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Head injuries in Vietnamese refugees in Hong Kong
Head injuries in Vietnamese refugees in Hong Kong
Keith Y.C. Goh FRCS W. Pak FRCS Joyce T'ang* FRACGP Wai S. Poon FRACS NeurosurgicaI Unit, Prince of Wales Hospital, The Chinese Universityof Hong Kong, and Medical Coordinator, Vietnamese Camps *
The Vietnamese refugee camps in H o n g Kong represent a unique social situation, where as many as 55 000 people have at one time lived. The Neurosurgical Division of the Prince of Wales Hospital receives all head injured patients from two of the largest camps for management. A retrospective analysis was undertaken of all Vietnamese patients hospitalised with head injuries over a four year period from January 1990 to December 1993. Our results showed that there was a higher incidence of head injuries as compared to epidemiological studies in the USA (Marshall, 1981) and Britain (Jennett, 1981), with the highest risk group being children aged 12 years and below. The majority of head injuries were minor, with the most c o m m o n cause being a fall from bed. With these findings, appropriate preventive measures were advised and steps were taken to reduce the incidence of head injuries amongst the Vietnamese children. Journal of Clinical Neuroscience 1996 3 (1) :26-28
© Pearson Professional 1996
Keywords: Refugees, Mechanism, Children, Prevention
Introduction The Vietnamese asylum seekers numbered 55 000 during the peak years of 1990 to 1992. At present, 25 000 remain housed in 5 detention centres in various parts of Hong Kong. They live in over crowded conditions, the camps comprising a collection of large zinc roofed huts surrounded by fences of barbed wire. Entire families sometimes have to share two double or even triple decker bunk beds. Medical care is provided by the H o n g Kong governm e n t and various volunteer groups, such as the British Red Cross and Medecins Sans Frontieres. From 2 of the largest camps in the New Territories, namely the High Island Detention Centre and Whitehead Detention Centre which together house 75% of the refugee population, all head injured patients are referred to the Prince of Wales Hospital, which is the nearest major hospital in the area with neurosurgical facilities. These patients are then screened by the Accident and Emergency D e p a r t m e n t doctors and referred to the Neurosurgical Unit for further assessment.
Patients and m e t h o d s All Vietnamese patients admitted to the Neurosurgical wards of the Prince of Wales Hospital with head injuries over a four year period, from January 1990 to December 1993, were retrospectively reviewed. We were interested in identifying the following : 1) incidence of head injury
26
in the defined population; 2) high risk groups; 3) mechanism of injury; 4) possible avoidable factors. It should be m e n t i o n e d that the Vietnamese population is not static but constantly in flux because of the frequent new arrivals of refugees and departures of those returning to Vietnam u n d e r the voluntary repatriation scheme. The population figures we quoted were compiled by the offices of the United Nations High Commissioner for Refugees.
Results Between 1990 and 1993, 1206 head injured Vietnamese patients were admitted, an average of 301.5 patients per year (Table 1). They comprised 8.4% of the total n u m b e r of admissions for head injuries in 1990, 17.7% in 1991, 12% in 1992 and 16.3% in 1993 (Table 1). The ages ranged from 2 months to 42 years, with a mean age of 21 years. O f this number, a total of 601 cases were children aged 12 years and below, and they comprised approximately 49.8 % of all cases per year. On average, 70% of these children were u n d e r 5 years old (Table 1), with the youngest being only 2 months old. The mean paediatric age was 6 years with a median age of 5 years. Between 8 and 10% of these children per year had radiological evidence of a skull fracture either of the vault or
