An epidemiological report on the burden and trend of injuries in the Philippines from 2011 to 2018

Imee T. Macaranas, Kin Israel R. Notarte, Abbygail Therese M. Ver, Adriel M. Pastrana,Franchesca J. Chua, Derick Erl P. Sumalapao

1Faculty of Medicine and Surgery, University of Santo Tomas, Espa?a, Manila, Philippines

2Department of Epidemiology and Biostatistics, College of Public Health, University of the Philippines Manila, Manila, Philippines

ABSTRACT Objective: To describe the epidemiological distribution of injury cases in the Philippines from 2011 to 2018.Methods: A retrospective review of records from the Online National Electronic Injury Surveillance System involving trauma cases was done, and data were collated, tabulated, and statistically analyzed.Results: A total of 668 179 injury cases were recorded, and 68.99% of these cases involved males. Vulnerable individuals belonged to the group aged 15-29 years (34.01%). The most populated regions in the country, the National Capital Region(14.90%) and Region ⅣA (13.96%), incurred the highest number of recorded cases. Traffic crash (32.67%) was reported to be the major cause of injury; and open wounds (37.56%) and abrasion(26.23%) were found to be the most common types of injury.Conclusions: The burden of injury remains high in the Philippines due to the lack of resources and inadequate healthcare. The findings of the present study on the distribution of injury cases provide useful information for taking appropriate preventive measures, developing effective safety guidelines, allocating limited resources in an appropriate manner, and implementing necessary public health programs.

KEYWORDS: Traffic crash; Trauma; Surveillance system

1. Introduction

Injuries are a serious cause of mortality and morbidity worldwide, accounting for over five million deaths per year or approximately 16 000 deaths per day[1]. According to the World Health Organization (WHO)[2], the burden of injuries worldwide is disproportionately concentrated in low- and middle-income countries. This is evident in 2004 wherein over 91% of unintentional injury deaths and 94% of disability-adjusted life-years were lost in low- and middle-income countries[3]. Clearly, the highest injury burden often occurs in those countries with the weakest evidence to guide intervention strategies, the fewest resources, and the least developed infrastructure to effect change[4].

The Philippines is among the vulnerable countries in Asia in terms of the burden of injury, considering that over 26 million Filipinos lived in poverty in 2018[5]. The challenges people face are vulnerability to natural disasters, weak governance, inadequate health services, and lack of natural resources[4]. Despite the high burden of injury in the Philippines, there has been a severe undercounting of deaths from all causes, including non-fatal health outcomes. In fact, the vital statistics registration systems reflect only 10.2% of all deaths in the region[6]. Although studies suggest that injury deaths in the Philippines are well attributed to vehicular collisions and intentional causes, available literature has only characterized injuries in the Philippines from 1960 to 1995[6] and from 2013 to 2014[7]. Other than these reports, no data are available describing the burden of injury in the Philippines in the most recent decade. Given this gap in knowledge, the present study investigated the epidemiological distribution of injury cases in the Philippines from 2011 to 2018 using the data from Online National Electronic Injury Surveillance System (ONEISS) quarterly published by the Department of Health (DOH), Philippines. Furthermore, this study described the distribution of injury cases by sex, age, geographical region, and type and cause of injury per year.

2. Materials and methods

2.1. Ethics approval

This study was registered with the Research Grant Administration Office, University of the Philippines Manila (RGAO-2020-0302) and did not contain any studies involving human participants nor animals performed by the authors.

2.2. Data collection and classification

A retrospective study describing trauma cases in the Philippines from 2011 to 2018 was conducted. Epidemiological information such as age, sex, geographical regions, causes and types of injuries sustained was retrieved from the data from ONEISS published by the DOH, Philippines. Data from these quarterly factsheets were collated and tabulated in spreadsheets using Microsoft Excel software.Frequency of cases across different age ranges, sex groups, and geographic regions was computed. Injury cases were also described according to the reported gender-age specific proportions and the reported missing data were classified as unknown.

Moreover, causes of injuries were classified into 10 major categories including: traffic crash, mauling, fall, bites and stings,sharp objects, burns, gunshots, chemicals, hanging and strangulation,and drowning. Unknown causes and other causes were classified under ‘others’ (i.e.sexual assault and abuse, firecracker, exposure to forces of nature). Internal causes of trauma injuries were not reported in the ONEISS and were not covered in the study. Injuries were classified into 8 major types: open wound, abrasion, contusion,fracture, avulsion, concussion, burn, and traumatic amputation.Unknown injuries sustained other than the aforementioned types were classified as ‘others’ (i.e.dislocation, sprain, strain, swelling,deformity). It is to be noted that more than one type of injury may be accounted for one trauma case.

2.3. Statistical analysis

Data were analysed by using STATA?12.0. Descriptive data were expressed as frequency and percentage. Difference in proportions of cases involving two categories was examined usingz-test while homogeneity of the proportions of these cases across three or more categories was assessed using χ2-test. The significant level of this study was set at α＜0.05.

