ViolenceViolence--related Injury Surveillance related Injury Surveillance
(VIS)(VIS)
Deep South, Thailand, 2007Deep South, Thailand, 2007
Vorasith Sornsrivichai, MD, PhD, FETP Cert.Epidemiology Unit,
Prince of Songkla University, Hat Yai, Thailand
http://medipe2.psu.ac.th/~vis , [email protected]
2
WHO Conceptual Definition of Violence, 2002
• The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community
• Results in or has a high likelihood of resulting in
– Injury & death
– Psychological harm
– Maldevelopment
– Deprivation
3
Thailand’s Deep South
• 3 southernmost provinces of Thailand: Yala, Pattani and Narathiwat
• 80% of the 1.8 million population are Muslim (most of Thailand's 4% Muslim minority)
• Muslim militants fought with the government up to the mid 1980s
4
What is the Deep South Situation?
• Deep South violence
erupted in January 2004
when an army depot was
raided, 400 M16 rifles
were stolen
• Widespread terrorist
attacks targeting on
symbols of authority
(police officer, soldier,
teacher) and civilian
5Source: Srisompob Jitpiromsri, Faculty of Political Sciences, Prince of Songkla University, Pattani Campus
> 800 Deaths
Number of Violence Events in
the 3 Southernmost Provinces, Thailand, 1993-2004
6 32 27 42 83 139 10732
114 82
1843
84
0
200
400
600
800
1000
1200
1400
1600
1800
2000
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Number
> 800 Deaths
6
Impact on Public Health
• During 2004-2007, there
were 5.4 violent events,
4.6 injured victims (1.8
dead) per day
• 3rd rank of DALYs
among men, 4th rank
among both genders in
2004
• Up to 2007 the recorded
direct victims are > 6,000
7
Violence-related Injury Surveillance
• Collaboration between Thailand Ministry of Public Health and Prince of Songkla University
• Implemented in January 2007
8
Objectives
• To monitor the magnitude and trend of violent events
• To identify risk factors of the victims
• To improve Emergency Medical Service (EMS) and referral system
• To allocate related public health resources
• To target the victim in need forhumanitarian relief
Method
• Setting: All (47) government hospitals
• Population under surveillance: The intentionally injured victims who underwent treatment or autopsy at the hospitals
• Data collection: By the hospital nurses
ResultsResults
Magnitude
• In 2007,
– 1,228 violent events (3.4 events/day)
– 2,362 injured persons (6.5 persons/day)
(70.8/100,000 population/year)
– 628 deaths (1.7 deaths/day)
(19.2/100,000 population/year)
• 2/3 of which died at the scene
– The case fatality rate (CFR) was 26.6%
1212
Trend of Events
VIS 2007 vs DSCC 2004-7
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VIS (��.( �/�� )0)
DSCC (all events)
VIS (hospital-based)
Month/Year
No
. o
f E
ve
nt
Jan 04 Jan 05 Jan 06 Jan 07 Jan 08
EventEvent
14
Time Distribution of Events
(VIS, 2007)
Songkhla
Pattani
Yala
Narathiwas
TotalTime
(HH:MM)
Province
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00:00 04:00 08:00 12:00 16:00 20:00
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SongkhlaPattani
Spot Map of
Violent Event
(VIS, 2007)Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
DecNarathiwas
Yala
Songkhla
Pattani
Most (27.8%) of the events occurred while the victims were engaged in work-related activities
Majority (59.9%) of the events
occurred
on the road
External Causes of Injury
• The ICD-10 external causes of injury were:
– “assault by other and unspecified firearm
discharge” (41.8%)
• CFR = 49.3%
– “assault by explosive material” (34.2%)
• CFR = 6.6%
VictimVictim
Characteristics of Victims
by Age Group, Gender & Religion
(VIS, 2007)
19
19
0 20 40 60 80 100 120 140 160 180 200 220 240 260 280 300 320
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
>75
Male
020406080100
Female IslamUnknownBuddhism
Years
Numbers
The majority of the victims were:
• Male (82.6%)
• Median age = 34 yrs (IQR 25-45 yrs)
• Buddhist (45.9%)
• Farmers (17.5%), soldiers (16.9%)
20
Area Map of
Violence-related Injury
(VIS, 2007)
Injury rate
/100,000/ month
Narathiwas
Yala
Songkhla
Pattani
No. of injured
cases/month
InjuryInjury
Emergency Medical Services (EMS)
• Transfer from place of occurrence to hospital – Median time = 30 minutes (inter quartile
range-IQR = 15-60 minutes)
– Pre-hospital CFR = 18.2%
• Refer between hospitals (n = 527 victims)– Median referral time was 50 minutes (IQR =
30-80 minutes)
– In hospital CFR = 10.3%
2323
Quality of Care during Transfer
VIS 2007
CareGood Not good Not done
No. % No. % No. %
Airway 90 12.3 10 1.4 634 86.4
Bleeding 169 15.7 41 3.8 869 80.5
CC--Spine CollarSpine Collar 30 5.7 3 0.6 496 93.8
Splint / Slab 51 7.3 12 1.7 635 91
IV fluid 68 8.3 5 0.6 743 91.1
2424
Quality of Care during Referral
VIS 2007
CareGood Not good Not done
No. % No. % No. %
Airway 233 95.1 4 1.6 8 3.3
Bleeding 432 96.4 9 2 7 1.6
CC--Spine CollarSpine Collar 27 51.9 1 1.9 24 46.2
Splint / Slab 145 84.3 3 1.7 24 14
IV fluid 361 96 3 0.8 12 3.2
Public Health Resource Burden
Median (IQR) Total
Length of stay* (day) 1 (1-3) 5,253
Direct medical cost** (Baht) 1,037 (230-4,329) 12,513,694
26
