Insights in Public Health

The “Measurement Trap”

In 1992, Graham and Campbell employed the term “measurement trap” in reference to insufficient data and action to combat maternal mortality.¹ They described the measurement trap as a self-reinforcing cycle in which the lack of data to establish the levels and trends of a health outcome, and to identify both the characteristics and determinants of that outcome, contribute to its neglect. As a consequence of the measurement trap, scarce data on a health outcome can suppress political will to invest in the infrastructure, equipment, and/or human resources needed to address that outcome.^1,2

One key feature of the measurement trap is that it disproportionately affects marginalized populations, especially those in low- and middle-income countries (LMIC). For example, it is well acknowledged by those who work in the field of maternal mortality that an important reason for the historical lack of political prioritization of the issue was the limited voices of those most impacted—namely poor women, with little education, living in poor countries.³ The measurement trap is not unique to maternal mortality.

Global Injury Research is Caught in the Measurement Trap

The World Health Organization acknowledges that injury has long been neglected by the global health agenda.⁴ Globally, an estimated 6 million lives are lost each year due to injury, with injuries contributing to more deaths than HIV/AIDS, tuberculosis, and malaria combined.⁴ Nearly three-quarters of injury deaths are considered unintentional and encompass a variety of causes, including traffic accidents, drownings, burns, poisonings, animal encounters, and falls.⁴ Fatal injuries are only the tip of the iceberg. There are thousands of non-fatal injuries for every fatal one.⁴ For example, one study of United States' children estimated nearly 1,000 non-fatal emergency room visits for every injury-related death.⁵

Injury mortality and morbidity are not distributed equally. Injury deaths have been steadily increasing in many LMIC,⁴ where approximately 90% of the world's population lives.⁶ Children are particularly affected by injury; 2010 Global Burden of Disease data estimate close to 20% of global deaths among children are attributable to unintentional injury.⁷ Poorer and less educated people are also at greater risk of injury.^4,8 These are populations with limited voices to advocate for better research and improved prevention efforts, and they often reside in communities and countries with limited resources, training, or infrastructure to allow these efforts to happen.

The measurement trap significantly hampers research on injuries for many of the same reasons that it impeded maternal mortality research in the 1990s. Despite evidence that unintentional injury contributes importantly to global morbidity and mortality, basic research to identify the population burden of injuries, their causes, and consequences is critically lacking in many LMIC.⁶ This lack of data has stymied effective responses, as well as global prioritization of the issue.^6,7

Article Goal

In this Insights article, we will describe the measurement trap in the context of unintentional injury research in the Philippines. Specifically, in the case of box jellyfish sting injuries, there is a historical lack of longitudinal morbidity and mortality data. Towards addressing this issue, we present recently acquired data on the topic that highlight critical data gaps and injury underreporting. We also provide information about an interdisciplinary and international collaboration with expertise in biochemistry, pathophysiology, ecology, and public health towards the objective of developing a collaborative translational research program with the ultimate goal of reducing box jellyfish sting injury and death. This includes pilot survey results from participants attending educational workshops in Philippines as part of this project in 2018.

Critical Data Gaps on Injury in the Philippines

In the early 2000s, Rafael Consunji and Adnan Hyder attempted to characterize injury in the Philippines from 1960 to 1995, based on published and available literature.⁹ Their efforts included a systematic review of published research articles on the topic, as well as screening for information on injury in the databases of the Philippine Commission on Health Research and Development, Philippine Departments of Health, Transportation and Communication, Philippine Information Agency, Philippine College of Surgeons, Philippine National Police, and the National Statistics Office. Despite such an extensive search, which covered a 30-year period, only 22 articles could be reviewed.

The majority of studies reviewed were hospital-based and more than half were case studies on very specific topics, such as pelvic fractures and thoracic trauma. There were only two population-based studies of sufficient quality to generate estimates of injury incidence and fatality.⁹ Differences between the population and hospital-based studies were fascinating. For example, no hospital-based study mentioned drowning as a cause of admission, despite estimates that 11% of all reported injury deaths in the Philippines were due to this cause.⁹ The authors explained this discrepancy as likely reflecting a combination of high case-fatality rates, underreporting, and inadequate pre-hospital care for drowning cases.⁹ As will be shown below, these same issues likely impede adequate recording, reporting, and response to box jellyfish stings.

