Further evidence of misclassification of the injury deaths in South Africa: When will the barriers to accurate injury death statistics be removed?

BACKGROUND: Contrary to the World Health Organization's internationally recommended medical certificate of cause of death, the South African (SA) death notification form (DNF) does not allow for the reporting of the manner of death to permit accurate coding of external causes of injury deaths. OBJECTIVES: To describe the injury cause-of-death profile from forensic pathology records collected for the National Cause-of-Death Validation (NCoDV) Project and compare it with profiles from other sources of injury mortality data. In particular, the recording of firearm use in homicides is compared between sources. METHODS: The NCoDV Project was a cross-sectional study of deaths that occurred during a fixed period in 2017 and 2018, from a nationally representative sample of 27 health subdistricts in SA. Trained fieldworkers scanned forensic records for all deaths investigated at the forensic mortuaries serving the sampled subdistricts during the study period. Forensic practitioners reviewed the records and completed a medical certificate of cause of death for each decedent. Causes of death were coded to the International Statistical Classification of Diseases, 10th revision (ICD-10), using Iris automated coding software. Cause-specific mortality fractions for injury deaths were compared with Injury Mortality Survey 2017 (IMS 2017) and Statistics South Africa 2017 (Stats SA 2017) datasets. The cause profile for all firearm-related deaths was compared between the three datasets. RESULTS: A total of 5 315 records were available for analysis. Males accounted for 77.6% of cases, and most decedents were aged between 25 and 44 years. Homicide was the leading cause of death (34.7%), followed by transport injuries (32.6%) and suicide (14.7%). This injury cause profile was similar to IMS 2017 but differed markedly from the official statistics, which showed markedly lower proportions of these three causes (15.0%, 11.6% and 0.7%, respectively), and a much higher proportion of other unintentional causes. Investigation of firearm-related deaths revealed that most were homicides in NCoDV 2017/18 (88.5%) and IMS 2017 (93.1%), while in the Stats SA 2017 data, 98.7% of firearm deaths were classified as accidental. Approximately 7% of firearm-related deaths were suicides in NCoDV 2017/18 and IMS 2017, with only 0.3% in Stats SA 2017. CONCLUSION: The official cause-of-death data for injuries in SA in 2017 differed substantially from findings from the NCoDV 2017/18 study and IMS 2017. Accurate data sources would ensure that public health interventions are designed to reduce the high injury burden. Inclusion of the manner of death on the DNF, as is recommended internationally, is critically important to enable more accurate, reliable and valid reporting of the injury profile.

South Africa's male homicide epidemic hiding in plain sight: exploring sex differences and patterns in homicide risk in a retrospective descriptive study of postmortem investigations.

Background: South Africa has homicide rates six times the global average, predominantly among men, but little is known about male victims. As part of the country's first ever study of male homicide we compared 2017 male and female victim profiles for selected covariates, against global averages and previous estimates for 2009. Methods: We conducted a retrospective descriptive study of routine data collected through postmortem investigations, calculating age-standardised mortality rates for manner of death by age, sex and province and male-to-female incidence rate ratios with 95% confidence intervals. We then used generalised linear models and linear regression models to assess the association between sex and victim characteristics including age and mechanism of injury (guns, stabs and blunt force) within and between years. Findings: 87% of 19,477 homicides in 2017 were males, equating to seven male deaths for every female, with sharp force and firearm discharge the most common external causes. Rates were higher among males than females at all ages, and up to eight times higher among males aged 15-44 years. Provincial rates varied overall and by sex, with the highest comparative risk for men vs. women in the Western Cape Province (11.4 males for every 1 female). Male homicides peaked during December and were highest on weekends, underscoring the prominent role of alcohol as a risk factor. Significantly more males tested positive for alcohol than females. Interpretation: The massive, disproportionate and enduring homicide risk borne by adult South African men highlights the negligible prevention response. Only through challenging the normative perception of male invulnerability can we begin to address the enormous burden of violence impacting men. There is an urgent need to address the insidious effect of such societal norms alongside implementing structural interventions to overcome the root causes of poverty and inequality and better control alcohol and firearms. Funding: South African Medical Research Council and Ford Foundation.

Overview.

