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Traumatic brain injury: a global challenge
Comment
Traumatic brain injury: a global challenge users who do not wear helmets are three times more likely to suffer a TBI in a crash than are those who wear helmets. The impact is greatest in LMICs, where helmet-wearing rates hover slightly above zero; child passengers rarely wear helmets and those who do often wear adult helmets, which offer inadequate protection. Mandatory helmet laws are urgently needed worldwide; where enacted, strong enforcement has yielded a 40% reduction in the risk of death.4 The Commission1 points to the changing epidemiology of TBI, highlighting an increasing incidence of falls in the 0–14 year age group and in populations aged over 65 years, particularly in high-income countries (HICs). Annually, more than 600 000 individuals worldwide die from falls, the majority from TBI.5 The US Centers for Disease Control and Prevention reported that, in 2013, nearly 80% of all TBI-related emergency department visits, hospital admissions, and deaths in adults aged 65 years and older were caused by falls.6,7 The incidence of falls in LMICs is probably dramatically under-reported, and therefore the global incidence of fall-related TBI is likely to be much higher than suggested by current estimates.1 Fall prevention is difficult to achieve because the causes and contexts of falls are multifactorial, affecting both extremes of age, and innovative prevention strategies are needed. Firearms-related events, whether self-inflicted or resulting from violence, are an important mechanism
www.thelancet.com/neurology Published online November 6, 2017 http://dx.doi.org/10.1016/S1474-4422(17)30362-9
Lancet Neurol 2017 Published Online November 6, 2017 http://dx.doi.org/10.1016/ S1474-4422(17)30362-9 See Online/The Lancet Neurology Commission http://dx.doi.org/10.1016/ S1474-4422(17)30371-X
Adam Hart-Davis/Science Photo Library
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with enormous economic consequences. The Lancet Neurology Commission1 on TBI sets priorities and provides recommendations for future clinical practice, research, and policy to reduce this overwhelming burden. The Commission comes at a time when the global incidence of TBI is rising, access to care is severely lacking in many parts of the world, and methods of monitoring and diagnosis are frequently inadequate. The increasing incidence of TBI reflects, in part, the rise in road traffic accidents and trauma-related violence in low-income and middle-income countries (LMICs), where 90% of all TBI-related deaths occur.2 However, as highlighted by the Commission authors,1 the precise global incidence of all neurotrauma-related injuries and deaths is difficult to quantify, partly because of underdeveloped data-collection systems, methodological variations in epidemiological studies, out-of-hospital deaths, and a lack of comprehensive studies of TBI incidence in defined populations. Incidences reported from a selection of countries are estimated to range between 200 and 600 injuries per 100 000 people per year,3 but epidemiological patterns of TBI worldwide will be fully understood only with improved, standardised methods of monitoring. The Commission does an excellent job of identifying the main global causes of TBI and the unmet needs of patients. Some important, practical steps should now be taken in terms of prevention and treatment to significantly reduce the burden of TBI. According to the World Health Organization (WHO), road traffic accidents are the number one cause of death among those aged 15–29 years, killing almost 1·3 million people of all ages each year; approximately half of those killed are pedestrians, cyclists, and motorcyclists.4 Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all of the top five risk factors for injury and premature death: speeding and drink-driving, and lack of helmet, seat-belt, and child-restraint use. Road traffic injuries are currently estimated to be the ninth leading cause of death globally, and are predicted to become the fifth leading cause of death by 2030.4 Among the people most at risk of sustaining a TBI are those using powered two-wheel vehicles. Vehicle
1
Comment
