a Accident & Trauma Research Centre, UKK Institute for Health Promotion Research, Tampere, Finland.
b Tampere Research Center of Sports Medicine, UKK Institute for Health Promotion Research, Tampere, Finland.
c National Institute of Public Health, Helsinki, Finland.
d Department of Surgery, University Hospital and Medical School, University of Tampere, Tampere, Finland.
Reprint requests to: Jari Parkkari, UKK Institute, PO Box 30, FIN-33501 Tampere, Finland. E-mail: mejapa{at}uta.fi
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Abstract |
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Methods We selected from Official Cause-of-Death Statistics and National Hospital Discharge Register children aged 014 years who died or required treatment at a hospital department because of an injury in 19711995. The number of Finnish children was 1.1 million in 1971, and 1.0 million in 1995.
Results During the entire study period injuries were the leading cause of death in children aged 114 years, but not in infants. However, in these years the incidence (per 100 000 people) of fatal injuries in Finnish children decreased considerably in all age groups and both sexes, in girls from 20.1 in 1971 to 4.6 in 1995, and in boys from 36.7 in 1971 to 9.3 in 1995. In 1995, 41% of all the injurious deaths among 014 year old Finnish children were motor vehicle accidents, 12% were drownings, and 24% intentional injuries. The overall number and incidence of serious non-fatal injuries among Finnish children showed no clear trend change in 19711995. The mean hospitalization time of injured children shortened between 1971 and 1995, from 7.4 days to 2.7 days.
Conclusions We conclude that the number and incidence of fatal childhood injuries have decreased dramatically in Finland between 1971 and 1995. The reasons for this positive development are multifactorial, but improved traffic safety and trauma care are probably very important. In children's serious non-fatal injuries the development has not been so encouraging and therefore children's injury prevention should receive continuous intense attention.
Keywords Injury, children, time trends, prevention
Accepted 4 November 1999
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Introduction |
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Fatal injuries are, however, only the tip of an iceberg; it has been estimated that up to one-quarter of all children experience a medically attended injury each year.5,11,12 Fortunately, most of these injuries are mild to moderate strains, contusions, wounds and abrasions only. The more serious injuries that lead to hospitalization, absence from school and other daily activities and, in the worst cases, to permanent disability, form about 510% of all children's injuries.12,13 These injuries, along with the fatal accidents, cause not only major suffering to the children and their families but also large economic burden to society.14,15
In spite all this, very little epidemiological information on injuries and injury-induced deaths among children is available, and to our knowledge, no nationwide study investigating the recent numbers, incidences and secular trends of fatal and serious non-fatal injuries has been published. An understanding of the underlying epidemiological changes would allow assessment of the efficacy of preventive measures and the need for further preventive strategies.
The purpose of this study was therefore to examine the time trends for the absolute number and the age- and sex-specific incidence rates of the fatal and serious non-fatal injuries among 014 year old children in Finland in 19711995.
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Methods |
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The Official Cause-of-Death Statistics of Finland contains data on age, sex, place of residence, and place, cause and time of the death of the deceased. The main categories for unintentional injury deaths are the road traffic accidents, water traffic accidents, falls, drownings and poisonings.16 For intentional injury deaths, the main categories are suicides and violence. For the current study, all Finns <15 years of age who died from an injury in 19711995 were selected from this database.
The coverage of the Official Cause-of-Death Statistics of Finland is in practice 100% since each death certificate and the corresponding personal information in the population register are cross-checked;16 for example, in 1994 only four death certificates out of a total 47 938 were not issued before the deadline and publication of the 1994 statistics.16,17
The accuracy of the data of the Official Cause-of-Death Statistics of Finland is maximized by triple-checking each code on the death certificate issued by the physician who certified the death.16 The first check is done by the local population authority (accuracy of the population data of the deceased), the second by the legal medical officer at the county administration (accuracy and consistency of the cause-of-death codes with the original death certificate), and the third and final check is made at Statistics Finland (computer-driven checking of the logic of the entire database). In each phase, further information can be obtained from the certifying physician. In 1995, further information was requested on 1.3% of the death certificates.16 In injury-based deaths, the accuracy of the Finnish death certificate and its cause-of-death codes is further improved by the fact that an autopsy is performed in 9497% of these deaths.16,18
The mortality data of children were drawn from the entire children population of Finland, which was 1 107 280 in 1971 and 972 007 in 1995; thus the absolute numbers and incidences of deaths were therefore not cohort-based estimates but true final results of the population.
