Childhood injuries from motor vehicle—pedestrian
collisions in Wuhan, The People’s Republic of China
, Xin Zhoub
, Cuiping Jiaa
, Chunxiang Yanb
, Huiyun Xiangc,
Department of Social Medicine, School of Public Health, Tongji Medical College, Wuhan, China
Wuhan Children’s Hospital, Wuhan, China
Center for Injury Research and Policy, Columbus Children’s Research Institute, Columbus Children’s Hospital, The Ohio State University, 700 Children’s Drive, Columbus, OH 43205, USA Accepted 1 December 2005 www.elsevier.com/locate/injury KEYWORDS Children; Injuries; Vehicle; Pedestrian; Collisions; China Summary
Objectives: To examine motor vehicle—pedestrian collision injuries resulting in hospitalisation among children admitted into Wuhan Children’s Hospital, The People’s Republic of China.
Methods: From the 1993 to 2004 inpatient data of Wuhan Children’s Hospital, we identified injury cases from motor vehicle traffic crashes among children aged 18 years or less using the discharge diagnosis defined by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). We examined character-istics of injuries from motor vehicle traffic crashes (ICD-9-CM = E810—E819) and then calculated the proportion of injuries from motor vehicle—pedestrian collisions (ICD-9-CM = E814) among all hospitalisations for childhood injuries (ICD-9-(ICD-9-CM = 800—959). The trend of injuries from motor vehicle—pedestrian collisions from 1993 to 2004 was described.
Results: Of the 12,939 injuries resulting in hospitalisation among children admitted into Wuhan Children’s Hospital during 1993—2004, a total of 528 injuries were caused by motor vehicle traffic crashes. The majority of the injured children in motor vehicle traffic crashes were males (59.3%). In comparison with other traffic injuries, a higher proportion of motor vehicle—pedestrian collisions occurred among children aged 12— 15 years. Motor vehicle—pedestrian collision injuries resulted in significantly longer lengths of stay in the hospital than other motor vehicle traffic injuries (19.4 days versus 14.3 days, respectively; t-test = 2.59, p-value < 0.05). The percentage of motor vehicle—pedestrian collision injuries among all hospitalisations for childhood
* Corresponding author. Tel.: +1 6143552768; fax: +1 6147222448. E-mail address: firstname.lastname@example.org (H. Xiang).
0020–1383/$ — see front matter # 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2005.12.002
Injuries are a leading cause of morbidity and mor-tality for children around the world.2,12,15,
Traditionally, infectious diseases predo-minated as the leading cause of mortality in devel-oping nations. However, as economic and living conditions in some developing nations improved, the leading cause of death among children in these nations shifted to injuries.2,12,15,21,23,24,31,33,35 Although there have been substantial declines in injury death rates among children in developed nations,4,11possibly attributable to rigorous injury research and active injury prevention,7—9 the impact of injuries on children in developing coun-tries has not been researched to the extent that the magnitude of the problem requires.1,3,6,8,9,14,16,18,35 Thus, research on childhood injuries in developing countries is rarely seen in the scientific litera-ture.8,9,14,35
China is one of the developing countries that have experienced rapid modernisation and urbanisation during the past decade. Along with rapid moderni-sation, the profile of major public health threats to children in China has shifted.13,33,34 Unintentional injuries are currently the leading cause of death among children in China, with more than 80,000 children dying from injuries each year.25In addition, motor vehicle traffic crashes have become the sec-ond leading cause of both death and injury-related hospitalisations among children and young adults.13,28
Researchers have tested the hypothesis that motor vehicle traffic crashes have increased in con-junction with the 266-fold increase between 1990 and 1999 in motor vehicle ownership in China.28,29,32 Official data from China report that in 1998, the number of road traffic crashes, traffic-related deaths, and injuries were 58.4, 91.6, and 43.2 times higher, respectively, than in 1951, and 3.2, 4.0, and 3.0 times higher, respectively, than in 1978.28,29 In 1999, pedestrians accounted for 26% of all road users killed in road traffic crashes.24As motor vehi-cle ownership increased dramatically and as traffic roads expanded to even small villages during the past decade, road traffic injuries have been
recog-nised as an important public health problem in China.28,29,32 Yet, injuries from motor vehicle— pedestrian collisions among children in China have yet to be described in detail.7,28,29
This study examines patterns of childhood inju-ries from motor vehicle traffic crashes that resulted in hospitalisations from 1993 to 2004 in a large metropolitan children’s hospital of southern China. Of special interest are the trends over time and characteristics of injuries from motor vehicle— pedestrian collisions. We hypothesise that the pro-portion of injuries from motor vehicle—pedestrian collisions among all hospitalisations for childhood injuries at this children’s hospital increased signifi-cantly during the past decade.
