National Injury Mortality Surveillance System Research Articles

A qualitative exploration of forensic pathology service staff perceptions of the implementation barriers and facilitators of manual- and electronic injury mortality surveillance system methods in South Africa

BackgroundInjury mortality surveillance systems are critical to monitor changes in a population’s injury outcomes so that relevant injury prevention responses may be adopted. This is particularly the case in South Africa, where the injury burden is nearly twice the global rate. Regular evaluations of surveillance systems are pivotal to strengthening surveillance capacity, performance, and cost effectiveness. The National Injury Mortality Surveillance System (NIMSS) is an injury mortality surveillance system that is currently focused in Mpumalanga and utilises manual and electronic web-based systems for data collection. This study explored Forensic Pathology Service (FPS) staff perceptions of the implementation barriers and facilitators of manual- and electronic injury mortality surveillance system methods.MethodsA qualitative study was employed using purposive sampling. Forty-seven participants, aged 29 to 59 years comprising 31 males and 16 females were recruited across 21 FPS facilities that serve the province. The formative evaluation occurred over the November 2019 to November 2022 period. Twelve focus group discussions were thematically analysed to determine emerging themes and patterns related to the use of the system using the WHO surveillance system guidelines as a framework.ResultsThe key themes concerning the barriers and facilitators were located along WHO attributes of simplicity, acceptability, timeliness, flexibility, data quality and stability. Distinctions between the manual and e-surveillance systems were drawn upon across the attributes highlighting their experience with the system, user preference, and its contextual relevance. With Mpumalanga predominantly rural, internet connectivity was a common issue, with most participants consequently showing a preference for the manual system, even though the electronic system’s automated internal validation process was of benefit. The data quality however remained similar for both methods. With program stability and flexibility, the manual system proved more beneficial as the dataset was reported to be easily transferrable across computer devices.ConclusionObtaining FPS perceptions of their experiences with the system methodologies are pertinent for the enhancement of injury surveillance systems so to improve prospective engagements with the systems. This will facilitate timely and accurate injury mortality information which is vital to inform public policy, and injury control and prevention responses.

Child pedestrian, drowning and burn mortality in Johannesburg

The study examined the extent, demographics and risks for child pedestrian, burns and drowning mortality in Johannesburg. Information on the demographics, scene and temporal circumstances for childhood injury deaths from 2000 to 2010 was gleaned from the National Injury Mortality Surveillance System. Descriptive statistical methods were used. The study recorded 756 pedestrian (8.7/100,000), 439 drowning (5.1/100,000), and 399 burn injury deaths (4.6/100,000) among children aged 0–14 years. Male children were the main victims, with male-to-female ratios of 2.3 for drowning, 1.7 for pedestrian and 1.2 for burn mortality. The pattern of child mortality differed across age groups with older children recording higher rates for pedestrian deaths and younger children higher rates for the non-traffic deaths. Pedestrian and burn mortality especially affected black children, while drowning affected both black and white children. The time, day and month of greatest injury mortality varied by injury cause, with e.g. pedestrian mortality common in afternoons and evenings, weekends, and dispersed across the year although increasing towards year end. The study highlighted the salience of differentiating risks for childhood injuries by discrete external cause for purposes of informing prevention responses.

Risk factors for female and male homicidal strangulation in Johannesburg, South Africa.

There is a paucity of research on homicidal strangulation by gender. A sex-disaggregated and comparative research approach was used to investigate individual-level risk factors for female and male homicidal strangulation in Johannesburg, South Africa (2001 - 2010). Data were drawn from the National Injury Mortality Surveillance System. Logistic regressions were used to examine associations between each of the independent variables and homicidal strangulation in females and males relative to all other female and male homicides, respectively. The risk of fatal strangulation was high for both females and males aged ≥60 years, but markedly high only for male children and adolescents. Temporal risk for females was undifferentiated for day of the week, and the risk for males was high during weekdays. Females were more likely to be strangled in public places, and males in private locations. The study underlines the importance of disaggregating homicide by external cause and gender.

