Section A:

Injury and Violence in India

A1. Introduction
With a population of more than a billion, India is
facing many challenges to meet health needs of its
people. The triple epidemics of Communicable and
infectious diseases, Noncommunicable diseases
(NCDs) and injuries pose many challenges for health
systems and to our policy makers. Various policies
and programs by successive governments at both
central and state level have had some success in
changing some vital indicators. Despite this
noticeable change, the consequences of globalisation,
urbanization and motorization have emerged as
major challenges amidst existing social inequities
and wide disparities in health systems between and
within states. Absence of efficient health systems as
revealed by the inadequacies related to planning,
financing, human resources, infrastructure, supply
systems, governance, information, and monitoring
are some well known problems of our health care
systems (Patel et al, 2011).
India has witnessed rapid and unprecedented changes
in urbanization, motorization, industrialization and
migration along with changing life styles, habits
and value systems of people. The ongoing
epidemiological, demographic, economic and social
transition has resulted in the emergence of injury
and violence as a major public health problem in
the 21st century. India has been making small and

significant progress in NCD prevention and control

programs along with expansion of trauma care
services. The augmentation of facilities and services,
though marked in urban areas and deficient in rural
areas, has been receiving attention of policy makers
and administrators. In recent years, increasing
participation of the private health sector comprising
of specialty hospitals, corporate hospitals, teaching
hospitals, nursing homes and other family
practitioners along with the public health sector has
been noticeable. Simultaneously, increasing costs of
health care, greater burden on individuals and
families, and the limited and adverse impact of
various policies and problems has also been a matter
of great concern.
Recent data indicates that NCDs and injuries
contribute for nearly three fourths of deaths and
disabilities in India (Patel et al, 2011). Even though
recent years have witnessed some concerns from
policy makers on the growing incidence and burden
of injuries, the problem has not received major
attention in terms of a unified approach to address
the problem. While some of the recent programs
are making systematic efforts to address the growing
burden of NCDs, efforts for injury prevention and
control are totally lacking as they are not even
recognized as public health problems in India.

A2. Scientific basis of injuries

Traditionally and for too long, injuries have been
considered as accidents. The term accident simply
means that it just happens and nothing much can be
done about it. Consequently and for a long time, the
fatalistic attitudes in our communities have persisted
and continue even today. Injuries have been referred
to as - acts of God, sins of past life, price one has to
pay, and several such understandings. Due to this
prevailing thinking by politicians, people and even
professionals, the field of injury prevention and
control has not taken deeper grounding in India.

mechanisms at different time periods and at various

levels (Haddon, 1968). This concept that originated
in 1970s brought in a new understanding of injury
mechanisms by identifying the contributory factors
among people, vehicles or products, and the
environment (Table 1). Within each of these three
domains, factors that operate before, during or after
the crash that influence the possible outcomes can be
delineated. Identifying and developing mechanisms
to address each of these for different injuries has helped
in reducing RTIs and other injuries.

The epidemiological triad of agent, host and

environment has been in practice for several
years that evolved from the understanding of
communicable disease control. Haddon Matrix
is a very scientific method to understand injury

In recent years, the Safe Systems approach is an

extension of this model by identifying measures for
safe people, safe vehicles and safe roads for prevention
and control of RTIs. This approach considers different
interactions between and within each component and
is based on physiological tolerance of individuals. It
is based on the understanding that human body is
extremely vulnerable for injury and that people are
likely to make mistakes. Hence, road crashes are the
outcomes of different interactions among a number
of factors and interactions. Based on this
understanding it is essential to address multiple
components that cause injuries by different partners
(Mohan et al, 2006). This approach focusses on
Safe people, Safe roads and Safe vehicles. This
understanding has revolutionized the field of Road
safety as well as injury prevention and control over
time and it has been possible to identify injury
prevention programs that can be effectively
implemented.

Table 1: Example of Haddons matrix as

applied to two wheeler road traffic injury
Vehicle

Environment

Pre-event Increase
Increase
awareness
visibility of
about helmet vehicle
wearing, drink
driving, safe
driving, etc.

Human

Implement
safety features
on roads

Event

Early transfer
to hospital
and required
care

Better braking Crash

systems of two protective
wheelers
road side
stationary
objects

Postevent

Rehabilitate
and improve
health care
services

Improve safety
technologies
and components

Facilities for
early rescue
of injured
persons

A3. Injury and violence as a public health

problem in India
Commonly, injuries are classified as unintentional and
intentional based on intent. Unintentional injuries
include Road Traffic Injuries (RTIs), falls, burns,
poisoning, drowning, work related injuries, fall of
objects, injuries in disasters and animal bites.
Intentional injuries include suicides and violence.
Violence includes a wide variety of conditions like
youth violence, violence against women, children and
elderly, communal violence and those occurring in

BRSIPP 2011

custodial institutions. Another method of classifying

injuries is based on the mechanism of injury as it
happens in road traffic injuries, poisoning, falls and
others. The third method of classification is based on
the place of occurrence like roads, home, play sites
or work places. The anatomical type and location of
injuries depending on the injured body organs like
head injuries, intracranial injuries, fractures and
dislocations are the fourth method of classification.

Several international frame works like the WHO

international classification of diseases (WHO, 1998),
International Classification of External Causes of
Injuries (WHO, 2004a), and the International
Classification of Functional Impairments are available
for more detailed understanding of injury process and
mechanisms (WHO, 2001a).
It is common to see, read, hear or witness injury
deaths and events in our lives on a day to day basis.
Like any health condition, injury and violence also
has the typical epidemiological understanding of
agent (product), host (person) and environmental
association. The term, injury, by definition means
that it is a body lesion due to an external cause,
either intentional or unintentional, resulting from a
sudden exposure to energy through mechanical,
electrical, thermal, chemical or radiate sources that
is generated due to interaction between agent and
host (WHO, 1999). This definition has been
expanded to include impairments and others. The
interaction of these elements results in transfer of
energy to the host, which when it exceeds the
physiological tolerance of the individual results in
damage to body organs. Depending on the product,
the energy that is responsible can be mechanical (as
in RTIs), chemical (as in poisoning), thermal
(burns), electrical or radiant in nature. It is also
possible that injuries can occur due to sudden
withdrawal of a vital requirement of the body as in
drowning due to lack of oxygen.