BACKGROUND: South Africa (SA) faces multiple health challenges. Quantifying the contribution of modifiable risk factors can be used to identify and prioritise areas of concern for population health and opportunities for health promotion and disease prevention interventions. OBJECTIVE: To estimate the attributable burden of 18 modifiable risk factors for 2000, 2006 and 2012. METHODS: Comparative risk assessment (CRA), a standardised and systematic approach, was used to estimate the attributable burden of 18 risk factors. Risk exposure estimates were sourced from local data, and meta-regressions were used to model the parameters, depending on the availability of data. Risk-outcome pairs meeting the criteria for convincing or probable evidence were assessed using relative risks against a theoretical minimum risk exposure level to calculate either a potential impact fraction or population attributable fraction (PAF). Relative risks were sourced from the Global Burden of Disease, Injuries, and Risk Factors (GBD) study as well as published cohort and intervention studies. Attributable burden was calculated for each risk factor for 2000, 2006 and 2012 by applying the PAF to estimates of deaths and years of life lost from the Second South African National Burden of Disease Study (SANBD2). Uncertainty analyses were performed using Monte Carlo simulation, and age-standardised rates were calculated using the World Health Organization standard population. RESULTS: Unsafe sex was the leading risk factor across all years, accounting for one in four DALYs (26.6%) of the estimated 20.6 million DALYs in 2012. The top five leading risk factors for males and females remained the same between 2000 and 2012. For males, the leading risks were (in order of descending rank): unsafe sex; alcohol consumption; interpersonal violence; tobacco smoking; and high systolic blood pressure; while for females the leading risks were unsafe sex; interpersonal violence; high systolic blood pressure; high body mass index; and high fasting plasma glucose. Since 2000, the attributable age-standardised death rates decreased for most risk factors. The largest decrease was for household air pollution (-41.8%). However, there was a notable increase in the age-standardised death rate for high fasting plasma glucose (44.1%), followed by ambient air pollution (7%). CONCLUSION: This study reflects the continued dominance of unsafe sex and interpersonal violence during the study period, as well as the combined effects of poverty and underdevelopment with the emergence of cardiometabolic-related risk factors and ambient air pollution as key modifiable risk factors in SA. Despite reductions in the attributable burden of many risk factors, the study reveals significant scope for health promotion and disease prevention initiatives and provides an important tool for policy makers to influence policy and programme interventions in the country.

Estimating the changing burden of disease attributable to interpersonal violence in South Africa for 2000, 2006 and 2012.

BACKGROUND: South Africa (SA)'s high rate of interpersonal violence persists as a leading public health problem for the country. The first South African Comparative Risk Assessment Study (SACRA1) in 2000 quantified the long-term mental and physical health burden attributable to interpersonal violence by supplementing the direct injury burden of disease attributable to interpersonal violence injuries with the substantial contribution of mental health, behavioural and reproductive health consequences accruing from exposure to intimate partner violence (IPV) and child sexual abuse. OBJECTIVES: To revise and improve these estimates by including the additional burden from other forms of child maltreatment, community violence, sexual violence by non-partners, and bullying victimisation in SA for 2000, 2006 and 2012, and trends over time. METHODS: We used comparative risk assessment methods to calculate population attributable fractions (PAFs) for interpersonal violence. This method requires inputs on the prevalence of exposure to the interpersonal violence risk factor subtypes, namely child maltreatment, bullying, IPV, sexual violence by non-partners and other community violence; the burden of related health outcomes (mortality and morbidity); and relative risks of health outcomes in individuals exposed to the risk factor v. those unexposed. We estimated the PAF for the combinations of all interpersonal violence subtypes together to estimate the burden attributable to interpersonal violence overall for 2000, 2006 and 2012. RESULTS: Between 2000 and 2012, there was a decrease in interpersonal violence age-standardised attributable death rates from 100 to 71 per 100 000. In the second South African Comparative Risk Assessment Study (SACRA2), estimates of the attributable disability-adjusted life years (DALYs) for interpersonal violence for the year 2000 were revised, from 1.7 million to 2 million DALYs, taking into account attributable mortality and disability from additional forms of violence. There was a decrease in DALYs attributable to interpersonal violence from 2 million in 2000 to 1.75 million in 2012, accounting for 8.5% of the total burden for SA, ranking second highest, after unsafe sex, among 18 risk factors evaluated in 2012. CONCLUSION: Overall, interpersonal violence-attributable DALYs decreased substantially but remain high. The reduction in age-standardised attributable death rates indicates that some policy and social intervention aspects are effective. Further strengthening of existing laws pertaining to interpersonal violence, and other prevention measures, are needed to intensify the prevention of violence, particularly gender-based violence. Additional forms of violence included in this analysis have improved our understanding of the interpersonal violence burden, but the attributable burden in males, although exceedingly high, remains an underestimate. There is a need to improve the epidemiological data on prevalence and risks for the different types of interpersonal violence, particularly for males.