Injury-related deaths before and during the Islamic State insurgency \u2013 Baghdad, Iraq, 2010\u20132015

BackgroundFollowing a period of low intensity conflict during 2009–2012, the emergence of the Islamic State of Iraq and Levant (or Islamic State) in 2013 was associated with a resurgence of violence in Baghdad, Iraq’s capital and largest city. We evaluated trends in injury-related deaths in Baghdad before and during the Islamic State insurgency.MethodsIraqi National Injury Mortality Surveillance System prospectively collects information on fatal injuries from governorate coroner offices using standardized reporting forms. Trained coroner clerks collect information on victim demographics, intention of injury and mechanism of injury during medical examinations using reports from police and families. We analyzed data on all deaths reported by the Baghdad Forensic Institute from January 1, 2010 to December 31, 2015.ResultsThere were 17,555 injury-related deaths with documented intent and mechanism (range 2385–3347 per year): 6241 from gunfire (36%), 1381 explosions (8%), 1348 non-gunfire assaults (8%), 3435 traffic accidents (20%), and 5150 other unintentional injuries (29%). Rates of gunfire (23.45 per 100,000) and explosion (5.90 per 100,000) deaths were significantly higher in 2014 than in all other years during the review period (p < 0.001 and p = 0.03, respectively). During the same period from 2010 to 2015, traffic accident deaths declined significantly from 13.29 to 6.35 (p = 0.002), with declines observed primarily among pedestrians. Trends in the rate of non-gunfire-assault and unintentional deaths, comparing 2010 and 2015, were not significant (p = 0.12 and p = 0.63, respectively). Unintentional deaths were mostly attributed to burns (46%) and electricity-related injuries (31%). The proportion of both females and children was highest in unintentional injury deaths.ConclusionsDuring the study period, deaths from both gunfire and explosions in Baghdad peaked in 2014, corresponding with emergence of the Islamic State. Trends suggest a potential impact of insurgency-related activity on other injuries as evidenced by a decrease in the death rate from traffic accidents. The decreased traffic-related death rate could be from decreased vehicle and pedestrian activity during times of violence. Monitoring trends in injury mortality during conflict allows Iraq to identify priority injury causes to inform public health interventions.

Child mortality trends and causes of death in South Africa, 1997 - 2012, and the importance of a national burden of disease study.

The Rapid Mortality Surveillance System has reported reductions in child mortality rates in recent years in South Africa (SA). In this article, we present information about levels of mortality and causes of death from the second SA National Burden of Disease Study (SA NBD) to inform the response required to reduce child mortality further. To estimate trends in and causes of childhood mortality at national and provincial levels for the period 1997 - 2012, to highlight the importance of the SA NBD. Numbers of registered child deaths were adjusted for under-reporting. Adjustments were made for the misclassification of AIDS deaths and the proportion of ill-defined natural causes. Non-natural causes were estimated using results from the National Injury Mortality Surveillance System for 2000 and the National Injury Mortality Survey for 2009. Six neonatal conditions and 11 other causes were consolidated from the SA NBD and the Child Health Epidemiological Reference Group lists of causes of death for the analysis. The NBD cause-fractions were compared with those from Statistics South Africa, the United Nations Children's Fund (UNICEF) and the Institute for Health Metrics and Evaluation (IHME). Under-5 mortality per 1000 live births increased from 65 in 1997 to 79 in 2004 as a result of HIV/AIDS, before dropping to 40 by 2012. The neonatal mortality rate declined from 1997 to 2001, followed by small variations. The death rate from diarrhoeal diseases began to decrease in 2008 and the death rate from pneumonia from 2010. By 2012, neonatal deaths accounted for 27% of child deaths, with conditions associated with prematurity, birth asphyxia and severe infections being the main contributors. In 1997, KwaZulu-Natal, Free State, Mpumalanga and Eastern Cape provinces had the highest under-5 mortality, close to 80 per 1 000 live births. Mortality rates in North West were in the mid-range and then increased, placing this province in the highest group in the later years. The Western Cape had the lowest mortality rate, declining throughout the period apart from a slight increase in the early 2000s. The SA NBD identified the causes driving the trends, making it clear that prevention of mother-to-child transmission of HIV, the Expanded Programme on Immunisation and programmes aimed at preventing neonatal deaths need to be equitably implemented throughout the country to address persistent provincial inequalities in child deaths. The rapid reduction of childhood mortality since 2005 suggests that the 2030 Sustainable Development Goal target of 25 per 1 000 for under-5 mortality is achievable for SA. Comparison with alternative estimates highlights the need for cause-of-death data from civil registration to be adjusted using a burden-of-disease approach.