The understanding that injury is damage to one or

more body organs, which occur quite rapidly due
to sudden energy transfer being the cause,
revolutionized the science of injury prevention and
control. The definitive interaction between agent,
host and environment along with energy transfer
results in injuries of varying nature and severity. The
chances of repeated occurrence are also frequent.
Over time, moving from this concept, the safe
systems approach has evolved for prevention and
control.
Any health problem is a public health problem, if it
affects large sections of society, has identifiable and
measurable risk factors, is amenable to prevention
and can be addressed through public health
approaches (Detels et al, 2009). Due to lack of good
quality data on the burden, pattern and impact of
injuries, the problem remains unrecognized and
consequently unaddressed in India. However, the
death of nearly 5,00,000 persons as per official
reports every year indicates the enormous
magnitude of the problem. Injuries predominantly
affect the young people in the society, primarily in
the age group of 15-44 years and men, with majority
belonging to lower and middle income strata of the
society. International research and experience reveals
that the risk factors of injuries are clearly discernable
and are amenable for prevention as seen by a decline
in injury deaths and disabilities in recent decades in
many High Income Countries (HICs)(WHO, 2004b).

A4. Burden of injury and violence in India

The only major source of information on injury and
violence in India is the National Crime Records
Bureau (NCRB) under the Ministry of Home Affairs,
Government of India. NCRB publishes annually
Accidental deaths & Suicides in India and Crime in
India.The reports of 2009, published in 2010, gives
salient findings on injury burden and patterns from
different states, union territories and the mega cities
of India (NCRB, 2009a & b). Despite limitations of
reporting and timely publication, the report offers
valuable insights into the current situation of injury
and violence. Some of the salient observations are
also provided in the accompanying report entitled
Injury and violence in India: facts and figures
(Gururaj, 2011).

In 2009, there were 4,76,576 accidental deaths in

the country due to manmade causes (Table 2).
A total of 6,47,904 unnatural accidents caused
4,76,576 deaths and injuries among 1.5 million
persons with a male to female ratio of 3: 1. A 4.3%
increase in accidental deaths has been reported, while
a 7.2% decrease was noticed from deaths due to
natural causes. Significant variations exist across
the states due to population characteristics and levels
of motorisation and urbanisation.
The major unnatural cause of death was road traffic
injuries, which resulted in death of 1, 26,876 persons
in 2009. The share of accidents due to natural
causes decreased from 7% in 2008 to 6.2% in 2009.

Table 2 : Deaths and injuries in India, Karnataka state and Bangalore city due to
various causes, 2009
Sl. No
A
I
II
1
2
3
4
5
III
1
2
IV
V
1
2
VI
1
2
VII
1
2
VIII
1
2
3
4
IX
X
XII
1
2
3
4
5
XIII
XIV
1
2
3
XV
XVI
B
XVII
1
2
3
XVIII
1
2
3
4
5
6
7

Causes
Unintentional injuries
Air-Crash
Collapse of Structure (Total)
House
Building
Dam
Bridge
Others
Drowning (Total)
Boat Capsize
Other Cases
Electrocution
Explosion (Total)
Bomb Explosion
Others (Boilers, Gas Cyld. etc.)
Fall (Total)
From Height
Into Pit/Manhole
Factory
Machine Accidents
Mines or Quarry Disaster
Fire (Total)
Fireworks/Crackers
Short-Circuit
Cooking Gas Cylinder/Stove Burst
Other Fire Accidents
Fire-Arms
Killed by Animals
Poisoning (Total)
Food/Accidental intake of Insect. etc.
Spurious/Poisonous liquor
Leakage of gases etc.
Snake Bite/Animal Bite
Other
Stampede
Traffic Accidents (Total)
Road Accidents
Rail-Road Accidents
Other Railway Accidents
Other Causes
Causes Not Known
Total of unintentional injuries
Intentional Injuries
Intentional Injury Deaths
Homicides
Dowry deaths
Suicides
Other Intentional Injuries
Attempt to commit murder
Rape
Kidnapping and abduction
Molestation
Sexual harassment
Cruelty by husband and relatives
Other IPC crimes
Total of intentional injuries
Grand Total (A+B)

Source: NCRB report, 2009a & b

BRSIPP 2011

Bangalore
Injured

Killed

Karnataka

India

Injured

Killed

Injured

Killed

0
0
0
0
0
0
0
5
0
5
4
1
0
1
7
3
4
0
0
0
32
0
0
13
19
0
1
20
0
2
0
1
17
6
5705
5705
0
0
74
63
5918

0
9
0
1
0
0
8
43
0
43
29
4
0
4
108
100
8
2
2
0
449
11
19
89
330
15
1
388
57
22
0
2
307
0
742
742
0
0
676
0
2466

0
9
8
1
0
0
0
6
0
6
11
3
0
3
14
10
4
4
4
0
55
0
2
34
19
0
5
25
5
2
0
1
17
6
61697
61697
0
0
78
66
61979

1
282
146
17
0
0
119
2014
51
1963
365
9
0
9
470
442
28
33
32
1
1625
12
126
341
1146
18
50
2491
181
180
13
722
1395
12
10163
8714
0
1449
1022
1125
19680

0
556
242
47
15
32
220
553
33
520
453
735
491
244
2416
959
1457
598
552
46
3034
258
207
241
2328
671
198
5269
1662
109
10
1900
1588
6
470941
466649
477
3815
4500
1389
491319

12
2847
1091
265
30
44
1417
25911
984
24927
8539
668
261
407
10622
8796
1826
1467
1044
423
23268
547
1328
4127
17266
1504
962
26634
8154
1450
247
8035
8748
110
152689
126896
1516
24277
35906
17534
308673

0
0
0

256
50
2167

0
0
0

1702
264
12195

0
0
0

32369
8383
127151

338
65
270
251
35
367
9992
11318
17236

0
0
0
0
0
0
0
2473
4939

1607
509
892
2186
64
3185
61108
69551
131530

0
0
0
0
0
0
0
14161
33841

29038
21397
33860
38711
11009
89546
865541
1089102
1580421

0
0
0
0
0
0
0
167903
476576

Under the broad category of traffic accidents,

4,21,628 road accidents, 2080 rail-road accidents
and 27,575 other railway accidents were reported.
RTIs and suicides were the major causes
contributing for 31% & 27% respectively. (Figure1).
The report highlights an increase of road crashes
in the country by 7.3% during 2009 compared to
2008. Tamil Nadu reported highest rate of road
accidents contributing for nearly 21% of the
national total (Figure 2). Road accidents in India
increased by 1.4% during 2009 as comared to 2008.
In total, 4,15,855 road accidents were reported,
that resulted in death of 1,26,896 persons with an
accident severity index of 30%. The annual
mortality rate was 10.9/1,00,000 population. The
four states of Tamil nadu, Maharashtra, Karnataka
and Kerala accounted for 47% of total road
accidents. The 32 mega cities contributed for 14%
of total road deaths.

