives of that system. The 

increasing use of electronic data collection from reporting sources, via 

the Internet, and the increasing use of electronic data interchange by 

surveillance systems, might promote timeliness. 

Injury Surveillance Training Manual 9 Participant Guide — Session VII 
i. Stability: This measure assesses the reliability (i.e., the ability to collect, 

manage, and provide data properly without failure) and availability 

(the ability to be operational when it is needed) of the public health 

surveillance system. A lack of dedicated resources might affect the 

stability of a public health surveillance system. A more formal 

assessment of the system’s stability can be made through modeling 

procedures. Stability largely reflects the dependability and robustness 

of data processing equipment. 

1.5. Justify and State Conclusions and Make Recommendations 

Evaluation conclusions can be reached through appropriate analysis, synthesis, 

interpretation, and judgment of the gathered evidence for performance of the 

public health surveillance system. Recommendations should address the 

modification or continuation of the public health surveillance system. Efforts to 

improve sensitivity, PVP, representativeness, timeliness, and stability can 

increase the cost of the system, although savings in efficiency with computer 

technology might offset some of these costs. 

1.6. Use Evaluation Findings and Share Lessons Learned 

 Deliberate effort is needed to ensure that the findings from a public health 

surveillance system evaluation are used and disseminated appropriately. 

Strategies for communicating evaluation findings and recommendations 

should be tailored to relevant audiences, including those who provided data 

used for the evaluation. 

2. Review Public Health Indicators Proposed to Monitor Injuries 

 

An injury indicator describes a health outcome of an injury, such as hospitalization 

or death, or a factor known to be associated with an injury, such as a risk or 

protective factor, within a specified population.6 Indicators are statistical measures 

used to monitor progress toward a desired outcome. There are a number of different 

indicators available to study the severity of the problem of injuries in a country or a 

region.7

The Inter-American Coalition for the Prevention of Violence, an alliance of 

seven agencies, has proposed a set of indicators to be used by countries of the 

Americas to monitor violence in the region.8 The following organizations are 

involved in this coalition: 

• Inter-American Development Bank (IADB) 

• Pan American Health Organization (PAHO) 

• World Health Organization (WHO) 

• Centers for Disease Control and Prevention (CDC) 

Injury Surveillance Training Manual 10 Participant Guide — Session VII 
• United Nations Educational, Scientific, and Cultural Organization 

• Organization of American States 

• United States Agency for International Development 

Two major components of violence, self-directed (suicides and parasuicides) and 

interpersonal violence, were considered for monitoring. Indicators were built on 

three objectively measurable outcomes of violence: death, illness, and violent 

behaviors, including crimes. Applying those indicators proposed by the Coalition is 

not always possible because few injury data are generated uniformly in these 

countries. Furthermore, the denominators needed to calculate some of these 

indicators usually are not available; or if available, the denominators may not be 

broken down by standard age categories. The indicators are classified as follows: 

2.1 Basic Indicators 

These indicators are considered basic because they can be generated from 

information systems that exist in all countries of the Americas. Data on deaths 

usually can be obtained from the health sector, police, forensic office, or 

national statistics office. This information and a standard population are 

necessary to calculate adjusted rates. The information related to assault, 

robbery, and kidnapping may be found in offices of the police, district 

attorney, human rights, etc. The basic indicators are: 

• Age-adjusted suicide rate, per 100,000 population; 

• Age-adjusted homicide rate among males aged 15–44 years, 

per 100,000 population; 

• Age-adjusted homicide rate among females aged 15–44 years, 

per 100,000 population; 

• Homicide rate among children aged 0–4 years, 

per 100,000 population; 

• Reports of assault, per 1,000 population; 

• Reports of robbery, per 1,000 population; 

• Reports of kidnapping, per 1,000 population. 

Developmental Indicators 

The information needed for these indicators is not uniformly available in all 

countries of the Americas. For example, deaths due to intimate partner violence 

(IPV), child abuse, or elder abuse are hard to find because information about the 

relationship between the perpetrator and victim is not routinely collected in the 

information systems. Hospital discharge data is shared data and generally does 

not reflect context. Data for civil rights violations may be collected by NGOs or 

special offices in the government, but this information is hard to get. Information 

about child maltreatment and school fights might be found through surveys. 

Developmental indicators include both morbidity and mortality data to yield a 

Injury Surveillance Training Manual 11 Participant Guide — Session VII 
more balanced assessment of violence. The first level of indicators requires 

morbidity data that parallels basic mortality indicators and that should be 

available in a minimally functioning hospital information system. The second 

and third levels require increasingly more effort to collect the data. 