The incidence and characteristics of homicides in elderly compared with non-elderly age groups in Johannesburg, South Africa.

Even though the rate of eldercide(homicide in the age group ≥60 years) in South Africa (SA) is higher than the global rate, it receives little attention compared with homicide in younger (&lt;60 years) age groups. To: (i) establish the proportion and rates of eldercide relative to homicide in young adult and middle-aged populations, and determine whether proportions of homicide across the age groups differ by race; and (ii) determine differences in homicide victim and incident characteristics across the three age categories and establish whether these differences vary by race. This retrospective study analysed homicide data for adults (aged ≥15 years) drawn from the National Injury Mortality Surveillance System (NIMSS) for the City of Johannesburg, SA (2001 - 2010). Percentages and rates were used to describe the incidence of eldercide (age ≥60 years) relative to homicide in middle age (35 - 59 years) and youth (15 - 34 years). Eldercide and middle-age and youth homicides were compared by sex, race, weapon used, scene of injury, day of the week and time of death. For the 10-year period 2001 - 2010, NIMSS registered a total of 14678 adult homicide deaths for Johannesburg. Of these, a very small proportion (3.8%) were eldercides, 46.9% were middle-age homicides, and the majority (58.4%) were young adult homicides. The average annual eldercide rate (23.1/100 000) was also lower than the rate for the middle-aged (46.9/100 000) and young adult (58.4/100000) groups. However, the difference in rates between the age groups decreased considerably over the study period. Race-specific patterns were observed in the distribution of homicide across age groups. Compared with the circumstantial patterns for youth and middle-age homicides, eldercide involved higher proportions of females and white victims, and greater use of blunt force and strangulation. Whereas homicides in the other age groups tended to occur in public spaces and during weekends and nights, eldercides occurred mainly in a home, during the week and during daytime. The characteristics of eldercide differ from those of youth and middle-age homicides. The specificities of the circumstances suggest that interventions should take cognisance of the temporal and spatial dimensions of eldercide and go beyond the regular security and policing measures to ensure the safety of the elderly in Johannesburg.

Trends of drowning mortality in Vietnam: evidence from the national injury mortality surveillance system

ObjectiveTo describe the trends of drowning mortality in Vietnam over time and to identify socioeconomic characteristics associated with higher drowning mortality at the provincial level.MethodsWe analysed data from the Ministry...

The incidence and epidemiology of eldercide in the city of Johannesburg, South Africa

The current study describes the incidence and epidemiological characteristics of eldercide (homicides among victims aged 60 years and older) in Johannesburg for the period 2001 to 2010. A retrospective population-based study was conducted on cases drawn from the National Injury Mortality Surveillance System. A total of 557 eldercides were recorded by NIMSS for the study period with an average annual rate of 23.1 per 100 000. The average annual rate for males was 42.4 per 100 000 and 8.9 per 100 000 for females. There was little variation in the rates by race. Eldercide victims were predominantly male (77.4%), black (48.3%) or white (43.2%), and were mainly killed by firearms (44.8%) or the use of blunt force (27.8%), in a private residence (66.0%), on a week day (53.8%) and during the day (56.1%). The study also found that the characteristics of eldercide varied across males and females, and across black and white race groups. The high incidence of eldercides points to the need for interventions that give special attention to the risk configurations and circumstances associated with these violent deaths.