Hospital discharge data from Wuhan Children’s Hos-pital were used in this study. With a city population of approximately 4.5 million in 2001, Wuhan is the capital city of Hubei Province, The People’s Republic of China. Wuhan Children’s Hospital is the only comprehensive children’s hospital in Hubei Province and it has been ranked as one of the best children’s hospitals in China. Supported by approximately 700 medical staff and researchers, Wuhan Children’s Hospital provides a full range of clinical services and health promotion and prevention for children of Hubei and neighbouring provinces. The hospital currently has three outpatient departments and two inpatient buildings. It has 600 beds and treats approximately 30,000 inpatients and a total of 900,000 children at outpatient and emergency departments (ED) each year. According to the 2004 internal statistics from the Bureau of Health of Wuhan Municipality (unpublished data, 2005), Wuhan Children’s Hospital treats about 55% of total pediatric outpatient and ED cases in Wuhan city.
Data were extracted from the Wuhan Children’s Hospital’s medical records stored in the hospital information system. In this information system, medical records of all inpatients treated at the
injuries increased significantly from 1.6% (95% confidence interval [CI] = 1.2—2.1) in 1993 to 3.1% (95% CI = 2.7—3.6) in 2004 ( p < 0.05).
Conclusions: Hospitalisations for injuries from motor vehicle—pedestrian collisions at this large children’s hospital increased significantly in the past decade. These data underscore the need for additional research and a major concerted effort to prevent motor vehicle—pedestrian collisions among children in China.
Wuhan Children’s Hospital are reviewed by profes-sional International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and diag-nosis codes are assigned. The database has no limita-tion on the number of diagnosis codes that can be assigned; however, the majority of cases only have one to two diagnosis codes. One diagnosis code is used to depict the primary reason for hospitalisation, and for each patient hospitalised because of injury, an external cause of injury code (E-code) is used to describe the leading cause of the injury event.
The subjects of this study were children aged 18 years or less who were discharged as inpatients from the Wuhan Children’s Hospital with a discharge diagnosis of traumatic injury during 1993—2004. A researcher at the Wuhan Children’s Hospital’s Data Management Department obtained information on hospitalisations for children aged 18 years or less from the Hospital Information System. All personal identifiers were then deleted and the de-identified data were transferred to researchers at the School of Public Health, Tongji Medical College, Wuhan, for this research study. Using the ICD-9-CM injury diag-nosis codes of 800—959,30a total of 13,372 injury-related hospitalisations among children aged 18 years or less during 1993—2004 were identified. The completeness of the records was determined and 433 records with missing E-codes were excluded. Thus, the final data included 12,939 child-hood injury hospitalisations.
Injury case definition
This study analysed all childhood injuries from motor vehicle traffic crashes, which were identified by ICD-9-CM E-codes = E810—E819. Injuries from motor vehicle—pedestrian collisions (E814) were the focus of this study. The ICD-9-CM definition of a pedestrian in a motor vehicle—pedestrian collision is ‘‘any person involved in an accident who was not at the time of the accident riding in or on a motor vehicle, railroad train, streetcar, animal-drawn or other vehicle, or on a bicycle or animal.’’
Data were analysed with SAS Statistical Software (SAS Institute Inc., Cary, NC).27 We first examined characteristics of injuries from motor vehicle traffic crashes. Then, the trends of all injuries, injuries from motor vehicle traffic crashes, and injuries from motor vehicle—pedestrian collisions were assessed. We then calculated the proportion of injuries from motor vehicle—pedestrian collisions among all hos-pitalisations for childhood injuries for each year from 1993 to 2004.
We conducted statistical significance tests to compare difference between motor vehicle—pedes-trian collision injuries and all other motor vehicle traffic injuries by gender, age, severity of injury, and outcomes of injury (Chi-square test), and by length of stay at the hospital (t-test). In all analyses, a two-sided p-value of <0.05 was considered statistically significant.
Figure 1 Hospital discharges for all injuries and for motor vehicle traffic-related injuries, Wuhan Children’s Hospital, China, 1993—2004. Note: Data are plotted on the log scale. Source: Wuhan Children’s Hospital Information System.
A total of 12,939 injury-related hospitalisations among children admitted to Wuhan Children’s Hospi-tal were identified and analysed for the study period. Injury-related hospitalisations accounted for approxi-mately 4—5% of all hospitalisations each year among children aged 18 years or less.Fig. 1illustrates the changes in hospital charges over time for all injuries and for motor vehicle traffic-related injuries. From 1993 to 2004, the total number of discharges for all injuries increased by 54.7%, from 805 cases in 1993 to 1245 cases in 2004. The total number of discharges for motor vehicle traffic-related injuries increased by 37.0%, from 46 cases in 1993 to 63 cases in 2004. The total number of discharges for motor vehicle— pedestrian collisions increased by 200%, from 13 cases in 1993 to 39 cases in 2004.