J. Clin. Neuroscience Volume 3 Number 1 January 1996
Head injuries in Vietnamese
Table 1
Clinical studies
Table 3
Number of admissions for head injuries
1990
1991
1992
1993
Total No. of Vietnamese adults + children
308
366
325
224
% (Vietnamese) of total no. of admissions for head injuries
8.4%
17.7%
12%
16.3%
No. of Vietnamese children (12 years or less)
172
155
169
105
% (children 12 years or less) of total no. of Vietnamese admission
55.8% 45%
52.9%
45.8%
No. of Vietnamese children (5 years or less)
117
107
125
66
% (children 5 years or less) of total no. of Vietnamese children
68%
69%
74%
63%
base (Table 2), but very few required any surgical intervention. Only four children in this four year study period u n d e r w e n t major surgery. Two craniotomies for extradural h a e m a t o m a s , one craniectomy for an intracerebral contusion, and one elevation of a depressed fracture were p e r f o r m e d . Two patients required b u r r holes for intracranial pressure m o n i t o r i n g of diffuse h e a d injury. All survived and were discharged h o m e within a month. O f the paediatric patients per year 90 to 92% had m i n o r head injuries (Glasgow C o m a Scores of 13-15 on admission), with the r e m a i n d e r being moderate head injuries (Glasgow C o m a Scores of 9 - 12 - - Table 3). T h e r e were no severe head injuries during the four year period. T h e most c o m m o n m e c h a n i s m of injury was a fall f r o m a b u n k bed, occurring in 429 cases in total over 4 years, or between 57 and 75% of paediatric cases p e r year (Table 2). Between 60 and 78% of these cases (average 72%) were children aged 5 years a n d below (Table 2). O f the adults, 97 - 98% of the cases were m i n o r h e a d injuries, (Table 3), with skull fractures occurring in Table 2
Incidence of skull fractures and mechanism of injury 1990
1991
1992
1993
No. of skull fractures (children)
15 (8%)
13 (8%)
17 (10%)
9 (8.6%)
No. of skull fractures (adult)
4 (2.9%)
5 (2.3%) 4 (2.5%)
5 (4.2%)
No. of children who fall from bed
126(73%)116(75%)127(75%) 60(57%)
No. of children 5 years 87 (74%) 82 (76%) 75 (60%) or lesswho fall from bed
52 (78%)
No. of adults who fall from bed
57(49%)
54(40%) 107(51%)71 (46%)
between 2.3 and 4.2% of cases only (Table 2). Eight out of 612 adult patients required surgical intervention. Two craniotomies for extradural h a e m a t o m a s , two craniotomies for acute subdural h a e m a t o m a s , two craniectomies for intracerebral contusions, and two elevations for depressed skull fractures were p e r f o r m e d . T h e r e were no mortalities.
Severity of head injury in paediatric and adult cases
1990
1991
1992
1993
Paediatric Minor Moderate Severe
92% 8% 0
92% 8% 0
90% 10% 0
91.4% 8.6% 0
Adult Minor Moderate Severe
97.8% 1.3% 0.9%
99.3% 0.3% 0.4%
99.1% 0 0.9%
98.7% 0.6% 0.07%
T h e most c o m m o n m e c h a n i s m of injury in the adult g r o u p was also a fall f r o m bed, similar to the paediatric group, with between 40 a n d 51% (average 46.5%) of patients injured this way (Table 2). T h e r e m a i n d e r were either assaulted or fell on slippery floors. T h e incidence of h e a d injuries requiring hospitalisation per population size (admission rate p e r population) was, on average, 924 per 100 000 p e r year (Table 4).
