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Journal of Trauma & Treatment
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Trends in Childhood Injury Mortality in Tianjin, China 1999-2008: Sex, Age, and Geography Disparities

Guohong Jiang1,2*, Dezheng Wang2, Wei Li1, Hui Zhang1, Zhuo Wang1 and Wenlong Zheng1
1Tianjin Centers for Disease Control and Prevention, Tianjin (300011), China
2School of Public Health, Tianjin Medical University, Tianjin (300070), China
Corresponding Author : Dr. Guohong Jiang
Director, Institute of Non- Communicable Disease Control and Prevention
Tianjin Centers for Disease Control and Prevention
Tianjin, China 300011
Received November 12, 2012; Accepted November 29, 2012; Published December 01, 2012
Citation: Jiang G, Wang D, Li W, Zhang H, Wang Z, et al. (2012) Trends in Childhood Injury Mortality in Tianjin, China 1999-2008: Sex, Age, and Geography Disparities. J Trauma Treat 1:153. doi:10.4172/2167-1222.1000153
Copyright: © 2012 Jiang G, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Objectives: To examine the differences between the injury and poisoning related death rates and leading cause among childhood by sex, age, and urban/rural areas so that the effective methods will be implemented to control the priorities of childhood injury in Tianjin.
Methods: Annual all-cause of death records for 1999-2008 provided demographic data of injury mortality including sex, age, and geography, and cause of death. Trend analyses were conducted using linear regression.
Results: From 1999-2008, the injury and poisoning related death was the first leading cause of  childhood. The injury mortality rates of children remained around 10-15/100,000 while death rates of male and rural were twofour times more than that in female and urban, also much higher than the total. The unintentional injury was up to over 75% in total. Traffic and drowning were the two leading causes in children, and motor vehicle related death proportions were increased significantly during the study period.
Conclusions: This study found important patterns, priorities and disparities in injury death by genders, age groups and urban/rural areas which can be used for identifying high risk groups and guiding prevention strategies. The effective legislation and practice action should be implemented for reducing the burden of injury, particularly, in rural area.