Database for the serious non-fatal childhood injuries
All Finns <15 years of age who were admitted to hospital departments between 1971 and 1995 for primary treatment of an injury were selected from the National Hospital Discharge Register (NHDR). Thus hospital department admission was used as an indicator and criterion for a serious injury. The unique personal identification number allowed us to focus the analysis on each child's first recorded admission. In 1976, the children's NHDR injury database was clearly deficient and thus this year could not be used in the analysis.
The NHDR contained data on age, sex, place of residence, hospital number and department, day of admission and discharge, place and cause of injury, diagnosis, and the place of further treatment. The Finnish NHDR is the oldest established nationwide discharge register in the world, and the data provided by this register are well suited to epidemiological study: the register has been shown to cover the acute injuries of the population adequately (annual coverage of injuries is 95100%) and record them accurately (annual accuracy is over 95%).1922
The injuries were recorded by both the main and secondary diagnoses. According to the directives given by the Finnish National Board of Health, the first diagnosis described the main reason for the patients' hospital stay. The second, third and fourth diagnosis indicated other possible diseases or injuries. The diagnoses were coded with a five-digit code according to the Eighth (19711986) and Ninth (19871995) Revision of the International Classification of Diseases (ICD) indicating the type of injury.
As in the mortality data, the study was based on the whole Finnish population, thus completely covering the intended study population (Finnish children).
Calculation of the age- and sex-specific incidences
To establish age-specific incidences for the selected age-groups (<1, 14, 59, 1014), the annual numbers of fatal and non-fatal injuries were divided by the midyear population for each age and sex group. The rates were expressed as the number of cases per 100 000 people per year, by sex and by age group. The annual midyear population figures for each age group between 1971 and 1995 were taken from the Official Statistics of Finland, the official population register of the country.23 In this statutory computer-based register, every Finn has been registered by her or his personal identification number and the register is continuously quality-controlled and updated by the Statistics Finland.
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Results |
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In 1971, motor vehicle accidents caused 48% of all injurious deaths among 014 year old Finnish children, drownings 17% and intentional injuries 9%. In 1995, the corresponding proportions were 41%, 12% and 24%.
Serious non-fatal injuries among children
Among Finnish boys 014 years of age, the number of serious non-fatal injuries (i.e. injuries resulting in hospitalization of the victim) slightly decreased during the study period, from 5300 in 1971 to 4391 in 1995 (Figure 4). The corresponding incidences (per 100 000 boys) were 938 and 884, respectively. In girls, these numbers and incidences were lower than those in boys and showed little change over the period 19711995 (Figure 4
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Discussion |
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A major strength of this study was that the data of injuries and deaths were drawn from two nationwide registers (The Finnish NHDR and the Official Cause-of-Death Statistics of Finland) with high accuracy and excellent coverage.1622 The described trends of absolute numbers and incidences of injuries were thus not cohort-based estimates but true nationwide results. On the other hand, our study is limited because the number, incidence and secular trends of the injuries and deaths cannot be directly generalized to other countries, although it is likely that the trend has been similar in other developed western societies. Another concern that needs attention is the fact that the reported serious non-fatal injuries included hospitalized children only, and it has been suggested that (depending on the definition of injury) only 320% of all injured children are admitted to hospital.12,13,24 On the other hand, in epidemiological studies like this the hospitalized children are considered the most severely injured and were thus selected for this study.
Our results are in accordance with those reported from other western countries, with injuries being the most common cause of death among 114 year old children1,25 and motor vehicle accidents, in turn, being the most common reason for fatal injuries.1,25,26 It is also evident that boys have a higher risk of injury than girls;12,26 the incidence of fatal injuries among Finnish boys being roughly 100%, and non-fatal injuries 50%, higher than that in Finnish girls. Interestingly, the excess involvement of males can be seen even in the first year of life.
In Denmark, the mortality rate of children aged 014 from unintentional injuries was 8.2 (per 100 000 person-years) for girls and 14.4 for boys between 1976 and 1985.26 In our study, the corresponding incidences over this same 10-year period were 7.2 and 16.5, respectively. In Iceland, the similar injury mortality rate (boys and girls together) was 9.8 in 19871991.12 In 1988, this rate was 8.9 in Norway and 7.4 in Sweden27 and, according to the present study, 9.4 in Finland. By the year 1995, this Finnish injury mortality rate dropped to 7.0.
