Abstract
Objective
To assess the availability and quality of global death registration data used for estimating injury mortality.
Methods
The completeness and coverage of recent national death registration data from the World Health Organization mortality database were assessed. The quality of data on a specific cause of injury death was judged high if fewer than 20% of deaths were attributed to any of several partially specified causes of injury, such as “unspecified unintentional injury”.
Findings
Recent death registration data were available for 83 countries, comprising 28% of the global population. They included most high-income countries, most countries in Latin America and several in central Asia and the Caribbean. Categories commonly used for partially specified external causes of injury resulting in death included “undetermined intent,” “unspecified mechanism of unintentional injury,” “unspecified road injury” and “unspecified mechanism of homicide”. Only 20 countries had high-quality data. Nevertheless, because the partially specified categories do contain some information about injury mechanisms, reliable estimates of deaths due to specific external causes of injury, such as road injury, suicide and homicide, could be derived for many more countries.
Conclusion
Only 20 countries had high-quality death registration data that could be used for estimating injury mortality because injury deaths were frequently classified using imprecise partially specified categories. Analytical methods that can derive national estimates of injury mortality from alternative data sources are needed for countries without reliable death registration systems.
الملخص
الغرض
تقدير مدى توافر وجودة المعطيات العالمية المتعلقة بتسجيل الوفيات، والتي تستخدم لتقدير معدلات الوفيات الناجمة عن الإصابات.
الطريقة
تم تقييم مدى الاكتمال والتغطية بأحدث المعطيات الوطنية المتعلقة بتسجيل الوفيات، وهي المعطيات المتوافرة في قاعدة معطيات منظمة الصحة العالمية حول معدلات الوفيات. وتعتبر جودة المعطيات الخاصة بسبب معين للوفاة الناجمة عن الإصابات، عالية إذا ما عزيت نسبة تقل عن 20% من الوفيات إلى أي من الأسباب العديدة والمحدَدة جزئياً للإصابات، مثل "الإصابة غير المقصودة وغير المحددة".
الموجودات
توافرت أحدث معطيات تسجيل الوفيات لـ 83 بلداً، مشكلة بذلك 28% من إجمالي سكان العالم، واشتملت على غالبية البلدان ذات الدخل المرتفع، ومعظم بلدان أمريكا اللاتينية، وعدد من بلدان آسيا الوسطى وجزر الكاريبي. وكانت الفئات المستخدمة والأكثر شيوعا للأسباب الخارجية والمُحدَدة جزئياً للإصابة المفضية للوفاة تشمل " نية غير محددة"، و "آلية غير محددة لإصابة غير مقصودة"، و"إصابة غير محددة على الطريق"، و"آلية غير محددة لجرائم القتل". ولقد اقتصرت المعطيات العالية الجودة على 20 بلداً فقط، ورغم ذلك، وبسبب احتواء الفئات المُحددَة جزئيا على بعض المعلومات الخاصة بآليات الإصابات، يمكن الحصول على تقديرات يعول عليها للوفيات الناجمة عن أسباب خارجية للإصابات، مثل الإصابات على الطرق، والانتحار وجرائم القتل، وذلك لعدد أكبر من البلدان.
الاستنتاج
20 بلداً فقط هو عدد البلدان التي كانت لديها معطيات عالية الجودة حول تسجيل الوفيات، والتي أمكن استخدامها في تقدير معدلات الوفيات الناجمة عن الإصابات، حيث أن هذه الوفيات يشيع تصنيفها في فئات محدَدة جزئياً وغير دقيقة. ويحتاج الأمر إلى طرائق تحليلية يمكن من خلالها الحصول على تقديرات وطنية للوفيات الناجمة عن الإصابات وذلك من مصادر بديلة للمعطيات، وهذا في البلدان التي لا تمتلك نظما يعوَّل عليها لتسجيل الوفيات.
Résumé
Objectif
Évaluer la disponibilité et la qualité des données mondiales d’enregistrement des décès utilisées pour estimer la mortalité d’origine traumatique.
Méthodes
Nous avons évalué l’exhaustivité et la couverture des données récentes d’enregistrement des décès nationaux, données provenant de la base de l’OMS sur la mortalité. La qualité des données relatives à une cause spécifique de décès par traumatisme a été jugée élevée si moins de 20% des décès étaient attribuables à l’une des causes de blessure partiellement définies, comme une «blessure non définie et involontaire».
Résultats
Les données récentes d’enregistrement des décès étaient disponibles pour 83 pays, soit 28% de la population globale. Elles incluaient la plupart des pays à revenu élevé, la majorité des pays d’Amérique latine et plusieurs pays d’Asie centrale et des Caraïbes. Les catégories les plus utilisées pour les causes de traumatismes externes partiellement définies entraînant le décès comprenaient: une «intention indéterminée», un «mécanisme non défini de traumatisme involontaire», des «blessures non définies suite à des accidents de la circulation» et un «mécanisme non défini d’homicide». Seuls 20 pays présentaient une qualité de données élevée. Néanmoins, comme les catégories partiellement définies contiennent des informations sur les mécanismes des traumatismes, il est possible d’obtenir des estimations fiables des décès dus à des causes de traumatismes externes spécifiques pour de nombreux autres pays, notamment les accidents de la circulation, les suicides et les homicides.
Conclusion
Seuls 20 pays ont présenté des données d’enregistrement des décès de qualité élevée, pouvant être utilisées pour estimer la mortalité attribuable à un traumatisme car les décès d’origine traumatique ont souvent été classés à l’aide de catégories partiellement définies et imprécises. Les méthodes analytiques qui peuvent fournir des estimations nationales sur la mortalité par traumatisme à partir d’autres sources de données sont nécessaires aux pays qui ne disposent pas de systèmes fiables d’enregistrement des décès.
Resumen
Objetivo
Evaluar la disponibilidad y la calidad de los datos de los registros mundiales de defunción utilizados para calcular la mortalidad por traumatismos.
Métodos
Se han evaluado la integridad y el alcance de los datos recientes de los registros nacionales de defunción procedentes de la base de datos de mortalidad de la Organización Mundial de la Salud. Se consideró que la calidad de los datos en un caso específico de defunción por traumatismos era elevada si menos del 20% de las muertes se atribuyeron a cualquiera de las causas de traumatismos especificadas parcialmente, como « traumatismos no intencionados y no especificados».