Level I: 

• Age-adjusted death rate due to IPV, per 100,000 population; 

• Death rate due to child abuse, per 1,000 population; 

• Death rate due to elder abuse, per 100,000 population; 

• Age-adjusted homicide rate due to robbery, per 100,000 population; 

• Age-adjusted hospital discharge rate due to suicide attempts 

per 100,000 population; 

• Age-adjusted hospital discharge rate due to assault of males 

aged 15–44 years, per 100,000 population; 

• Age-adjusted hospital discharge rate due to assault of females 

aged 15–44 years, per 100,000 population; 

• Hospital discharge rate due to assault of children aged less than 

5 years, per 100,000 population; 

• Hospital discharge rate for assault of the elderly, 

per 100,000 population; 

• Reported civil rights violations, per 1,000 population; 

• Reported cases of child maltreatment, per 1,000 population 

aged less than 5 years; 

• Reported cases of school fights, per 100,000 population of 

school-aged children, per year. 

Level II: 

• Age-adjusted hospital discharge rate for assault resulting from IPV, 

per 100,000 population; 

• Hospital discharge rate for assault resulting from child abuse, 

per 100,000 population; 

• Hospital discharge rate for assaults due to elder abuse, 

per 100,000 population. 

Injury Surveillance Training Manual 12 Participant Guide — Session VII 
Level III: 

• Age-adjusted rate of emergency-room visits due to suicide attempts, 

per 100,000 population; 

• Age-adjusted rate of emergency-room visits among males 

aged 15–44 years due to assaults, per 100,000 population; 

• Age-adjusted emergency-room visit rates due to assaults 

resulting from IPV, per 100,000 population; 

• Emergency-room visit rates due to assaults resulting from 

child abuse, per 100,000 population; 

• Emergency-room visit rates for assaults due to 

elder abuse, per 100,000 population. 

2.2 Research Indicators 

Data to build research indicators are not routinely available; however, these 

data may be obtained through surveys or special research. Such data can 

include: 

• Rate of suicide ideation, per 100,000 population; 

• Rate of suicide attempts in past 12 months; 

• Self-reported weapon-carrying rate among adolescents at school, 

per 100 school children; 

• Self-reported fighting rate among adolescents at school, 

per 100 school children; 

• Self-reported rate of IPV, per 100,000 respondents. 

Injury Surveillance Training Manual 13 Participant Guide — Session VII 
Exercise: Working in three groups, select basic, developmental, and research 

indicators for IPV. Answer the following questions: 

1. In your region, is it easy to obtain data to build the selected 

indicators? 

2. Do the indicators provide information that is useful 

to monitor this event? 

3. How can you use these indicators to monitor 

public health issues in your country? 

 

3. Use Injury Surveillance Data to Monitor Prevention Activities 

 

Injury surveillance data provides information that can be useful to: 

• Monitor the association of the implementation of prevention strategies with 

changes in the number, rate and characteristics of injury, which allows 

decision makers to decide whether or not to continue the prevention 

activities. 

• Monitor changes in the trend of an event before and after a strategy is 

applied (i.e., helmet or seat belt law). 

• Monitor the impact of strategies applied for purposes other than injury 

prevention that could positively or negatively affect the events under 

surveillance (i.e., firearm restriction during an election period). 

• Possible over- or under-representation of certain groups in the population 

(elderly people, youth, men, women, etc.). 

• Possible over or under presence of some types of events in areas of the city 

or region (clusters of events in specific areas). 

• Examples: 

a. An evaluation of the impact of child-resistant drug packaging illustrates 

the usefulness of both multiple assessments and active or passive 

surveillance systems for monitoring trends. In this case, trend data from 

poison control centers documented steep declines in unintentional 

poisoning deaths and ingestions by children after new packaging policies 

were put into place. A review of annual mortality rates associated with 

unintentional ingestion of oral prescription drugs for children less than 5 

years of age also showed that mortality rates declined 45% from the period 

before policy implementation through 1992.9

b. Motorcyclist deaths have been an important public health problem in Cali. 