VIOLENT DEATHS IN SA: The 2003 National Injury Mortality Surveillance System

The latest data from the National Injury Mortality Surveillance System – the most detailed source on the ‘who, what, when, where and how’ of fatal injuries in South Africa – shows that homicide remains the most common cause of injury-related deaths. Homicide rates varied significantly between the four major urban centres covered, and firearms were a key contributor to the high homicide rates. Alcohol was confirmed as an important risk factor for murder, with the highest percentage of alcohol positive cases being recorded in Cape Town.

THE DANGERS OF DATA: Recognising the limitations of crime statistics

It is frequently noted that police crime statistics can reflect reality badly because of under-reporting and under-recording. Less frequently noted is the fact that other sources of data can be just as problematic. This article reflects on two sources of statistics on murder – the National Injury Mortality Surveillance System and the MRC’s Burden of Disease estimates – and argues that the incautious use of these data can lead to erroneous conclusions.

The epidemiology of homicidal strangulation in the City of Johannesburg, South Africa

Studies that provide accurate descriptions of the occurrence of fatal strangulation events are limited, both in South Africa and elsewhere in the world. The current study describes the extent and distribution of female and male homicidal strangulation in the City of Johannesburg for the period 2001–2010. The study is a register-based cross sectional study of homicidal strangulation that draws on data recorded by the National Injury Mortality Surveillance System. Crude, unadjusted strangulation rates, and proportions of strangulation across specific circumstances of occurrence were computed for each year and aggregated in some instances. Results indicated fatal strangulation to be the fourth leading cause of homicide in the City of Johannesburg. A total of 334 strangulation homicides were recorded, representing an average annual strangulation homicide rate of 0.90 per 100,000 population. Gender disproportionality in victimisation was reflected in the average annual rate of 1.03 per 100,000 population for females and 0.74 per 100,000 population for males. The highest rates were recorded among the elderly, and amongst coloured females and white males. Temporal and spatial descriptions indicated that victims were strangled primarily during the day, over the weekday period, and in private locations. When the scene of death was considered by race and age group, results indicated the victimisation of white females and males in private places, and the elderly in private settings. The majority of strangulation victims tested negative for alcohol. The results highlight the need for multi-level prevention strategies that target specific risk groups and situations.

The Situational Context of Adolescent Homicide Victimization in Johannesburg, South Africa.

Although studies have described the incidence and epidemiology of adolescent homicide victimization in South Africa, little is known about the situational contexts in which they occur. This study aimed to describe the victim, offender, and event characteristics of adolescent homicide and to generate a typology based on the particular types of situational contexts associated with adolescent homicide in South Africa. Data on homicides among adolescents (15-19 years) that occurred in Johannesburg (South Africa) during the period 2001-2007 were obtained from the National Injury Mortality Surveillance System (NIMSS) and police case records. Of the 195 cases available for analysis, 81% of the victims were male. Most of the offenders were male (90%), comprising of strangers (42%) and friends/acquaintances (37%). Arguments (33%) were the most common precipitating circumstances, followed by revenge (11%), robbery (11%), and acts of vigilantism/retribution for a crime (8%). Through the use of cluster analysis, the study identified three categories of adolescent homicide: (a) male victims killed by strangers during a crime-related event, (b) male victims killed by a friend/acquaintance during an argument, and (c) female victims killed by male offenders. The results can serve to inform the development of tailored and focused strategies for the prevention of adolescent homicide.

Adolescent homicide victimization in Johannesburg, South Africa: incidence and epidemiological characteristics (2001–2009)

This study describes the incidence and epidemiological characteristics of adolescent homicides (15–19 years) in Johannesburg, South Africa. A retrospective population-based study was conducted on cases drawn from the National Injury Mortality Surveillance System. A total of 590 adolescent homicides were registered for 2001–2009 corresponding to an average annual homicide rate of 23.4/100,000. The average annual rate was 39.8/100,000 for males and 7.9/100,000 for females. Black and coloured adolescents had the highest homicide rates. There was a considerable decline in the firearm homicide rates over the study period. In contrast, sharp instrument and blunt force homicides increased. Public places were the predominant scenes for male deaths, while female homicides occurred primarily in residential locations. Most male homicides took place over weekend nights. Alcohol was a prominent feature of homicides. The high homicide rates reported in this study underscore the need to develop interventions directed specifically at adolescents. Prevention efforts are required to pay particular attention to black and coloured adolescent males, and to address the availability of weapons and alcohol use among adolescents.