Figure1: Causes of injury deaths in India in 2009

In the same year, several more died due to other

injury causes as shown in Figure 1. Nearly 1,27,151
persons ended their lives voluntarily in suicidal acts,
while 26,634 died due to accidental poisoning and
23,268 due to burns. The data also shows the huge
extent of underreporting of injuries in official reports
as seen by the fact that injuries were less than deaths.
As deaths are only the tip of iceberg, for every death,
nearly 30 50 reach hospitals and it is estimated
that the actual number of hospitalised persons are
likely to be in the range of 30 40 million every
year (Gururaj G, 2005a).
In 2009, 1,27,151 persons ended their lives in a
suicidal act. The five states of West Bengal (11.5%),
Andhra Pradesh (11.4%), Tamil Nadu (11.3%),
Maharashtra (11.2%) and Karnataka (9.6%),
contributed for more than half of suicides in the
country (Figure 3). The five southern states registered
40% of total suicides in the country. The four cities
of Bangalore (2,167), Chennai (1,412), Delhi
(1,215), and Mumbai (1,051) together reported
nearly 44% of total suicides among the 35 mega
cities of the country. Bangalore city had the highest
rate: 38.1 per 1,00,000 population. In the total series,
1 out of every 3 suicides occurred in the age group
of 15-44 years with an overall male to female ratio
of 2:1. However, in young children less than 14 years,
male to female ratio was almost equal. One out of
every 5 suicides was registered among housewives.
The age sex distribution of the affected populations
varied across the country. As per the national report,
majority of the deaths due to injuries were in the

Figure 2: State wise distribution of RTIs in India, 2009

(National average 10.9/100,000 population)
State
Tamil Nadu
Haryana
Goa
Andhra Pradesh
Himachal Pradesh
Karnataka
Sikkim
Rajasthan
Chhattisgarh
Gujarat
Maharashtra
Delhi
Madhya Pradesh
Kerala
Arunachal Pradesh

Rate
20.48
20.07
19.17
17.43
16.77
14.97
14.50
13.69
13.07
12.04
11.99
11.80
11.34
11.04
10.25

State
Jammu and Kashmir
Punjab
Uttarakhand
Orissa
Uttar Pradesh
Meghalaya
Jharkhand
Assam
Tripura
Mizoram
West Bengal
Manipur
Bihar
Nagaland

Rate
9.07
8.87
8.80
8.78
7.58
7.48
6.63
6.50
6.41
6.30
5.62
4.68
4.60
2.25

Figure 3: State wise distribution of suicides in India, 2009

National average - 10.9/100,000 population
State
Sikkim
Kerala
Chhattisgarh
Tamil nadu
Karnataka
Tripura
Andhra pradesh
Goa
West Bengal
Maharashtra
Madhya Pradesh
Orissa
Gujarat
Haryana
Assam

younger age groups of the population. Nearly 6.5%

of deaths were in children less than 14 years and
majority of deaths were in the age group 15-44 years.
Data from the million death study identified
unintentional and intentional injuries as a leading
cause of death in younger age groups (RGI, 2009).
Most importantly, unintentional injuries were the
4th leading cause of death in 1 to 4 years, while it
was the number one cause of death in 15-24 years
with 11.8% and 15.6% for the two groups of

Rate
39.9
25.3
24.4
21.5
21.0
20.7
17.4
16.4
16.4
13.2
12.9
10.8
10.7
10.3
9.7

State
Arunachal Pradesh
Himachal Pradesh
Delhi
Rajasthan
Mizoram
Meghalaya
Jharkhand
Uttarakhand
Punjab
Jammu and Kashmir
Uttar Pradesh
Nagaland
Bihar
Manipur

Rate
9.0
8.4
8.3
7.7
6.9
4.3
3.6
3.5
3.1
2.5
2.1
1.4
1.1
1.0

unintentional injuries and intentional self harm.

Injuries were the leading cause of death in the 5 - 14
years age group. In total, motor vehicle injuries
contributed to 3.7% of deaths in 5-14 years and 6.9%
in 15-24 years. Injuries were the 8th and the 9th cause
of death in 25-69 years of age group. The top 3 causes
of death in 15-24 years were due to other unintentional
injuries (14.7%), intentional self harm (14.3%), and
motor vehicle accidents to the extent of 12.4%. Injuries
were one among the top 10 leading causes of deaths
in all the groups as shown in tables 3, 4 and 5.

A5. Burden of injury and violence in Karnataka

Karnataka with a population of 66 million is one of
the most progressive states in India. The state with a
motor vehicle population of 3.69 million is
predominantly rural with an urbanization rate of
37% (http://www.municipaladmn.gov.in/
dmaWebsite/urbanization.htm). With literacy rate
of 66.7% and per capita income of Rs 40,998(RBI,
2010), the state is an evolving knowledge and
industrial hub of the country.
During 2009, 33,481 persons (19,680 accidental and
12,195 suicidal deaths) died due to injury and
violence in the state (Figure 4). Among the major
causes, road traffic crashes (8714) and suicides
(12,195) topped the list, respectively. Among other
causes for injury deaths, 2491 were due to poisoning
and 2014 due to drowning. Intentional injury causes
like homicide and dowry resulted in 1702 and 264,
deaths respectively. In the same year, 1,31,350

BRSIPP 2011

persons were injured as per police reports giving a

ratio of nearly 1:8 for deaths injuries. Considering
underreporting of injuries, the number hospitalized
could have both 1 1.2 million during the year.
Figure 4: Causes of injury deaths in Karnataka in
2009

Perinatal
conditions (49.2)

