432 Establishing injury surveillance in emergency departments in Nepal: epidemiology and burden of paediatric injuries
Authors: Magnus Dan , Bhatta Santosh , Mytton Julie 
Published: January 2021

Aims/Objectives/Background

Globally, injuries cause more than 5 million deaths annually. Children and young people are a particularly vulnerable group and injuries are the leading cause of death in people aged 5–24 years globally and a leading cause of disability.

In most low and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited. There is a continuing need for better data on childhood injuries and for injury surveillance.

The aim of our study was to introduce a hospital-based injury surveillance tool – the first of its kind in Nepal and explore its feasibility. We undertook prospective collection of data on all injuries/trauma presenting to 2 hospital emergency departments to describe the epidemiology of paediatric hospital injury presentations and associated risk factors.

Methods/Design

A new injury surveillance system for use in emergency departments in Nepal was designed and used to collect data on patients presenting with injuries. Data were collected prospectively in two hospitals 24 h a day over 12 months (April 2019 - March 2020) by trained data collectors using tablet computers.

Abstract 432 Table 1

Socio-demographic profile and characteristics of injury among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020 (N=2696)

CharacteristicsFrequencyGender Male 1778  Female 918 Age groups 0–4 years 653  5–9 years 866  10–14 years 680  15–17 years 497  Median year (IRQ) 8 (5 – 13) Ethnicity/caste Janajati 1384  Brahmin/Chhetri 892  Dalit 148  Madhesi 146  Muslim 74  Others 50  Unknown 2 Place where injury occurred Home/Compound 1576  Highway/road/street 636  School 233  Recreational area 138  Workplace 76  Other 37 Activities at the time injury occurred Leisure/Play 1889  Travelling (other than to/from school/work) 296  Work 202  Travelling (to/from school/work) 184  Education 42  Organised sports 11  Other 52  Unknown 20 Intent of injury Unintentional 2560  Intentional (self-harm) 61  Intentional (assault) 75 Unintentional (n=2560)  Fall 912  Animal or insect related 728  Road traffic injury 356  Injured by a blunt force 201  Stabbed, cut or pierced 176  Fire, burn or scald 65  Poisoning 52  Suffocation/choking 36  Electrocution 12  Drowning and submersion 7  Other 13  Unknown 2 Self-harm (n=61)  Poisoning 38  Hanging, strangulation, suffocation 12  Stabbed, cut or pierced 6  Injured by blunt object 4  Other 1 Assault (n=75)  Bodily force (physical violence) 43  Injured by blunt object 18  Stabbed, cut or pierced 8  Pushing from a high place 2  Poisoning 2  Sexual assault 1  Other 1 Nature of injury (one most severe) Cuts, bites or open wound 1378  Bruise or superficial injury 383  Fracture 299  Sprain, strain or dislocation 243  Internal injury 124  Head Injury/Concussion 83  Burns 67  Other 115  Unknown 2  Not recorded 2 Severity of injury No apparent injury 125  Minor 1645  Moderate 813  Severe 111  Not recorded 2 Disposition Discharged 2317  Admitted to hospital 164  Transferred to another hospital 179  Died 21  Leave Against Medical Advice (LAMA) 11  Unknown 2  Not recorded 2

Note:

Not recorded = missing cases

95% CI calculated using one proportion test and normal approximation method in Minitab.

Abstract 432 Table 2

Distribution of injuries by age-group, sex and mechanism of injury among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020