Resultados
Se dispuso de los datos recientes de los registros de defunciones de 83 países, lo que representa el 28% de la población mundial, entre los que se encontraban la mayoría de los países de ingresos elevados, la mayor parte de los países de América Latina y algunos de Asia Central y el Caribe. Las categorías empleadas generalmente para las causas externas parcialmente especificadas de los traumatismos con resultado de muerte fueron: «intención indeterminada», «mecanismo no especificado de traumatismo no intencional», « traumatismos por accidente de tránsito no especificados» y «mecanismo no especificado del homicidio». Únicamente 20 países poseían datos de alta calidad. No obstante, debido a que las categorías especificadas parcialmente contienen cierta información sobre los mecanismos de los traumatismos, en muchos países se pudieron extrapolar estimaciones fiables de las defunciones por traumatismos externos específicos, tales como los traumatismos por accidentes de tránsito, los suicidios y los homicidios.
Conclusión
Sólo 20 países disponían de datos de alta calidad de registro de defunciones que se pudieran utilizar para calcular la mortalidad por traumatismos, debido a que las defunciones por traumatismos se clasificaron con frecuencia en categorías imprecisas y sólo parcialmente especificadas. Es necesario aplicar métodos analíticos que permitan obtener las estimaciones nacionales de mortalidad por traumatismos a partir de fuentes de datos alternativos para aquellos países que carezcan de sistemas fiables de registro de defunciones.
Резюме
Цель
Оценить доступность и качество глобальных данных регистрации случаев смерти, используемых для оценки смертности от травм.
Методы
Оценивались полнота и охват новейших национальных данных регистрации случаев смерти, содержащихся в базе данных Всемирной организации здравоохранения. Качество данных о конкретной причине смерти в результате травмы оценивалось как высокое, если менее 20% случаев смерти были отнесены к одной из нескольких частично конкретизированных причин травмы, таких как «неуточненная непреднамеренная травма».
Результаты
Новейшие данные регистрации случаев смерти были доступны по 83 странам, на долю которых приходится 28% населения мира. Они включали в себя большинство стран с высоким доходом, большинство стран Латинской Америки и несколько стран Центральной Азии и Карибского бассейна. К числу категорий, широко используемых для характеристики частично уточненных внешних причин травмы, явившейся причиной смерти, относились: «неопределенное намерение», «непреднамеренная травма неуточненным способом», «неуточненная дорожно-транспортная травма» и «убийство неуточненным способом». Только в 20 странах имелись высококачественные данные. Тем не менее, ввиду того, что частично конкретизированные категории содержат определенную информацию о механизмах травмы, надежные оценки смертности по конкретным внешним причинам травм, таким как дорожно-транспортная травма, самоубийство и убийство, могут быть получены для гораздо большего числа стран.
Вывод
Поскольку случаи смерти от травм часто классифицировались с использованием неточных, частично уточненных категорий, только в 20 странах имелись высококачественные данные регистрации случаев смерти, которые могут быть использованы для оценки смертности от травматизма. Для стран, в которых отсутствуют надежные системы регистрации случаев смерти, необходимы аналитические методы, с помощью которых можно получать национальные оценки смертности от травматизма на основе альтернативных источников данных.
摘要
目的
评估用于估计伤害死亡率的全球死亡登记数据的可用性和质量。
方法
评估了来自世界卫生组织死亡率数据库的近期国家死亡登记数据的完整性和覆盖面。如果不足20%的死亡是由一些部分指定的伤害原因中的任何一个造成的，如“不明的意外伤害”，那么就认为与特定伤害死亡原因相关的数据具有高质量。
结果
83个国家提供了最近的死亡登记数据，占全球人口的28%。这些国家包括大多数高收入国家，拉丁美洲的大部分国家以及中亚和加勒比地区的几个国家。常见的导致死亡的伤害的部分指定外因类别包括“意向未定”、“不明确的意外伤害机制”、“未指定的道路伤害”和“不明的杀人机制”。只有20个国家的数据质量较高。不过，由于部分指明的类型包含一些伤害机制信息，因此由于道路伤害、自杀和杀人等特定外在伤害原因造成的死亡的可靠估算数据可能是针对更多国家的。
结论
只有20个国家的死亡登记数据质量较高。伤害死亡常使用不精确的部分指定的类别进行分类，因而这些数据可能被用于估计伤害死亡率。那些没有可靠死亡登记系统的国家需要从替代数据源得到国家伤害死亡率估值的分析方法。
Introduction
Reliable estimates of the burden of death and disability due to injury are essential for shaping national and global health priorities. Although the quality of the information available in developing countries is relatively poor, past efforts at quantifying the global burden of disease1–3 have convincingly established that injuries contribute approximately 10% to global mortality and 12% to global morbidity. A study into the global burden of disease was commissioned by The World Bank in 1991 and a new study is currently under way.4 Substantial collaborative efforts by the global injury research community will ensure that the best available evidence is incorporated into new estimates of the global burden of injuries.5 Thus, this is an opportune time to undertake an evaluation of the global data sources used for estimating the global burden of injuries. This paper focuses on the availability and quality of global mortality data reported by national death registration systems to the World Health Organization (WHO) mortality database.6
The WHO mortality database is the largest single repository of international data on causes of death. Our study builds on past work by Mathers et al.,7 who examined the quality of cause-of-death data in this database. They assessed quality by examining the proportion of deaths assigned to ill-defined cause-of-death codes, or “dump” codes. Unfortunately, some of the most important dump codes for injury were not included in their quality assessment. For instance, there was no assessment of code X59 of the International classification of diseases and related health problems, tenth revision (ICD-10), namely “accidental exposure to other and unspecified factors,” which is extensively used in death registers to classify injury deaths. Moreover, the WHO mortality database has grown over the past 5 years and a reassessment of data quality is now due.
Following the lead of Mathers et al.,7 our aim was to assess the availability of recent mortality data, the completeness and coverage of regional death registration, and the quality of data derived from injury dump codes. In addition, we discuss the effect of data quality on the reliability of estimates of deaths due to road traffic injury, suicide and homicide.
Methods
Availability of mortality data
We obtained death registration data for a range of countries from the publicly available WHO mortality database (21 April 2009 update).6 The database includes details of deaths registered by national civil registration systems in which the underlying cause of death is coded by the relevant national authority in accordance with ICD rules.8 The analysis included only WHO member countries (listed at: http://www.who.int/countries) for which data were available from after 2000. For most countries, the latest data available were coded using ICD-10. For some, however, the latest available data were classified using the ICD-9 basic tabulation list, which is not adequate for estimating injury mortality, as subsequently discussed. We also included data classified using detailed ICD-9 codes from countries that made such data available to WHO: Guyana, Kiribati, the Netherlands (for Aruba), Saint Vincent and the Grenadines, Singapore, Slovenia and Thailand.