Respiratory
infection (20.5)

Diarrheal diseases
(9.0)

Other infectious and

parasitic diseases
(7.9)

Congenital
anomalies (3.4)

III defined
conditions (2.9)

Nutritional
deficiencies (1.8)

Unintentional
injuries: Other (1.5)

Malaria (0.9)

Fever of unknown
origin (0.9)

10

Digestive
Diseases (1.6)

Congenital
Anomalies (1.9)

Fever of Unknown
Origin (3.1)

Nutritional
deficiencies (4.3)

III defined
conditions (5.3)

Malaria (6.6)

Unintentional
injuries: Other (9.3)

Other infectious and

parasitic diseases
(15.5)

Respiratory
Infections 21.4)

Diarrheal
diseases (22.0)

1-4

Fever of unknown
origin (1.5)

Malaria (2.4)

Nutritional
deficiencies (2.4)

Congenital
anomalies (3.0)

Unintentional
injuries: Other (3.4)

Ill-defined
conditions (3.5)

Other infectious and

parasitic diseases
(9.8)

Diarrheal
diseases (12.3)

Respiratory
infections (20.7)

Perinatal
conditions (36.9)

0-4

Fever of unknown
origin (2.5)

Digestive diseases
(2.9)

Malignant and other

neoplasms (3.8)

Motor vehicle
accidents (5.3)

Ill-defined
conditions (5.4)

Malaria (8.1)

Respiratory
infections (8.4)

Other infectious and

parasitic diseases
(13,5)

Diarrheal diseases
(15.2)

Unintentional
injuries: Other
(19.4)

5-14

Maternal
conditions (-)

Malaria (4.8)

Diarrheal diseases
(5.1)

Other infectious and

parasitic diseases
(5.2)

Tuberculosis
(6.0)

Cardiovascular
diseases (6.3)

Ill-defined
conditions (7.2)

Motor vehicle
accidents :; ;;,
(12.4)

Intentional
self-harm (14.3)

Unintentional
injuries: Other
(14.7)

15-24

Malaria (2.4)

Intentional
self-harm (3.3)

Diarrheal
diseases (4.0)

Ill-defined
conditions (4.8)

Unintentional
injuries: Other (5.0)

Digestive diseases
(6.1)

Malignant and other

neoplasms (7.8)

COPD, asthma, other

respiratory diseases
(10.1)

Tuberculosis
(11.4)

Cardiovascular
diseases (26.3)

25-69

Cardiovascular
diseases (20.3)

All Ages

Fever of unknown
origin (2.8)

Respiratory
infections (3.4)

Unintentional
injuries: Other (3.7)

Ill-defined
conditions (4.4)

Tuberculosis (4.5)

Malignant and other

neoplasms (4.6)

Diarrheal diseases
(7.3)

Senility (13.1)

Senility (4.0)

Ill-defined
conditions (4.6)

Unintentional
injuries: Other (5.2)

Malignant and other

neoplasms (5.4)

Respiratory
infections (5.4)

Perinatal conditions
(6.4)

Diarrheal diseases
(6.7)

Tuberculosis (7.1)

COPD, asthma, other COPD, asthma, other

respiratory diseases
respiratory diseases
(15.7)
(9.3)

Cardiovascular
diseases (26.5)

70+

Ref: http://cghr.org/publications/FINAL%20REPORT-Millon% 20Death%20study%202001-2003%20-phase%201.pdf

<1

Rank

Table 3: Top 10 causes of death by age groups in India: Male

BRSIPP 2011

Perinatal
conditions (43.1)

Respiratory
infection (23.3)

Diarrheal
Diseases (10.6)

Other infectious and

parasitic diseases
(8.8)

III defined
conditions (3.2)

Congenital
anomalies (2.8)

Nutritional
deficiencies (2.3)

Unintentional
injuries: Other (1.3)

Malaria (1.3)

Fever of unknown
origin (0.9)

10

Congenital
anomalies (1.3)

Digestive diseases
(1.8)

Fever of Unknown
Origin (3.1)

III defined
conditions (3.9)

Nutritional
deficiencies (5.1)

Unintentional
injuries: Other (6.2)

Malaria (6.6)

Other infectious and

parasitic diseases
(16.2)

Respiratory
Infections (23.3)

Diarrheal
diseases (25.2)

1-4

Fever of unknown
origin (1.6)

Congenital
anomalies (2.3)

Unintentional
injuries: Other (2.9)

Malaria (3.0)

Nutritional
deficiencies (3.2)

Ill-defined
conditions (3.4)

Other infectious and

parasitic diseases
(11.2)

Diarrheal diseases
(15.3)

Respiratory
infections (23.3)

Perinatal
conditions (29.2)

0-4

Malignant and other

neoplasms (2.0)

Motor vehicle
accidents (2.1)

Digestive diseases
(2.8)

Fever of unknown
origin (3.3)

Ill-defined
conditions (4.6)

Malaria (10.7)

Respiratory
infections (11.1)

Unintentional
injuries:
Other (12.0)

Other infectious and

parasitic diseases
(16.7)

Diarrheal diseases
(19.6)

5-14

Malignant and other

neoplasms (11.8)

Cardiovascular
diseases (22.5)

25-69

Senility (18.4)

Cardiovascular
diseases (24.8)

70+

Diarrheal diseases
(9.9)

Cardiovascular
diseases (16.9)

All Ages

Motor vehicle
accidents (1.7)

Other infectious and

parasitic diseases
(4.4)

Malaria (4.6)

Cardiovascular
diseases (6.3)

Diarrheal diseases
(7.2)

Ill-defined conditions
(7.2)

Tuberculosis (7.5)

Intentional
self-harm (2.6)

Malaria (3.4)

Digestive diseases
(3.5)

Unintentional
injuries: Other (4.1)

Ill-defined
conditions (6.0)

Diarrheal diseases
(6.6)

Tuberculosis (8.3)

Tuberculosis (2.6)

Respiratory
infections (3.4)

Malignant and other

neoplasms (3.5)

Fever of unknown
origin (3.9)

Ill-defined
conditions (4.5)

Unintentional
injuries: Other (4.6)

Diarrheal diseases
(9.8)

Unintentional
injuries: Other (4.5)

Tuberculosis (4.7)

Ill-defined
conditions (5.0)

