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Neurotrauma in Africa Olive C. Kobusingye, M.Med(Surg) MPH PAANS Conference 6 June 2016 Global Neurotrauma • Silent epidemic • Incidence is increasing • Injury to brain is more likely to result in death and disability • Burden varies by regions of the world – Worse TBI outcomes in LMICs compared with HICs • Affects 10 million people annually Langlois JA t al 2005, Hyder AA et al 2007, International Brain Injury Association 2016 Global Neurotrauma • In the United States, TBI results in: – One million hospital emergency visits per year – 50,000 deaths per year • In Europe, TBI accounts for – One million hospital admissions per year Langlois JA t al 2005, Hyder AA et al 2007, International Brain Injury Association 2016 Global Neurotrauma Estimates of global incidence of TBI Roozenbeek B et al 2013 Global Neurotrauma Global Neurotrauma • Males more than females – Observed in studies from USA, China, Pakistan, India and several African countries • Tri-model age groups – Under 5 years Falls – 5 – 24 years RTIs and violence – Over 75 years Falls • Associated risk factors – Alcohol use Bruns J et al 2003, Zhao YD et al 2001, Roozenbeek B et al 2013, International Brain Injury Association 2016 Global Neurotrauma • Mechanism – – – – Road traffic injuries (60%) Falls (20-30%) Violence (10%) Work place and occupational injuries (10%) • Examples – Europe • RTIs accounts for 50% of all TBI • Falls among > 65 years and older • RTI under 65 years – Pakistan • RTIs and falls • Urban more than rural Gururaj et al 1997, Gabella B et al 1997, Zhao YD et al 2001 Singer MS et al 2004, International brain Injury Association 2016 Global Neurotrauma • TBI trends – RTIs are currently the leading cause of TBI and is projected to be the 3rd leading cause of premature death amongst all age categories by the year 2020 – Increasing violence on Sub-Saharan Africa and the Middle East • Issues – – – – Minor TBI data is not captured TBI in the presence of multiple injuries is under reported Lack of injury surveillance systems or registries Lack of uniform definition on TBI Murray CJ et al 1996, Hyder AA et al 2007, WHO , Roozenbeek B et al 2013 Global Neurotrauma • Reduction in TBI incidence in HICs due to – – – – Implementation of injury prevention measures Safety legislation Public education initiatives Improvements and wider availability of emergency medical systems and regional trauma centers – Improvements in neuro-critical care – Implementation of evidence-based treatment guidelines for severe TBI Murray CJ et al 1996, Kelly DF et al 2001, Hyder AA et al 2007, WHO Neurotrauma in Africa • Use of “head injury” instead of “TBI” lack of definition • Lack of data – Mild TBI because it is underreported – Severe TBI because patients die before reaching hospital – Studies either focus on adults or children so no overall TBI incidence rates • Available data is from: – Urban secondary and tertiary care centers Hyder AA et al 2007 Neurotrauma in Africa • Males more than females • Age groups – Children Falls – Productive age groups Violence and RTIs • Mechanism – RTIs – Violence – Fall Hyder AA et al 2007 EXAMPLES Example Study 1 Epidemiology of Neurotrauma in Ife-Ijesha Zone of Nigeria • Objective – Describe epidemiology of neurotrauma in the region so as to highlight essential factors for trauma prevention programs • Methods – Cross sectional study – Information was obtained directly from patients or patients’ relations/eyewitness when the former could not give information as in unconscious patients – Variables: patients’ demographic data, etiology of injury, duration of injury, site, and cause of accident among others Adeolu AA et al 2013 Example Study 1 Epidemiology of Neurotrauma in Ife-Ijesha Zone of Nigeria • Results – Patient demographics • Males (83%) • 20 – 39 years (53.0%) • Mean