Completeness of registration
The completeness of national death registration was quantified by comparing the number of deaths recorded by death registration data for each country with estimates of projected mortality from the United Nations Population Division.9 Clearly such estimates of completeness are only crude indicators and should not be used for deriving incidence rates for cause-specific mortality. Nevertheless, they do provide some indication of the level of completeness of death registration in each country. In our study, we judged completeness to be high when it was greater than 80% of the expected value, medium when between 60% and 80%, and low otherwise.
Data quality
We classified all injury deaths using 48 categories of specified external causes of death, which constitute the reporting categories recommended by the injury expert group of the 2005 Global Burden of Diseases, Injuries and Risk Factors Study (i.e. the GBD Injury Expert Group),10 and 21 categories of partially specified external causes (Table 1, available at: http://www.who.int/bulletin/volumes/88/11/09-068809). Several countries coded the cause of death using condensed versions of ICD-9 and ICD-10, which do not contain sufficient detail to classify injury deaths according to the full list of external causes of injury shown in Table 1. In addition, these condensed versions group together dump codes with imprecise definitions. For example, the ICD-10 basic tabulation list includes the code X59, for unspecified unintentional injury, in the category 1103 (i.e. all other external causes). The impossibility of separating dump codes means that deaths classified using these codes cannot be reassigned to specified causes and, consequently, the incidence of these causes cannot be estimated. Thus, we excluded countries that used basic tabulation lists from further quality assessment.
Table 1. Categories of specified and partially specified external causes of death used to classify deaths due to injurya.
| Specified external causes of death | Detailed category | Code | ICD-10 codeb | ICD-9 codeb |
|---|---|---|---|---|
| Unintentional | ||||
| Road injury | Pedestrian | 1 | V01–V04, V06, V09 | E811–825 (0.7 subsections only), E826–829 (0.0 subsections only) |
| Bicyclist | 2 | V10–V19 | E810–825 (0.6 subsections only), E826–829 (0.1 subsections only) | |
| Two-wheeler riderc | 3 | V20–V29 | E810–825 (0.2 and 0.3 subsections only) | |
| Three-wheeler occupantc | 4 | V30–V39 | ||
| Car occupantd | 5 | V40–V49 | E810–825 (0.0 and 0.1 subsections only) | |
| Van occupantd | 6 | V50–V59 | ||
| Truck occupantd | 7 | V60–V69 | ||
| Bus occupantd | 8 | V70–V79 | ||
| Other road injury | 9 | V80, V82–V85 | E810–825 (0.4, 0.5 and 0.8 subsections only), E826–829 (0.2, 0.3, 0.4 and 0.8 subsections only) | |
| Rail transport injury | Rail | 10 | V05, V81 | E800–807, E810.7 |
| Other transport injury | Other transport | 11 | V86, V91, V93–V98 | E831, E833–838, E843 |
| Fall | Fall | 12 | W00–W19 | E880–886, E888, E929.3 |
| Threats to breathing | Drowning | 13 | V90, V92, W65–W74 | E830, E832, E910 |
| Other threats to breathing | 14 | W75–W84 | E911–913 | |
| Fire | Fire | 15 | X00–X19 | E890–899, E924, E929.4 |
| Mechanical force | Firearm | 16 | W32–W34 | E922 |
| Sharp object | 17 | W25–W29, W45–W46 | E920 | |
| Machinery | 18 | W24, W30–W31 | E919 | |
| Poisoning | Gas | 19 | X46–X47 | E862, E867–869 |
| Pesticide | 20 | X48 | E863 | |
| Other poison | 21 | X40–X45, X49 | E850–858, E860–861, E864–866, E929.2 | |
| Adverse effects of medical treatment | Adverse effects of medical treatment | 22 | Y40–Y84, Y88 | E870–879, E930–949 |
| Animal contact | Animal contact | 23 | W53–W59, X20–X27, X29 | E905.0–E905.6, E905.8, E905.9, E906 |
| Forces of nature | Forces of nature | 24 | X30–X39 | E900–904.9 (excluding E900.1 and E901.1), E907–909, E929.5 |
| Other unintentional | Other unintentional | 25 | W20–W23, W35–W44, W49–W52, W60–W64, W85–W99, X28, X50–X58 | E840, E841, E842, E844–848, E900.1, E901.1, E902–904, E905.7, E914–918, E921, E923, E925–928.8, E929.8 |
| Intentional, self-inflicted | ||||
| Fall | Fall | 26 | X80 | E957 |
| Threats to breathing | Drowning | 27 | X71 | E954 |
| Other threats to breathing | 28 | X70 | E953 | |
| Fire | Fire | 29 | X76–X77 | E958.1 |
| Mechanical force | Firearm | 30 | X72–X74 | E955 (except E955.5) |
| Sharp object | 31 | X78 | E956 | |
| Poisoning | Gas | 32 | X67 | E951–952 |
| Pesticide | 33 | X68 | E950.6 | |
| Other poison | 34 | X60–X66, X69 | E950.0–950.5, E950.7–950.9 | |
| Other self-inflicted injury | Other self-inflicted injury | 35 | X75, X79, X81–X83 | E955.5, E958.0, E958.2–958.8 |
| Intentional, interpersonal | ||||
| Fall | Fall | 36 | Y01 | E968.1 |
| Threats to breathing | Drowning | 37 | X92 | E964 |
| Other threats to breathing | 38 | X91 | E963 | |
| Fire | Fire | 39 | X97–X98 | E968.0 |
| Mechanical force | Firearm | 40 | X93–X95 | E965.0–965.4, E968.6 |
| Sharp object | 41 | X99 | E966 | |
| Poisoning | Gas | 42 | X88 | E962.2 |
| Pesticide | 43 | X87 | NAe | |
| Other poison | 44 | X85–X86, X89–X90 | E961, E962.0, E962.1, E962.9 | |
| Other interpersonal injury | Other interpersonal injury | 45 | X96, Y00, Y02–Y08 | E960, E965.5–965.9, E967, E968.2–968.5, E968.7–968.8 |
| Intentional, collective violence | ||||
| Collective violence | Collective violence | 46 | Y36 | E979, E990–998 |
| Intentional, legal intervention | ||||
| Mechanical force | Firearm | 47 | Y35.0 | E970 |
| Other legal intervention | Other legal intervention | 48 | Y35.1–Y35.6 | E971–975, E978 |
| Partially specified external causes of death | ||||
| Partially specified, undetermined intent, and unspecified cause | ||||
| Road injury | Unspecified unintentional road injury not including pedestrian or bicyclist | 49 | V87–V88 | E810–825 (0.9 subsections only) |