*Most were OPD cases **Data from 1,512 patients (64%)
27
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Comparison between District of
Occurrence(Acute Service)
& District of Victim’s Home
(Long-term Service)
Home address
Place of
Occurrence
28
Humanitarian Relief
• Up to 2006, estimated 20,000 dependants of the victim
• < 70% coverage of relief activity, thousands waiting for the essential support from the government
• PSU’s Deep South Coordination Center-DSCC(http://medipe2.psu.ac.th/~dscc/) was established in mid 2006 under the National Reconciliation Committee Fund to coordinate academic activities to support the victims & their dependants
29
Humanitarian Relief
• At DSCC, VIS data was linked withmilitary, police & media news clipping to create integrated database
• Then supplied to every hospital’s Mental Health Crisis Center to help its community psychologists & psychiatric nurses in identifying the people in need
30
Deep South Integrated Database
31
Humanitarian Relief
• Not only as essential rehabilitation/tertiary prevention, but also a reconciliation and peace making--it is a primary preventionfor the new generation of neglected person taking revenge
Multidisciplinary Cooperation
• Cooperation with Military College of Medicine to utilize VIS data to improve the high CFR (~ 30%) of soldiers
33
Multidisciplinary Cooperation
• The Deep South Watch project (http://www.deepsouthwatch.org) was set up by academics, rural doctors and the Thai Journalists Association to serve in the area of situation analysis, investigative journalism and balanced information for right understanding of the Deep South situation
34
www.deepsouthwatch.org
Deepsouth Bookazine
Vol.2
35
Conclusions
• VIS is used to improve violence-related health services and facilitate humanitarian relief
• However, the physical and psychosocial health burden of Deep South violence is enormous and increasing
• Multidisciplinary peace and reconciliation programs are urgently needed
3737© www.photosunday.com
Thank youThank you
ObrigadoObrigado
39
Any Room for the Academic?
• Health Care System Management in the Deep South Crisis Project in 2004-2008 (HSRI-PSU)
• Surveillance System Development in the Lower South of Thailand, 2005-2007 (MoPH)
Any Room for the Academic?
• 3 MSc theses (public health, pharmacy, nursing)
• 2 PhD theses (epidemiology, economic)
• 3 Practicum (2 FETP, 1 MSc in peace study & conflict management)
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Injury Surveillance – VIS, January – May 2005)
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2 publications in national MMWR-like journal
Any Room for the Academic?
• Panel discussion “Trans-Pacific Case Studies:
Experience from Thailand's Deep South
Violence” in APRU World Institute Workshop
“The Role of Universities in Addressing
Emerging Public Health Threats in the Asia
Pacific Region” April 2007, China
• Oral presentation “Man-made Disaster:
Violence in the Deep South of Thailand” in
“Public-Private Mix: a Public Health Fix?
Strategies for Health Sector Reform in South
and Southeast Asia” June 2007, Thailand
44
httphttp://://medipe2medipe2..psupsu..acac..thth//~vis~vis
45
VIS Web 2.0 MindMap(http://medipe2.psu.ac.th/~vis/mindmap)
45
46
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VIS Web 2.0 MindMap(http://medipe2.psu.ac.th/~vis/mindmap)
47
VIS Web 2.0 WebStat: http://medipe2.psu.ac.th/~vis/webstat
47
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How Do Epidemiologists Get Involved?
• A survey conducted in Mid 2004 showed little effect on health care service, however 85-98% of local health professions were concerned most about their security
• So far, 28 health care officers were attacked (9 dead) 12 health centers and 10 health center officer’s houses were burned down, 5 hospitals were shot/bombed/mobbed
50
• A group of volunteer epidemiologist, rural doctor & Medecins Sans Frontieres (MSF) developed a package of security preparedness in the health care setting
• We subsequently cooperated with Military College of Medicine in development of Incidence Action Plan and Emergency Incident Command System
How Do Epidemiologists Get Involved?
51
Online Security &
Safety Resourcehttp://medipe.psu.ac.th/
security&safety/
What’s Next?
• Collaboration with WHO Collaboration Centre for Research on the Epidemiology of Disasters, Belgium (CRED) and Karolinska Institute, Sweden to study impact from Deep South violence on public health system
• Method
– Secondary data linkage
– Comparative analysis: before VS after, high VS low violence area
– Associative analysis
What’s Next?
Public health system indicators
1. Surveillance system: coverage, completeness, validity and timeliness of notifiable disease surveillance system
2. Disease prevention: vaccine coverage, vaccine management system
3. Disease control: TB’s cure rate, default rate; Malaria’s active case finding, residual spray
4. Health care service utilization: inpatient hospitalization,length of stay, direct medical cost
5. Burden of disease: TB, malaria, vaccine preventable disease incidence, DALY of violence-related injury
55