Levels and Trends in Injury Mortality and Morbidity in by wvd19763

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									                Levels and Trends in Injury Mortality and Morbidity in Sweden Since 1978

                  by Leif Svanstr6m, Ph.D., Lars Berg, M.D., Anders ~berg, and Lothar Schelp


Abstract

Sweden has after the Second World War established itself as a Welfare State, with a high life expectancy. However
the reputation of a leading statistical system goes even further back. All citizens are covered in the national
population register, since 1749. Death diagnoses are known since 1911, but there are reports on mortality pattern
as early as in the late 18th century. The population is now 8,700,000, with 18 percent above 65 years of age.

Overall mortality has decreased substantially after the second world war. Injuries are the leading cause of death up
to 45 years of age. However the rate of fatal injuries has decreased from above 100 per 100,000 mean population
for men 1977 to 75 the year 1991. The corresponding figures for women are from 70 to 40. All types of injuries,
intentional as well as non- intentional, have decreased about the same, for both genders.

Forty people per 100,000 cars in traffic (14 per 100,000 population) were killed in traffic injuries the year 1975.
Corresponding figures 1992 were 19 (9 per 100,000 population). The number of work related fatal injuries were
around 400 in 1955, and in 1992 it was less than 80.

About I0 percent of hospital care is due to injuries. About 1/3 of care days for males and more than 1/2 for females
are caused by femoral fractures.

This means that there are new priorities above the traditional in injury prevention. A National Injury Prevention
Programme has been established since 7-8 years ago.


Background

Sweden has after the Second World War established itself as a Welfare State, with a high life expectancy. However
the reputation of a leading statistical system goes even further back. All citizens are covered in the national
population register, since 1749.

Life expectancy at current rates in Western Europe, the United States, Canada, Australia, New Zealand and Japan
exceeds 75 years; in Japan and the Scandinavian countries (and in some states of the United States such as Hawaii
and Minnesota) life expectancy for women is around 80 years. The most reliable data on mortality rates up to the
most advanced ages over a long period of time pertain to Sweden. Excellent data exists for Sweden since 1750;
"superlative" data have been achieved since 1895 (Vaupel and Lundstr6m 1993). Death diagnoses are known since
1911, but there are reports on mortality pattern as early as in the late 18th century.

The Swedish population is now 8,700,000. Twenty-four and six-tenths percent (1990) are below 20 years of age,
17.8 percent 65 and above. The projection for the year 2025 is 23.2 percent and 21 percent respectively.


Injury Mortality Trends

After heart disease and cancer injury is the most common cause of mortality, while in the age groups -45 years
injury is the number one cause of death. Looking at a long term perspective nonintentional injuries have been
increasing as a cause of death since the beginning of this century but has constantly decreased since 1971 (figure
1). However that development is basically due to the traffic mortality, while drownings has constantly decreased
and falls increased during this century.




                                                         5-1
Looking at a short term perspective there has been a decrease in the overall fatal injury rate from around 100 per
100,000 of mean population for males 1976 to 75 per 100,000 in 1991 (figure 2). Corresponding rates for females
are 70 per 100,000 and 40 per 100,000. Looking at causes for males all show a decrease during this period with
the exception of homicide, which however stays on a very low level (figure 3).

Suicide, falls and motor vehicle dominate as causes. For females there is a corresponding decrease of all causes,
however falls are by far the dominating cause of mortality (figure 4).

In general the current picture of mortality is for intentional injuries dominated by suicide. The non-intentional
injuries as a cause of death are dominated by falls, about 40 percent, motor vehicles and other traffic, about 30
percent, drownings, another 10 percent, while fire only causes 3 percent (figure 5).

Looking into some specific causes traffic injuries has decreased substantially both per population and per vehicles
(table 1). In 1975 40 persons per 100,000 vehicles were killed, 1992 the rate had decreased to 19. The
corresponding rates per 100,000 mean population were 14 and 9 respectively.

These rates places Sweden among the leading countries in the world together with Norway and Great Britain (table
2). There is a more intermediate group with Denmark, Italy and Finland, while countries like USA and France
shows the double rate. The bicycle injury rate is high but is now slowly decreasing (figure 6).

There is a remarkable decrease of work related fatal injuries (figure 7).