Age groups & Sex0 - 4 years5 - 9 years10–14 years15–17 yearsMaleFemaleTotalIntent & mechanismsn (%)n (%)n (%)n (%)n (%)n (%)n (%)Unintentional Fall 239 (26.2) 328 (36.0) 249 (27.3) 96 (10.5) 636 (69.7) 276 (30.3) 912 (100)  Animal or insect related 175 (24.0) 260 (35.7) 190 (26.1) 103 (14.1) 470 (64.6) 258 (35.4) 728 (100)  Road traffic injury 49 (13.8) 108 (30.3) 86 (24.2) 113 (31.7) 223 (62.6) 133 (37.4) 356 (100)  Injured by a blunt force 54 (26.9) 74 (36.8) 49 (24.4) 24 (11.9) 150 (74.6) 51 (25.4) 201 (100)  Stabbed, cut or pierced 20 (11.4) 56 (31.8) 49 (27.8) 51 (29.0) 127 (72.2) 49 (27.8) 176 (100)  Fire, burn or scald 42 (64.6) 10 (15.4) 9 (13.8) 4 (6.2) 27 (41.5) 38 (58.5) 65 (100)  Poisoning 33 (63.5) 6 (11.5) 5 (9.6) 8 (15.4) 26 (50.0) 26 (50.0) 52 (100)  Suffocation/choking 24 (66.7) 5 (13.9) 2 (5.6) 5 (13.9) 20 (55.6) 16 (44.4) 36 (100)  Electrocution 2 (15.7) 0 (0.0) 3 (25.0) 7 (58.3) 10 (83.3) 2 (16.7) 12 (100)  Drowning and submersion 1 (14.3) 1 (14.3) 3 (42.9) 2 (28.6) 3 (42.9) 4 (57.1) 7 (100)  Other 6 (46.2) 4 (30.8) 3 (23.1) 0 (0.0) 10 (76.9) 3 (23.1) 13 (100)  Unknown 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100) 2 (100)  Total 647 (25.3) 852 (33.3) 648 (25.3) 413 (16.1) 1702 (66.5) 858 (33.5) 2560 (100) Self-harm Poisoning 0 (0.0) 0 (0.0) 6 (15.8) 32 (84.2) 7 (18.4) 31 (81.6) 38 (100)  Hanging 0 (0.0) 0 (0.0) 3 (25.0) 9 (75.0) 4 (33.3) 8 (66.7) 12 (100)  Stabbed, cut or pierced 0 (0.0) 0 (0.0) 2 (33.3) 4 (66.7) 1 (16.7) 5 (83.3) 6 (100)  Injured by blunt object 0 (0.0) 2 (50.0) 2 (50.0) 0 (0.0) 4 (100) 0 (0.0) 4 (100)  Other 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) 1 (100) 0 (0.0) 1 (100)  Total 0 (0.0) 2 (3.3) 13 (21.3) 46 (75.4) 17 (27.9) 44 (72.1) 61 (100) Assault Bodily force (physical violence) 3 (7.0) 1 (2.3) 11 (25.6) 28 (65.1) 37 (86.0) 6 (14.0) 43 (100)  Injured by blunt object 2 (11.1) 8 (44.4) 4 (22.2) 4 (22.2) 13 (72.2) 5 (27.8) 18 (100)  Stabbed, cut or pierced 1 (12.5) 0 (0.0) 2 (25.0) 5 (62.5) 7 (87.5) 1 (12.5) 8 (100)  Pushing from a high place 0 (0.0) 1 (50.0) 1 (50.0) 0 (0.0) 1 (50.0) 1 (50.0) 2 (100)  Poisoning 0 (0.0) 1 (50.0) 0 (0.0) 1 (50.0) 1 (50.0) 1 (50.0) 2 (100)  Sexual assault 0 (0.0) 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 1 (100) 1 (100)  Other 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) 1 (100)  Total 6 (8.0) 12 (16.0) 19 (25.3) 38 (50.7) 59 (78.7) 16 (21.3) 75 (100) Abstract 432 Table 3

Association of injury location, nature and severity with age among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020