Overall, Consunji and Hyder (2004) concluded that injuries were a growing health problem in the Philippines. But mostly, their review highlighted the paucity of data on injury from the Philippines, especially at the population and community levels. They highlighted the need for well-conducted surveillance systems and research to identify high-risk populations and key determinants of injury in the country.⁹ Since the publication of their article, the situation has hardly improved. For example, if one conducts a PubMed abstract/title search of “Philippines ‘unintentional injury’,” there is only one result and it is about road crash deaths of United States' citizens abroad. Similarly, among articles citing the 2004 Consunji and Hyder paper, only one examined injury in the Philippines. The others were papers about injury in South Africa, Bangladesh, Peru and other countries. Thus, the needs identified nearly two decades ago remain today.

Box Jellyfish Stings are a Public Health Concern

Box jellyfish species comprise the most highly specialized class (Cubozoa) of the Cnidaria phylum, and account for the majority of deaths among jellyfish sting victims worldwide.^10–12 The main orders of the class Cubozoa are Carybdeida and Chirodropida (figure 1A and 1B). Box jellyfish species are predominantly found in tropical latitudes and are especially abundant across the Indo-Pacific, including certain coastal areas of Hawai‘i. Many cubozoan species inflict life-threatening stings. Contact with certain chirodropids results in acutely necrotic injury and often, lethal cardiovascular collapse. More than 40 box jellyfish species are known worldwide. While only some box jellyfish species are associated with fatal stings, most of these lethal box jellyfish species are abundant in coastal Philippine waters. Injury from box jellyfish stings in this country presents a significant but poorly documented public health concern for coastal inhabitants and visitors to those areas.

Figure 1.

Cubozoa and Sting injuries. A. Carybdeid; B. Chirodropid; C-D Erythematous and Necrotic Stings

More human lives have been lost from box jellyfish sting injuries than from shark attacks during the past 40 years.¹³ Victims of serious box jellyfish stings may develop acute cardiovascular collapse, with death occurring within 1 hour, or a complex, life-threatening sequelae, known as Irukandji syndrome, characterized by minutes- to hours-long delayed onset of multi-system symptoms and signs, including chest and abdominal pain, hypertension followed by hypotension, and pulmonary edema, with death occurring in 4–48 hours usually from cerebral hemorrhage.^12,14,15 Chirodropid species box jellyfish stings are highly necrotic; survivors of these stings are frequently left with disfiguring, life-long keloid scars (figure 1C and 1D). Various professionals have described the scars as “ladder-like transverse bands” or “whip marks”;¹⁶ they are often immediately recognizable as box jellyfish scars. The leading global hotspot for these lethal sting injuries is the Philippines, where it is estimated that thousands of serious stings and potentially hundreds of fatalities occur each year.¹⁰

While sting incidence and prevalence in the Philippines have never been systematically assessed, case reports suggest that childhood deaths and injuries due to box jellyfish stings represent a critical and currently unmet, health challenge. Underlying this challenge is the fact that box jellyfish sting incidents and fatalities are often considered “environmental accidents” and not reported in regional and provincial health records. This issue is compounded by the speed at which death can occur especially in the absence of any effective first aid. In many cases, transport to an acute care facility is not feasible or victims die before reaching a health facility, and while local community members grieve the fatality, the event is not officially reported or recorded in searchable records. When those with sting injuries succeed in presenting for clinical care, the stings are typically coded either as “other injuries” or combined with envenomations, which also includes snakebites and poisonings (personal communication, July 2018). Thus, box jellyfish sting injuries cannot be disaggregated from other injuries in available surveillance data. Consequently, in affected areas, it is currently impossible to estimate the annual number of sting injuries, resulting deaths, and populations most affected. Finally, data are lacking with regard to how these stings are treated locally.