Non-fatal injuries among boys and girls presenting to Red Cross War Memorial Children's Hospital, Cape Town, South Africa.

BACKGROUND: In South Africa (SA), road traffic injuries, homicides and burns are the leading causes of injury-related deaths among children. Injury-related deaths are well documented for SA, but this is not the case for non-fatal injuries. OBJECTIVES: To describe the non-fatal injuries sustained among children aged 0 - 13 years, to identify any significant sex differences by age group, cause of injury, admission status and injury severity. METHODS: The trauma unit database from 1997 to 2016 at Red Cross War Memorial Children's Hospital, Cape Town, was utilised for this analysis. The prevalence of injuries and the boy/girl ratios with 95% confidence intervals (CIs) were reported. RESULTS: Analysis indicated significant differences by sex for individual injury causes (transport, assault, burns, falls and other injuries), age group, injury severity and admission status. Moderately severe injuries were largely caused by burns, while severe injuries were mostly transport related. Boys had significantly higher proportions of all injury causes. The boy/girl ratio was lowest for assault (1:18), where significantly more girls aged 1 - 3 and 4 - 6 years were injured. Rape/sexual assault was 5.5 times higher for girls, with a significantly higher proportion of moderate-severity injuries (87%; 95% CI 84.7 - 89.4). CONCLUSION: The study findings call for a more targeted prevention response for boy and girl children. Interventions should be targeted at the prevention of burns, traffic collisions and interpersonal violence, in particular sexual assaults against girls.

Utility of crime surveys for Sustainable Development Goals monitoring and violence prevention using a public health approach.

The Sustainable Development Goals (SDGs) have highlighted interpersonal violence and violence against women and girls as impediments to development globally. South Africa is adversely affected by violence and injury. The annual Victims of Crime Survey (VoCS) provides a potentially useful source of complementary data to bolster vital registration and police crime statistics, but it may not provide data that are sufficiently accurate and reliable to inform prevention efforts. We conducted a critical assessment of the VoCS's methodological robustness and strength as a data source for high-level analyses, adopting a public health and SDGs monitoring perspective that was based on expert opinion and comparison with other data sources. We concluded that either the survey methods should be improved to provide findings that are better aligned with the SDGs agenda and are robust enough to inform high-quality research and prevention, or the funds used to conduct the VoCS should be redirected to other more suitable instruments.

Reducing homicide through policy interventions: The case of gun control.

Injuries impose a fourth major disease burden on the South African population, which is driven in particular by the high incidence of interpersonal violence. There was a significant decline in mortality from interpersonal violence between 1997 and 2012, and research conducted by South African Medical Research Council (SAMRC) researchers has ascribed much of this decline to a decrease in firearm homicide. In the present brief review, we summarise South African research on fatal and non-fatal firearm injuries, with a particular focus on research conducted by SAMRC intra- and extramural units between 1969 and 2019. More recent data suggest a lapse in firearm control that has led to an increase in homicide and that the fluctuating homicide rate is being influenced by adherence to firearm control policies.

A retrospective time trend study of firearm and non-firearm homicide in Cape Town from 1994 to 2013.

BACKGROUND: Gunshot injuries from interpersonal violence are a major cause of mortality. In South Africa (SA), the Firearms Control Act of 2000 sought to address firearm violence by removing illegally owned firearms from circulation, stricter regulation of legally owned firearms, and stricter licensing requirements. Over the last few years, varied implementation of the Act and police corruption have increased firearm availability. OBJECTIVES: To investigate whether changes in firearm availability in SA were associated with changes in firearm homicide rates. METHODS: This was a retrospective time trend study (1994 - 2013) using postmortem data. Time trends of firearm and non-firearm homicide rates were analysed with generalised linear models. Distinct time periods for temporal trends were assigned based on a priori assumptions regarding changes in the availability of firearms. RESULTS: Firearm and non-firearm homicide rates adjusted for age, sex and race exhibited different temporal trends. Non-firearm homicide rates either decreased or remained stable over the entire period. Firearm homicide increased at 13% annually from 1994 through 2000, and decreased by 15% from 2003 through 2006, corresponding with changes in firearm availability in 2001, 2003, 2007 and 2011. A 21% annual increase in firearm homicide after 2010 coincided with police fast-tracking new firearm licence applications. Cape Town's coloured population experienced a significantly greater increase than other population groups following additional exposure to illegal firearms from 2007. CONCLUSIONS: The strong association between firearm availability and homicide, and the reversal of a decreasing firearm homicide trend during a period of lax enforcement, provide further support for the association between reduced firearm homicide and stricter regulation.