Fatal drownings are to 1/3 related to boats activities, 29 out of 167 are related to activities on ice or with
snowmobilesand only 18 of 167 are related to bathing (table 3). The figures have varied during the last decade from
145 to 203, with an average of 172.

In general there has been a remarkabledecrease of childhood injuries in Sweden. A comparison made by Bergman
and Rivara shows that USA and Sweden had the same injury mortality in the age group 5-14 years 1957-59 and
Sweden had a higher rate for age 1-4 years, while 30 years later Sweden showed a rate of 1/4 to 1/3 of that of USA
(figure 8).

Falls account to a major part of the mortal nonintentional injuries. Looking at trends (figure 9) for females as well
as for males (figure 10) there is a remarkable decrease from 1980 to 1986. This is explained by changes in coding
routines. However there seems to be a decrease for females from 1988 onwards, but an increase for males during
the same period.

Injury "Morbidity" Trends

Hospital discharge registers is the main source of information on injuries besides the mortality register. By far the
most dominating cause of hospital in-patient care due to non-intentional injuries is falls, 57 percent in 1988,
thereafter transport, 13 percent (figure 11). Actually about 1/3 of the hospital care days for males and more than
1/2 for females in Sweden were caused by femoral fractures (table 4).

There has since long been an increase iu the rate of non-intentional injuries leading to hospital care for females,
dominated by falls (figure 12). However there is now a levelling of, even a decrease. There is also a corresponding
development for males (figure 13).

Looking at hospital care due to intentional injuries shows that almost 60 percent are caused by suicide attempts and
20 percent by assaults (figure 14).

During the last 15-20 years there is a growing source of information on injuries through local surveillance systems
based on all kinds of doctor's and hospital visits. In table 5 are reported percent distribution of registered injuries




                                                         5-2
in two counties and one municipality. About 1/3 of injuries occur at home, 1/6 at transport, production/cormnerce
and sports environment respectively.

Looking at a similar surveillance in FalkOping 1978 (Schelp and SvanstrOm 1986) indicates an injury incidence in
total of 113 per 1,000 inhabitants and year out of which 27 per 1,000 are home injuries, 22 per 1,000 are work
related injuries and 9 per 1,000 are transport injuries. The surveillancesystem from Motala municipalityshows for
1983-84 that 38 percent of traffic-related injuries are caused by cyclists and another 29 percent by pedestrians
(figure 15). A similar study from LidkOping municipality 1984 shows that the dominating age group is 15-24
followed by 0-14 (table 6).

The study from the Motala surveillance system also shows that 40 percent of sports injuries are caused by soccer,
10 percent by basket/volleyball/handball and 10 percent by bandy and ice-hockey.


Summary and Conclusion

The rate of fatal injuries has do'teased from above 100 per 100,000 mean population for men 1977 to 75 the year
1991. The corresponding figures for women are from 70 to 40. All types of injuries, intentional as well as non-
intentional, have decreased about the same, for both genders.

Forty people per 100,000 cars in traffic (14 per 100,000 population) were killed in traffic injuries the year 1975.
Corresponding figures 1992 were 19 (9 per 100,000 population). The number of work related fatal injuries were
around 400 in 1955, in 1992 it was less than 80. Actually more people are now killed in bicycle injuries yearly than
at work!

About 10 percent of hospital care is due to injuries. About I/3 of care days for males and more than 1/2 for females
are caused by femoral fractures.

This means that there are new priorities than the traditional in injury prevention. A National Injury Prevention
Programme has been established since 7-8 years ago in order to formulate national targets and strategies as well
as to support regional and local preventive activities. There is also a priority to improve the quality of national,
regional and local registers and surveillance systems.


References

I.       Bergman AB and Rivara FP. Sweden's Experience in Reducing Childhood Injuries. Pediatrics 1991:88(1).

2.       Causes of Death 1987. Stockholm: Statistics Sweden, 1989.

3.       Causes of Death 1988. Stockholm: Statistics Sweden, 1991.

4.       Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

5.       Drowning statistics 1993. Stockholm: Press Information, Swedish IMe Saving Society, 1994.

6.       Hospital Discharge Registry. Stockholm: National Board of Health and Welfare, Centre for Epidemiology,
         1994.

     .   Lindqvist K. Towards Community-Based Injury Prevention. The Motala Model. Link~6ping: Link0ping
         University, Dept. of Community Medicine, 1993. Thesis.