Malignant and other

neoplasms (6.0)

Perinatal conditions
(6.2)

Senility (6.5)

Respiratory
infections (7.1)

COPD, asthma, other COPD, asthma, other COPD, asthma, other

Unintentional
respiratory diseases
injuries: Other (9.1) respiratory diseases
respiratory diseases
(12.4)
(10.4)
(8.0)

Maternal
conditions (12.6)

Intentional
self-harm (16.9)

15-24

Ref: http://cghr.org/publications/FINAL%20REPORT-Millon% 20Death%20study%202001-2003%20-phase%201.pdf

<1

Rank

Table 4: Top 10 causes of death by age groups in India: Female

Perinatal
conditions (46.3)

Respiratory
infection (21.8)

Diarrheal
diseases (9.7)

Other infectious and

parasitic diseases
(8.3)

Congenital
anomalies (3.1)

III defined
conditions (3.0)

Nutritional
deficiencies (2.0)

Unintentional
injuries: Other (1.4)

Malaria (1.1)

Fever of unknown
origin (0.9)

10

Congenital
anomalies (1.5)

Digestive diseases
(1.7)

Fever of Unknown
origin (3.1)

III defined
conditions (4.5)

Nutritional
Deficiencies (4.8)

Malaria (6.6)

Unintentional
injuries: Other (7.5)

Other infectious and

parasitic diseases
(15.9)

Respiratory
Infections (22.5)

Diarrheal
diseases (23.8)

1-4

Fever of unknown
origin (1.5)

Congenital
anomalies (2.7)

Malaria (2.7)

Nutritional
deficiencies (2.8)

Unintentional
injuries: Other (3.2)

Ill-defined
conditions (3.4)

Other infectious and

parasitic diseases
(10.5)

Diarrheal
diseases (13.8)

Respiratory
infections (22.0)

Perinatal
conditions (33.1)

0-4

Fever of unknown
origin (2.9)

Digestive diseases
(2.9)

Malignant and other

neoplasms (2.9)

Motor vehicle
accidents (3.7)

Ill-defined
conditions (5.0)

Malaria (9.4)

Respiratory
infections (9.7)

Other infectious and

parasitic diseases
(15.1)

Unintentional
injuries: Other
(15.7)

Diarrheal
diseases (17.4)

5-14

Malaria (4.7)

Other infectious
and parasitic
diseases (4.8)

Diarrheal
diseases (6.2)

Cardiovascular
diseases (6.3)

Maternal
conditions (6.5)

Tuberculosis (6.8)

Motor vehicle
accidents (6.9)

Ill-defined
conditions (7.2)

Unintentional
injuries: Other
(11. 8)

Intentional
self-harm (15.6)

15-24

Malaria (2.8)

Intentional
self-harm ' (3.0)

Unintentional
injuries: Other (4.6)

Diarrheal diseases
(5.0)

Digestive diseases;
(5'1>

Ill-defined
conditions (5.3)

Malignant and other

neoplasms (9.4)

Tuberculosis (10.1)

COPD, asthma, other

respiratory diseases
(10.2)

Cardiovascular
diseases (24.8)

25-69

Tuberculosis (6.0)

Respiratory
infections (6.2)

Perinatal
conditions (6.3)

Diarrheal diseases
(8.1)

COPD, asthma, other

respiratory diseases
(8.7)

Cardiovascular
diseases (18.8)

All Ages

Fever of unknown
origin (3.3)

Respiratory
infections (3.4)

Tuberculosis (3.6)

Ill-defined
conditions (4.8)

Unintentional
injuries: Other (4.9)

Senility (5.1)

Unintentional
Malignant and other
injuries: Other (4.1)
neoplasms (5.7)

Malignant and other

neoplasms (4.1)

Ill-defined
conditions (4.4)

Diarrheal diseases
(8.5)

COPD, asthma, other

respiratory diseases
(14.1)

Senility (15.7)

Cardiovascular
diseases (25.7)

70+

Ref: http://cghr.org/publications/FINAL%20REPORT-Millon% 20Death%20study%202001-2003%20-phase%201.pdf

<1

Rank

Table 5: Top 10 causes of death by age groups in India; Person

A6. Data limitations

Data from NCRB report the total number of deaths
for the country and also for different states and 32
mega cities. Even in official reports, the number of
injured are far less than deaths in some injuries. This
shows that many nonfatal injuries are not reported
to police and reasons could be several. The reasons
for underreporting lie in social, cultural, economic
and administrative issues and vary from cause to
cause. Three of the studies from India undertaken in
Bangalore (Gururaj et al, 2000), Haryana (Varghese
and Mohan, 2003) and Hyderabad (Dandona et al,
2008) reveal that the actual burden of RTIs to be
higher than official figures. The Bangalore study
reported that RTI deaths and injuries were
underreported by 5 10% and > 50%, respectively.
Dandhona et al (2008) reported from Hyderabad
that the RTI mortality rate was 38 / 1,00,000
population, much higher than officially reported
figures. The ratio of deaths: critically injured: mild
injuries was 1: 29: 65 among the surveyed villages
of Haryana. NIMHANS study on suicides showed the
ratio of completed: attempted: suicidal ideations was
1: 10: 100 based on data from hospitals and general
population survey (Gururaj et al, 2004). Sanghvi
et al (2009) reported the number of deaths due to
burns to be 1,63,000 based on estimates, while the

official reported deaths were 22,000 in the same

year.
Reflecting on the data further, it is observed that
national reports provide gross numbers & trend data
with additional information on age and gender, urban
and rural, month and time, sociodemographic
correlates like education and occupation and broad
causes for RTIs and suicides. Further, data is not readily
available for researchers & policy analysts in the public
domain for analysis & interpretation. This data is
supplemented further with few research studies from
different parts of the country on different injury causes.
In summary, comprehensive data required for policies
and programs is not available in the country. It is
time that national institutions like Department of
Health Research (ICMR) and health professionals take
keen interest in developing good quality national level
data on injuries through a combination of quantitative
and qualitative research methods. There is also need
for information from other disciplines like engineering,
transport, industry, law and other sources on different
aspects of injuries. Information from all sources needs
to be available to examine different aspects and to
provide inputs for policies and programs.