Age groups0 – 4 years5 – 9 years10–14 years15–17 yearsTotalChi-SquareInjury characteristicsn (%)n (%)n (%)n (%)n (%)P valueLocation of injury sustained Home/Compound 537 (34.1) 504 (32.0) 319 (20.2) 216 (13.7) 1576 (100) <0.001  Highway/road/street 85 (13.4) 196 (30.8) 190 (29.9) 165 (25.9) 636 (100)  School 15 (6.4) 107 (45.9) 85 (36.5) 26 (11.2) 233 (100)  Recreational area 9 (6.5) 44 (31.9) 55 (39.9) 30 (21.7) 138 (100)  Workplace 1 (1.3) 4 (5.3) 19 (25.0) 52 (68.4) 76 (100)  Other 6 (16.2) 11 (29.7) 12 (32.4) 8 (21.6) 37 (100)  Total 653 (24.2) 866 (32.1) 680 (25.2) 497 (18.4) 2696 (100) Nature of injury Cuts, bites or open wound 328 (23.8) 506 (36.7) 314 (22.8) 230 (16.7) 1378 (100) <0.001  Bruise or superficial injury 81 (21.1) 99 (25.8) 118 (30.8) 85 (22.2) 383 (100)  Fracture 48 (16.1) 101 (33.8) 112 (37.5) 38 (12.7) 299 (100)  Sprain, strain or dislocation 48 (19.8) 78 (32.1) 72 (29.6) 45 (18.5) 243 (100)  Internal injury 44 (35.5) 8 (6.5) 18 (14.5) 54 (43.5) 124 (100)  Head Injury/Concussion 18 (21.7) 26 (31.3) 18 (21.7) 21 (25.3) 83 (100)  Burns 42 (62.7) 9 (13.4) 10 (14.9) 6 (9.0) 67 (100)  Other 41 (35.7) 38 (33.0) 18 (15.7) 18 (15.7) 115 (100)  Unknown 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100)  Total 652 (24.2) 865 (32.1) 680 (25.2) 497 (18.4) 2694 (100) Severity of injury No apparent injury 39 (31.2) 45 (36.0) 26 (20.8) 15 (12.0) 125 (100) <0.001  Minor 419 (25.5) 535 (32.5) 406 (24.7) 285 (17.3) 1645 (100)  Moderate 171 (21.0) 262 (32.2) 225 (27.7) 155 (19.1) 813 (100)  Severe 23 (20.7) 23 (20.7) 23 (20.7) 42 (37.8) 111 (100)  Total 652 (24.2) 865 (32.1) 680 (25.2) 497 (18.4) 2694 (100) Abstract 432 Table 4

Association of injury location, nature and severity with sex among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020

SexMaleFemaleTotalChi-SquareInjury characteristicsn (%)n (%)n (%)P valueLocation of injury sustained Home/Compound 979 (62.1) 597 (37.9) 1576 (100) <0.001  Highway/road/street 421 (66.2) 215 (33.8) 636 (100)  School 176 (75.5) 57 (24.5) 233 (100)  Recreational area 111 (80.4) 27 (19.6) 138 (100)  Workplace 62 (81.6) 14 (18.4) 76 (100)  Other 29 (78.4) 8 (21.6) 37 (100)  Total 1778 (65.9) 918 (34.1) 2696 (100) Nature of injury Cuts, bites or open wound 959 (69.6) 419 (30.4) 1378 (100) <0.001  Bruise or superficial injury 246 (64.2) 137 (35.8) 383 (100)  Fracture 200 (66.9) 99 (33.1) 299 (100)  Sprain, strain or dislocation 154 (63.4) 89 (36.6) 243 (100)  Internal injury 50 (40.3) 74 (59.7) 124 (100)  Head Injury/Concussion 59 (71.1) 24 (28.9) 83 (100)  Burns 27 (40.3) 40 (59.7) 67 (100)  Other 79 (68.7) 36 (31.3) 115 (100)  Unknown 2 (100) 0 (0.0) 2 (100)  Total 1776 (65.9) 918 (34.1) 2694 (100) Severity of injury No apparent injury 81 (64.8) 44 (35.2) 125 (100) 0.048  Minor 1102 (67.0) 543 (33.0) 1645 (100)  Moderate 533 (65.6) 280 (34.4) 813 (100)  Severe 60 (54.1) 51 (45.9) 111 (100)  Total 1776 (65.9) 918 (34.1) 2694 (100) Abstract 432 Table 5

Distribution of injuries by outcome and mechanism of injury among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020