                                                        5-3
 .    Schelp L and Svanstr6m L. One-Year Incidence of tlome Accidents in a Rural Swedish Municipality.
      Scand J Soc Med 1986;14:75-82.

 .    Strategies for a Safe Sweden. Stockholm: National Board of llealth and Welfare, 1991.

10.   Traffic Injuries 1991. Stockholm: Statistics Sweden, 1992.

11.   Vaupel J W and LundstrOm H. Longer Life Expectancy?: Evidence from Sweden of Reductions in
      Mortality Rates at Advanced Ages. Odense University, Denmark and Duke University, USA and Statistics
      Sweden. Manuscript. 1993.

12.   Work- related Injuries. Stockholm: Statistics Sweden, 1992.




                                                  5-4
Table 1. Fatal traffic injuries in Sweden 1975-1992, by 100 000 vehicles in traffic,
100 000 mean population and year. Source: Traffic Injuries 1991. Stockholm:
Statistics Sweden 1992.

                           Year
                           1975 1980 1985 1990 1992

Killed/100 000 veh               40     28      24   20     19

Killed/lO0 000 pop                14    10      10   9      9



Table 2. No. of killed in traffic injuries per 100 000 inhabitants in some selected
countdes, by year. Source: Traffic Injuries 1991. Stockholm: Statistics Sweden
1992.

                           Year
                           1975 1980 1985 1990

Norway                     13    9      10      8
Sweden                     14    10     10      9
GB                         12    11     9       9
Denmark                    16    13     15      12
Italy                      18    16     13      12
Finland                    19    12     11      13
USA                        21    22     18      18
France                     27    25     21      20




                                          5-5
Table 3. Number of fatal drownings in Sweden 1992, by cause and age. Source:
Drowning statistics 1993. Stockholm: Press Information, Swedish Life Saving
Society, 1994.


Cause             Children                      Adults               Total
                  0-4    5-9   10-14

Ice/
snowmobile        1      2     1                         25          29
Bathing           0      2     0                         16          18
Sport boats       0      0     2                         52          54
Vessels           0      0     0                         2           2
Other             6      0     1                         57          64

Total              7     4     4                         152         167




Table 4. Number of hospital discharges and care days caused by injuries in Sweden
1989, by diagnosis and gender. Source: Hospital Discharge Registry. Stockholm:
National Board of Health and Well, Centre for Epidemiology, 1994.

Diagnosis          Gender      No. discharges            No. care days       %

Scull fractures    M           2 846                     19 558
                   F           1 080                     8 400
Femoral fractures M            6 599                     196 069             31
                   F           18 117                    693 081             54
Other fractures    M           18 234                    181 319
                   F           21 292                    366 627
All other injuries M           38 796                    243 653
                   F           28 8 5 0                  209 285

Total             M            66 475                    640 599             100
                  F            69 339                    1 277 393           100




                                          5-6
Table 5. Injuries by environment in t w o Swedish counties and one
municipality. %- distribution. Source: Strategies for a Safe Sweden. Stockholm:
National Board of Health and Welfare, 1991.


Environment        Geographical area
                   Bohus county      Lidk6ping municip Viistmanland county

Transport          12                 16                 15
Home               37                 33                 29
Production/
Commerce           14                 20                 16
School               7                  7                11
Sport              15                 16                 18
Entertainment      3                  2                  4
Nature             6                  3                  3
Sea,lake etc       3                  1                  1
Other              2                  1                  3

Total              100                100                 100




Table 6. Traffic injuries in Lidk6ping, Sweden, 1984, by age group and gender. In
numbers, % and per 1 000 mean population/year. Source: Lindqvist K. Towards
Community- Based Injury Prevention. The Motala Model. Link6ping: Link6ping
University, Dept. of Community Medicine, 1993. Thesis.