of TBI-related death. The mortality rate from firearmsrelated events is particularly high in the USA: in 2014, there were over 33 000 firearms-related deaths, which is similar to the total number of deaths from road traffic accidents in the USA.6 This is a massive public health issue relevant to both HICs and LMICs, with huge numbers of senseless deaths and increasing rates of suicide, which occur irrespective of socioeconomic class and geographical boundaries.7 The only measure that can clearly reduce the incidence of firearms-related TBI is restricting the availability of firearms.8 As emphasised by the Commission authors,1 crucial to TBI outcomes are prehospital emergency care at the scene of the injury, inpatient care at the health-care facility, and postacute care, which is rarely available in low-resource settings. While 85% of HICs have some type of emergency specialty for doctors, a recent WHO systematic review of emergency care in 59 LMICs reported that only 28% of facilities had attending or consultant-level physicians available full-time; 18% were staffed by specialty-trained emergency physicians, but in only 4% were these available at all times.9 Thus, general practitioners, clinical officers, and nurses, often without proper training, are often left to manage acute trauma. Furthermore, many patients with TBI require emergency neurosurgical intervention that is frequently nonexistent. In many countries in Africa, for example, the ratio of neurosurgeons to members of the population is roughly 1 to 9 million.10 The Commission highlights 12 key messages and recommendations. Although more precise details will be needed for some of these recommendations, several priorities are clearly outlined. Certainly, with TBI, an ounce of prevention is worth a pound of cure. First and foremost, all stakeholders must develop and implement best-practice strategies aimed at all aspects of prevention, including enforced measures to address the top five risk factors for injury and death from road traffic accidents in every country, along with adequate maintenance of roads and vehicles. Second, comprehensive guidelines need to be developed for optimum management of TBI within a wide variety of contexts. Currently, in low-resource settings where computed tomography (CT) or magnetic resonance imaging (MRI) is unavailable, no resource-
2
stratified algorithms exist to guide TBI management on the basis of available infrastructure, supplies, and trained personnel; these are urgently needed. Third, capacity of hospitals needs to be increased in terms of infrastructure, equipment, and supplies. Fourth, training programmes need to be scaled up to increase the size of the qualified trauma-management workforce, including certified neurosurgeons and, in some settings, mid-level providers through taskshifting. Additionally, a concerted effort is needed to reduce the 10/90 gap, whereby less than 10% of current global research funding goes towards diseases that afflict more than 90% of the global population.11 These steps are imperative if we are ever to achieve the UN Sustainable Development Goals (SDGs), particularly SDG 3.6, which aims to halve global deaths and injuries from road traffic accidents, and ensure universal health coverage by 2030. *Walter D Johnson, Dylan P Griswold World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland [email protected] We declare no competing interests. ©2017. World Health Organization. Published by Elsevier Ltd. All rights reserved. 1
Maas AIR, Menon DK, Adelson PD, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; published online Nov 6. http://dx.doi.org/10.1016/S14744422(17)30371-X. 2 WHO, UNODC, UNDP. Global status report on violence prevention 2014. http://www.who.int/violence_injury_prevention/violence/status_ report/2014/en/ (accessed Sept 12, 2017). 3 Rubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research challenges and opportunities. Nature 2015; 527: S193–97. 4 WHO. Global status report on road safety 2015. http://www.who.int/ violence_injury_prevention/road_safety_status/2015/GSRRS2015_ Summary_EN_final2.pdf?ua=1 (accessed Sept 12, 2017). 5 WHO. Media Centre fact sheet: falls. http://www.who.int/mediacentre/ factsheets/fs344/en/ (accessed Sept 12, 2017). 6 Centers for Disease Control and Prevention. FastStats all injuries: mortality data, 2014. https://www.cdc.gov/nchs/fastats/injury.htm (accessed Sept 27, 2017). 7 Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ 2017; 66: 1–16. 8 Chapman S, Alpers P, Agho K, Jones M. Australia’s 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev 2006; 12: 365–72. 9 Obermeyer Z, Abujaber S, Makar M, et al, on behalf of the Acute Care Development Consortium. Emergency care in 59 LMICs: a systematic review. Bull World Health Organ 2015; 93: 577–86G. 10 El Khamlichi A. Neurosurgery in Africa. Clin Neurosurg 2005; 52: 214–17. 11 Osrin D, Azad K, Fernandez A, et al. Ethical challenges in cluster randomized controlled trials: experiences from public health interventions in Africa and Asia. Bull World Health Organ 2009; 87: 772–79.