Motorcyclists accounted for 30% of motor vehicle-related deaths during 

the past 10 years. Different strategies have been implemented to address 

this problem (Figure 3). The Fatal Injury Surveillance System established in 

Injury Surveillance Training Manual 14 Participant Guide — Session VII 
Cali has been useful for monitoring the trend of motorcyclist fatalities 

before and after each strategy was implemented.10

Motorcycle Driver

and Passenger 

Helmet Law, 

November 1997

Repeal of

daytime 

reflective vest 

law. 2002 

Law passed 

requiring mandatory 

driving school after

infraction, 2001

Motorcycles

banned from 

roadways on 

certain days in 

December 1999 

Reduction in number

of enforcement 

personnel, 2000 

Repeal of Daytime

Reflective Vest

Law, 2002 

Law passed requiring

mandatory driving school

after infraction, 2001 

Year

112

163

179

142

135

110 107

145

71

93 

0

20 

40 

60 

80 

100 

120 

140 

160 

180 

200 

1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 

Figure 3. Motorcyclist Deaths and Interventions in 

Cali, Colombia, 1993–2002 

Motorcycle Driver

Helmet Law, 

August 1996 

Motorcycles banned

from roadways on 

certain days in 

December 2001 

Reflective Vest 

Law passed, 

2001 

Motorcycles 

banned from 

roadways on 

weekends, 2001 

Number 

of 

Deaths 

Exercise: Working in two groups, give your opinions about the impact of 

prevention strategies applied in Cali and Samoa. 

 

Injury Surveillance Training Manual 15 Participant Guide — Session VII 
4. Summary 

Now that you have completed this session, you should be able to: 

• Know the steps to evaluating an injury surveillance system. 

• Review public health indicators proposed for monitoring injuries. 

• Use surveillance data to monitor prevention activities. 

You have completed the Injury Surveillance Training Manual! You are now able to: 

• Understand the conceptual framework of injury prevention; 

• Assess injury data sources and describe the injury problem; 

• Build a coalition to support the injury surveillance system 

and prevention activities; 

• Determine the appropriate methodology for the 

surveillance system; 

• Define and develop an analysis plan for the surveillance data; 

• Use injury surveillance data to inform injury prevention; 

• Define an evaluation plan for the surveillance system and monitor 

prevention activities. 

You are now ready to establish an injury surveillance system in your region 

or country. 

 Congratulations! 

Injury Surveillance Training Manual 16 Participant Guide — Session VII 
Steps to Develop and 

Maintain an 

Injury Surveillance System

7. Define an evaluation plan

 for the surveillance system

 and monitor prevention 

 activities 

Apply the criteria to evaluate 

the surveillance system and

monitor the strategies 

1. Understand the conceptual 

 framework of injury prevention 

Define and understand typology 

of unintentional and violencerelated injuries

2. Assess injury data sources 

 and describe the injury 

 problem 

Identify strengths and 

weakness of injury data 

sources and size of the 

problem 

3. Build a coalition to support 

 the injury surveillance system 

 and prevention activities 

4. Determine the appropriate

 methodology for the 

 surveillance system 

Determine events, data 

elements, type of surveillance, 

and data-collection instruments

5. Define and develop an 

 analysis plan for the 

 surveillance data 

Use data to identify preventable 

injuries, high-risk groups, and 

most appropriate interventions 

6. Use injury surveillance data 

 to inform injury prevention 

Calculate indicators, demographics, and environmental 

characteristics 

Identify partners to include 

in a coalition to support the 

injury surveillance system 

Injury Surveillance Training Manual 17 Participant Guide — Session VII 
REFERENCES 

 1. Centers for Disease Control and Prevention. Framework for program evaluation in 

public health. Morbidity and Mortality Weekly (MMWR). 1999;48(RR11):1–40. 

 2. Teutsch S, Churchill RE. Principles and Practice of Public Health Surveillance. 2nd ed. 

New York, NY: Oxford University Press; 2000. 

 3. Centers for Disease Control and Prevention. Updated guidelines for evaluating 

public health surveillance systems: recommendations from the guidelines working 

group. Morbidity and Mortality Weekly Report (MMWR). 2001; 50(RR13). 

 4. Espitia V, Guerrero R, Gutierrez M., Cocha-Eastman A., Espinosa R. Ten years of a 

fatal injury surveillance system using linkage data. Cali, Colombia, 1993–2002.

Presented at: 7thWorld Injury Conference, June 2004; Vienna, Austria. 

 5. Zalewski T. Evaluation of the Injury Surveillance System in Emergency Room in 

El Salvador. Presentation at: EIS workshop; November 2003; Atlanta, GA. 

 6. Davies M, Connolly A, Horan J. State Injury Indicators Report. Atlanta, GA: Centers 

for Disease Control and Prevention, National Center for Injury Prevention and 

Control; 2001. 

 7. Barss P, Smith G, Baker S, Mohan D. Injury Prevention: An International Perspective 

(Epidemiology, Surveillance and Policy). New York, NY: Oxford University Press; 1998. 

 8. Inter-American Coalition for the Prevention of Violence. Towards Monitoring 

Violence Indicators. An Initiative of the Inter-American Coalition for the Prevention 

of Violence. Draft. Atlanta, GA; 2001. 