age 32.8 ± 15.12 years – Mechanisms • RTI (81%), falls (11.2%) – Severity • Head injuries (n= 116, 81.1%) • Of these 42 were mild, 34 moderate, and 40 severe head injuries Adeolu AA et al 2013 Example Study 2 Analysis of Prospective Trauma Registry Data in Francophone Africa: A Pilot Study from Cameroon • Objective – To create a prospective trauma registry to expand the data elements collected on injury at a busy tertiary center in Yaounde´ Cameroon • Methods – Injury defined based on ICD codes and WHO surveillance guidelines – Inclusion criteria: any patient presenting to the ED with an injury was included, regardless of hospital admission status or injury severity in order to maximize capture of injuries – Variables: injury context, presentation, care, cost, and disposition from the emergency department (ED) Juillard CJ et al 2014 Example Study 2 Analysis of Prospective Trauma Registry Data in Francophone Africa: A Pilot Study from Cameroon • Results – Patient demographics • Males (73%) • Mean age 30 years – Trauma mechanism • RTI (59%), fall (7%) – Outcome • • • • • Discharged home (69%) Operating room (18%) ICU (1%) Mortality 0.7% Estimated injury severity score (eISS) was <9 in 60 %, 9–24 in 35 %, and >25 in 2% – Predictors of mortality: ≥ 9 and Glasgow Coma Score ≤12. Juillard CJ et al 2014 TBI implications • Deficits associated with TBI, including – impaired attention, – poor executive function, – depression, impulsivity, – poor decision-making and aggressive behaviour, have particularly striking social and economic consequences for individuals, families and the development of societies as a whole Hofman P et al, 2005; Langlois J et al 2006 Research Priorities, Opportunities and Challenges • TBI is a growing burden in many LMICs including those of Sub-Saharan Africa • Lack of data on incidence and long-term sequel • Lack of standardized data collection mechanism • LMICS are less prepared to manage TBI – Need to have standardized protocols for resuscitation and TBI management – Lack of best practices – Registry based quality improvement – Post injury rehabilitation and prevention of disability Runyan DK et al 2008, Hyder AA et al 2007, Kesinger MR et al 2014 Traumatic Brain Injury Across the Lifespan in Uganda Background-LMICs • In LMICs, those with TBI are generally young adult pedestrians, cyclists or motorcyclists. • In regions where the prevalence of armed violence is higher (Central America, the Middle East and Central Africa), assault and gunshot injuries are important causes of TBI. Roozembeek B, 2013 Background - Regional • Compared to incidence on a global level, TBI rates in sub-Saharan Africa (SSA) are much higher • Incidence rates of intracranial short-term Global SSA Per 100,000 Population injuries due to Per 100,000 Population Road traffic injuries 106 156 Violence 43 144 Source: Hyder et al., 2007 Background - Regional • Incidence rates of intracranial long-term injuries due to Global SSA Per 100,000 Population Per 100,000 Population War 3.8 20.7 Violence 2.2 7.2 Other unintentional injuries 7.2 13.4 Source: Hyder et al., 2007 Uganda – Background information • Basic information – Low income country located in East Africa – Population: 34.9 million (2014) (35.8 projection 2015) – GNI per capita: $550 (March 2015) Source: UBOS 2015, 2015; WB World Dev Ind Database, 2015 Goal The overall goal of the Traumatic Brain Injury across the Lifespan in Uganda project is to define the health and economic burden of traumatic brain injuries across the lifespan in Uganda. Aims • Specific Aim 1: Define core variables and Internet platforms for a data registry focused on traumatic brain injuries in Uganda • Specific Aim 2: Pilot-test an Internet-based traumatic brain injury registry at Mulago Hospital, Makerere University for a year • Specific Aim 3: Support a core group of clinicians with