In our nationwide statistics, incidences of fatal and non-fatal (admission to hospital) injuries were somewhat higher than those in Metropolitan Toronto, Canada.28 In Toronto, the incidence (per 100 000 014 year olds) of fatal and serious non-fatal injuries was 7.3 and 567, respectively, in 1986, and 6.8 and 436 in 1991.28 In our study, these figures were 9.2 and 755 in 1986 and 9.5 and 727 in 1991. This difference in incidence might be explained by the tendency to increased risk of injury in rural areas: Jørgensen reported that in Denmark the risk of unintentional injury death was 50% lower in the area around the capital than the national average.26 The same phenomenon was observed in Iceland where the overall accident mortality rate of 014 year old children was 9.8 (per 100 000 children) in 19871991, while during the same period the mortality rate was 34% lower (6.5) in the capital Reykjavik.12
Marganitt et al. examined hospitalization for traumatic injury among children aged 013 years in Maryland, USA from 1979 to 1988.29 They reported that the hospital discharge rate declined from 509 per 100 000 children in 1979 to 320 in 1988. These figures are clearly lower than ours in the corresponding years (712 and 787, respectively). This difference is partly explained by the fact that children's drownings, poisonings, suffocations, and injuries induced by intrusion of a foreign body to the body of the victim were not included in the Baltimore study. There should not be big differences in the hospitalization policy for injured children between the US and Finland, although this explanation cannot be ruled out either.
In Metropolitan Toronto, Canada, motor vehicle accidents involving occupants and pedestrians caused 30% of fatal injuries among 014 year olds between 19861991, intentional injury was in the second place causing 21% of the deaths, and third-place drownings caused 16% of deaths.28 During the same period our nationwide files showed that motor vehicle accidents caused 45% of the fatal injuries, intentional injuries 17% and drownings 15% of deaths; thus these three were the most usual causes of deaths from injury in Finland, too. In 1995, our corresponding proportions were 41%, 24% and 12% indicating that intentional injuries were proportionally an increasing problem among Finnish children. A similar trend has been seen in England and Wales where intentional injuries made up 13% of injury deaths in 1980 while in 1995 these accounted 25% of all injury deaths.30
In Finland, injuries to children have been a well-recognised public health problem over a period of five decades.9,10 In 014 year old Finnish children, the incidence of fatal injuries was 40 per 100 000 children in 1950, 30 in 1960, and 27 in 1970.9 Our current study showed that this positive trend has continued up to the present (<10 fatal injuries per 100 000 children), with the greatest decline occurring in the number of fatal motor vehicle accidents. Most likely, this is due to improved traffic safety and the intense promotion of safety seats and belts to protect children.9,10 Also, improved trauma care may save lives better today than in the past.31 On the other hand, it has been suggested that the decline is the result of a reduction in children's exposure to traffic.32
The fairly stable incidence of serious non-fatal childhood injuries during the recent 25 years might be a worldwide phenomenon and further studies are required to show results for other populations. This lack of improvement is probably due to the multifactorial aetiology of these injuries. Rapid worldwide economic growth and technological changes may also have brought new challenges for injury prevention by providing previously unfamiliar sources of injuries in our homes and during leisure time activities. In this respect children's safety may often be forgotten in the development processes of society.
Public campaigns and other efforts that have been carried out to decrease the number of fatal drownings, poisonings, and burns are obvious, but some other types of serious injuries, such as falls and sports injuries, probably need further preventive work. Intentional injury (violence) as a cause of injury has not received much attention in Finland, although in this study it accounted for 24% of the total child injury-mortality in Finland in 1995. Although the total number of these violent childhood injuries is not very high, there is a need for preventive efforts in this area, too.
Finally, the steady decrease in the number of first-phase hospitalization days of injured children between 1971 and 1995 needs attention. This positive development may be due to a change in the treatment policy favouring further outpatient care (partly because the treatment of injuries has improved and become more effective), but it may also reflect the fact that today's injuries are less serious than in the past. Whatever its cause, the trend is clear and most welcome.
In conclusion, the number and incidence of fatal childhood injuries have decreased dramatically in Finland between 1971 and 1995. The reasons for the reduction are multifactorial, but improved traffic safety and trauma care are probably the most important single factors behind the positive development. In serious non-fatal childhood injuries the development has not been so encouraging. Since every fatal or non-fatal childhood injury is one too many, children's injury prevention needs continuous attention.
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Acknowledgments |
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Jari Parkkari was the lead investigator. Pekka Kannus, Seppo Niemi, Seppo Koskinen and Mika Palvanen were involved in the study design, data analysis, and writing of the paper. Ilkka Vuori was involved in the design, data management, and writing of the paper. Markku Järvinen contributed to the study design and analysis, finalization of the manuscript, and organization of funding.
This study was financially supported by the Finnish Ministry of Education, the Finnish Ministry of Health and the Medical Research Fund of Tampere University Hospital, Tampere, Finland.
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