Discussion T h e o c c u r r e n c e of h e a d injuries is so frequent that it has b e e n referred to as the silent e p i d e m i c ) Although a m a j o r world health problem, it is often u n d e r rated in terms of economic, logistic, social and emotional costs. In the USA for instance, t r a u m a is the third leading cause Table 4
Incidence of head injuries per population size 1990
1991
1992
1993
Total Vietnamese population 33 000
40 000
34 000
25 000
No. of head injured patients 308 admitted
366
325
224
Incidence ( per 100 000 )
915
955
896
933
Average: 924 per 100 000
of death overall, and the leading cause of death in persons younger than 44 years of age. 2 It has b e e n estimated that h e a d injuries cost society 83.5 billion U.S. dollars per year? In H o n g Kong, the Vietnamese refugees, who at one time n u m b e r e d almost 60 000, present a significant financial b u r d e n to the taxpayer, not only in terms of their m a i n t e n a n c e in the camps, b u t also where health costs are concerned. As revealed in this study, Vietnamese refugees account for between 8.4 and 17.7% (average 13.6%) of all e m e r g e n c y admissions for h e a d injury in our hospital (Table 1). This a m o u n t s to significant hospitalisation costs, especially when b e d occupancy, radiological investigations, medication, surgery and nursing care are considered. This is even m o r e i m p o r t a n t when the majority of h e a d injuries fall into the ' m i n o r ' h e a d injury group, m a n y of w h o m can be safely m a n a g e d without hospitalisation. By studying the epidemiology of this particular population group, the high risk patient groups and preventable factors can
J. Clin. N e u r o s c i e n c e
V o l u m e 3 N u m b e r 1 January 1996
27
Clinical studies be identified, thus allowing the problem to be tackled at its roots. In this way, hospital admissions, with all their accompanying costs, can be reduced, which is an important consideration in these times of escalating health expenses. T h e most significant finding in this study was the high incidence of h e a d injuries amongst children, especially those aged 5 years and below. As c o m p a r e d with other epidemiological studies where the p e a k incidence g r o u p was young adults aged 15 - 24 years, 4 the largest n u m b e r of h e a d injured patients comprised children aged 12 years and below, approximately 50% of all cases. O f these, 70% were 5 years and below. In this high risk g r o u p of patients, the most frequent m e c h a n i s m of injury was a fall f r o m the b u n k bed, occurring in approximately 70% of cases. T h e most likely reason for this was the lack of safety features a r o u n d the b u n k beds for prevention of falls. T h e r e were no railings or safety netting a r o u n d the p e r i m e t e r of the bunks. In addition, inadequate parental supervision and the lack of awareness of the dangers these children faced by being in high areas, were contributary factors. Although c a m p rules prevented the allocation of higher bunks to families with young children, the children still climbed up to play. In 40 - 50% of adults, falling f r o m the b u n k beds was also a frequent cause of injury. When the n u m b e r of h e a d injured patients admitted to hospital per population size was analysed, we f o u n d that the incidence in this population g r o u p was higher than in the US (San Diego) 4 and UK 5 studies. T h e r e were 366 h e a d injured Vietnamese admitted in 1991, in a population of approximately 40 000, or 915 per 100 000. T h e average incidence over the four year period of study was 924 per 100 000. Marshall in San Diego4reported an incidence of 294/100 000 in 1978 whilst J e n n e t t in the United Kingdom 5 r e p o r t e d an incidence of 583/100 000 in England, Wales and Scotland in 1974. Undoubtedly, the criteria for hospital admission in these studies varied to some extent. Nevertheless, our study showed a high incidence of Vietnamese refugees seeking medical t r e a t m e n t for mainly m i n o r h e a d injuries, and being hospitalised. It was interesting to note that one reason for the frequent admissions was the difficulty in c o m m u n i c a t i n g with these patients who spoke only Vietnamese. At least 90% of all attendees at the e m e r g e n c y d e p a r t m e n t were hospitalised for overnight observation. Whilst hospital admissions provide the best data for c o m p a r i n g incidences in different geographical areas, attendance rates at the casualty d e p a r t m e n t s provide the most reliable guide to incidences in the community. 5 In this population group, where the two were almost the same, (90% admission rate), the overall incidence of head injury in the Viemamese refugee c o m m u n i t y was actually less than that quoted in other epidemiological studies. An extensive study of Scottish hospitals for 1974 showed an annual attendance rate at the e m e r g e n c y d e p a r t m e n t of 1775 per 100 000 with the p r o p o r t i o n admitted to hospital at about 20%, 6 c o m p a r e d to this study where the hospital admission incidence was 924 per 100 000, representing 90% of e m e r g e n c y d e p a r t m e n t attendees.
28
Head injuries in Vietnamese This was not altogether u n e x p e c t e d because unlike n o r m a l societies, the refugee c a m p situation could be likened to a very controlled domestic environment, without the exposure of the c o m m u n i t y to m o t o r vehicle accidents or firearm and criminal violence. Studies on the incidence of h e a d injuries in the domestic situation are sadly lacking.
Recommendations Prevention is the most i m p o r t a n t aspect of child care if the sequelae of h e a d t r a u m a is to be avoided .7 Based on o u r findings, we were able to r e c o m m e n d to the responsible authorities a p p r o p r i a t e measures to reduce the incidence of h e a d injuries. Firstly, there was the n e e d to construct safety nets or railings a r o u n d the p e r i m e t e r of the b u n k beds to prevent falls. Secondly, as children were identified as the high risk group, parental education and awareness of the n e e d to continually supervise young children, was of major importance. As such, a health educational campaign was launched in the camps once these findings were m a d e known. Hospital admissions have since b e e n reduced by a b o u t 50%.