Alcohol consumption in adolescent homicide victims in the city of Johannesburg, South Africa.

To describe the blood alcohol concentration (BAC) of adolescent homicide victims in Johannesburg, South Africa and to identify the victim and event characteristics associated with a positive BAC at the time of death. Logistic regression of mortality data collected by the National Injury Mortality Surveillance System (NIMSS). Johannesburg, South Africa. A total of 323 adolescent (15-19 years) homicide victims for the period 2001-9 who had been tested for the presence of alcohol. Data on the victims' BAC level, demographics, weapon or method used, scene, day and time of death were drawn from NIMSS. Alcohol was present in 39.3% of the homicide victims. Of these, 88.2% had a BAC level equivalent to or in excess of the South African limit of 0.05 g/100 ml for intoxication. Multivariate logistic analysis showed that a positive BAC in homicide victims was associated significantly with the victim's sex [male: odds ratio (OR) = 2.127; 95% confidence interval (CI) = 1.012-4.471], victim's age (18-19 years: OR = 2.364; CI = 1.343-4.163); weapon used (sharp instruments: OR = 2.972; CI = 1.708-5.171); and time of death (weekend: OR = 3.149; CI = 1.842-5.383; night-time: OR = 2.175; CI = 1.243-3.804). Excessive alcohol consumption is associated with a substantial proportion of adolescent homicides in Johannesburg, South Africa, and is more prevalent among male and older adolescent victims and in victims killed with sharp instruments over the weekends and during the evenings.

Unwanted pregnancies in Gauteng and Mpumalanga provinces, South Africa: examining mortality data on dumped aborted fetuses and babies.

Across the world, millions of women unintentionally become pregnant and decide to terminate the pregnancy. Despite progressive abortion laws in South Africa (SA), evidence suggests that many women of all ages still resort to unsafe terminations outside legal, designated facilities. Media reports alert the public to an increase in the illegal dumping of fetuses and abandoned babies, suggesting an increase in unsafe termination practices as well as concealed births. To examine mortality data to identify trends in the dumping of aborted fetuses and abandoned babies in SA. This study utilised data from the National Injury Mortality Surveillance System in two provinces, namely Gauteng and Mpumalanga. A total sample of mortality data was used to analyse trends associated with this phenomenon from 2009 to 2011. Descriptive, exploratory statistics were used and included the calculation of crude population incidence rates for abortions and abandoned babies as well as figures (n) and percentages (%) for each category under investigation. An increase in the rate of discovery of non-viable fetuses was noted for both provinces over the 3-year period, while there was a significant decrease in the discovery of deceased abandoned babies in Gauteng only. The illegal dumping of fetuses and babies is a very real public health concern in both Gauteng and Mpumalanga. Information is insufficient for adequate surveillance, and improved data collection systems should be prioritised.

Childhood psychosocial development and fatal injuries in Gauteng, South Africa.

In South Africa, injuries are the third leading cause of death and disability. Children are especially susceptible to unintentional injuries, especially pedestrian injuries, burns and drowning. Injury risk is informed by children's exposure to adverse environmental circumstances, and individual capacities dependent on developmental maturity. Boys are at greater risk than girls. This study investigates the incidence of fatal childhood injuries as well as sex differences across psychosocial development stages. Data on fatal injuries in Gauteng, South Africa's most populous province, were obtained from the National Injury Mortality Surveillance System. The analysis drew on Erikson's psychosocial theory of development which was used to create meaningful age groups. Age-specific population data from the 2011 Census were used to calculate rates, and significant differences were determined through the generation of risk ratios and confidence intervals. There were 5404 fatal injuries among children in Gauteng from 2008 to 2011. The average age of victims was 8.9 years, and the majority male (65.6%). In infancy, the mortality rates for all injuries and non-traffic unintentional injuries were significantly higher than for the other age groups. Burns were the most common cause of death in infancy and early childhood. Pedestrian injuries accounted for a third of mortality in preschool and school age, and homicide rates were significantly higher in adolescence than in the other developmental stages. For injuries in general, boys had significantly higher mortality rates than girls in all age groups except preschool. The only instance where the mortality rate for girls was significantly higher than for boys was for adolescent ingestion poisoning suicides. The exposure to environmental and social risks is differentially moderated with maturing age and levels of autonomy. The sex of the child also informs risk. The nature of these risks is important when considering child injury prevention strategies.