TBI research skills and data analysis capacity at Mulago Hospital, Makerere University in Uganda • Specific Aim 4: Develop and publish a TBI management protocol for Mulago Hospital Aims • Specific Aim 1: Define core variables and Internet platforms for a data registry focused on traumatic brain injuries in Uganda • Specific Aim 2: Pilot-test an Internet-based traumatic brain injury registry at Mulago Hospital, Makerere University for a year • Specific Aim 3: Support a core group of clinicians with TBI research skills and data analysis capacity at Mulago Hospital, Makerere University in Uganda • Specific Aim 4: Develop and publish a TBI management protocol for Mulago Hospital Multipronged Approach NINDS Potential Core Variables Previous Registries Literature review Literature Review • Identify databases – PubMed/Medline, Embase, Scopus, Cochrane Reviews for scientific literature, System for Information on Grey Literature, Global Health Ovid • Identify search words – Search terms were generated using key words and mesh headings for: • Brain injury AND Africa • Brain injury AND registry AND low-and-middle-income countries Literature Review PubMed, Embase, Scopus, Global Health Ovid, Cochrane Database of Systematic Review, System for Information on Grey Literature (N=1,301) Excluded Studies remaining after screening title or abstract (N=142) Excluded Not about TBI (N=13) Not about LMIC (N=5) TBI but no variables (N=18) Not about TBI (N= 911) Not about LMIC (N= 101) TBI but no variables (N=113) Abstract only (N=34) Studies remaining after de-duplication(N=71) Studies remaining after review of full text (N=35) 29 Results: Top 5 Study Location Country Number of Studies 1. Nigeria 7 2. South Africa 5 3. Tunisia 4 4. Tanzania 3 5. Uganda 2 Results: Percentage of TBI Patients • • Variable reporting of TBI therefore wide range (1% - 94.7%) Very few looked at TBI in the context of injury and trauma Countries Percentage of TBI patients Tunisia 14.4% of adult hospital admissions (Bahloul 2004) 16.2% of all pediatric ICU patients were due to TBI (Bahloul 2009) Tanzania 21.9% - 34.1% cases with CT scan had TBI (Maier 2014) 1% - 21.4% of all admissions were due to head injuries (Winkler 2010, Chalya 2011) Malawi 19% trauma cases coming to ED had head injury (Qureshi 2013) Nigeria 13% of head injury cases among children (Udoh 2013) 23% - 94.7% cases on head injuries among neurotrauma patients (Adeleye 2009, Adeolu 2013, Idowu 2014) Cameroon 30% injury cases coming to ED had head injury (Juillard 2014) Uganda Cumulative incidence of admissions is 89 per 100,000 population (Tran 2015) Results: Demographic Information Countries Demographic information TBI patients Tunisia Males (89.9%), 15 – 29 years (45%) (Bahloul 2004) Boys (73.4%), 6-10 years (38%) (Bahloul 2009) Tanzania Higher prevalence in rural areas compared to urban areas (34.2% vs 21.9%); males more than females (Maier 2014) Males (60.8%), mean age 26.84 years Chalya 2011) Males (81%), Mean age 30 ± 17.0 years (Winkler 2010) Malawi Males (79.6%), 15 – 44 years (86.4%) (Qureshi 2013) Nigeria Males (51.1%), 7-10 years age group (26.7%) (Udoh 2013) Males (85.3%), (Adeleye 2009) Uganda Males ( 81.7%) 15 – 29 years (42.5%) (Tran 2015) Results: Mechanism of Injury Countries Mechanism of injury in TBI patients Tunisia RTIs (85.6%), Assault (2.7%) (Bahloul 2004) RTIs (75.7%), Assault (0.4%) (Bahloul 2009) Tanzania RTIs (46.3% in urban setting), Crime related (31.5% in rural setting) (Maier 2014) RTIs (49.2%), assault (30.8%), fall (16.2%) (Chalya 2011) Assault (59%), RTI (24%), Falls (11%) (Winkler 2010) Malawi RTIs among those who died (88.2%), Assault among those who survived (55.7%) (Qureshi 2013) Nigeria RTIs (68%), falls (15%), Violence (7%) (Udoh 2013) RTIs (75%) , falls (11.2%) assault (9.8%) (Adeleye 2009) Cameroon RTs (30.2%) , fall (16.4%) Uganda RTIs (79%) (Tran 2015) (Juillard 2014) Results: mortality, severity Countries Mechanism of injury in TBI patients Tunisia Age >40 years, simplified acute physiology score >40, GCS <7, intracranial lesion, cerebral herniation were associated with poor prognosis (Bahloul 2004) PRISM score >20 and bilateral mydriasis on admission associated with poor prognosis; 24.3% deaths (Bahloul 2009) Tanzania Mortality associated with extreme of age, presence of pre-morbid condition, associated injuries, admission GCS <9, systolic BP <90 mmHg, injury severity score ≥ 16, longer duration of loss of consciousness, need for ICU admission and space occupying lesion on CT scan (Chalya 2011) Mortality was 2% (Winkler 2010) Malawi GCS and heart rates changes strogly correlated with mortality; four fold incresae in odds of mortality in moderate versus mild head injury based on GCS (Qureshi 2013) Nigeria Mortality 8.66%; GCS ranged from 4-8 (Udoh 2013) 19.58% deaths (Adeleye 2009) Uganda In-hospital morality of 25.8% (Tran 2015) Example Study 1 Distribution and characteristics of severe traumatic brain injury at Mulago National Referral Hospital in Uganda • Objective – To identify associations between outcomes and patient characteristics presenting to the Mulago National Referral Hospital • Methods – Single center study – Retrospective chart review – Inclusion criteria: Confirmed diagnosis of TBI with an initial GCS between 3 and 8 – Exclusion criteria: Patients with general head injury – Variables: patient demographics, discharge status, initial and greatest GCS score, date of trauma, date of admission, date of treatments, mechanism of injury, pupillary reactivity, medications, neurosurgical procedure (if applicable), and pathologies detected by a diagnostic computed tomography (CT) scan Tran TM et al 2015 Example Study 1 (cont’d) Distribution and characteristics of severe traumatic brain injury at Mulago National Referral Hospital in Uganda • Results – Cumulative incidence of severe TBI admissions is 89 per 100,000 – 25.8% in hospital mortality – Patient demographics • Males (81.7%) • Young adults between 15 – 29 years (42.5%) – Mechanisms • RTIs (79%), Assault (13.3%), Fall (1.7%) – Median hospitalization length was 7 days (IQR 5-14.5 days) – Predictors of outcomes • Initial GCS, change in GCS during hospital stay, presence of hematoma Tran TM et al 2015 Example Study 2 Severe head injury among children: Prognostic factors and outcome • Objective – To determine predictive factors of mortality among children after traumatic brain injury • Methods – – – – Single center Retrospective study Inclusion criteria: Children (age <15 years) with severe TBI (GCS ≤8) All children were admitted directly from the scene of the accident, within 6 hours of injury. They were all examined and scored according to the GCS on arrival, and underwent CT scan as soon as feasible – Variables: Basic demographic, clinical, biological and radiological data were recorded on admission and during intensive care unit stay Bahloul M et al 2009 Example Study 2 Severe head injury among children: Prognostic factors and outcome • Results – Severe TBI represented 16.2% of all pediatric ICU admission – Patient demographics • Males (73.4%) • Mean age 7.54 ± 3.8 years (Age range 0.3 – 15 years) • 6 – 10 years (38%) – Mechanisms • RTIs (75.7%) – Outcome • • • • • • Mortality 24.3% Mean GlasgowComa Scale score was 6 ± 1.5, Mean Injury Severity Score (ISS) was 28.2 ± 6.9 Mean Paediatric Trauma Score (PTS) was 3.7 ± 2.1 Mean Paediatric Risk of Mortality (PRISM) was 14.3 ± 8.5 Factors associated with a poor prognosis were PRISM > 20 and bilateral mydriasis on admission Bahloul M et al 2009 Discussion Points • Given resources, prevention strategies? – Primary? – Secondary? – Tertiary? • Intervention studies? – Clinical Trials- In hospital – Standardized protocols Questions