www.thelancet.com/neurology Published online November 6, 2017 http://dx.doi.org/10.1016/S1474-4422(17)30362-9
Traumatic brain injury: a global challenge users who do not wear helmets are three times more likely to suffer a TBI in a crash than are those who wear helmets. The impact is greatest in LMICs, where helmet-wearing rates hover slightly above zero; child passengers rarely wear helmets and those who do often wear adult helmets, which offer inadequate protection. Mandatory helmet laws are urgently needed worldwide; where enacted, strong enforcement has yielded a 40% reduction in the risk of death.4 The Commission1 points to the changing epidemiology of TBI, highlighting an increasing incidence of falls in the 0–14 year age group and in populations aged over 65 years, particularly in high-income countries (HICs). Annually, more than 600 000 individuals worldwide die from falls, the majority from TBI.5 The US Centers for Disease Control and Prevention reported that, in 2013, nearly 80% of all TBI-related emergency department visits, hospital admissions, and deaths in adults aged 65 years and older were caused by falls.6,7 The incidence of falls in LMICs is probably dramatically under-reported, and therefore the global incidence of fall-related TBI is likely to be much higher than suggested by current estimates.1 Fall prevention is difficult to achieve because the causes and contexts of falls are multifactorial, affecting both extremes of age, and innovative prevention strategies are needed. Firearms-related events, whether self-inflicted or resulting from violence, are an important mechanism
www.thelancet.com/neurology Published online November 6, 2017 http://dx.doi.org/10.1016/S1474-4422(17)30362-9
Lancet Neurol 2017 Published Online November 6, 2017 http://dx.doi.org/10.1016/ S1474-4422(17)30362-9 See Online/The Lancet Neurology Commission http://dx.doi.org/10.1016/ S1474-4422(17)30371-X
Adam Hart-Davis/Science Photo Library
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with enormous economic consequences. The Lancet Neurology Commission1 on TBI sets priorities and provides recommendations for future clinical practice, research, and policy to reduce this overwhelming burden. The Commission comes at a time when the global incidence of TBI is rising, access to care is severely lacking in many parts of the world, and methods of monitoring and diagnosis are frequently inadequate. The increasing incidence of TBI reflects, in part, the rise in road traffic accidents and trauma-related violence in low-income and middle-income countries (LMICs), where 90% of all TBI-related deaths occur.2 However, as highlighted by the Commission authors,1 the precise global incidence of all neurotrauma-related injuries and deaths is difficult to quantify, partly because of underdeveloped data-collection systems, methodological variations in epidemiological studies, out-of-hospital deaths, and a lack of comprehensive studies of TBI incidence in defined populations. Incidences reported from a selection of countries are estimated to range between 200 and 600 injuries per 100 000 people per year,3 but epidemiological patterns of TBI worldwide will be fully understood only with improved, standardised methods of monitoring. The Commission does an excellent job of identifying the main global causes of TBI and the unmet needs of patients. Some important, practical steps should now be taken in terms of prevention and treatment to significantly reduce the burden of TBI. According to the World Health Organization (WHO), road traffic accidents are the number one cause of death among those aged 15–29 years, killing almost 1·3 million people of all ages each year; approximately half of those killed are pedestrians, cyclists, and motorcyclists.4 Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all of the top five risk factors for injury and premature death: speeding and drink-driving, and lack of helmet, seat-belt, and child-restraint use. Road traffic injuries are currently estimated to be the ninth leading cause of death globally, and are predicted to become the fifth leading cause of death by 2030.4 Among the people most at risk of sustaining a TBI are those using powered two-wheel vehicles. Vehicle
1
Comment