Of all 528 injuries caused by motor vehicle traffic crashes from 1993 to 2004, distribution of these injuries by age, gender, severity of injury, length of stay, and discharge outcomes were analysed and
results are shown in Table 1. The majority of the injured patients were males (59.7% of injuries from motor vehicle—pedestrian collisions and 58.6% of injuries from other motor vehicle traffic crashes). More than half of the injuries from motor vehicle traffic crashes occurred to children aged less than 6 years (58.2% of injuries from motor vehicle—pedes-trian collisions and 63.1% of injuries from other motor vehicle traffic crashes). Approximately one-third of the injuries occurred to children aged 6—11 years; however, a higher proportion of motor vehi-cle—pedestrian collision injuries occurred to chil-dren aged 12—15 years (8.6%) compared with other motor vehicle traffic injuries occurred in this age group (2.9%).
A higher proportion of motor vehicle—pedestrian collision injuries than other motor vehicle traffic injuries were diagnosed as severe at the admission (10.2% versus 6.9%, respectively), even though the difference was not statistically significant (X2= 1.637, p-value = 0.44). Furthermore, motor vehicle—pedestrian collision injuries resulted in
sig-Table 1 Characteristics of motor vehicle traffic-related injuries treated inpatient at Wuhan Children’s Hospital, China, 1993—2004
Selected characteristics Type of injury
Motor vehicle—pedestrian collision injuries
Other motor vehicle traffic-related Injuries
Total motor vehicle traffic injuries N = 325 (%) N = 203 (%) N = 528 (%) Gender Male 194 (59.7) 119 (58.6) 313 (59.3) Female 131 (40.3) 84 (41.4) 215 (40.7) X2= 0.06, p = 0.81 Age (years) <6 189 (58.2) 128 (63.1) 317 (60.0) 6—11 105 (32.3) 66 (32.5) 171 (32.4) 12—15 28 (8.6) 6 (2.9) 34 (6.5) 16—18 3 (0.9) 3 (1.5) 6 (1.1) X2= 7.06, p = 0.07 Severity of injury at admission
Mild 49 (15.1) 32 (15.8) 81 (15.3) Moderate 243 (74.7) 157 (77.3) 400 (75.8) Severe 33 (10.2) 14 (6.9) 47 (8.9) X2= 1.64, p = 0.44 Outcomes Full recovery 235 (72.3) 151 (74.4) 386 (73.2) Partial recovery 83 (25.5) 49 (24.1) 132 (25.0) Death 3 (0.9) 2 (1.0) 5 (0.9) Unknown 4 (1.3) 1 (0.5) 5 (0.9) X2= 0.90, p = 0.83 Length of stay (days)
Mean (S.D.) 19.4 (30.8) 14.3 (14.3) 17.4 (25.8)
t = 2.59, p = 0.05
Note: X2and t-test were used to compare motor vehicle—pedestrian collision injuries with all other motor vehicle traffic injuries. Source: Wuhan Children’s Hospital Information System.
nificantly longer lengths of stay in the hospital compared with other motor vehicle traffic injuries (19.4 days for motor vehicle—pedestrian collision injuries versus 14.3 days for other motor vehicle traffic injuries, t-test = 2.59, p-value < 0.05). More than two-thirds of the injured patients fully recov-ered when they were discharged from the hospital (73.2%) and only about 1.0% of the injuries resulted in death.
Fig. 2 shows the trend of injuries from motor vehicle—pedestrian collisions during the 12-year period from 1993 to 2004. The percentage of inju-ries from motor vehicle—pedestrian collisions among all hospitalisations for injuries increased significantly from 1.6% (95% confidence interval [CI] = 1.2—2.1) in 1993 to 3.1% (95% CI = 2.7—3.6) in 2004. The difference between percentage of injuries from motor vehicle—pedestrian collisions among all hospitalisations for injuries in 1993 and in 2004 was statistically significant with Z = 2.285 and p-value < 0.05.
The results of this study indicate that the proportion of injury-related hospitalisations from motor vehi-cle—pedestrian collisions among all injury-related hospitalisations at the Wuhan Children’s Hospital doubled from 1993 to 2004, with children aged less than 6 years having the highest number of these injuries. Our findings support the hypothesis that injuries from motor vehicle—pedestrian collisions admitted into this large comprehensive children’s hospital increased significantly during the past dec-ade.