| Unspecified unintentional road injury | 50 | V89, Y85.0 | E826–829 (0.9 subsections only), E929.0 | |
| Transport injury | Unspecified unintentional transport injury | 51 | V99, Y85.9 | E929.1 |
| Non-transport injury | Unspecified unintentional non-transport injury | 52 | Y86 | NA |
| Unintentional injury | Unspecified unintentional injury | 53 | X59 | E887, E928.9, E929.9 |
| Self-inflicted injury | Unspecified self-inflicted injury | 54 | X84, Y87.0 | E958.9, E959 |
| Interpersonal injury | Unspecified interpersonal injury | 55 | Y09, Y87.1 | E968.9, E969 |
| Fall | Undetermined intent – fall | 56 | Y30 | E987 |
| Drowning | Undetermined intent – drowning | 57 | Y21 | E984 |
| Threats to breathing other than drowning | Undetermined intent – threats to breathing other than drowning | 58 | Y20 | E983 |
| Fire | Undetermined intent – fire | 59 | Y26–Y27 | E988.1–988.2 |
| Mechanical force | Undetermined intent – firearm | 60 | Y22–Y24 | E985.0–985.4, E985.6–985.7 |
| Undetermined intent – sharp object | 61 | Y28 | E986 | |
| Poisoning | Undetermined intent – gas | 62 | Y17 | E981–982 |
| Undetermined intent – pesticide | 63 | Y18 | E980.7 | |
| Undetermined intent – other poison | 64 | Y10–Y16, Y19 | E980.0–980.6, E980.8, E980.9, E988.7 | |
| Other injury | Undetermined intent – other | 65 | Y25, Y29, Y31–Y33 | E985.5, E988.0, E988.3–988.6, E988.8 |
| All injuries | Undetermined intent – unspecified | 66 | Y34, Y87.2 | E988.9, E989 |
| Collective violence | Sequelae of collective violence | 67 | Y89.1 | E999 |
| Legal intervention | Unspecified legal intervention | 68 | Y35.7, Y89.0 | E976–977 |
| All injury | Unspecified injury mechanism | 69 | Y89.9 | NA |
ICD, International classification of diseases and related health problems; NA, not applicable.
a These ICD-based definitions of external causes of death were developed by the injury expert group of the 2005 Global Burden of Diseases, Injuries and Risk Factors Study.10
b There are also ICD codes outside the injury chapter that can include injury deaths. We used ICD-10 codes R95–R99 and ICD-9 codes 797–799 for the broadest unspecified cause-of-death category.
c ICD-9 does not distinguish between the riders and occupants of motorized two- and three-wheeler vehicles (i.e. codes 3 and 4).
d ICD-9 does not distinguish between occupants of different four-wheeled vehicles (codes 5–8).
e Poisoning due to pesticides is included with other poisoning in ICD-9 (code 44)
Data quality was assessed by determining the proportion of deaths that were classified as belonging to various partially specified categories: the quality of the data improves as the proportion of deaths assigned to partially specified categories decreases. Moreover, the partially specified categories may form a hierarchy in terms of their information content. This hierarchy is related to the specificity of the definition of each category. For example, the death of a car occupant who was killed in a road traffic accident may be coded using any of the following categories in a hierarchy of partially specified categories whose definition shows less specificity towards the end of the list:
unspecified road injury not including a pedestrian or bicyclist (ICD-10 codes: V87–V88);
unspecified unintentional road injury (ICD-10 codes: V89, Y85.0);
unspecified unintentional transport injury (ICD-10 codes: V99, Y85.9);
unspecified unintentional injury (ICD-10 code: X59);
unspecified injury mechanism (ICD-10 code: Y89.9);
unknown cause of death (ICD-10 codes: R95–R99).
To determine data quality, we computed the proportion of deaths in each partially specified category relative to the corresponding total number of deaths at that level of specificity: e.g. the proportion of road injuries recorded as an unspecified unintentional road injury. Data quality was rated as high when this proportion was smaller than 20%.
Finally, we examined the distribution of deaths classified as belonging to the partially specified categories to determine the circumstances in which the data can, nevertheless, be used to derive reliable estimates of mortality for various specific external causes of death. The countries for which deaths due to road injury, homicide and suicide can be reliably estimated are given as an illustrative example.
Results
Availability of mortality data
Table 2 (available at: http://www.who.int/bulletin/volumes/88/11/09-068809) summarizes the availability of death registration data in the WHO mortality database for countries in the 21 different regions of the world defined by the 2005 Global Burden of Diseases, Injuries and Risk Factors Study.10 For each country, the most recent year for which data are available and the number of years of data availability are listed. In all, 83 countries met the inclusion criteria. They accounted for 28% of the global population. Recent data were available from most countries in high-income regions except for a few notable exceptions: Switzerland used a basic tabulation list and no recent data were available from Belgium. The coverage of death registration data in low- and middle-income regions was more irregular. Three of the four Asian regions (i.e. South, South-East and East Asia) were severely underrepresented, with less than 15% of the regional population covered. The continent of Africa was even less well covered. Data from sub-Saharan Africa were available for only one country (i.e. South Africa). However, low- and middle-income countries in Latin America and the Caribbean were well represented, with over 80% of the population covered. The availability of injury data from eastern Europe, central Europe and central Asia was limited, primarily because of the use of basic tabulation lists.