Conclusion T h e i m p o r t a n c e of any epidemiological study lies in its ability not only to d e t e r m i n e the incidence of a particular p r o b l e m in a defined population, but also in its identification of high risk groups and avoidable or preventive factors. This study illustrates these points clearly, a n d has contributed significantly to catering to the needs of the Vietnamese refugee population. Received2 December 1994 Accepted for publication 31 January 1995
Correspondence and offprint requests : Dr Wai S. Poon, Senior Lecturer and Chief, Neurosurgical Unit, Prince of Wales Hospital, The Chinese Universityof Hong Kong, Shatin, N. T., Hong Kong. Tel. No. : (852) 6362624 Fax : (852) 6370979 References 1. Cooper PR. Epidemiology of head injury. Head Injury. Baltimore : Williams & Wilkins ; 1982 : 1-14 2. Baker SP, O'Neill B, Karpf RS. The injury fact book. Boston : DC Health & Co ; 1980 3. Trunkey D. Neural trauma from the point of view of the general surgeon. In : Dacey RGJr, Winn HR, Rimel RW, Jane JA, eds. Trauma of the central nervous system. New York : Raven Press ; 1985 : 9-10 4. Klauber, Barrett-Connor E, Marshall LF : The epidemiology of head injury, AmJ Epidemiol, 1981 ; 113 : 500-509. 5. Jennett B, MacMillan R : Epidemiology of Head Injury, Brit MedJ, 1981 ; 282 : 101-104. 6. SLrang I, MacMillan R, Jennett B : Head injuries in accident and emergency departments at Scottish hospitals, Injury, 1978; 10 : 154- 159. 7. James HE. The Management of Head Injury in Children. Neurosurgery Quarterly. New York, Raven Press 1993, 3(4) : 272- 282.
J. Clin. Neuroscience Volume 3 Number 1 January 1996
Keith Y.C. Goh FRCS W. Pak FRCS Joyce T'ang* FRACGP Wai S. Poon FRACS NeurosurgicaI Unit, Prince of Wales Hospital, The Chinese Universityof Hong Kong, and Medical Coordinator, Vietnamese Camps *
The Vietnamese refugee camps in H o n g Kong represent a unique social situation, where as many as 55 000 people have at one time lived. The Neurosurgical Division of the Prince of Wales Hospital receives all head injured patients from two of the largest camps for management. A retrospective analysis was undertaken of all Vietnamese patients hospitalised with head injuries over a four year period from January 1990 to December 1993. Our results showed that there was a higher incidence of head injuries as compared to epidemiological studies in the USA (Marshall, 1981) and Britain (Jennett, 1981), with the highest risk group being children aged 12 years and below. The majority of head injuries were minor, with the most c o m m o n cause being a fall from bed. With these findings, appropriate preventive measures were advised and steps were taken to reduce the incidence of head injuries amongst the Vietnamese children. Journal of Clinical Neuroscience 1996 3 (1) :26-28
© Pearson Professional 1996
Keywords: Refugees, Mechanism, Children, Prevention
Introduction The Vietnamese asylum seekers numbered 55 000 during the peak years of 1990 to 1992. At present, 25 000 remain housed in 5 detention centres in various parts of Hong Kong. They live in over crowded conditions, the camps comprising a collection of large zinc roofed huts surrounded by fences of barbed wire. Entire families sometimes have to share two double or even triple decker bunk beds. Medical care is provided by the H o n g Kong governm e n t and various volunteer groups, such as the British Red Cross and Medecins Sans Frontieres. From 2 of the largest camps in the New Territories, namely the High Island Detention Centre and Whitehead Detention Centre which together house 75% of the refugee population, all head injured patients are referred to the Prince of Wales Hospital, which is the nearest major hospital in the area with neurosurgical facilities. These patients are then screened by the Accident and Emergency D e p a r t m e n t doctors and referred to the Neurosurgical Unit for further assessment.