Childhood injury; Surveillance; Mortality; Trend; Prevention control
Injuries are the leading cause of childhood death and a significant contributor to childhood morbidity, long term disability, and healthcare costs worldwide [1,2]. Every year, there are approximate 830,000 children age under 18 died from unintentional injury globally. Traffic and drowning are up to 50% of unintentional injury deaths. Furthermore, 95% childhood injuries are happened in low and mid income countries [3]. China is a developing country with large population of childhood under 20 years old. Childhood injury has also been a serious public health problem in recent several decades in China [4]. Beyond the first few months of life, injuries become the most frequent cause of death and long term disability in children [5]. It estimated that over 40 million person-time of injury happened in children, drowning is the first leading cause of injury mortality among 1-14 childhoods [6]. Tianjin is the third largest city of China with population of 10 million; and the proportion of child under 20 is about 22% of the total. The annual injury death number was about 270 with childhood from 1999-2008; and unintentional proportion was over 75% of the total [7]. The problem is clear that most injuries among children could be prevented.
The challenge for the injury control is to take priority action in right population. Applying the public health response to solving this issue would be logical. The steps to this approach include defining the issue through data collection or surveillance; analyzing data to identify potential risk factors, enabling factors, and barriers; developing interventions based on the analysis; implementing interventions through community based programs; and using evaluation results to modify and re-evaluate original interventions [8].
This study aimed to identify differences and disparities in injury mortality between sexes, ages and geographic areas with surveillance data, the epidemiological transition of childhood injury mortality in recent 10 years, in order to identify priority issues with childhood injury, those at higher or lower risk of specific injuries and to make recommendations for prevention and control. It would be benefits to implement the effective and preventive methods to decrease the childhood injury in Tianjin, as well as develop strategies of injury prevention in other areas even in the entire China.
Subjects of this study included all children residents who had official residential permits in Tianjin died of injury and poisoning between 1999 and 2008 with confirmed medical death certificates. Cause of death classification was based on the International Classification of Diseases ICD-9 and ICD-10. ICD-9 was used to code deaths between 1999 and 2002, whilst ICD-10 was used for deaths between 2003 and 2008. Death data were collected for this study through the all-cause mortality surveillance system, maintained by the Tianjin Centers for Disease Control and Prevention (CDC), which monitors the entire residential population in Tianjin. It has been granted approval from Tianjin CDC Ethic Committee. According to municipal and local regulations, death certificates are required to be filled out and entered into the Cause of Death Reporting System by all the hospitals and community clinical centers in the Tianjin. The district or county CDCs oversee and check the daily reported deaths at the primary level, on a case-by-case basis. Nonhospital deaths are included in the Reporting System through collecting from the police station and the government mortuary, then interview the deceased relatives by community clinicians on a door to door basis. The district or county CDCs are responsible for collecting and verifying these additional medical death certificates, and then adding them into the Reporting System on a weekly basis. Tianjin CDC carries out secondary data verification, investigation of missing reports, as well as quality control, sorting and analysis of the data. It also provides technical training and support to the staff involved in the reporting process.
Each death certificate recorded 53 fields (variables). Death records with missing fields were excluded from the study. Statistical software SPSS16.0 was used for data analysis. The mortality rates and proportions of deaths from different causes of injury were analyzed. Chi-square test was used to test the association significance in mortality rates and proportions. Time trends were calculated by using linear regression. A significance level of 0.05 (two-sided) was used.
Epidemiologic trend of childhood injury mortality by gender and geography in Tianjin 1999-2008
The total 2691 cases of injury mortality were collected and analyzed in the study. Figure 1 showed that the total mortality rate of childhood injury was approximate 12 per hundred thousand while the male and the rural had the top level of injury death with two or three more times higher than that in female and urban, and much higher than the total.
The proportion of leading causes of childhood injury mortality in Tianjin
The distribution of five leading causes were addressed in figure 2, the rank was according to its proportion of all injury death in every year. The most injury death over 80% attributed to the five leading causes. The traffic was the first leading cause and the proportions increased from 34% to over 40%, even was up to 51% in year 2007. The drowning was the second cause of injury death. The third top reason was poisoning but with a decline trend followed by suicide and assault. The average proportion of unintentional injury was up to 75% of the total childhood injury death.
The transition trend of injury mortality rate of leading causes in Tianjin childhood
It is observed that a climbing trend of traffic and assault mortality while drowning and poisoning death appeared decline stream in table 1. There were significant differences with up and down tendency. The traffic death rate increased from 4.18 to 7.92 per hundred thousand. Almost two times rise of assault mortality in the study period. Comparatively, the drowning death rate had decreased a lot and even more in poisoning death rate. The mortality rate of suicide was steadily, the P value larger than 0.05.
The proportion distribution of leading causes of injury mortality by sexes and urban/rural areas
There were obvious disparities in the epidemiology distribution of five leading death of injury. Figure 3 described that the demographic tendency of top five ranks of injury mortality. The rural had the highest proportions with the five leading cause of the injury death. The second higher proportions were in male. Comparatively, the lowest proportions were in urban but the assault.
The secular trend of children injury mortality rates in different age group from 1999-2008
Table 2 addressed that secular trend of injury mortality rates in six different age groups. The mortality rate decreased from 11.72 to 7.66 per hundred thousand in the children aged 5-10 while a rise tendency was in 15 and above children population. Both up and down changing had significant statistics differences P<0.05. There was little fluctuation with mortality in the other four age groups. However, there were no significant differences observed.
Injury and poisoning is the first leading cause of death in childhood age under 20 in Tianjin from 1999-2008, and then followed by prenatal causes, congenital malformation, malignant neoplasm and diseases of the nervous system. Similarly, injury is the first death cause among the children under 20 in most high income countries, such as Canada, Finland [9]. Our analysis illuminated that injury and poisoning is the priority health issue in the children in Tianjin. This study analyzed the 2691 injury death cases and addressed the secular trend, demography distribution, priority causes so that the pertinent strategies of injury prevention would be developed in Tianjin, even more child lives could be saved, and more disables could be prevented.
The major finding of this study is that the five leading reasons of injury death were traffic, drowning, poisoning, suicide and assault which were up to over 80% of the total children injury death. The top two causes were same as the global rank of childhood injury mortality, as well as the most countries with high or low and mid income [3]. While the drowning constituted over 50% ranked the number one cause of injury death in the south and the national bank of China. Also, the obvious disparities existed between sexes, age and urban/rural areas in Tianjin. The serious burden of injury death was in male and rural childhood with 2-4 times higher mortality rates compared to the female and urban. There was a rising tendency of injury mortality in the children age over 15. Similarly, in most regions and countries, the gender gap for fatal injuries increases with age. At the global level, in children aged 5-9 years, male death rates are a third higher than female rates, a discrepancy that increases to 60% among those aged 10-14 years. However, adolescents aged 15-17 years show an adult profile, with males in that age group accounting for more than 86% of all injury deaths. It may attention that intentional self-harm was the tenth leading cause of injury death in the age group of 5-10 while it was the third or fourth leading rank in the children age over 10 to 20 in this study period. The phenomena reminded the intentional injury should be an emphasis of prevention along with the child growing up. The proportion and mortality rate of traffic were climbing significantly. It is popular that motor vehicle drivers did not seal the safety belt and people did not wear headpiece with the auto bike and bicycle which induced the traffic accidents to be the first leading cause of injury death in urban and rural areas [9-13]. The serious burden in the rural area caused by crowded traffic, poor road condition and most water area without warning sign and isolated fencing [14]. Also, the male child had higher mortality rate since the boys are more active and naughty than girls in the daily life, particularly in physical activity [15,16]. Consequently, the boys and rural children became the target population of injury prevention in Tianjin [17-19].
A majority of injury is preventable and the death rate can be reduced over 20% by effective methods. However, our study lack of data that addressed positive results from effective intervention or education in Tianjin. The reason might be insufficient awareness and actions of injury prevention in China. The government should establish the law or regulation to strengthen the safety of road and water areas. It is important to enforce the driver with seat belt, prohibit driving after drinking, require child passenger restraints, and advocate the rider with head helmet. Much more investments should go to the rural areas for the construction and maintenance of roads and streets. There was above 80% children could not swim in the coast cities in the eastern China [20]. The proportion may be higher in the inner-land of China. Swimming training should be popularized in schools, even kindergartens. Indeed, the warning sign and isolation fencing must be set alongshore of the water. The parents and teachers should educate children general knowledge about injury prevention. It is a huge challenge to create a perfect system of trauma aid and rehabilitation in Tianjin. Improving the organization and planning of trauma care services is an affordable and sustainable way to decrease injury death. Much of injury disability could be avoided with improved rehabilitation services. This would involve improving services in health care facilities and as well as access to community based rehabilitation. It is important for Tianjin to implement diversity methods to develop health promotion of injury prevention so that the burden of children injury will be decreased by improving awareness, action and legislation.

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