Table 2. Death registration data available in the WHO mortality database, 2009.
| Regiona | Death registration data available |
|---|---|
| Country (most recent year with data available, number of years of data availability)b,c,d | |
| Asia Pacific, high-income countries | Japan (2007, 13), Republic of Korea (2006, 12), Singapore (2003, 13); Country with no data, comprising 0.2% of the regional population: Brunei Darussalam |
| Central Asia | Azerbaijan (2007, 1), Georgia (2001, 4), Kyrgyzstan (2006, 7), Uzbekistan (2005, 2); Countries with no data, comprising 42% of the regional population: Armenia, Kazakhstan, Mongolia, Tajikistan, Turkmenistan |
| East Asia | China, Hong Kong Special Administrative Region (2007, 7) Countries with no data, comprising 99.5% of the regional population: China,e Democratic People's Republic of Korea. |
| South Asia | Countries with no data, comprising 100% of the regional population: Afghanistan, Bangladesh, Bhutan, India,e Nepal, Pakistan |
| South-East Asia | Maldives (2005, 6), Mauritius (2007, 10), Thailand (2002, 11); Countries with no data, comprising 89% of the regional population: Cambodia, Indonesia, Lao People's Democratic Republic, Malaysia, Myanmar, Philippines, Seychelles, Sri Lanka, Timor-Leste, Viet Nam |
| Australasia | Australia (2004, 8), New Zealand (2005, 9); Countries with no data: none |
| Caribbean | Antigua and Barbuda (2006, 7), Bahamas (2002, 4), Barbados (2003, 4), Belize (2001, 5), Bermuda (2002, 7), Cuba (2006, 7), Dominica (2004, 5), Dominican Republic (2004, 8), Grenada (2005, 5), Guyana (2005, 9), Haiti (2003, 5), Saint Kitts and Nevis (2005, 10), Saint Lucia (2002, 7), Saint Vincent and the Grenadines (2004, 6), Suriname (2005, 8), Trinidad and Tobago (2002, 4); Country with no data, comprising 6% of the regional population: Jamaica |
| Central Europe | Croatia (2006, 12), Czech Republic (2007, 14), Hungary (2005, 10), Poland (2006, 8), Romania (2007, 9), Serbia (2007, 10), Slovakia (2005, 12), Slovenia (2007, 23); Countries with no data, comprising 14% of the regional population: Albania, Bosnia and Herzegovina, Bulgaria, Montenegro, The former Yugoslav Republic of Macedonia |
| Eastern Europe | Estonia (2005, 9), Latvia (2007, 12), Lithuania (2007, 10), the Republic of Moldova (2007, 12); Countries with no data, comprising 95% of the regional population: Belarus, Russian Federation, Ukraine |
| Western Europe | Austria (2007, 9), Cyprus (2006, 2), Denmark (2006, 13), Finland (2007, 12), France (2006, 10), Germany (2006, 9), Greece (2006, 9), Iceland (2007, 12), Ireland (2007, 11), Israel (2005, 10), Italy (2006, 9), Luxembourg (2005, 8), Malta (2007, 13), Netherlands (2007, 12), Norway (2006, 11), Portugal (2003, 5), San Marino (2000, 6), Spain (2005, 9), Sweden (2006, 11), United Kingdom (2007, 9); Countries with no data, comprising 4% of the regional population: Andorra, Belgium, Monaco, Switzerland |
| Latin America – Andean countries | Ecuador (2006, 10), Peru (2000, 2); Country with no data, comprising 18% of the regional population: Bolivia |
| Central Latin America | Colombia (2005, 8), Costa Rica (2006, 10), El Salvador (2006, 10), Guatemala (2006, 7), Mexico (2006, 9), Nicaragua (2005, 9), Panama (2006, 8), Venezuela (2005, 10); Country with no data, comprising 3% of the regional population: Honduras |
| Southern Latin America | Argentina (2005, 9), Chile (2005, 9), Uruguay (2004, 6); Countries with no data: none |
| Tropical Latin America | Brazil (2005, 10), Paraguay (2004, 9); Countries with no data: none |
| North Africa and the Middle East | Bahrain (2001, 5), Egypt (2000, 1), Kuwait (2002, 8); Countries with no data, comprising 81% of the regional population: Algeria, Islamic Republic of Iran, Iraq, Jordan, Lebanon, Libyan Arab Jamahiriya, Morocco, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Tunisia, Turkey, United Arab Emirates, Yemen |
| North America, high-income countries | Canada (2004, 8), United States of America (2005, 9); Countries with no data: none |
| Oceania | Kiribati (2001, 11); Countries with no data, comprising 99% of the regional population: Cook Islands, Fiji, Marshall Islands, Federated States of Micronesia, Nauru, Palau, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tuvalu, Vanuatu |
| Southern sub-Saharan Africa | South Africa (2005, 10); Countries with no data, comprising 30% of the regional population: Botswana, Lesotho, Namibia, Swaziland, Zimbabwe |
| Central sub-Saharan Africa | Countries with no data, comprising 100% of the regional population: Angola, Central African Republic, Congo, Democratic Republic of the Congo, Equatorial Guinea, Gabon |
| East sub-Saharan Africa | Countries with no data, comprising 100% of the regional population: Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar, Malawi, Mozambique, Rwanda, Somalia, Sudan, Uganda, United Republic of Tanzania, Zambia |
| West sub-Saharan Africa | Countries with no data, comprising 100% of the regional population: Benin, Burkina Faso, Cameroon, Cape Verde, Chad, Côte d’Ivoire, Gambia, Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria, Sao Tome and Principe, Senegal, Sierra Leone, Togo |
ICD, International classification of diseases and related health problems; WHO, World Health Organization.
a Countries were grouped into the 21 global regions defined by the 2005 Global Burden of Diseases, Injuries and Risk Factors Study.10
b Only WHO member countries (listed at: http://www.who.int/countries) for which data were available from after 2000 were included.
c Any year in which a country reported data using the ICD-10 basic tabulation list was excluded. Since all ICD-9 data in the WHO mortality database were coded using the basic tabulation list, years reported in this way were generally not included. However, in a few instances, detailed ICD-9 data were available from WHO, enabling the relevant countries to be included. Countries that were excluded because a basic tabulation list was used were: Central Asia: Armenia, Azerbaijan, Kazakhstan, Mongolia, Tajikistan and Turkmenistan; East Asia: China; South Asia: Pakistan; South-East Asia: Malaysia, Philippines, Seychelles and Sri Lanka; Caribbean: Jamaica; Central Europe: Albania, Bosnia and Herzegovina and Bulgaria; Eastern Europe: Belarus, Russian Federation and Ukraine; Western Europe: Monaco and Switzerland; Central Latin America: Honduras; North Africa and the Middle East: Islamic Republic of Iran, Syrian Arab Republic and Turkey; and Oceania: Papua New Guinea.
d For example, after applying exclusion criteria, 2007 was the most recent year in which death registration data for Japan were available from the WHO mortality database and 13 years of data were available.
e China and India have sample registration systems that report the cause of death in some regions.