of TBI-related death. The mortality rate from firearmsrelated events is particularly high in the USA: in 2014, there were over 33 000 firearms-related deaths, which is similar to the total number of deaths from road traffic accidents in the USA.6 This is a massive public health issue relevant to both HICs and LMICs, with huge numbers of senseless deaths and increasing rates of suicide, which occur irrespective of socioeconomic class and geographical boundaries.7 The only measure that can clearly reduce the incidence of firearms-related TBI is restricting the availability of firearms.8 As emphasised by the Commission authors,1 crucial to TBI outcomes are prehospital emergency care at the scene of the injury, inpatient care at the health-care facility, and postacute care, which is rarely available in low-resource settings. While 85% of HICs have some type of emergency specialty for doctors, a recent WHO systematic review of emergency care in 59 LMICs reported that only 28% of facilities had attending or consultant-level physicians available full-time; 18% were staffed by specialty-trained emergency physicians, but in only 4% were these available at all times.9 Thus, general practitioners, clinical officers, and nurses, often without proper training, are often left to manage acute trauma. Furthermore, many patients with TBI require emergency neurosurgical intervention that is frequently nonexistent. In many countries in Africa, for example, the ratio of neurosurgeons to members of the population is roughly 1 to 9 million.10 The Commission highlights 12 key messages and recommendations. Although more precise details will be needed for some of these recommendations, several priorities are clearly outlined. Certainly, with TBI, an ounce of prevention is worth a pound of cure. First and foremost, all stakeholders must develop and implement best-practice strategies aimed at all aspects of prevention, including enforced measures to address the top five risk factors for injury and death from road traffic accidents in every country, along with adequate maintenance of roads and vehicles. Second, comprehensive guidelines need to be developed for optimum management of TBI within a wide variety of contexts. Currently, in low-resource settings where computed tomography (CT) or magnetic resonance imaging (MRI) is unavailable, no resource-
2
stratified algorithms exist to guide TBI management on the basis of available infrastructure, supplies, and trained personnel; these are urgently needed. Third, capacity of hospitals needs to be increased in terms of infrastructure, equipment, and supplies. Fourth, training programmes need to be scaled up to increase the size of the qualified trauma-management workforce, including certified neurosurgeons and, in some settings, mid-level providers through taskshifting. Additionally, a concerted effort is needed to reduce the 10/90 gap, whereby less than 10% of current global research funding goes towards diseases that afflict more than 90% of the global population.11 These steps are imperative if we are ever to achieve the UN Sustainable Development Goals (SDGs), particularly SDG 3.6, which aims to halve global deaths and injuries from road traffic accidents, and ensure universal health coverage by 2030. *Walter D Johnson, Dylan P Griswold World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland [email protected] We declare no competing interests. ©2017. World Health Organization. Published by Elsevier Ltd. All rights reserved. 1
Maas AIR, Menon DK, Adelson PD, et al. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; published online Nov 6. http://dx.doi.org/10.1016/S14744422(17)30371-X. 2 WHO, UNODC, UNDP. Global status report on violence prevention 2014. http://www.who.int/violence_injury_prevention/violence/status_ report/2014/en/ (accessed Sept 12, 2017). 3 Rubiano AM, Carney N, Chesnut R, Puyana JC. Global neurotrauma research challenges and opportunities. Nature 2015; 527: S193–97. 4 WHO. Global status report on road safety 2015. http://www.who.int/ violence_injury_prevention/road_safety_status/2015/GSRRS2015_ Summary_EN_final2.pdf?ua=1 (accessed Sept 12, 2017). 5 WHO. Media Centre fact sheet: falls. http://www.who.int/mediacentre/ factsheets/fs344/en/ (accessed Sept 12, 2017). 6 Centers for Disease Control and Prevention. FastStats all injuries: mortality data, 2014. https://www.cdc.gov/nchs/fastats/injury.htm (accessed Sept 27, 2017). 7 Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths—United States, 2007 and 2013. MMWR Surveill Summ 2017; 66: 1–16. 8 Chapman S, Alpers P, Agho K, Jones M. Australia’s 1996 gun law reforms: faster falls in firearm deaths, firearm suicides, and a decade without mass shootings. Inj Prev 2006; 12: 365–72. 9 Obermeyer Z, Abujaber S, Makar M, et al, on behalf of the Acute Care Development Consortium. Emergency care in 59 LMICs: a systematic review. Bull World Health Organ 2015; 93: 577–86G. 10 El Khamlichi A. Neurosurgery in Africa. Clin Neurosurg 2005; 52: 214–17. 11 Osrin D, Azad K, Fernandez A, et al. Ethical challenges in cluster randomized controlled trials: experiences from public health interventions in Africa and Asia. Bull World Health Organ 2009; 87: 772–79.
www.thelancet.com/neurology Published online November 6, 2017 http://dx.doi.org/10.1016/S1474-4422(17)30362-9