 9. Doll L, Bartenfeld T, Binder S. Evaluation of interventions designed to prevent and 

control injuries. Epidemiologic Reviews. 2003;25:51–53. 

10. Espitia V., Gutierrez M., Velez L., Espinosa R. Assessment of motorcyclists helmet 

use after passing a helmet law in Cali, Colombia, 1996-1999. Presented at: 6thWorld 

Injury Conference; May 2002; Montreal, Canada. 

Injury Surveillance Training Manual 18 Participant Guide — Session VII 
Appendixes
Appendix 1.1 

Posttest 

Length: 10 minutes 

City/Country: ____________________________________________ 

Date: ___ / ___ / ____ 

1. Which of the following items are components of the injury definition? 

a) Damage to a person caused by exposure to physical agents in amounts that 

exceed the threshold of human tolerance. 

b) Damage to a person caused by a sudden lack of essential agents (oxygen 

or heat). 

 c) Psychosocial trauma which results in emotional injury. 

2. For each type of injury, place a check mark under the appropriate injury classification: 

Violence-related 

injuries 

Unintentional 

injuries 

Other type of 

injuries 

Types of injuries 

Child abuse 

Assault by firearm 

Poisoning with pesticide 

Pedestrian injury 

Intimate partner violence 

Suicidal behavior 

Injury Surveillance Training Manual Appendix 1.1 Posttest 

 

1
3. Place the following etiological factors in the appropriate phase of the Haddon Matrix: 

Etiological factors Pre-event Event Post-event 

Impaired driving laws 

Quality of medical services 

Speed of the vehicle at impact 

Seat belt use 

Speed limit laws 

Brakes and tires of the vehicle 

involved 

Pedestrian walking in the roadway 

Recovering areas in case of 

emergency 

4. Select potential partners for a coalition that supports the injury surveillance system and 

prevention activities: 

Potential Partners YES NO 

Health 

(hospital and health center directors, ministries of health) 

Justice 

(forensic medicine, coroners/medical examiners, courts, 

prosecutors)

Security 

(police, security companies, homicide investigators) 

Transportation 

(transportation department offices or officers)

Administration 

(planning officers)

Education 

(academic directors)

Community 

(community organizations, youths, mothers) 

Private organizations 

(NGOs, human rights groups) 

Political 

(national, regional, or local authorities) 

Other 

(mention which one)

Injury Surveillance Training Manual Appendix 1.1 Posttest 

 

2
5. Place the following factors for intimate partner violence in the appropriate level of the 

Ecological Model: 

Factors Individual Relationship Community Societal 

Absent or rejecting 

father 

Acceptance of 

violence as a way to 

resolve conflict 

Isolation of women 

and family 

Witnessing marital 

violence as a child 

Marital conflict 

Norms related to male 

authority over women 

Injury Surveillance Training Manual Appendix 1.1 Posttest 

 

3
Appendix 2 

Session Evaluation 

Length: 10 minutes 

City/Country: _______________________________________________ 

Date: ___ / ___ / ____ 

Use this form to evaluate workshop sessions. Check the appropriate box. Give this form 

to the instructor at the end of the workshop. 

Were session 

objectives met? 

Was adequate 

time allowed for 

the session?

Did the instructor 

conduct the class 

well?

Did you learn 

something new in 

this session?

Sessions 

YES NO YES NO YES NO YES NO 

I 

II 

III 

IV 

V 

VI 

VII 

Additional comments (indicate the session) 

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Injury Surveillance Training Manual 1 Appendix 2. Session Evaluation 
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Injury Surveillance Training Manual 2 Appendix 2. Session Evaluation 
Appendix 3 

 

Workshop Evaluation 

Length: 10 minutes 

City/Country: ____________________________________________ 

Date: ___ / ___ / ____ 

Use this form to evaluate the workshop. Check the appropriate box. Give this form to the 

instructor at the end of the workshop. 

Agree Neither agree 

nor disagree Disagree 

1. Workshop objectives were met 

2. Sessions progressed in a logical manner

3. The instructor(s) were well prepared 

4. This workshop would adequately prepare someone to 

follow the steps for establishing an injury surveillance 

system 

5. I would recommend this workshop to anyone interested 

in establishing an injury surveillance system 

 

Additional comments: 

_________________________________________________

_________________________________________________

_________________________________________________

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Injury Surveillance Training Manual 1 Appendix 3. Workshop Evaluation 
Centers For Disease Control and Prevention

National Center for Injury Prevention and Control

4770 Buford Highway NE

Mail Stop K-65

Atlanta, Georgia 30341

Telephone: 770-488-1506

Fax: 770-488-1667

E-mail: ohcinfo@cdc.gov

Website: www.cdc.gov/injury