A7. Data requirements for road safety and

injury prevention
Unlike communicable disease programs, there is
need for variety of data for road safety and injury
prevention. Primarily, good quality reliable and
comprehensive data is required for policy makers
Figure 5: Use of data for public health and safe
system approaches

Formulate
strategy
Identify risk
factors,
priorities
Define
problems

10

BRSIPP 2011

Set targets
and monitor
performance

and professionals to develop meaningful and evidence

based policies/programs and interventions. As per
WHO (WHO, 2010a) reliable and accurate data can
help build political will to prioritise road safety by:

documenting the nature and magnitude of the

road traffic injury problem;

demonstrating the effectiveness of interventions

that prevent crashes and injuries;

providing information on reductions in socioeconomic costs that can be achieved through

effective prevention.
Informative and good road crash data systems should
provide information on (Figure 5)

Magnitude of the problem in terms of deaths,

hospitalisations, disabilities and impact
Characteristics of vehicle, the road user and
the road/environment
Situation context and circumstances of road
crashes
Risk factor identification for selection of
countermeasures
Effectiveness of interventions in terms of
reduction and changes in the burden, and
Provide reliable output in a timely manner to
facilitate evidence-based decisions.

Using variety of data from different sources,

indicators can be developed to measure progress

in many areas of burden, characteristics and

impact. At each level, different data is required
and this has to be obtained from different sources
by varied methods. A comprehensive road safety
data system would therefore encompass data
collection and analysis mechanisms that cover deaths and serious injuries to road users,
characteristics of the crashes; exposure information:
speed, seat-belt and helmet use rates, drink driving,
and vehicle and infrastructure safety ratings; and
impact data in terms of socioeconomic costs to the
society. As discussed in the earlier sections of
this report, such data is not readily available in
India.

A8. Injury surveillance

Strong and robust data is an essential prerequisite
to formulate effective road safety and injury
prevention programs (WHO, 2010a). Information is
required on the number of fatal and non fatal injuries,
characteristics of the affected people, the place and
time of injury occurrence, the various contributing
risk factors and causes, trauma care details and
other aspects. This type of comprehensive
information and its availability and utilization will
support development and implementation of policies
and programs.
Surveillance is a very familiar concept in public
health research and refers to ongoing, continuous
and systematic collection, analysis, interpretation,
dissemination, utilization and feed back of data for
reducing the burden of any public health problem
(WHO, 2001b). A similar approach has been used
for injury prevention and control as well in many
HICs. It includes gathering information on individual
cases or assembling information from different
sources, analysing and interpreting information,
dissemination and providing feed back into
programs (Figure 6). It is essential to note that
surveillance is a continuous activity with an inbuilt
feedback mechanism and an action component.
Surveillance helps in recognizing the existing and
changing burden of injuries, understanding various
patterns, identifying new emerging problems,

prioritizing issues and provides a situation analysis

of the current scenario. The data from surveillance
programs needs to be essentially used for
prioritization of issues, capacity strengthening and
human resource development, identifying areas for
interventions, and monitoring and evaluation of
activities. Road safety and injury surveillance data
Figure 6: Designing and building a
surveillance system
1. Identify
stakeholders

2. Define system
objectives

4. Identify
data sources

5. Assess available
resources

3. Define
a case

6. Inform and involve

stakeholders

7. Define
data needs

8. Collect data

12. Monitor and

evaluate

11. Train staff and

activate system

9. Establish a data
processing system

10. Design and

distribute reports

Source: WHO, 2001b

11

can be a meaningful input to several programs and

activities of different ministries, government
departments, health professionals and all others
involved in these activities. It is extremely important
to realize that surveillance moves beyond just data
collection to actually using data for policies and
programs(WHO, 2001b). Further, it is also essential
to understand that surveillance alone will not be
an answer and needs to be supplemented with
variety of different data to pinpoint selection of
interventions. In India, due to absence of central
coordinating agency and data not being valued, most
of the surveillance data remains underutilized, even
in Communicable Diseases surveillance activities.
Many, including professionals believe that RTI/injury
surveillance requires building entirely new systems
that involve huge resources. This is not true.

Surveillance program can be built within existing

systems with minimal resources. These existing
systems can be improved, strengthened and utilized
to develop the requisite information (Gururaj et al,
2010).
For surveillance system to be effective, operational,
and sustainable, it should be simple, acceptable,
sensitive, reliable, representative, sustainable, timely,
cost effective, and most importantly useful. The
essence of surveillance is to collect small amounts
of good quality reliable information by scientific
approaches and utilize the information to develop
policies programs and interventions. As surveillance
is an ongoing activity the data would reveal the
efficacy and effectiveness of interventions as seen by
change in the injury burden and patterns.

A9. Data sources for surveillance

There are multiple sources of data for injuries in
India. Each source collects different types and
quantum of data for its own purposes. The common
sources of data are from vital registration systems,
police, transport, health, welfare, insurance, legal
sector and others.

12

Injury deaths in India are considered medico

legal events since historical times.
Consequently, the police department undertakes
investigation on all accidental and unnatural
deaths and details are documented as per
official procedures. Information on traffic
deaths is collected by the traffic division, while
intentional injury deaths are documented by
the crime division. Information on few other
injury deaths is also collected by law and order
division of police department. The available
information varies from place to place and
summary statistics are sent to NCRB which
compiles and publishes national statistics.
However, the information collected is mainly
from an administrative, criminal and legal
point of view and mechanisms to use
information for policies and programs are
totally lacking. Further, data analysis and

BRSIPP 2011

interpretation is not undertaken at state or local

levels.
Similarly, information on transport injuries is
also collected by the transport department.
Apart from information on type and number
of registered vehicles, the department also
collects and publishes data on deaths and
injuries. The published reports are somewhat
similar to NCRB reports with some additional
information on highway deaths and few
established indicators of road safety. However,
the periodicity of reports is not uniform and
there are delays in publication of these reports.
The vital registration system in every city and
district collect and compiles data on births and
deaths at local levels. Information on deaths is
collected (form no.4) and compiled regularly. ICD
10 coding is used in few cities and districts for
this purpose. The use of ICD 10 varies from place
to place and depends on completion of death
certificates in institutions and coding by
physicians. The local level data is available on
age, sex, place, cause while, ICD code details
are available in some situations. The accuracy
of information is influenced by completeness of
registration and quality of data at the local level.