3. Results

In 2011 to 2018, the ONEISS program of the DOH reported a total of 668 179 injury cases in the Philippines (Table 1). The spike in cases reported in 2012 could be ascribed to more hospitals reporting the injury cases compared to 2011 and 2013. Another spike in data was also observed in 2016 with the double reported cases compared to 2015. Males accounted for 461 002 (68.99%)of the injuries which significantly differed with the proportion of cases involving females (P＜0.01). Males had an annual average of 57 625 injury cases while females had an average of 25 897(P=0.0 41). Over the years, the frequency of injury cases in the Philippines remained higher among males with an average proportion of 0.70±0.01 when compared with females (χ2=290.37,P=0.000, Table 1). Males consistently accounted for the majority of the registered injuries from ages ＜1 year-old to 60-64 yearsold, but in ages ≥65, there was a higher incidence among females.Moreover, the age group of 20-24 years (12.57%) showed the highest number of injury cases from 2011 to 2018 with an annual average of 10 502 cases. Likewise, the age groups 15-19 years(10.74%) and 25-29 years (10.70%) had relatively higher incidence of injury cases. Thus, it was observed that the frequency of injury cases over the years was associated with age (χ2=4 000,P=0.000).

For the geographical distribution of injury cases, the majority of these cases (14.90%) were recorded in the National Capital Region (NCR) in the Philippines from 2011 to 2018 (Table 2). In addition to NCR, Regions ⅣA (13.96%), Ⅺ (9.10%), Ⅵ (8.16%),and Ⅲ (7.82%) had high proportions of injury cases among the geographical regions in the country (geographical regions in the Philippines are numbered in Roman numeral). The results showed that the distribution of the injury cases over the past years was associated with geographical regions (χ2=160 000,P=0.000).

Of the reported injury cases in the Philippines from 2011 to 2018,the majority were subjected to open wounds (37.56%), while abrasion and contusion accounted for 26.23% and 13.34% of the types of these injuries, respectively (Table 3). It was observed that the distribution of the injury cases was associated with the types of injuries (χ2=4 300,P=0.000). Multiple injuries could explain the difference between the total number of reported cases and the total number of reported types and causes of injuries. For the causes of injuries (Table 4), the reported cases from 2011 to 2018 were primarily due to traffic crash (32.67%). Three other major causes of injuries were fall (14.75%), contact with sharp objects (14.43%),and mauling (14.39%). Thus, there was an association between the distribution of these injury cases in the Philippines and the causes of injury over the years (χ2=19 000,P=0.000).

Table 1. Distribution of injury cases in the Philippines by sex and age from 2011 to 2018.

Table 2. Distribution of injury cases in the geographical regions of the Philippines from 2011 to 2018.

Table 3. Distribution of injury cases in terms of types of injuries in the Philippines from 2011 to 2018.

Table 4. Distribution of reported injuries by cause in the Philippines from 2011 to 2018.

4. Discussion

The study examined the eight-year (2011-2018) epidemiologic distribution of injury cases in the Philippines using data from ONEISS. More than five million people die each year because of injuries worldwide, which account for ～9% of total deaths,and these injuries resulted in higher mortality than malaria,tuberculosis, and HIV/AIDS combined[2]. These deaths have been increasing over the years in low- and middle-income countries.Although not all injuries lead to death, millions of people around the world suffer injuries which sometimes lead to disability.Therefore, an epidemiologic study on the distribution of injury cases is of great importance. In the present study, a total of 668 179 injury cases were reported and various parameters (sex, age, cause,region, and type of injury) were used to find their association with the distribution of the reported cases.

Of the 668 179 cases, 461 002 were males (68.99%) while 207 177 were females (31.01%). Males in the Philippines accounted for the majority of injury cases, which is consistent with the study of Riveraet al.[7] based on the 2013-2014 surveillance data. The study also reported the prevalence of younger patients, there was no clear definition for the involved population. In the present study, the age groups that were found to be highly vulnerable were the younger ones: 15-19 (10.74%), 20-24 (12.57%), and 25-29(10.70%). Furthermore, a similar gender distribution is observed in other literature, but there are varying accounts in age distribution.In African countries, cases were higher among male patients. In Nigeria, the majority of the patients were aged between 20-29,similar to this study’s findings[8]. In Senegal, 50% of the cases were 20 years old and below, and 28% aged 21-40 years old[9].The researcher also noted that as age increases, the number of patients declines. Similar findings were observed in a study from Iran[10] where most number of trauma cases were identified in the age group 15-24 with males greatly surpassing the females (3:1).Another study from Sichuan, China investigated the distribution in rural and urban areas from 2006 to 2015[11]. Higher proportions of male patients were observed both in rural and urban surveillance.Injury rates were recorded to be higher for ages 0-4 years old and 20-29 years old among urban residents. Rural residents had a slightly older population of 35-40 years old.