Preoperative fasting times: Prescribed and actual fasting times at Universitas Hospital Annex, Bloemfontein, South Africa.

BACKGROUND: Guidelines recommend a preoperative fasting period of 6 hours for solid food and 2 hours for clear fluids. Because of fixed meal times and imprecise operation starting times, patients often fast for an extended period of time. OBJECTIVE: To investigate the prescribed preoperative fasting times, and the actual duration of fasting, compared with the internationally accepted fasting times for solid food and clear fluids. METHODS: Patients (N=105) aged 14 - 60 years, who were scheduled for elective surgery in the morning session (list starting time 07h00), were included in this prospective study. On arrival in theatre, all patients were asked when they last ate and drank. Anaesthetic records were used to determine the prescribed fasting times and operation starting times. RESULTS: For solids, patients were most frequently prescribed to start fasting from 22h00 to 00h00 (53.3% and 39.1%, respectively). No patient fasted <8 hours. The median duration of fasting was 14 hours and 45 minutes (range 9 hours and 45 minutes - 19 hours and 5 minutes). For fluids, patients were most frequently prescribed to start fasting from 05h00 (46.7%), 00h00 (27.6%) and 22h00 (7.6%). In practice, no patient ingested fluids after 22h30 or <9 hours preoperatively. The median fasting time for oral fluids was 13 hours and 25 minutes (range 9 hours and 37 minutes - 19 hours and 5 minutes). CONCLUSION: Most patients started fasting too early preoperatively, consequently withholding food and oral fluids for longer than recommended. An increased awareness regarding complications of unnecessarily long fasting times, and interventions to correct this problem, is required.

Preoperative fasting times: Prescribed and actual fasting times at Universitas Hospital Annex, Bloemfontein, South Africa

Background. Guidelines recommend a preoperative fasting period of 6 hours for solid food and 2 hours for clear fluids. Because of fixed meal times and imprecise operation starting times, patients often fast for an extended period of time.Objective. To investigate the prescribed preoperative fasting times, and the actual duration of fasting, compared with the internationally accepted fasting times for solid food and clear fluids.Methods. Patients (N=105) aged 14 - 60 years, who were scheduled for elective surgery in the morning session (list starting time 07h00), were included in this prospective study. On arrival in theatre, all patients were asked when they last ate and drank. Anaesthetic records were used to determine the prescribed fasting times and operation starting times. Results. For solids, patients were most frequently prescribed to start fasting from 22h00 to 00h00 (53.3% and 39.1%, respectively). No patient fasted <8 hours. The median duration of fasting was 14 hours and 45 minutes (range 9 hours and 45 minutes - 19 hours and 5 minutes). For fluids, patients were most frequently prescribed to start fasting from 05h00 (46.7%), 00h00 (27.6%) and 22h00 (7.6%). In practice, no patient ingested fluids after 22h30 or <9 hours preoperatively. The median fasting time for oral fluids was 13 hours and 25 minutes (range 9 hours and 37 minutes - 19 hours and 5 minutes).Conclusion. Most patients started fasting too early preoperatively, consequently withholding food and oral fluids for longer than recommended. An increased awareness regarding complications of unnecessarily long fasting times, and interventions to correct this problem, is required

Validating homicide rates in the Western Cape Province, South Africa: Findings from the 2009 Injury Mortality Survey.