Age           Gender     Total        %            Per 1 000 pop/year
              M    F

0-14          25   27     52          29           8
15-24         34   23     57          31           11
25-34         8    3      11          6            2
35-44         5    9      14          8            3
45-54         8    7      15          8            4
55-64         3    10     13          7            3
65-74         6    9      15          8            4
75-           3    2      5           3            2

Total         92   90     182          100         5




                                          5-?
 4000

 3500

 3000

 2500                                                                                                                            Total
                                     o


 2000

 1500
                                                         I                                                                       Drowning
 1000
                                                                                                           '~         ~-,        Traffic
   500
                                                                                       L
                 I         i             i         I         I         I           i       --   I
                                                                                                                  I          I   Fall
     0
           911       -21       -31           -41       -51       -61        -71        -81           -85        -86         -87
   SOURCE: Causes of Death 1987. Stockholm: Statistics Sweden, 1989.

Figure 1. Number of non-intentional injuries in Sweden 1911-87, by cause
and year



   110

   100

     90

    80
                                                                                                    ~ ' ~        Men
     70

    60
                                     \
    50

    40      .  .   .  , ,  ~-.    ~                  ,--~,Womon            ,,,,,,,,.~ ,''1
          76 77 78 79 80 81 82. 83 84 85 86 87 88 89 90 91
    SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

Figure 2. Fatal injuries in Sweden 1976-91, by gender and year. Rate year 100,000 of mean
population.




                                                                               5-8
            Motor vehicle           "-"!1- Alcohol poisoning        "~-        Falls
    - - O - - Other non-intentional ' - - 0 - Suicide                - '-'0- - Other
                                                                               intentional
    ~       Homicide
   32

   28
   24

   20
   16

   12

     8
    4

     0
         76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91
    SOURCE: Causesof Death 1991.Stockholm:StatisticsSweden,1993.

Figure 3. Fatal injuries in Sweden 1976-91, by cause and year. Rates per 100,000
of mean population. Males.


                 Motor vehicle           " - - I I - Alcohol poisoning " i l ' -    Falls
                   Other non-intentional ~        Suicide                 - " - e I'-- Other
         - - X - - Homicide                                                            intentional

  40
  35

  30

  25

  2O

   15

   10
    5
    0
      76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91
   SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.

Figure 4. Fatal injuries in Sweden 1976-91, by cause and year. Rates per 100,000
of mean population. Females.


                                                         5-9
                                                                                                      ....   1%
           Poisonir

    Other 10%



           Drownir
           etc. 9%                                                                                           pen fire 3%

                                                                                                             .~r traffic 5%
                    Mot . . . . . . . . . . . . . .

   SOURCE Causes of Death 1988. Stockholm: Statistics Sweden, 1991.

Figure 5. Fatal non-intentional in Sweden 1988, by cause. Number
(n=1804) and percent.




           .....        0-14              ---15-24               ----25-64                .....                     Total
                                                                                                  65 and
 4,5                                                                                              over
 4,0                                                                 I
                                                                         I',

                                                                               %
       m
 3,5
 3,0
 2,5                •    d                                                                 %      j


 2,0
 1,5   B




 1,0
 0,5
   0            I            I        I        i        I        I             I     ~"" I I  I  I
           78       79           80       81       82       83       84            85 86 87 88 89 90
  SOURCE: Traffic injuries 1991. Stockholm: Statistics Sweden, 1992.

Figure 6. Fatal bicycle injuries in Sweden 1978-90, by age group and year•
Rates per 100,000 of mean population




                                                                                   5-10
  450        B




  400        D




  350

  300

  250        B




  200        B




  150        m




  100        B




                 l   l   l       [        l       l          l   l   l   l   l   l    l    l     l     l      l   l   l   l   l   l   l    l   l   l   l   l   l   l   l   l    [   l    l   l   l   l
    50
         54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92
  SOURCE: Work-related Injuries. Stockholm: Statistics Sweden, 1992.

Figure 7. Number of work related fatal injuries in Sweden 1955-92, by year




  50                                                                                  : : :~i                                                                  Age
                                                                                                                                                               E] 1-4                   II       5-14
  40
                                                                                     •<:<iii

                                                                                     : / 71 ~C ;:~!:!
  30                         :. i:: :::~.:~:~i~i ::;i:~i::
                                                                                                  i< !
                                                                                     ~i!i i;~i!:i,~ii~~ii!i

  20

  10

    0    m

                              USA 57/59                                          Sweden 57/59                                             USA 86                               Sweden 86
  SOURCE: Bergman AB and Rivara FP. Sweden's Experience-in Reducing
  Childhood Injuries. Pediatrics 1991:88(1 ).