Effective motor vehicle—pedestrian collision pre-vention approaches have been developed and stu-died in many developed nations as well as in a few developing countries.6,7,17,28,29,35 Among a variety of approaches, sidewalks, roadway barriers, and pedestrian crossing signs combined with clearly marked crosswalks and warning lights have shown the potential for a huge impact on preventing motor vehicle—pedestrian collisions.5—7,10,20,22 However, since most pedestrian safety engineering practices are based on experience in developed countries, a priority in developing countries is to identify ade-quate interventions according to epidemiologic characteristics of crashes, social culture context, and local land use.19 What has been found to be effective in a developed country may not necessa-rily work in a developing country such as China.
Prevention of motor vehicle—pedestrian colli-sions should also consider personal factors. A recent survey conducted among children aged 8—10 years in three big cities in China found that about 75% of children walked to school but only 30% did so under adult supervision.26Our findings that children aged less than 6 years accounted for more than half of the injury-related hospitalisations from motor vehicle— pedestrian collisions, which is inconsistent with previous studies26 and findings from developed nations,5,22 underscores the need to search for underlying local social factors. Lack of awareness of appropriate behaviours in traffic and of the hazardous play environment may be important con-tributors to motor vehicle—pedestrian collision inju-ries in the study region.
A recent survey in three big cities in China indi-cated that only 16.4% of parents have received any training in childhood injury prevention.26The ‘‘Walk
Figure 2 Percentage of injuries from motor vehicle—pedestrian collisions among all injuries treated inpatient, Wuhan Children’s Hospital, China, 1993—2004. Note: Y-axis denotes standard errors of percentage. Source: Wuhan Children’s Hospital Information System.
This Way’’ is a school-based education programme on child pedestrian safety that was initiated recently in China.26Such school-based child safety programmes likely will not reach parents of toddlers or children aged less than 6 years. Injury prevention and pedestrian safety education programmes tar-geting parents or caregivers of toddlers or young children should be developed and evaluated in China.
Interpretation of our results should take into consideration several limitations of the hospital discharge data and of our study. First, hospital discharge data used in our study came from only one large children’s hospital in China. Although Wuhan Children’s Hospital treats about 55% of all paediatric outpatient and ED cases in Wuhan, results from our study should not be used as a surveillance of motor vehicle—pedestrian collisions in the whole Wuhan city over the study period, nor should the data be considered as a probability sample of those injuries in Wuhan. However, our analysis is the first step in determining the morbidity and mortality from motor vehicle—pedestrian collisions in Wuhan and in all of China.
We did not obtain and analyse the total number of motor vehicles in Wuhan city during the study per-iod. It is almost impossible to obtain a reliable statistic of motor vehicles used in Wuhan city because motor vehicles from neighbouring cities or rural areas come to Wuhan city daily but they are not registered with the Bureau of Transportation of Wuhan Municipality. Furthermore, because our data came from one children’s hospital, we could not use those data to calculate the injury rates per 100,000 cars or per 100,000 miles travelled for the whole city. Third, the hospital discharge data at the Wuhan Children’s Hospital did not have standardised measurements of injury severity such as injury severity score, abbreviated injury severity scale, or glasgow coma scale score. We could only use the condition severity information provided by the attending physician at admission to classify injuries into mild, moderate, or severe categories; there-fore, the study was limited in measuring the injury severity of the injured patients.
Despite the limitations mentioned, our study is the first of its kind to conduct a comprehensive analysis of motor vehicle traffic injury-related hos-pitalisations at a large children’s hospital in China. We found that the proportion of injury-related hos-pitalisations from motor vehicle—pedestrian colli-sions among all injury-related hospitalisations increased significantly in the past decade. Although motor vehicle crashes currently are not the leading cause of non-fatal injuries among children in China, it is anticipated that injuries from motor vehicle—
pedestrian collisions will become a more common public health problem in China as significantly more families own motor vehicles and as roads get more crowded. This public health problem calls for a major concerted effort by government and all sta-keholders concerned with finding effective approaches to prevent motor vehicle—pedestrian collisions among children in China.
Human participant protection
De-identified data were prepared by the Wuhan Children’s Hospital for analyses that were con-ducted by researchers at School of Public Health, Tongji Medical College, Wuhan, China. The research data contained no personal identifiers, and no human subjects were involved in the study. Thus, no institutional review board approval was required for this secondary data analysis study.
Data analysis and preparation of the manuscript was supported in part by a research grant from the Centres for Disease Control and Prevention, the U.S. Department of Health and Human Services to Dr. Xiang (Grant #: R49CE00241-01). The views expressed here are those of the authors and do not necessarily reflect the official views of the Centres for Disease Control and Prevention.
We thank Sara Sinclair at the Centre for Injury Research and Policy, Columbus Children’s Research Institute for editing the manuscript.
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