Patients and m e t h o d s All Vietnamese patients admitted to the Neurosurgical wards of the Prince of Wales Hospital with head injuries over a four year period, from January 1990 to December 1993, were retrospectively reviewed. We were interested in identifying the following : 1) incidence of head injury
26
in the defined population; 2) high risk groups; 3) mechanism of injury; 4) possible avoidable factors. It should be m e n t i o n e d that the Vietnamese population is not static but constantly in flux because of the frequent new arrivals of refugees and departures of those returning to Vietnam u n d e r the voluntary repatriation scheme. The population figures we quoted were compiled by the offices of the United Nations High Commissioner for Refugees.
Results Between 1990 and 1993, 1206 head injured Vietnamese patients were admitted, an average of 301.5 patients per year (Table 1). They comprised 8.4% of the total n u m b e r of admissions for head injuries in 1990, 17.7% in 1991, 12% in 1992 and 16.3% in 1993 (Table 1). The ages ranged from 2 months to 42 years, with a mean age of 21 years. O f this number, a total of 601 cases were children aged 12 years and below, and they comprised approximately 49.8 % of all cases per year. On average, 70% of these children were u n d e r 5 years old (Table 1), with the youngest being only 2 months old. The mean paediatric age was 6 years with a median age of 5 years. Between 8 and 10% of these children per year had radiological evidence of a skull fracture either of the vault or
J. Clin. Neuroscience Volume 3 Number 1 January 1996
Head injuries in Vietnamese
Table 1
Clinical studies
Table 3
Number of admissions for head injuries
1990
1991
1992
1993
Total No. of Vietnamese adults + children
308
366
325
224
% (Vietnamese) of total no. of admissions for head injuries
8.4%
17.7%
12%
16.3%
No. of Vietnamese children (12 years or less)
172
155
169
105
% (children 12 years or less) of total no. of Vietnamese admission
55.8% 45%
52.9%
45.8%
No. of Vietnamese children (5 years or less)
117
107
125
66
% (children 5 years or less) of total no. of Vietnamese children
68%
69%
74%
63%
base (Table 2), but very few required any surgical intervention. Only four children in this four year study period u n d e r w e n t major surgery. Two craniotomies for extradural h a e m a t o m a s , one craniectomy for an intracerebral contusion, and one elevation of a depressed fracture were p e r f o r m e d . Two patients required b u r r holes for intracranial pressure m o n i t o r i n g of diffuse h e a d injury. All survived and were discharged h o m e within a month. O f the paediatric patients per year 90 to 92% had m i n o r head injuries (Glasgow C o m a Scores of 13-15 on admission), with the r e m a i n d e r being moderate head injuries (Glasgow C o m a Scores of 9 - 12 - - Table 3). T h e r e were no severe head injuries during the four year period. T h e most c o m m o n m e c h a n i s m of injury was a fall f r o m a b u n k bed, occurring in 429 cases in total over 4 years, or between 57 and 75% of paediatric cases p e r year (Table 2). Between 60 and 78% of these cases (average 72%) were children aged 5 years a n d below (Table 2). O f the adults, 97 - 98% of the cases were m i n o r h e a d injuries, (Table 3), with skull fractures occurring in Table 2
Incidence of skull fractures and mechanism of injury 1990
1991
1992
1993
No. of skull fractures (children)
15 (8%)
13 (8%)
17 (10%)
9 (8.6%)
No. of skull fractures (adult)
4 (2.9%)
5 (2.3%) 4 (2.5%)
5 (4.2%)
No. of children who fall from bed
126(73%)116(75%)127(75%) 60(57%)
No. of children 5 years 87 (74%) 82 (76%) 75 (60%) or lesswho fall from bed
52 (78%)
No. of adults who fall from bed
57(49%)
54(40%) 107(51%)71 (46%)
between 2.3 and 4.2% of cases only (Table 2). Eight out of 612 adult patients required surgical intervention. Two craniotomies for extradural h a e m a t o m a s , two craniotomies for acute subdural h a e m a t o m a s , two craniectomies for intracerebral contusions, and two elevations for depressed skull fractures were p e r f o r m e d . T h e r e were no mortalities.