While historical death registration data were available for over a decade for many high-income countries, the most recent data for many of these countries dated from before 2005 (Table 3), which suggests that there were delays in reporting to WHO. Although low- and middle- income countries had been reporting data for a shorter time, 5 years of recent data were available for many. It should be noted that all of the ICD-9 data in the WHO mortality database were coded using the ICD-9 basic tabulation list, which limits the length of the historical record in these cases.
Table 3. Completeness of national death registration, the number of deaths due to different causes and the proportion of deaths assigned to various partially specified causes for selected countries included in the WHO mortality database, 2000–2007a.
| Region,b country and year of most recent data |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Asia Pacific, high-income countries | Central Asia | East Asia | South-East Asia | Australasia | Caribbean | Central and Eastern Europe | Western Europe | Latin America | Northern Africa and the Middle East | North America, high-income countries | Southern sub-Saharan Africa | |
| Japan | Uzbekistan | China, Hong Kong SAR | Thailand | Australia | Cuba | Poland | Germany | Brazil | Egypt | USA | South Africa | |
| 2007 | 2005 | 2007 | 2002 | 2004 | 2006 | 2006 | 2006 | 2005 | 2000 | 2005 | 2005 | |
| Completeness of death registration | High | High | High | High | High | High | High | High | Medium | High | High | Medium |
| All-cause deaths, No. | 1 083 796 | 140 585 | 38 678 | 380 364 | 132 314 | 84 824 | 368 285 | 830 227 | 1 006 827 | 382 138 | 2 448 017 | 591 213 |
| % of all-cause deaths ascribed to an unknown cause (ICD-10 codes: R95–R99) | 0 | 1 | 1 | 14 | 1 | 1 | 4 | 2 | 9 | 1 | 1 | 11 |
| Injury deaths, No. | 75 380 | 10 142 | 2 150 | 42 803 | 7 970 | 7 047 | 25 363 | 33 024 | 127 608 | 16 709 | 176 406 | 53 124 |
| % of injury deaths ascribed to unspecified mechanism and intent | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| % injury deaths ascribed to undetermined intent | 3 | 13 | 6 | 24 | 1 | 4 | 10 | 7 | 9 | 42 | 3 | 66 |
| Deaths due to unintentional injury, No. | 41 937 | 6 356 | 827 | 24 117 | 5 603 | 4 670 | 16 134 | 19 993 | 59 519 | 9 424 | 120 462 | 12 853 |
| % of unintentional injury deaths ascribed to an unspecified unintentional injury | 7 | 11 | 11 | 13 | 18 | 0 | 5 | 5 | 4 | 0 | 5 | 19 |
| Deaths due to transport injury, No. | 9 968 | 2 395 | 197 | 13 389 | 1 687 | 1 315 | 5 959 | 5 657 | 36 592 | 5 446 | 48 047 | 5 454 |
| % of transport injury deaths ascribed to unspecified transport injury | 1 | 3 | 1 | 0 | 0 | 0 | 3 | 0 | 1 | 6 | 0 | 0 |
| Deaths due to road injury, No. | 9 434 | 2 277 | 175 | 13 251 | 1 582 | 1 255 | 5 456 | 5 409 | 35 736 | 4 381 | 45 812 | 5 354 |
| % of road injury deaths ascribed to unspecified unintentional road injury | 4 | 7 | 0 | 39 | 7 | 2 | 11 | 28 | 26 | 1 | 25 | 87 |
| % of road injury deaths of vehicle occupants ascribed to unspecified unintentional road injury not including pedestrian or bicyclist | 6 | 0 | 0 | 0 | 1 | 2 | 0 | 0 | 2 | 45 | 16 | 10 |
| Deaths due to non-transport injury, No. | 29 205 | 3 237 | 538 | 7 601 | 2 921 | 3 343 | 9 446 | 13 305 | 20 477 | 3 976 | 65 864 | 4 911 |
| % of non-transport injury deaths ascribed to unspecified unintentional non-transport injury | 5 | 0 | 0 | 0 | 2 | 21 | 0 | 0 | 0 | 4 | 1 | 0 |
| Deaths due to intentional injury, No. | 31 159 | 1 959 | 1 185 | 8 328 | 2 278 | 2 083 | 6 603 | 10 730 | 56 701 | 315 | 51 202 | 5 435 |
| Deaths due to interpersonal injury, No. | 600 | 735 | 36 | 3 402 | 162 | 684 | 558 | 454 | 47 590 | 50 | 18 124 | 4 950 |
| % of interpersonal injury deaths ascribed to an unspecified mechanism | 6 | 14 | 6 | 19 | 11 | 3 | 5 | 7 | 6 | 4 | 11 | 11 |
| Deaths due to self-inflicted injury, No. | 30 557 | 1 221 | 1 149 | 4 905 | 2 114 | 1 398 | 6 045 | 10 270 | 8 552 | 49 | 32 637 | 462 |
| % of self-inflicted injury deaths ascribed to an unspecified mechanism | 0 | 4 | 0 | 8 | 0 | 0 | 0 | 2 | 4 | 4 | 1 | 5 |
| Deaths due to legal intervention, No. | 1 | 2 | 0 | 21 | 2 | 1 | 0 | 2 | 559 | 216 | 414 | 17 |
| % of legal intervention deaths ascribed to an unspecified mechanism | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 1 | 0 | 2 | 0 |
| Deaths due to collective violence, No. | 1 | 1 | 0 | 0 | 0 | 0 | 0 | 4 | 0 | 0 | 27 | 6 |
ICD, International classification of diseases and related health problems; SAR, Special Administrative Region; USA, United States of America; WHO, World Health Organization.
a Boldfaced table entries highlight instances where the percentage of injury deaths ascribed to a partially specified cause exceeds 20%, which is the upper limit for describing the data quality as high.
b Countries were grouped into the 21 global regions defined by the 2005 Global Burden of Diseases, Injuries and Risk Factors Study.10 The most populous country in each region from which data were analysed is shown. However, only one country is listed from the four Latin America regions and one from central and eastern Europe combined. The figures for all 83 countries analysed in the study are included in Appendix A (available at: http://www.globalburdenofinjuries.org/gimd/Quality_Global_Injury_Mortality_Data.pdf).