Figure 8. Fatal child injuries in USA and Sweden 1957-59 and 1986, by age
group and year. Rates per 100,000 of mean population




                                                                                                                                          ,5-11
               •--~-65-69             -N--75-79       ,..4-85-89              *         95 and over
   400         -o-70-74               .-a-80-84       .-.t~-90-94


   ooo

   60o

   2o0

    8oo           7

   4OO

      o
          78 79 80 81                 82 83 84 85 86 87 88 89 90 91

    SOURCE:Causes of Death1991.Stockholm:Statistics Sweden, 1993.


 Figure 9. Fatal injuries in Sweden due to falls 1978-91, by age group
 and year. Rates per 100,000 of mean population



                  -i-65-69                .~ 75-79                  85-90                   95 and over
   24002800~      --o-70-74             ,-a.- 80-84         ,..o... 90-94




   16oo

   1200

    800

    400
                      • o- - -
                      • ,. - -   __
                                 __               .                 " - '-.
                                                                    -             ,;o
                                                                                  ,;o



          78 79       80 8~1 82           83 84        85     86 87               88      89 90   91
    SOURCE: Causes of Death 1991. Stockholm: Statistics Sweden, 1993.


Figure 10. Fatal injuries in Sweden due to falls 1978-91, by age group and year.
Rates per 100,000 of mean population

                                                         5-12
                                                                                      57%

     Open fire 1%
         Machine
         etc 9 %
   Other traffic 3 c


                                                                                   "vehicle 10%
                 Othel       . . . . . . . . . . . . . .                        ~ 2%
   SQURCE: Hospital Discharge Registry. Stockholm: National Board of Health
   and Welfare, Centre for Epidemiology, 1994.


Figure 11. Hospital d i s c h a r g e s in S w e d e n d u e to n o n - i n t e n t i o n a l    injuries
1988, by c a u s e , n u m b e r ( n = 1 4 3 , 5 8 9 ) and p e r c e n t




    1400--                          -I-    Transport @           Poisoning ~           Falls

    1200--
    1000~.~                    4~"~
     8OO

     600

     400

     200     m
                   m
                   i
                         n
                         l
                               i
                               i
                                    I     iN
                                          --
                                                     m
                                                      I
                                                           i
                                                           |
                                                                  j
                                                                  m
                                                                       i
                                                                       m
                                                                            I
                                                                            m
                                                                                  m
                                                                                  --     |




        0
             ep-.,i-e,-.~-~ a ~ ~ = L ~ I           ~ ~ L ~--m--~. ~ ~ ~ , , ~ , ,           3
            78    79     80    81   82    83   84    85   86     87   88    89    90    91

  SOURCE: Hospital Discharge Registry. Stockholm: National Board of Health and Welfare,
  Centre for Epidemiology, 1994

Figure 12. Hospital discharges in Sweden due to non-intentional injuries 1978-91,
by cause and year. Rates per 100,000 of mean population




                                                          5-13
   900                        --I1"- Transport ~                          Poisoning ~          Falls
   800
   700
   600
   500
   400
                  m       m       I           m       Jim

   300    m       m       i       i       w



   200
    100
              I       I       I       |           I         I   i   I          I   I   I   I   I
      0
          78 79 80 81 82 83 84 85                                       86 87 88 89 90 91

  SOURCE: Hospital Discharge Registry. Stockholm: National Board of Health and Welfare,
  Centre for Epidemiology, 1994


Figure 1 3. Hospital discharges in Sweden due to non-intentional injuries 1978-91,
by cause and year. Rates per 100,000 of mean population




     Assault 20%
                                                                                                       58%




   Unknown 14%




   SOURCE: Hospital Discharge Registry. Stockholm:National Board of Health and
   Welfare, Centre for Epidemiology, 1994.


Figure 14. Hospital discharges in Sweden due to intentional injuries 1991,
by cause, number (n=14,069 and percent)



                                                                        5-14
                                                                          (38%)




                                                                         ssengers
                                                                         =(2%)

                                 Pedestrians (29%)

   SOURCE: Lindqvist K. Towards Community-Based Injury Prevention. The Motala
   Model. Link~ping: Link6ping University, Dept. of Community Medicine, 1993. Thesis.

Figure 15. Traffic injuries in Motala, Sweden 1983-84, by category and
percent (n=632)




                                               5-15

								
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