Milestones in Public Health: Chapter 2

January 2011

Lectures for Graduate Public Health Education

Identify energy as main cause of injury Describe injury risk factors across life span Discuss risk factors for teen motor vehicle

crashes and factors demonstrated to reduce these risks

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Describe injury outcomes and disability Define injury control and describe at the

three levels of prevention Explain federal funding for research to

identify, implement, and maintain successful interventions

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Illustrate how the 5 E’s of injury control (Education, Engineering, Economic Incentives, Empowerment, Enactment of Legislation) are used to prevent injury

Illustrate how the Haddon framework can be applied to automobile safety

Analyze linked systems of safety features in automobile manufacturing

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1. Historical Perspective/Background2. Context: The Milestones and its Impact on

Public Health3. Biology, Behavior and Science4. Systems, Policies and Programs5. Looking Ahead6. References and Resources

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Historical Perspective/Background

20th Century Motorization of America1896 First recorded fatality occurred in

London in an onlooker during a demonstration drive

September 1899

First U.S. fatality occurred in NYC

Mid-1960s Modern injury science emerged as a distinct field

1985 Shift of focus: Accident prevention to injury prevention

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NHTSA 2020 Report

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Motor vehicle safety: A 20th century public health achievement

Challenge for 21st century to SUSTAIN AND IMPROVE Motor Vehicle Safety

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Context: The Milestone and its Impact on Public Health

More than 79,500 adults ages 20 to 49 died from injuries in 2002

Motor vehicle crashes were the leading cause of those deaths

CDC (2006)

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CDC (2006)

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CDC (2006)

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Motor vehicle injuries occur at all stages of life and include the following issues:

– Alcohol-related motor vehicle injuries– Child passenger safety– Older adult drivers– Road traffic safety– Teens behind the wheel

CDC (2006)

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An alcohol-related motor vehicle crash kills someone every 31 minutes and injures someone non-fatally every 2 minutes

More than 1.4 million drivers were arrested for driving under the influence of alcohol or narcotics

About 3 in 10 Americans are involved in an alcohol-related crash in their lifetimes

The number of alcohol-related fatal crashes is growing

Costs Americans approximately $51B annuallyCDC (2006); Quinlan et al. (2005), Dept. of Justice

(2005)

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Motor vehicle injuries are among the greatest public health problem facing U.S. children today

During 2003, a total of 1,591 children aged 14 years and younger died as occupants in motor vehicle crashes, and approximately 220,000 were injured

Most of these children were riding unrestrained, thus many of these injuries could have been prevented

Drinking and driving are injury and fatality risk factors for children

CDC (2006)

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In 2002, a total of 7,688 people ages 65 and older died in motor vehicle crashes in the U.S.

Drivers ages 65 and older have higher crash death rates per mile driven than all but teen drivers

Rates for motor vehicle-related deaths and injury are twice as high for older men as for older women

Motor vehicle-related deaths and injuries among older adults are rising

CDC (2006)

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Road traffic crashes kill 1.2 million/year worldwide

Road traffic crashes injure or disable 20 million to 50 million each year

Ranks as 11th cause of death and account for 2% of all deaths globally

By 2020, road traffic injuries predicted to become 3rd largest contributor to global burden of disease

Economic cost of road traffic injuries is an estimated $518 billion

CDC (2006)

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Motor vehicle-related injuries are the biggest health threat to teens in U.S.

Account for 2/5 of deaths overall In 2002, >5,000 teens, ages 16-19 died of

injuries caused by motor vehicle crashes Risk highest among 16-19 year-olds Cost (fatal and non-fatal) involving drivers

15-20 years was $40.8 billion in 2002 CDC (2006)

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Biology, Behavior and Science

Injuries occur when the tissues of the human body absorb energy that is above the tissue threshold

McKay (2009)

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Kinetic Electrical Chemical Thermal/Radiant Energy

McKay (2009)

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Kinetic: falls, motor vehicle crashes Electrical: lightning strikes, downed wires Chemical: poisonings Thermal/Radiant Energy: steam or flame

burnsTwo types involved in motor vehicle crashes:

