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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