Completeness of registration
Of the 83 countries analysed, completeness was high (i.e. > 80%) in 62, medium (i.e. 60–80%) in 9, low (< 60%) in 5, and could not be assessed in the 7 for which no estimate of all-cause deaths was available from the United Nations Population Division. Table 3 lists the completeness of national death registration and the proportion of deaths assigned to various partially specified causes for selected countries. The figures for the remaining countries are listed in Appendix A (available at: http://www.globalburdenofinjuries.org/gimd/Quality_Global_Injury_Mortality_Data.pdf).
Data quality
Use of the broadest unspecified cause-of-death category, i.e. unknown cause of death (ICD-10 codes: R95–R99), was relatively rare. Only Haiti assigned more than 20% of all-cause deaths to this category. However, the use of codes for undetermined intent (ICD-10 codes: Y10–Y34, Y87.2) was common, with 18 countries, including one high-income country (i.e. Singapore), classifying more than 20% of injury deaths as due to undetermined intent. Two of the three countries from North Africa and the Middle East (i.e. Bahrain and Egypt) placed over one-third of all injury deaths in this category. The other countries with an exceptionally high number of deaths in this category included: Azerbaijan (83%), the Dominican Republic (45%), Egypt (42%), Guatemala (37%), Maldives (98%), Suriname (35%) and South Africa (66%). In contrast, the number of deaths classified as being due to an unspecified injury mechanism with undetermined intent (ICD-10 code: Y89.9) was negligible in all countries.
With regard to unintentional injuries, many countries coded a large number of deaths using the broadest unspecified mechanism category: unspecified unintentional injury (ICD-10 code: X59). In 15 countries, over half of which were in Western Europe, over 20% of unintentional injury deaths were allocated this code. The proportion of deaths coded to the unspecified non-transport injury subcategory of unspecified unintentional non-transport injury (ICD-10 code: Y86) was negligible in all countries, with the notable exception of Cuba.
With regard to transport deaths, only Georgia (46%) and Serbia (22%) allocated more than 20% of deaths to the broadest unspecified category: unspecified unintentional transport injury (ICD-10 codes: V99, Y85.9). However, many countries coded a large number of deaths due to road injury using the broadest unspecified category: unspecified unintentional road injury (ICD-10 codes: V89, Y85.0). In total, 40 countries used this code for more than 20% of road deaths. Many were high-income countries, including two in North America (i.e. Canada and the USA) and six in Western Europe, two of which (i.e. France and Portugal) allocated over 80% of road deaths to this category. The other partly specified subcategory of road injury, unspecified road injury not including a pedestrian or bicyclist (ICD-10 codes: V87–V88), was used less often. Only seven countries used this category for more than 20% of vehicle occupant deaths. Three of these (i.e. Greece, Ireland and San Marino) used ICD-9, which does not differentiate between different types of vehicle occupant.
With regard to suicide, the mechanism of death was usually specified. With the exception of Georgia, Haiti and Saint Lucia, no country attributed more than 20% of suicide deaths to an unspecified mechanism. However, the mechanism of homicide deaths was much less likely to be specified. In 13 countries, the mechanism was not specified for more than 20% of homicides. These countries included Portugal (27%) and Spain (22%) in Western Europe and, notably, Israel (43%). The mechanism of deaths classified as being due to a legal intervention was always specified. In no country, were more than 3% of these deaths attributed to an unspecified mechanism.
In general there was considerable heterogeneity between countries in the use of unspecified codes. While Australia and the United Kingdom of Great Britain and Northern Ireland classified a large proportion (i.e. 18% and 24%, respectively) of injury deaths as due to unspecified unintentional injury (ICD-10 code: X59), far fewer deaths were coded in this way in the USA (5%). On the other hand, 12% of all injury deaths were coded as due to undetermined intent (ICD-10 codes: Y10–Y34, Y87.2) in the United Kingdom, while the proportions were much smaller in Australia and the USA (1% and 3%, respectively).
Overall, only 20 countries did not allocate more than 20% of deaths to any partially specified category (Table 4). However, since the use of most partially specified categories influences data on only certain external causes of death, the number of countries whose data can be used to provide reliable estimates of deaths due to a particular external cause may be much larger than 20. For example, Table 4 lists 47 countries for which reliable estimates of road injury deaths were available and 60 for which reliable estimates of death due to suicide or homicide were available.
Table 4. Countries whose death registration data can be used to derive reliablea national estimates of deaths due to all external causes of injury, road injury, or suicide or homicide.
| Regionb | Country |
||
|---|---|---|---|
| Reliable estimates of deaths due to all external causes of injury (n = 20) | Reliable estimates of deaths due to road injury (n = 47) | Reliable estimates of deaths due to suicide or homicide (n = 60) | |
| Asia Pacific, high-income countries | Japan, Republic of Korea | Japan, Republic of Korea | Japan, Republic of Korea |
| Central Asia | Uzbekistan | Kyrgyzstan, Uzbekistan | Kyrgyzstan, Uzbekistan |
| East Asia | China, Hong Kong SAR | China, Hong Kong SAR | China, Hong Kong SAR |
| South-East Asia | Mauritius | Mauritius | |
| Australasia | Australia, New Zealand | Australia, New Zealand | Australia, New Zealand |
| Caribbean | Barbados, Trinidad and Tobago | Bahamas, Barbados, Belize, Cuba, Guyana, Saint Lucia, Trinidad and Tobago | Bahamas, Barbados, Belize, Cuba, Guyana, Martinique, Saint Lucia, Trinidad and Tobago |
| Central Europe | Hungary, Poland, Slovakia, Slovenia | Croatia, Czech Republic, Hungary, Poland, Romania, Slovakia, Slovenia | Croatia, Czech Republic, Hungary, Poland, Romania, Slovakia, Slovenia |
| Eastern Europe | Estonia, Lithuania | Estonia, Latvia, Lithuania, the Republic of Moldova | Estonia, Latvia, Lithuania, the Republic of Moldova |
| Western Europe | Finland, Iceland, Ireland, Luxembourg, Malta | Austria, Finland, Germany, Greece, Iceland, Ireland, Luxembourg, Malta, Portugal, Spain | Austria, Cyprus, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Spain, Sweden, United Kingdom |
| Latin America – Andean countries | Ecuador | ||
| Central Latin America | Panama | Colombia, Costa Rica, El Salvador, Mexico, Panama | Colombia, Costa Rica, El Salvador, Mexico, Panama |
| Southern Latin America | Chile | Argentina, Chile, Uruguay | |
| Tropical Latin America | Brazil, Paraguay | Brazil, Paraguay | |
| North Africa and the Middle East | Kuwait | Kuwait | |
| North America, high-income countries | Canada, United States of America | Canada, United States of America | |
SAR, Special Administrative Region.