Information on injuries and related deaths is

also collected by mortuary centres of selected
institutions as per legal requirements. Mortuary
data is collected by forensic medicine
professionals and stored for longer periods of
time due to legal requirements. Information
on sociodemographic details, cause of death,
situation- context circumstances of injury,
description of injury details and cause of death
are documented for every case. However, no
collective analysis is being done by any agency.
Currently, an ongoing study in Bangalore is
examining mechanisms to use autopsy data
for injury surveillance purposes (Gururaj,
2010a).
All hospitals document details of injury patients
and deaths for care and administrative reasons.
There is no uniformity and the practice varies
from hospital to hospital. There are no national
or state level guidelines for documenting details
of injury patients or even other patients.
Unfortunately, hospitals do not even bring out
summary statistics of their respective
institutions. The MCCD system collects data
from specific institutions for national and state
reporting systems (GOK, 2010).

Data on injury deaths are also available from

insurance sector. However, this data is not in
the public domain and cannot be accessed
easily for policy or research purposes.
In summary,

there are multiple sources of data

depth and quality of information varies
from agency to agency

no national or professional guidelines
exist for data collection (except for MLC
summary formats)

no uniform format exists for reporting
from hospitals

quality and nature of information has not
been examined

except NCRB, there is no national
coordinating agency

no agency exists for analysis,
interpretation and dissemination, and

data is rarely used for interventions,
policies and programs
A major drawback of the current situation is that
total information on all aspects of injuries is not
available in the public domain for planners, policy
analysts and researchers as the existing information
systems are fragmented, and piece meal in nature.

13

Section B:

The Program and Methods

B1. Bangalore road safety and

injury prevention program
The Bangalore Road Safety and Injury Prevention
Program (BRSIPP) was started in 2007 to develop
systematic activities for prevention and control of
road traffic injuries and other injuries. At the national
level, information available from the National Crime
Records Bureau through its annual reports of
Accidental deaths and Suicides in India provides
information on number of fatal and non fatal injuries,
age sex profiles, state and city wise distribution,
education and occupation levels, road user categories
for RTIs, time and period distribution, and a vague
distribution of causes for road traffic injuries,
suicides and all accidental deaths. While this
information is definitely helpful from a national
perspective, local data is required for a number of
activities. Hence, a surveillance approach was
adopted to gather information from multiple sources
in the city. This demonstration program attempted
to develop systematic road safety and injury
prevention programs based on data and evidence
adopting comprehensive and multiple approaches.

14

BRSIPP 2011

The overall goal of BRSIPP is to achieve a reduction

in injury (RTIs, suicides and others) deaths,
hospitalisations and disabilities in Bangalore along
with strengthening injury information systems.
The specific objectives of Bangalore Road Safety and
Injury Prevention Program were to:
1. Collect and analyse data from police sources,
selected participating health care institutions,
and transport sector on specific aspects of RTIs
and other injuries through a surveillance
approach.
2. Use data for road safety and injury prevention
programs at the city level to facilitate
development of road safety and injury
prevention through advocacy activities
3. Facilitate application and utilization of data
for planning and implementing general and
specific countermeasures through various
programs.

B2. Methods
In Bangalore, under the program, attempts were
made to generate data through specific mechanisms
and pool data from different sources. The program
has been strengthened during the last three years
and attempts are in progress to develop an integrated
data collection system. The extent, type and nature
of data to be collected were finalized in consultation
with stakeholders at the beginning of program.

undertaken during 3 years based on data collected

are discussed in later sections of this report. Some
salient aspects of data collection are highlighted below.
Figure 7: Sources of information for injuries

Details of data collection activities have been

discussed in earlier reports of 2009 and 2010 (Gururaj
et al, 2008 and 2010). The development phase focused
on consultation with stake holders, sources of data,
selection of centres, inventory of hospitals, pilot study,
organizing logistics of data collection, training
programs, testing validity and reliability of data
collection methods, feedback mechanisms and data
utilization aspects. The various sources of data in
the program are shown in Figure 7. Activities

B3. Fatal injuries

Information on fatal injuries was collected from two
sources: city police and vital statistics division of
the city administration. As all injury deaths are
considered either unnatural or accidental, they
are routinely reported to police. Investigations
are undertaken as per established norms and
procedures. Under the program, information
was initially collected (in 2008 and 2009) through
paper based formats. Under the leadership of the
Additional Commissioner (Traffic and Road Safety),
Sri. Praveen Sood, the paper version has been
replaced with a web based format in 2010. The
computerization support was provided by the staff
of National Informatics Centre in the city. Since all
police stations in the city have been computerized
and there are identified writers and computer
programrs in each station, it was considered timely
and economical to shift to this method. Number of
training programs has been conducted for writers
and inspectors of traffic divisions in each police
station during 2009 and 2010 to implement and
improve the system. The writers complete a two page
proforma for every road death soon after completing
investigation formalities.

The proforma has five sections of basic identification

details, injury details (intent, type, place of injury,
product involved etc), details of Road traffic injuries
(place of occurrence, collision patterns, risk factors
(alcohol), use of safety devices (helmet and seatbelts)
and trauma care details (first aid, mode of
transportation etc) (Annexure 1).
Since it was not possible to collect detailed
information on other non-traffic injury deaths
(Annexure 2), primarily deaths due to intentional

15

injuries, in the urban component of the program,

summary statistics was obtained from the office of
the City Crime Records Bureau. This was compiled
for 2010 on different parameters and injury causes.
A similar mechanism has been developed under the
rural component of Bangalore Road Safety and Injury
Prevention Program in Tumkur. Since there are no
networked computer systems in the district, a paper
based format is being used and data is collected by
the team of trained research officers from NIMHANS.
The designated staff from the coordinating centre
collect information from individual records of traffic
and non-traffic deaths (primarily accidental and
intentional injuries) from the police headquarters of
Tumkur District. With computerization process in
the offing, it is hoped that there will be a shift to a
web based format in due course of time. This
mechanism is being strengthened through an ongoing
District Road Safety and injury Prevention program
with support from WHO and Ministry of Health
(Gururaj, 2010b).
In addition, a separate program has been established
in the Bangalore Metropolitan Transport department
(BMTC) to record information on all fatal bus crashes

in the city. In consultation with senior officials, a

procedure was introduced to document details of
each fatal crash involving buses. The proforma is
completed by the designated trained staff of BMTC
and transferred to Co-ordinating Centre (CC) on a
monthly basis.
Information was also collected from city vital
statistics division and latest data available was for
the year 2009. Under the Births and Deaths
Registration Act, each death has to be registered
using specific formats which include the cause of
death. In Bangalore, under the MCCD scheme, data
is collected from the different hospitals and is
compiled at the city level. This was also used to
examine injury deaths under the program.
A feasibility study has been initiated in December
2010 to collect data from 9 mortuary centres in the
city with support from WHO. Considering the
advantages of small number of centres and the legal
requirements of autopsy for all injury deaths, a
mechanism has been developed to obtain accurate
and reliable data from all autopsies of injury deaths
(Gururaj, 2010a) (Annexure 3).