– Kinetic – Thermal

McKay (2009)

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The Body’s Response to Injury Tissue Fragility and Injury Threshold (co-

morbid factors; growing bodies; advanced aging)

Tissue Healing Injury Mechanics

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The Body’s Response to Injury– Each body tissue has a unique ability to absorb

and dissipate energy without injury until a critical threshold is reached

Tissue Fragility and Injury Threshold– comorbid factors; age as a factor

Tissue Healing Injury Mechanics

– Kinetic energy causes the majority of injuries

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Age and Sex Experience Passengers Alcohol Driving at Night and Fatigue

National Research Council (2007)

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Improved parental management of teens learning to drive

Enhanced enforcement on teen drivers– Graduated driver licensing (GDL)– Nighttime curfews– Limit number of passengers– Enforce strict seat belt laws

National Research Council (2007)

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Torso injuries more likely to be life-threatening than permanently disabling

Head injuries both life-threatening and disabling

Spine injuries almost always permanently disabling

Bone injuries associated with long-term disability

Long-term psychosocial effects in injured persons and in family and friends

CDC (2006)

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Injury to each type of tissue and organ, or organ system:-- results in predictable patterns of damage

AND-- indicates predictable emergent

intervention

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Total number of years of productive life lost is greater than heart disease and cancer combined

1/10 of funding directed to injury-related topics compared to those two diseases

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Systems, Policies and Programs

These terms refer to the array of activities described as: prevention, control, acute care, and rehabilitation

Prevention: includes efforts to reduce risks and severity of injury

Treatment: refers to post-event efforts to ameliorate the effects of injury through acute care and rehabilitation

Institute of Medicine (1999)

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1. Pre-event phase, during which the energy becomes uncontrolled

2. Brief event phase, in which the uncontrolled energy is transferred to the individual, resulting in injury if the energy transfer exceeds the tolerance of the body to absorb it

3. Post-event phase, during which attempts can be made to restore homeostasis and repair the damage

Institute of Medicine (1999)

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Prevailing scientific paradigm for

studying causes and prevention

of injury

William Haddon, Jr. MD (1926-1985)

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Individual Individual behaviorbehavior AgentAgent

Physical Physical environmentenvironment

Socio-economic Socio-economic environmentenvironment

Pre-eventPre-event

EventEvent

Post-Post-eventeventP

hase

sPh

ase

s

FactorsFactors

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Human Vector/Vehicle Physical/Social Environment

Pre-Event IntoxicationSafety Belt UseSpeedAlertness/SleepinessExperience

Tire PressureBrake FunctioningI BeamsCrumple Zones

Speed CamerasWeatherSocial CultureWillingness to allow others to drive drunk

Event FrailtyAgeSize

Speed of ImpactAir BagsSizeStiffness of SurfacesStability Control

FlammabilityGuard railsStiffness of fixed objectsBarriersEmbankments

Post-Event

Body Mass IndexAgeCo-morbid conditions

Degree of crushFuel System integrity

EMS responseTrauma Center availabilityRehab Programs

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Worst among 16-year-olds Teens have highest crash risk of any group Highest involvement rates in crashes of all types Characteristics:

– Driver error– Speeding– Single-vehicle– Passengers– Alcohol– Night drivers– Low seatbelt use

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Alcohol is less a problem for 16-year-olds: 15% typically have BAC of 0.08% or more

But alcohol becomes a serious problem for later teen years

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Graduated licensing helps– Restricts night driving– Limits teen passengers– Requires specified amount of supervised practice

21 year old minimum drinking age laws in all states and D.C.– NHTSA estimates these laws have saved 24,560

lives since 1975 “Zero tolerance” laws for young drivers

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Crashes per million miles driven in 2006

Source: IIHS

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Fatality Analysis Reporting System (FARS) National Electronic Injury Surveillance

System (NEISS) The National Hospital Ambulatory Medical

Care Survey (NHAMCS) Healthcare Cost and Utilization Project

(HCUP) Web-based Injury Statistics Query and

Reporting System (WISQARS)