BACKGROUND: The Western Cape Province had the highest homicide rates in South Africa during the early 2000s. South African Police Service (SAPS) data suggested a significant decline in homicide rates in the Western Cape since 2007. It ranked second highest to the Eastern Cape Province until 2013 and ranked highest again at 52.1/100 000 in 2015. A recent national injury mortality survey offers an alternative data source to assess whether the decline in homicide rates in the Western Cape was real. METHODS: A retrospective record review of autopsies was conducted from 45 state mortuaries in eight provinces for 2009. In addition, mortality data for the Western Cape were sourced from the Provincial Injury Mortality Surveillance System. Age-standardised mortality rates and crude homicide rates per 100 000 population were calculated to compare with the SAPS crude rates. RESULTS: Our study found that the Western Cape had a provincial age-standardised homicide rate of 40.1/100 000 in 2009 and ranked fourth highest among the nine provinces. The crude homicide rate of 43/100 000 for the Western Cape was similar to the SAPS provincial homicide rate of 42.4/100 000. The Northern Cape Province was the only notable exception to our provincial homicide rate ranking comparison with the SAPS for 2009. CONCLUSIONS:  Conclusions. The Western Cape is fortunate to have alternative data sources to monitor trends in homicides over time. The latest release of the 2014/2015 SAPS crime statistics should be assessed in a similar manner, with a more recent data source, to validate accuracy of the provincial rates on a regular basis.

Improved and standardized method for assessing years lived with disability after injury.

OBJECTIVE: To develop a standardized method for calculating years lived with disability (YLD) after injury. METHODS: The method developed consists of obtaining data on injury cases seen in emergency departments as well as injury-related hospital admissions, using the EUROCOST system to link the injury cases to disability information and employing empirical data to describe functional outcomes in injured patients. FINDINGS: Overall, 87 weights and proportions for 27 injury diagnoses involving lifelong consequences were included in the method. Almost all of the injuries investigated (96-100%) could be assigned to EUROCOST categories. The mean number of YLD per case of injury varied with the country studied. Use of the novel method resulted in estimated burdens of injury that were 3 to 8 times higher, in terms of YLD, than the corresponding estimates produced using the conventional methods employed in global burden of disease studies, which employ disability-adjusted life years. CONCLUSION: The novel method for calculating YLD after injury can be applied in different settings, overcomes some limitations of the method used to calculate the global burden of disease, and allows more accurate estimates of the population burden of injury.

Single crystal structure and molecular dynamics analysis of a myo-inositol derivative.

The crystal structure of 5-O-tert-butyldimethylsilyl-3,4-O-carbonyl-1,2-O-cyclohexylidene-2-oxo-3-oxa-4-bornanylcarbonyl-D-myo-inositol has been studied by single-crystal X-ray diffraction at both room temperature and 173 K. At room temperature, the tert-butyldimethylsilyl group exhibits dynamical disorder. A molecular dynamics simulation was used to model the disorder and this indicates that the group librates between two stable conformations in the crystal. Approximate relative energies of the different forms and energy barriers for the transition were obtained by empirical force field methods. Calculations of the thermal motion of the atoms are in good qualitative, but fair to poor quantitative agreement with the X-ray data.

Resistance of Eisenia fetida (Oligochaeta) to cadmium after long-term exposure.

The reliance on earthworms as test organisms in risk assessment studies of polluted environments raises the question whether they can evolve resistance, e.g., by adaptation to specific toxicants. Protection criteria may be biased if sensitivity data from adapted populations are used. Increased resistance to the heavy metal cadmium has not yet been determined for terrestrial Oligochaeta. Eisenia fetida was exposed to a sublethal concentration of cadmium sulfate for more than 10 generations. Clitellate worms from this culture were used in experiments to determine the extent of possible tolerance for the heavy metal. Preexposed animals as well as worms with no previous history of exposure to cadmium were exposed to a control substrate without cadmium and also to two substrates with 600 and 1200 microg g-1 cadmium. Changes in biomass, cocoon production, and hatching success were monitored. The results obtained indicated that in both substrates in which cadmium was present the preexposed worms performed better than the unexposed worms with respect to growth rate but not reproductively. In the substrate without cadmium the preexposed worms exhibited signs of poisoning after a few weeks. Preexposed and unexposed worms were also exposed to concentrations of 1500 to 4000 microg g-1 cadmium sulfate in an artisol medium for a period of 2 weeks. The preexposed worms survived higher concentrations of cadmium than the unexposed group and some specimens from the unexposed group had a gross increase in body fluids. It is concluded that worms with a long-term history of exposure to the metal developed resistance to cadmium.