Outcome of injuryDischargedAdmittedTransferredDiedLAMAUnknownTotalIntent & mechanismsn (%)n (%)n (%)n (%)n (%)n (%)n (%)Unintentional Fall 787 (86.5) 65 (7.1) 53 (5.8) 0 (0.0) 4 (0.4) 1 (0.1) 910 (100)  Animal/insect bite/sting 704 (96.7) 3 (0.4) 19 (2.6) 0 (0.0) 1 (0.1) 1 (0.1) 728 (100)  Road traffic injury 260 (73.0) 47 (13.2) 44 (12.4) 5 (1.4) 0 (0.0) 0 (0.0) 356 (100)  Injured by a blunt force 190 (94.5) 4 (2.0) 6 (3.0) 0 (0.0) 1 (0.5) 0 (0.0) 201 (100)  Stabbed, cut or pierced 165 (93.8) 8 (4.5) 3 (1.7) 0 (0.0) 0 (0.0) 0 (0.0) 176 (100)  Fire, burn or scald 52 (80.0) 12 (18.5) 1 (1.5) 0 (0.0) 0 (0.0) 0 (0.0) 65 (100)  Poisoning 30 (57.7) 4 (7.7) 16 (30.8) 1 (1.9) 1 (1.9) 0 (0.0) 52 (100)  Suffocation/choking/asphyxia 24 (66.7) 4 (11.1) 6 (16.7) 1 (2.8) 1 (2.8) 0 (0.0) 36 (100)  Electrocution 7 (58.3) 2 (16.7) 2 (16.7) 1 (8.3) 0 (0.0) 0 (0.0) 12 (100)  Drowning and submersion 4 (57.1) 0 (0.0) 0 (0.0) 3 (42.9) 0 (0.0) 0 (0.0) 7 (100)  Other 12 (92.3) 1 (7.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 13 (100)  Unknown 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100)  Total 2237 (87.5) 150 (5.9) 150 (5.9) 11 (0.4) 8 (0.3) 2 (0.1) 2558 (100) Self-harm Poisoning 5 (13.2) 8 (21.1) 23 (60.5) 0 (0.0) 2 (5.3) 0 (0.0) 38 (100)  Hanging 1 (8.3) 0 (0.0) 1 (8.3) 10 (83.3) 0 (0.0) 0 (0.0) 12 (100)  Stabbed, cut or pierced 6 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 6 (100)  Injured by blunt object 4 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (100)  Other 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100)  Total 17 (27.9) 8 (13.1) 24 (39.3) 10 (16.4) 2 (3.3) 0 (0.0) 61 (100) Assault Bodily force (physical violence) 34 (79.1) 5 (11.6) 3 (7.0) 0 (0.0) 1 (2.3) 0 (0.0) 43 (100)  Injured by blunt object 18 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 18 (100)  Stabbed, cut or pierced 6 (75.0) 1 (12.5) 1 (12.5) 0 (0.0) 0 (0.0) 0 (0.0) 8 (100)  Pushing from a high place 2 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100)  Poisoning 1 (50) 0 (0.0) 1 (50.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (100)  Sexual assault 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100)  Other 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100)  Total 63 (84.0) 6 (8.0) 5 (6.7) 0 (0.0) 1 (1.3) 0 (0.0) 75 (100) Abstract 432 Figure 1

Seasonal variation of injuries identified by the injury surveillance system over a year among children attending emergency of hospitals in Makwanpur district, Nepal, April 2019 – March 2020

Results/Conclusions

The total number of ED patients with injury in the study was 10,154.

2,696 were patients aged <18 years. Most injuries in children were unintentional and over half of children presenting with injuries were <10 years of age. Falls, animal bites/stings and road traffic injuries accounted for nearly 75% of all injuries with some (drowning, poisonings and burns) under-represented. Over half of injuries were cuts, bites and open wounds. The next most common injury types were superficial injuries (14.2%); fractures (11.1%); sprains/dislocations (9.0%). Child mortality was 1%.

This is the biggest prospective injury surveillance study in a low or middle country in recent years and supports the use of injury surveillance in Nepal for reducing child morbidity and mortality through improved data.

CHILD PAPER: RESULTS SECTION

Total number of ED patients: 33046

Total number of ED patient with injury: 10154 (adult=7458 & children=2696)

8.2% (n=2696) patients with injury were children aged <18 years

Hetauda hospital:

2274 (84.3%)

Chure hill hospital:

422 (15.7%)