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Promptly suspending driver’s licenses of persons who drive while intoxicated

Health promotion efforts that use ecological framework to influence economic, organization, policy, and school/community action

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If at least one driver or non-occupant involved in a crash is determined to have had a blood alcohol concentration (BAC) of 0.01 gram per deciliter (g/dl) or higher:– The motor vehicle crash is considered an

alcohol-related crash– Any death is considered an alcohol-related

fatality

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12.6% of all drivers in fatal crashes were between 15 and 20 years old

16% of all drivers in police-reported crashes were young drivers

28% who were killed had been drinking 23% of these had BAC of 0.08g/dl or higher

(this had dropped 7% between 1995-2005)

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Severity of a crash increases with alcohol involvement– 2% - crashes involving property damage– 4% - crashes resulting in injury– 21% - crashes involved in fatal crashes

Alcohol involvement higher in young males– 24% of males involved in fatal crashes– 12% of females

Drivers less likely to use restraints when drinking– 64% in fatal crashes unrestrained– 74% of drivers in fatal crashes unrestrained

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Trauma care systems Planning, development, and outcome research

at HRSA and research in injury biomechanics on the pathophysiology and reparative processes. The aim is to further the understanding of injury causes and consequences on differences in risk perception, risk taking, and behavioral responses to safety improvements among different segments of the population

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Looking Ahead

Prevent injury and violence Increase use of safety belts Reduce motor vehicle crash-related deaths Reduce nonfatal motor vehicle crash-related

injuries

Healthy People 2020

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Linked systems of safety features:– Anti-lock brakes – foundation of systems– Sensor detection to read the road– Better suspension systems using electronics and

software– Skid controls: a system that rectifies driver error

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To sustain and improve motor vehicle safety will require further public health action to:– Expand surveillance to better monitor nonfatal

injuries, detect new problems, and set priorities– Direct research to emerging and priority

problems– Implement the most effective programs and

policies– Strengthen interagency, multidisciplinary

partnerships

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Continuing efforts shown to reduce alcohol-impaired driving and related fatalities/injuries

Promoting strategies such as graduated licensing that discourage speeding, teenage drinking and other risky driving behaviors and encourage safety belt use

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Enhancing pedestrian safety, especially for children and the elderly, through engineering solutions that– reduce exposure to traffic and permit crossing

streets safely– encourage safer pedestrian behaviors, such as

crossing streets at intersections– increase visibility to drivers and driver

awareness of pedestrians

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Accommodating the mobility needs of persons aged greater than 65 years – a population that will almost double to 65 million by 2030 – through a combination of alternative modes of transportation (e.g., walking and getter public transportation) and development of better strategies to reduce driving hazards

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Encouraging the routine use of safety belts (30% of the population do not wear safety belts)

Encouraging proper use of age-appropriate child-safety seats and booster seats, especially for older children who have outgrown their child seats but are too small for adult lap-shoulder belts

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Conducting biomechanics research to better understand the causes of nonfatal disabling injuries, particularly brain and spinal cord injuries, as a foundation for prevention strategies

Developing a comprehensive public health surveillance system at the federal, state, and local levels that tracks fatal and nonfatal motor-vehicle-related injuries in order to establish prevention and research priorities

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Development of seat belts Active restraint systems Trace the history in the U.S. and elsewhere What was some resistance based upon? Discuss issues of personal freedom which arose. What is the sole state that does not have seat belt

law? What does (did) a seat belt cost per car? What about legislation requiring large school buses

to install seat belts?

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NHTSA (2008)

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Trace the history of the development of air bags in the U.S.

What distinguishes the use of air bags from seat belt use?

Although most crashes are head-on impact, what is the comparative magnitude of crashes on the sides of autos?

What were some of the negative impact factors in crashes when air bags inflated? Were these anticipated?

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Which of these restraint systems has had a greater impact on saving lives?