Severity of head injury in paediatric and adult cases
1990
1991
1992
1993
Paediatric Minor Moderate Severe
92% 8% 0
92% 8% 0
90% 10% 0
91.4% 8.6% 0
Adult Minor Moderate Severe
97.8% 1.3% 0.9%
99.3% 0.3% 0.4%
99.1% 0 0.9%
98.7% 0.6% 0.07%
T h e most c o m m o n m e c h a n i s m of injury in the adult g r o u p was also a fall f r o m bed, similar to the paediatric group, with between 40 a n d 51% (average 46.5%) of patients injured this way (Table 2). T h e r e m a i n d e r were either assaulted or fell on slippery floors. T h e incidence of h e a d injuries requiring hospitalisation per population size (admission rate p e r population) was, on average, 924 per 100 000 p e r year (Table 4).
Discussion T h e o c c u r r e n c e of h e a d injuries is so frequent that it has b e e n referred to as the silent e p i d e m i c ) Although a m a j o r world health problem, it is often u n d e r rated in terms of economic, logistic, social and emotional costs. In the USA for instance, t r a u m a is the third leading cause Table 4
Incidence of head injuries per population size 1990
1991
1992
1993
Total Vietnamese population 33 000
40 000
34 000
25 000
No. of head injured patients 308 admitted
366
325
224
Incidence ( per 100 000 )
915
955
896
933
Average: 924 per 100 000
of death overall, and the leading cause of death in persons younger than 44 years of age. 2 It has b e e n estimated that h e a d injuries cost society 83.5 billion U.S. dollars per year? In H o n g Kong, the Vietnamese refugees, who at one time n u m b e r e d almost 60 000, present a significant financial b u r d e n to the taxpayer, not only in terms of their m a i n t e n a n c e in the camps, b u t also where health costs are concerned. As revealed in this study, Vietnamese refugees account for between 8.4 and 17.7% (average 13.6%) of all e m e r g e n c y admissions for h e a d injury in our hospital (Table 1). This a m o u n t s to significant hospitalisation costs, especially when b e d occupancy, radiological investigations, medication, surgery and nursing care are considered. This is even m o r e i m p o r t a n t when the majority of h e a d injuries fall into the ' m i n o r ' h e a d injury group, m a n y of w h o m can be safely m a n a g e d without hospitalisation. By studying the epidemiology of this particular population group, the high risk patient groups and preventable factors can
J. Clin. N e u r o s c i e n c e
V o l u m e 3 N u m b e r 1 January 1996
27
Clinical studies be identified, thus allowing the problem to be tackled at its roots. In this way, hospital admissions, with all their accompanying costs, can be reduced, which is an important consideration in these times of escalating health expenses. T h e most significant finding in this study was the high incidence of h e a d injuries amongst children, especially those aged 5 years and below. As c o m p a r e d with other epidemiological studies where the p e a k incidence g r o u p was young adults aged 15 - 24 years, 4 the largest n u m b e r of h e a d injured patients comprised children aged 12 years and below, approximately 50% of all cases. O f these, 70% were 5 years and below. In this high risk g r o u p of patients, the most frequent m e c h a n i s m of injury was a fall f r o m the b u n k bed, occurring in approximately 70% of cases. T h e most likely reason for this was the lack of safety features a r o u n d the b u n k beds for prevention of falls. T h e r e were no railings or safety netting a r o u n d the p e r i m e t e r of the bunks. In addition, inadequate parental supervision and the lack of awareness of the dangers these children faced by being in high areas, were contributary factors. Although c a m p rules prevented the allocation of higher bunks to families with young children, the children still climbed up to play. In 40 - 50% of adults, falling f r o m the b u n k beds was also a frequent cause of injury. When the n u m b e r of h e a d injured patients admitted to hospital per population size was analysed, we f o u n d that the incidence in this population g r o u p was higher than in the US (San Diego) 4 and UK 5 studies. T h e r e were 366 h e a d injured Vietnamese admitted in 1991, in a population of approximately 40 000, or 915 per 100 000. T h e average incidence over the four year period of study was 924 per 100 000. Marshall in San