B4. Nonfatal injuries

Information on non fatal injuries was collected in
2010 from hospital sources in both urban and rural
components of the program. In Bangalore City, the
program that was started in 2007 continued with
all the hospitals (3 of the hospitals discontinued due
to variety of reasons). Based on the feasibility study
and the practical difficulties encountered in 3 of the
hospitals (Victoria hospital, Bowring hospital and
St. Johns Hospital), data collection in these places
is being done by the CC staff. In all other hospitals,
data collection is undertaken by the hospital
designated team in the emergency room division,
which varies from institution to institution.
In rural areas, the information was collected by the
Casualty Medical Officers (CMOs) in Sri Siddhartha
Medical College Hospital. In the district hospital
and three of the community health centres, this is
undertaken by the hospital staff themselves from 2011

16

BRSIPP 2011

and it is expected to lead towards a sustainable long

term mechanism (ETCR, Anneure 4).
The collection of data is done by the ER team (nurses
or doctors) using Emergency Trauma Care Record.
During the last 3 years, a number of training
programs were conducted for ER staff at regularly.
The work in each hospital is supervised by a nodal

officer of the hospital and monitored on a weekly /

monthly basis by the CC staff. The focus of
information collection was on

Basic identification and brief sociodemographic details

Information on Injury and death (place, type,

activity, intent)

Details of road traffic deaths (where, who, how

and selected risk factors)

Details of other types of injury and deaths

(intent, place, type),
Pre-hospital care (first aid, transport, referral)
Management and outcome

The research component of the program was

approved by the institutional ethics committee of
NIMHANS in 2007.

B5. Population based observational surveys

In addition to the routinely collected data, special
surveys were undertaken by the coordinating centre
during January-February 2011 in focused areas.
These population based surveys in the geographically
defined boundaries of the city focused on helmet

use patterns, drinking and driving issues, speed

monitoring by police, seat belt use and pedestrian
safety issues. Detailed survey procedures are given
in later sections of the report under individual
areas.

B6. Data pooling

Data pooling was done during the year from
information available with transport department
especially with regard to motorization changes and
patterns. Information available in the annual report
was made use of for this purpose and remaining
data was collected from individual RTOs in the
city.
Information on traffic violations was collected from
the Traffic Management Centre under Bangalore City
Police of the city to examine pattern and nature of
violations, fines collected and level of enforcement
in the city.

Further, data on infrastructural projects of the city

was collected from Bruhat Bengaluru Mahangara
Palike (BBMP) and Bangalore Development Authority
(BDA) to identify completed projects during the year.
In summary, different sources of data were identified
and relevant information was collected to develop a
comprehensive picture of fatal and nonfatal injuries
for the city of Bangalore. Even though the major
focus was on road deaths and injuries, data was
collected for other injury causes as well. In addition,
the collected data was used for number of activities
as detailed in later sections of this report.

B7. Monitoring of activities

Inbuilt mechanisms have been developed to ensure
systematic monitoring of the program.

At the hospital level, data collected from

casualty is cross checked with medical records
and statistics to ensure coverage of cases.
At the ER level, the nodal officers ensure
inclusion of all cases, completeness of all forms,
transfer to a location in ER for storage and
transfer to coordinating centre periodically.

Coordinating centre staff ensure uniformity and

completeness of data collection with random
checks and independent monitoring of 5% cases.
A weekly meeting (Saturday) was held regularly
to monitor progress, recognize problems,
identify solutions and review progress.
All received forms from different sources were
examined for coverage and completeness.
Missing information was filled up from other
institutional records, wherever possible.

17

Meeting with all nodal officers once in 3 months

helped in reviewing progress, identifying
remedial measures for problems, ensured
better cooperation, and work out future
steps.
Continuous contact of CC staff with all
institutions was an inbuilt activity under
the program. Periodical visits and
communications on a regular basis was
undertaken to ensure completion of all activities
as per time schedule.

The program coordinator and the team visit

police stations and hospital departments at
periodical intervals and held discussions with
nodal officers, ER staff, medical record staff
and hospital administrator.
All data received from different sources were
checked for coverage, completeness and quality
by CC staff. Data was then entered into the
computer on a day to day basis. Data entry
and check formats have been developed using
EPI - INFO package.

B8. Sharing and disseminating of information

18

Surveillance is an ongoing continuous activity,

and the analysed data has to be shared with
all the partners; hence, feedback becomes a
regular feature of the program. As discussed
in the stakeholders and nodal officers meeting,
information was disseminated in number of
ways. The primary reason for using so many
combined methods was to encourage people
to get actively involved and also to ensure that
feedback becomes an inbuilt activity.
All reports have been developed, circulated and
disseminated under the title of Bangalore Road
Safety and Injury Prevention Program
Individual institutions were provided with
their respective data (on a CD) on a regular
basis. Member institutions were encouraged to
examine, use and develop reports for their
institutional activities.

BRSIPP 2011

Data was constantly reviewed in the nodal

officers meeting and used in all training
programs.
Specific detailed information has been
made available to member institutions as
and when required.
In 2009 and 2010, the annual reports, set
of 10 fact sheets (Injury, Child injury,
Injuries among elderly, road traffic injury,
two wheeler safety, pedestrian safety,
suicides, falls, burns, poisoning), 5 public
health alerts (Helmets, Seatbelts, Drinking
and driving, Speed management, trauma
care) and 4 injury prevention series
(Education, Engineering, Enforcement
and Emergency care) have been published
and disseminated under the program.