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CDC (1999)

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CDC (1999)

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References and Resources

1. Bergen, G. S., & National Center for Health Statistics. (2008). Injury in the united states : 2007 chartbook. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved from http://www.cdc.gov/nchs/data/misc/injury2007.pdf

2. Bonnie, R. J., Fulco, C., Liverman, C. T., & Institute of Medicine . Committee on Injury Prevention and Control. (1999). Reducing the burden of injury : Advancing prevention and treatment. Washington, D.C.: National Academy Press.

3. Centers for Disease Control and Prevention (CDC).Web-based injury statistics query and reporting system (WISQARS). Retrieved March 29, 2010, from http://www.cdc.gov/injury/wisqars/index.html

4. Centers for Disease Control and Prevention (CDC). (1999). Motor-vehicle safety: A 20th century public health achievement. MMWR.Morbidity and Mortality Weekly Report, 48(18), 369-374.

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5. Faden, V. B., & Goldman, M. S. (2008). Underage drinking: Understanding and reducing risk in the context of human development. Pediatrics, 121(Suppl 4), S231-S354. doi:10.1542/peds.2007-2243I

6. Federal Bureau of Investigation (FBI). (2005). Crime in the United States 2005: Uniform crime reports. Retrieved November 3, 2006 from http://www.fbi.gov/ucr/05cius/index.html

7. Insurance institute for highway safety, highway loss data institute. Retrieved March 29, 2010, from http://www.iihs.org/

8. Jones, R. K., Shinar, D., Walsh, J. M., & United States. National Highway Traffic Safety Administration. (2003). State of knowledge of drug-impaired driving : Final report. Washington, DC: National Highway Traffic Safety Administration, Office of Research and Technology. Retrieved from http://www.nhtsa.dot.gov/people/injury/research/StateofKnwlegeDrugs/StateofKnwlegeDrugs/

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9. McKay, M. P. (2009). Pathophysiology of injury: Why gravity is your enemy. Essentials of public health biology : A guide for the study of pathophysiology (pp. 199-212). Sudbury, MA: Jones and Bartlett Publishers. Retrieved from http://www.loc.gov/catdir/toc/ecip0812/2008009984.html

10. National Center for Injury Prevention and Control.CDC injury fact book. Atlanta, GA: Centers for Disease Control and Prevention (CDC).

11. National highway traffic safety administration (NHTSA). Retrieved March 29, 2010 from http://www.nhtsa.dot.gov/

12. National Highway Traffic Safety Administration (NHTSA). (2008). Occupant protection. Traffic Safety Facts, 1-7.

13. National Research Council . Transportation Research Board, & National Research Council . Board on Children, Youth, and Families. (2007). Preventing teen motor crashes : Contributions from the behavioral and social sciences : Workshop report. Washington, D.C.: National Academies Press.

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14. O'Neill, B. Accidents: Highway safety and William Haddon, Jr. Contingencies, 14(1), 30-32.

15. National Highway Traffic Safety Administration. (1997). People saving people: On the road to a healthier future: NHTSA 2020 report. Retrieved March 29, 2010 from http://www.nhtsa.dot.gov/nhtsa/whatis/planning/2020Report/2020report.html

16. National Highway Traffic Safety Administration. (2005). Traffic Safety Facts. Retrieved January 4, 2011 from http://www.nhtsa.gov/DOT/NHTSA/NRD/Multimedia/PDFs/Human%20Factors/Reducing%20Unsafe%20behaviors/810630.pdf

17. Pfizer Inc. (2006). Automotive safety. (pp. 275). New York: Pfizer Inc. 18. Public comment - healthy people 2020 Retrieved April 14, 2010 from

http://www.healthypeople.gov/HP2020/Objectives/TopicArea.aspx?id=31&TopicArea=Injury+and+Violence+Prevention

19. Quinlan, K. P., Brewer, R. D., Siegel, P., Sleet, D. A., Mokdad, A. H., Shults, R. A., & Flowers, N. (2005). Alcohol-impaired driving among U.S. adults, 1993-2002. American Journal of Preventive Medicine, 28(4), 346-350. doi:10.1016/j.amepre.2005.01.006

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