Diego4reported an incidence of 294/100 000 in 1978 whilst J e n n e t t in the United Kingdom 5 r e p o r t e d an incidence of 583/100 000 in England, Wales and Scotland in 1974. Undoubtedly, the criteria for hospital admission in these studies varied to some extent. Nevertheless, our study showed a high incidence of Vietnamese refugees seeking medical t r e a t m e n t for mainly m i n o r h e a d injuries, and being hospitalised. It was interesting to note that one reason for the frequent admissions was the difficulty in c o m m u n i c a t i n g with these patients who spoke only Vietnamese. At least 90% of all attendees at the e m e r g e n c y d e p a r t m e n t were hospitalised for overnight observation. Whilst hospital admissions provide the best data for c o m p a r i n g incidences in different geographical areas, attendance rates at the casualty d e p a r t m e n t s provide the most reliable guide to incidences in the community. 5 In this population group, where the two were almost the same, (90% admission rate), the overall incidence of head injury in the Viemamese refugee c o m m u n i t y was actually less than that quoted in other epidemiological studies. An extensive study of Scottish hospitals for 1974 showed an annual attendance rate at the e m e r g e n c y d e p a r t m e n t of 1775 per 100 000 with the p r o p o r t i o n admitted to hospital at about 20%, 6 c o m p a r e d to this study where the hospital admission incidence was 924 per 100 000, representing 90% of e m e r g e n c y d e p a r t m e n t attendees.
28
Head injuries in Vietnamese This was not altogether u n e x p e c t e d because unlike n o r m a l societies, the refugee c a m p situation could be likened to a very controlled domestic environment, without the exposure of the c o m m u n i t y to m o t o r vehicle accidents or firearm and criminal violence. Studies on the incidence of h e a d injuries in the domestic situation are sadly lacking.
Recommendations Prevention is the most i m p o r t a n t aspect of child care if the sequelae of h e a d t r a u m a is to be avoided .7 Based on o u r findings, we were able to r e c o m m e n d to the responsible authorities a p p r o p r i a t e measures to reduce the incidence of h e a d injuries. Firstly, there was the n e e d to construct safety nets or railings a r o u n d the p e r i m e t e r of the b u n k beds to prevent falls. Secondly, as children were identified as the high risk group, parental education and awareness of the n e e d to continually supervise young children, was of major importance. As such, a health educational campaign was launched in the camps once these findings were m a d e known. Hospital admissions have since b e e n reduced by a b o u t 50%.
Conclusion T h e i m p o r t a n c e of any epidemiological study lies in its ability not only to d e t e r m i n e the incidence of a particular p r o b l e m in a defined population, but also in its identification of high risk groups and avoidable or preventive factors. This study illustrates these points clearly, a n d has contributed significantly to catering to the needs of the Vietnamese refugee population. Received2 December 1994 Accepted for publication 31 January 1995
Correspondence and offprint requests : Dr Wai S. Poon, Senior Lecturer and Chief, Neurosurgical Unit, Prince of Wales Hospital, The Chinese Universityof Hong Kong, Shatin, N. T., Hong Kong. Tel. No. : (852) 6362624 Fax : (852) 6370979 References 1. Cooper PR. Epidemiology of head injury. Head Injury. Baltimore : Williams & Wilkins ; 1982 : 1-14 2. Baker SP, O'Neill B, Karpf RS. The injury fact book. Boston : DC Health & Co ; 1980 3. Trunkey D. Neural trauma from the point of view of the general surgeon. In : Dacey RGJr, Winn HR, Rimel RW, Jane JA, eds. Trauma of the central nervous system. New York : Raven Press ; 1985 : 9-10 4. Klauber, Barrett-Connor E, Marshall LF : The epidemiology of head injury, AmJ Epidemiol, 1981 ; 113 : 500-509. 5. Jennett B, MacMillan R : Epidemiology of Head Injury, Brit MedJ, 1981 ; 282 : 101-104. 6. SLrang I, MacMillan R, Jennett B : Head injuries in accident and emergency departments at Scottish hospitals, Injury, 1978; 10 : 154- 159. 7. James HE. The Management of Head Injury in Children. Neurosurgery Quarterly. New York, Raven Press 1993, 3(4) : 272- 282.
J. Clin. Neuroscience Volume 3 Number 1 January 1996