Establishing an Interdisciplinary Team to Address the Box Jellyfish Injury Measurement Trap

To tackle this poorly researched health concern, we have worked toward building an interdisciplinary and international collaboration between experts from Leyte Normal University, Mindanao State University, the University of San Carlos and the University of the Philippines Diliman (UP Diliman) and the University of Hawai‘i at Manoa. Team members bring expertise in biochemistry, pathophysiology, ecology, and public health. The goal of the collaborative translational research program is to reduce box jellyfish sting injuries. While together with the in country team members, we are still structuring the research program, we have begun pilot activities to get the most basic data on the public health burden of box jellyfish sting injury.

As part of a series of ongoing knowledge dissemination activities, we have conducted several in-person workshops in coastal regions of the Philippines where box jellyfish sting injuries and deaths (primarily in children) have been reported. During these workshops, box jellyfish sting pathophysiology and evidence-based life-saving first aid treatments were discussed. These workshops were a continuation of a training program in collaboration with researchers at UP Diliman, Marine Science Institute in Quezon City to which one of the authors (Yanagihara) has been an invited lecturer for the past 18 months. During workshops in summer 2018, a 10-minute survey of knowledge, attitudes and beliefs about box jellyfish stings was administered to participants, who were also asked about common and effective treatments, and whether the participant had personally been stung by a box jellyfish.

The workshops targeted healthcare professionals and first responders who provide care and treatment for people with injuries in their communities, including those with injuries resulting from box jellyfish stings. However, the workshops were not limited to any specific occupational group, and, as shown below, they attracted a diverse group of individuals interested in learning more about box jellyfish. This convenience sample provided an opportunity to get preliminary data about box jellyfish stings in communities known to have this organism in their coastal environments. It also provided vital information about what healthcare practitioners and first responders do when confronted with box jellyfish sting injury victims. This information is essential for developing and improving first-aid recommendations and guidelines.

Box Jellyfish Stings Commonly Reported by Survey Participants

Table 1 shows the demographic characteristics of the participants who attended the summer knowledge dissemination workshops. Most of the participants were middle-aged adults and credentialed public responders. Notably, close to a quarter were military, police, and/or disaster management personnel. We were told that the latter group was especially interested in learning about box jellyfish because they were often involved in jellyfish sting first response, or have to recover fatalities (eg, sting victims, drownings) from the water during which they may get stung.

Table 1.

Workshop participant characteristics (N=57)

Characteristic*	Mean	SD
Age, years	42	11
	n	%
Sex
Male	38	73%
Female	14	27%
Occupation
Healthcare Practitioner	15	28%
Government Employee/Civil Servant	19	35%
Military/Policy/Disaster Management	12	22%
Other Occupation	9	15%
Participant Works and Lives in the Same Community
Yes	42	76%
No	13	24%
Ever Stung by a Box Jellyfish
Yes	17	32%
No	36	68%

^*Missing values by characteristics are as follows: Age: 7; Sex: 5; Occupation: 3; Works and lives in same community: 2; Stung by a box jellyfish: 4.

Shockingly, one-third of the survey participants reported having ever been stung by a box jellyfish. Box jellyfish stings are excruciatingly painful and chirodropid stings leave highly recognizable scars. It is unlikely that participants reporting box jellyfish stings were mistaken. As figure 2 depicts, men were more likely to report suffering stings than women (38% versus 23%). This finding is consistent with global injury research; for example, men are almost twice as likely as women to die from injury and violence.⁴ There were also small differences in sting reports across professional categories with 27% (health professionals) to 35% (governmental employees) of participants reporting having ever been stung. Overall, these results may indicate that box jellyfish stings are common in coastal communities of the Philippines. They also highlight the ubiquity of exposure to coastal waters containing these species by all occupational groups living in affected communities.

Figure 2.

Proportion of Participants Reporting Having Ever Been Stung by a Box Jellyfish, According to Sex and Profession.