a Data on a particular external cause of death were rated as reliable if no more than 20% of deaths due to that external cause were attributed to any partially specified category. For example, deaths due to road injury can be reliably estimated if no more than 20% of deaths were attributed to the following categories: unknown cause of death (International classification of diseases and related health problems, 10th revision codes: R95–R99); injury death of unspecified mechanism; injury death of undetermined intent; death due to unintentional injury of unspecified mechanism; and death due to unintentional transport injury of unspecified mechanism. Similarly, deaths due to suicide or homicide can be reliably estimated if no more than 20% of deaths were attributed to the following categories: unknown cause of death (International classification of diseases and related health problems, 10th revision codes: R95–R99); injury death of unspecified mechanism; and injury death of undetermined intent.
b Countries were grouped into the 21 global regions defined by the 2005 Global Burden of Diseases, Injuries and Risk Factors Study.10
Discussion
Previous work on national and global mortality patterns has not paid sufficient attention to injuries. We undertook this analysis because the only other assessment of the quality of global cause-of-death data7 did not consider the use of the most common injury dump codes. Furthermore, the external causes of injuries are often poorly categorized in many administrative data systems. For instance, even in high-income countries with an extensive history of disease surveillance, hospital administration records commonly omit the external cause of an injury.11–13 Similarly, in an unpublished analysis of mortality surveillance data based on verbal autopsy, which is the only source of mortality data in many information-poor settings, we found that often only the nature of the injury was reported for injury deaths. This is a serious shortcoming that will hamper attempts to develop injury prevention strategies since reliable estimates of the incidence of external causes of injuries are needed.14,15
The inadequate classification of injuries by ICD basic tabulation lists is another reason why injury deaths have not been fully considered. These summary lists do not provide codes for the mechanism of a suicide or homicide. Thus, the incidence of many important mechanisms of injuries (e.g. firearm injury, poisoning and burn injury) cannot be determined. In addition, the summary lists pose a more substantial problem for assessing mortality due to specific causes of injury. Usually the key injury dump codes identified in our analysis (e.g. ICD-10 code: X59) are grouped together with other specified mechanisms. Without access to data on these injury dump codes, the quality of the data overall cannot be assessed and injury mortality cannot be reliably estimated.
Ultimately, the purpose of this analysis was to identify those countries where the incidence of death due to injury can be reliably estimated. In the absence of empirical evidence to support a more nuanced characterization of quality, we adopted a maximum of 20% for each partially specified category for the cause of death to define high-quality data. While this threshold is to some extent arbitrary, it is based on the understanding that, when a large number of deaths have been allocated to partially specified categories, reapportioning deaths to specified categories can introduce substantial biases. Nevertheless, we showed that these categories contain a hierarchy of information content (i.e. they are partially specified) that should be harnessed fully to derive estimates of the incidence of death due to injury. Thus, although only 20 countries had high-quality data on all quality indicators, many more had high-quality data for specific external causes such as road injury, suicide and homicide.
The considerable heterogeneity between countries in the use of partially specified codes shows that they differ in coding practices. An understanding of those differences may enable us to identify biases arising from the dump codes used in specific countries and to derive appropriate reclassification rules for these deaths. There may also be commonalities in coding practices across countries that could help explain, for instance, why death registers in most countries tend to report the mechanism of suicides but not the mechanism of homicides.
In many countries, vital registration is the only comprehensive source of data for estimating mortality due to specific causes. Consequently, it has been proposed that national data should be validated and data quality should be improved, and this has already been done in several settings.16–18 Although we focused on injury deaths, the standardized method for assessing data quality we used could be implemented by national agencies as part of their routine quality assurance practices. Temporal changes in data quality could be evaluated and one country’s data could be compared with those from other countries.
An important finding of our analysis is that reliable national death registration data were available for less than 30% of the global population, which means that alternative data sources must be used for estimating global injury mortality. The two most populous countries in the world, India and China, do not have reliable national death registration systems though they do have sample registration systems19 that may be useful for deriving estimates of death due to injury. Similarly, at present there are no national death registration systems in most of Africa and such systems are unlikely to become a reliable source of data for decades. Nevertheless, even in these information-poor settings there are several alternative data sources that can be used to estimate injury mortality. Notably these include demographic surveillance sites,20 mortuaries,21,22 national censuses containing information on the cause of death,23 and national health surveys that report the details of sibling mortality.24 Analytical methods that can derive national estimates of injury mortality from multiple data sources are urgently needed.
Our evaluation of the availability and quality of global death registration data has several limitations. First, we considered only the data available from the WHO mortality database, supplemented by additional data from a few countries. While this data set is the single largest global death registration repository, there are many countries that collect death registration data but do not report to WHO. It is also likely that more recent data are available from the national vital statistics agencies of many countries included in the WHO database. Second, our judgment of data quality was based on the proportion of deaths that was assigned to partially specified categories. However, the misclassification of deaths was not considered. For instance, it is likely that some deaths due to suicide were coded as due to an unintentional or undetermined cause because of the stigma associated with suicide, and other deaths may have been similarly coded because of medico-legal considerations associated with intentional death. Moreover, these misclassifications may vary substantially between countries. Misclassification could have significant impact on the accuracy of injury mortality estimates derived from death registration data.
Despite these shortcomings, this analysis is a step towards making global injury data comparable across countries. The next step in this process is to develop methods for processing death registration data sets such that reasonable estimates of cause-specific injury mortality can be derived. This would lead to the construction of an international database of injury deaths that could provide useful insights into the structural causes of variations in the incidence of injury mortality between countries. With access to such a database, the international injury research community could learn from the experiences of different countries and could identify the social, political and environmental prerequisites of safe and sustainable living conditions.
Funding:
No member of the GBD Injury Expert Group derived salary support from the Global Burden of Disease project. However, several members have ongoing funded research in closely associated areas. Kavi Bhalla and Saeid Shahraz are supported by a grant from the World Bank Global Road Safety Facility, but this funder played no role in the study design, data analysis, decision to publish or preparation of this manuscript.
Competing interests:
None declared.
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