In Canada, males also have higher mortality compared to females[12]. Prevalence based on age population varies depending on the cause. Mortality due to unintended injuries is higher among older patients. In Brazil, a more extensive review was conducted spanning 18 years (1998-2015) for intensive care hospitalization[13]. While males were found to have a higher hospitalization rate, an increased hospitalization rate of female patients was apparent in the recent years. The researchers attributed this to increased exposure to external causes. Majority of the age group reported belonged to 60 and older followed by 15-29 years old. Although this does not necessarily indicate that older patients are more frequently injured, severity or prognosis is worse for these age groups. This paper covered all injury cases, not limited to those that led to mortality and intensive care, which could be the main cause of disparity from the age distribution of the last two papers. Unlike in Brazil, no change has been observed with gender distribution over the past years. The higher prevalence of the 15-29 age group for this study may indicate higher exposure to external causes, particularly traffic crash.

Traffic crash has been the top cause (32.67%) of reported injury in the Philippines from 2011 to 2018, and this has been consistent throughout the years. For both 2004[14] and 2014[2], road traffic crash has been the number one cause of death among all injuries.By the year 2030, WHO projected that the road traffic crash will be the seventh leading cause of death surpassing HIV/AIDS and diarrheal diseases. Fall (14.75%), the second major cause of injury in the Philippines, is also predicted to be one of the leading causes of death by 2030. The other major causes of injury in the country include contact with sharp objects (14.43%) and mauling(14.39%). In a 2004-2007 study involving a Philippine university hospital, stab wounds (32.9%) were found to be the number one cause of injury, followed by vehicular crash (28.6%)[15]. In a study by Oesternet al.[16], there has been an increasing number of road traffic accidents recorded over the years in India, a lower middle-income country. A teaching hospital in Ghana, Africa also reported that road traffic accidents (39.1%) were the major cause of injuries[17]. Iran, an upper middle-income country, also reported that accidents and fall were among the major causes of trauma[10].In contrast to the first few accounts, Germany, a high-income country, reported a decline in road traffic accidents[16]. This disparity in injury cases is supported by the WHO data wherein injury-related mortality is increasing in low- and middle-income countries. This can be attributed to differences in infrastructure system, traffic laws, and healthcare system among countries[16].In the Philippines, the country is divided into 17 regions with Region ⅣA as the most populated region, followed by the NCR.For the past eight years, NCR has recorded the greatest number of injury cases, followed by Region ⅣA. Throughout the years,NCR has also been one of the top five regions to have the greatest number of cases. For the most recent three years, Region ⅣA recorded the greatest number of cases followed by NCR. Given the epidemiological data in the Philippines, traffic crash could be considered as the most common cause of injury in populated regions of the country. Although no study has yet been conducted on the association of incidence of traffic crash with population distribution in populated regions. In a study published in 2018,NCR also recorded the highest number of deaths due to injuries, but it should also be noted that it does not have the highest death rate,because of high population in the region[7]. Underreporting among the other regions can also be a factor since not even 20% of all the hospitals in the country report their data to the DOH. Moreover, as noted by the WHO, not all injuries require hospitalization; and not all injuries lead to death. However, the severity of an injury can be influenced by the type of injury sustained by a patient. The most common type of injury experienced by patients in the Philippines from 2011 to 2018 is the open wound (37.56%), which was also the number one cause of death of trauma patients in 2014[7].Abrasion, contusion, and fracture are the other major types of injuries suffered by Filipino patients. For the past eight years, there had been 668 179 recorded cases of injury in the country; but the total number of cases based on the distribution of types of injuries was 792 986. This means that over a hundred thousand of patients experienced multiple injuries. Multiple injuries can be more difficult to treat and can sometimes lead to multiple organ failure or sepsis in severe condition. According to the data reported in the Philippines, sepsis has been found to cause more deaths as time progresses[18]. In fact, sepsis has been reported to be the leading cause of death among trauma patients in 2011[15]. In Europe,severity of injury is the major cause of early death among patients.The type of injury sustained by patients is a reliable indicator of their survival[18].

Although the present study provided a comprehensive report on the number of injury cases from 2011 to 2018, one limitation of the study is the limited number of hospitals reporting to ONEISS. Data collection by ONEISS was done quarterly. However, the hospitals and reports per quarter vary which could eventually affect the analysis of data. Such is the case in some quarters of 2013 and 2014 where no data was reported from Regions Ⅴ, Ⅷ, and ⅩⅢ. Moreover,as the years progress, there has been more classifications for the cause of injuries. For the sake of uniformity in processing the data,the new classifications in the later years have been classified under the category ‘others’. This does not greatly impact the evaluation of data available and shows that a more detailed collection of data was done or some causes caught more attention in the past few years.

5. Conclusion

The burden of injury remains high in the Philippines due to the lack of resources and inadequate healthcare, with males and the younger age groups (15-29 years old) facing the highest risk. The NCR and Region ⅣA recorded the most number of cases, both of which are also the most populated regions. Traffic accidents remain the most prevalent cause of injury and open wounds as the most common injury throughout the period of study. The findings on the distribution of injury cases in the Philippine can provide useful information for taking appropriate preventive measures, developing effective safety guidelines, allocating limited resources in an appropriate manner, and implementing necessary public health programs. Recommendations from policy makers on appropriate plans to address the causes of injuries can be formulated. Intervention measures to mitigate the identified main causes of injuries particularly among geographical regions with a high number of cases can be provided.

Conflict of interest statement

The authors report no conflict of interest.

Authors’ contributions

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.