A comparison of urban–rural injury mortality rates across two South African provinces, 2007

This study explored urban–rural variations in the magnitude and patterns of fatal injuries in South Africa. The National Injury Mortality Surveillance System was utilised to select South African mortality cases for the 2007 period and a cross-sectional methodology was employed in order to comparatively analyse injury mortality rates in the urban province of Gauteng and the rural province of Mpumalanga. The results reveal several differences in urban–rural injury trends across the two South African provinces. Overall, homicide and unintentional (non-transport) injury death rates were significantly higher in the urban province (40.28/100,000 versus 28.48/100,000; (RR = 1.41 [1.32–1.51]) and 18.30/100,000 versus 13.19/100,000; (RR = 1.39 [1.25–1.54]), respectively), whilst transport-related injury mortality rates were significantly higher in the rural province (66.57/100,000 versus 45.83/100,000; (RR = 0.69 [0.66–0.71])). Such results could be attributed to economical, environmental, and infrastructural differences between urban–rural locations and suggest that injury control strategies could be better targeted to the needs of specific geographic populations in South Africa.

The magnitude and contextual circumstances of childhood (0–14 years) pedestrian fatalities in South African cities

BackgroundRoad traffic injuries continue to manifest as a contributor to the global burden of disease, and road deaths in poor countries are predicted to rise by 80% by 2020. South...

Unintentional drowning in urban South Africa: a retrospective investigation, 2001–2005

Drowning is a major public health concern in low- and middle-income countries. In South Africa there is sound information and an emerging knowledge base for drowning prevention. However, there remains a scarcity of analyses of drowning in the country. The purpose of this analysis was to quantify the magnitude and describe occurrence of unintentional drowning deaths in five major South African cities, recorded between 2001 and 2005 by the National Injury Mortality Surveillance System. Drowning in South African cities occurred at rates of between 1.4 and 2.7/100,000 population. The majority of drowning occurred among males, while the highest rates were observed among 0–4 year olds. Most drowning deaths occurred during recreational periods, over weekends and in the afternoon. Of adult drowning victims, 41.5% were alcohol-positive at the time of death. This study is based on one of only two known systematic sources of drowning mortality in Africa. It provides an indication of drowning rates in South African cities with young children and males at considerably more risk. The most likely locations for drowning varied from city to city. Among adult victims, especially men, alcohol is an important risk factor.

Fatal violence among children under 15 years in four cities of South Africa, 2001–2005

Homicide rates for South African children were estimated at double the global average in 2000. This article presents a secondary data analysis of the National Injury Mortality Surveillance System (NIMSS), with full coverage in four major metropolitan cities. Child homicide rates for 2001–2005 were calculated within the 0–4, 5–9 and 10–14 year age groups. The homicide rates were similar to the global pattern, with higher rates for boys, and among children aged 0–4 years than for older children. Poisson regression, accounting for city level clustering, was used to investigate age, sex and period effects in the homicide rate. The model indicated that the gender difference was more marked in the 10–14 year age groups (RR = 2.17; 95% CI 1.97–2.38) than in the 5–9 year (RR = 1.43; 95% CI 1.27–1.62) with the 0–4 year age group in-between (RR = 1.80; 95% CI 1.55–2.10). These data confirm previous observations that fatal violence among children is a public health concern, but, given the high rates of homicide among South African adults and other competing public health problems, it is difficult to motivate for action to address the issue of violence against children. Nonetheless, there are sufficient indications that efforts to reduce childhood violence are urgently needed.