Overwhelmingly (≈90%) survey participants reported that children under 12 were most likely to be stung and to die from box jellyfish stings. Unsurprisingly, the vast majority (≈75%) of those participants who had children reported that they were somewhat or very worried about their children being stung by box jellyfish. These observations are again consistent with global injury research indicating that children are particularly vulnerable to injury. In fact, injury is among the leading causes of death for young people.⁴

Children are potentially more susceptible to critical injury from box jellyfish than adults. Because of their thinner skin and small body sizes, a typical grazing contact sting could inflict a greater venom load (based upon sting site surface area to body mass) in children relative to adults and therefore, cause more significant injury in dose-dependent pathophysiological sequelae.¹⁴ Given the dose-dependent speed at which box jellyfish venom can result in death, it is highly likely that many children, especially in more rural communities, never arrive at health centers and are never recorded. As already mentioned, many consider these injuries to be environmental accidents, rather than health outcomes that warrant recording. Globally, underreporting of injury among children is pervasive. Childhood injuries are often considered accidents that cannot be intervened upon and for which there is no causal explanation.⁷ Thus, they are not considered medical issues to which the health system should or is equipped to respond.

In considering these pilot survey results, it is important to highlight that the participants attending the educational workshops were not representative of the general population of the Philippines, nor necessarily representative of the mostly coastal communities in which they reside. Workshop attendees clearly had an interest in box jellyfish stings, which may have originated from having once been stung. As such, the frequency of box jellyfish stings reported by this sample could be high. On the other hand, with the exception of some of the military/police/disaster management workers, most of the respondents were not engaged in typical maritime occupations (e.g., fisherfolk), which would present an occupational risk for stings. Typically, we would expect healthcare practitioners and civil servants to have fewer sting injuries than other occupational classes, because their jobs do not entail exposure to the coastal marine environment. However, many of these coastal communities are developed immediately adjacent to, or even within coastal zones, which exposes most community members, irrespective of occupation class, to high-risk waters when engaging in everyday activities, such as leaving and returning to their homes (figure 3). Thus, unlike other types of injuries, which follow strong social-class gradients in which poorer and less educated individuals experience much higher rates,^4,8 jellyfish stings in these communities may be distributed relatively evenly across socioeconomic strata.

Figure 3.

Filipino Stilt Homes, which are Common in Areas Where Box Jellyfish are also Prevalent. (Photo credit: Kier Mitchel E. Pitogo)

Limited Knowledge About How to Treat Box Jellyfish Stings

In the survey, workshop participants were also asked how comfortable they were with their skills in treating box jellyfish stings. Only a very small proportion (8%) reported they were very certain how to treat stings. Three-quarters of participants reported they were very uncertain or had no idea how to treat box jellyfish stings. Notably, among those participants who were health professionals, 85% reported being very uncertain or had no idea how to treat box jellyfish stings. Yet, these are the very persons who would be responsible for managing the care of people with sting injuries at clinics and hospitals.

Participants were also asked to report which first aid technique was most commonly applied in their communities to people with box jellyfish stings and which techniques they believed were most effective. They reported that vinegar, urine, and ice were the most commonly applied first aids, while they believed vinegar, ice, and citrus were the most effective. The majority of published, evidence-based research suggests that vinegar is an appropriate and effective first aid for box jellyfish stings.¹⁷ Other options listed by the participants are not supported by evidence-based research and may actually exacerbate the sting injury.^18,19

Conclusions and Next Steps

Box jellyfish stings result in serious injury, including permanent disfigurement and death. Yet, there is almost no epidemiological data on this type of injury from the Philippines. Scattered extant data from other locations with far fewer species and less notoriously lethal box jellyfish species in their coastal waters, which in the United States (US) includes Hawai‘i, Guam, Florida, the US Virgin Islands, Saipan in the Commonweath of the Northern Mariana Islands, and Puerto Rico, underscores the likelihood of vast underreporting. Yet, even with the limited survey data presented here, it appears that these stings are common in areas with abundant box jellyfish populations. Fortunately, there are relatively inexpensive and evidence-based first-aid treatments for box-jellyfish stings that could save lives. Unfortunately, these treatments are not reaching those most in need, in part, because of the measurement trap. Limited data on the subject hinders public health workers from quantifying the issue appropriately and soliciting the political will to properly address it. The challenges measuring and addressing box jellyfish stings are symptomatic of broader issues affecting injury research and action in the Philippines and globally. More work is warranted to draw attention to this serious injury for which there are life-saving prevention and treatment options.