European Report on Child Injury Prevention

EUROPEAN REPORT ON CHILD INJURY PREVENTION EUROPEAN REPORT ON CHILD INJURY PREVENTION Dinesh Sethi WHO Regional Offi...

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EUROPEAN REPORT ON CHILD INJURY PREVENTION

EUROPEAN REPORT ON CHILD INJURY PREVENTION

Dinesh Sethi

WHO Regional Office for Europe Elizabeth Towner

University of West of England Bristol, United Kingdom Joanne Vincenten

European Child Safety Alliance, EuroSafe Zoetermeer, the Netherlands Maria Segui-Gomez

University of Navarra Pamplona, Spain Francesca Racioppi

WHO Regional Office for Europe

Abstract Injuries are a leading cause of death and disability in children. This report presents evidence on how they can be prevented, and calls for greater commitment and action from policy-makers and practitioners to decrease the burden of injuries. Every year, nearly 42 000 children and teenagers aged 0–19 years die from unintentional injuries in the European Region, where injuries are the leading cause of death in children aged 5–19; 5 out of 6 of these deaths occur in low- and middle-income countries. Irrespective of country income, the burden falls disproportionately on children from the most disadvantaged groups. The leading mechanisms of unintentional injury death in children are road traffic crashes, drowning, poisoning, thermal injuries and falls. Whatever the mechanism, the main causes of injury and their underlying socioeconomic and environmental determinants are similar. Children are particularly vulnerable to injuries, and need special consideration to safeguard their right to health and to a safe environment, free from injury. The evidence base for prevention programmes is presented in this report. Health systems and in particular child health programmes throughout the European Region should prioritize child injury prevention and control. Keywords 1. Wounds and injuries – prevention and control 2. Accident prevention 3. Child welfare 4. Socieconomic factors 6. Europe ISBN 978 92 890 4295 6 Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office web site (http://www.euro. who.int/pubrequest). © World Health Organization 2008 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization.

Photo credits: M. Gallitto: p. 31 Istockphoto: pp. XII, XIII, XIV, XVI, 14, 23, 29, 38, 48, 58 / backgrounds pp. I, X, 13, 27, 37, 47, 57, cover M. Sledák: p. 24 N. Di Tanno: pp. XIII, 28 WHO Regional Office for Europe: p. 3 Design and layout: L’IV Com Sàrl, Morges, Switzerland Printed in Rome, Italy, by Servizi Tipografici Carlo Colombo s.r.l.

CONTENTS

ACRONYMS

VII

ACKNOWLEDGEMENTS

VIII

FOREWORD

XI

EXECUTIVE SUMMARY

XII

1. OVERVIEW: CHILD INJURIES IN THE WHO EUROPEAN REGION 1.1 Introduction 1.2 The concept of childhood and why children need special attention 1.3 Reason to focus on child injuries in the European Region 1.4 A changing Region with social inequalities 1.5 Injury prevention: an issue of social and environmental justice in the European Region 1.6 Global and European policy initiatives 1.7 Overcoming the problem 1.8 Defining a child and an injury 1.9 References

1 1 1 1 2 2 3 4 5 5

2. BURDEN OF UNINTENTIONAL INJURIES 2.1 Introduction 2.2 Variations in the burden 2.3 Leading causes of injury 2.4 Variations by age and sex 2.5 Inequalities in the Region by country income 2.6 Beyond fatal injuries 2.7 The burden of injuries 2.8 Costs of injuries in children 2.9 Conclusions 2.10 References

7 7 7 7 8 9 10 11 11 12 12

3. ROAD TRAFFIC INJURIES 3.1 Introduction 3.2 Burden in the Region 3.2.1 Mortality 3.2.2 Sociopolitical and economic change in the Region 3.2.3 Changing patterns of transport and exposure 3.2.4 Socioeconomic determinants 3.2.5 Gender 3.2.6 Morbidity 3.2.7 Psychological and social effects 3.2.8 Costs

15 15 15 15 16 17 17 18 19 20 20

CONTENTS III

3.3 Risk factors for RTIs 3.4 What can be done 3.4.1 Societal responsibility 3.4.2 Community awareness 3.4.3 Improving road design 3.4.4 Speed 3.4.5 Alcohol 3.4.6 Child car restraints, seat-belts and seating position 3.4.7 Helmets 3.4.8 Conspicuity 3.5 Conclusions 3.6 References

20 21 21 22 22 23 23 23 24 24 24 24

4. DROWNING 4.1 Introduction 4.2 Burden in the Region 4.2.1 Mortality 4.2.2 Morbidity 4.3 Why children are at risk 4.3.1 Socioeconomic determinants 4.3.2 Economic change 4.3.3 Tourism 4.3.4 Medical conditions 4.3.5 Supervision 4.3.6 Alcohol 4.3.7 Transport 4.3.8 Climate change 4.4 Prevention 4.4.1 Engineering and environmental approaches 4.4.2 Legislation and standards 4.4.3 Education and skill development 4.4.4 Measures to avoid 4.5 Conclusions 4.6 References

29 29 29 29 29 31 31 31 32 32 32 32 32 32 32 33 33 34 34 35 35

5. POISONING 5.1 Introduction 5.2 Burden in the Region 5.2.1 Mortality 5.2.2 Morbidity 5.2.3 Costs 5.3 Risk factors 5.3.1 Age and gender 5.3.2 Poisonous agents 5.3.3 Socioeconomic determinants and association with poverty 5.3.4 Characteristics of the agent 5.3.5 Storage of chemicals 5.3.6 Seasonal variation 5.4 Prevention 5.4.1 Environmental modification 5.4.2 Engineering approaches

39 39 39 39 39 40 41 41 41 41 42 42 42 42 42 43

IV EUROPEAN REPORT ON CHILD INJURY PREVENTION

5.4.3 Legislative approaches 5.4.4 Educational approaches 5.4.5 Poison control centres and health care 5.4 Conclusions 5.5 References

43 43 44 45 45

6. THERMAL INJURIES 6.1 Introduction 6.2 Burden in the Region 6.2.1 Mortality 6.2.2 Morbidity 6.2.3 Costs 6.3 Risk factors 6.3.1 Age 6.3.2 Gender 6.3.3 Environmental factors 6.3.4 Tobacco and alcohol 6.3.5 Supervision 6.3.6 Socioeconomic determinants and association with poverty 6.3.7 Medical conditions and “outsider” status 6.3.8 Fireworks 6.3.9 Ultraviolet radiation exposure through tourism 6.3.10 Fire disasters 6.4 What can be done 6.4.1 Design and other engineering measures 6.4.2 Environmental modifications 6.4.3 Legislative approaches 6.4.4 Educational approaches 6.4.5 First aid for thermal injuries 6.4.6 Management of burns 6.4.7 Intersectoral action 6.5 Conclusions 6.6 References

49 49 49 50 51 51 51 51 51 51 52 52 52 52 52 52 52 52 53 53 53 53 54 54 54 54 54

7. FALLS 7.1 Introduction 7.2 Burden in the Region 7.2.1 Mortality 7.2.2 Morbidity 7.2.3 Costs 7.3 Risk factors 7.3.1 Age, developmental stage and gender 7.3.2 Environments 7.3.3 Consumer products 7.3.4 Playground equipment 7.3.5 Contact with animals 7.3.6 Poverty 7.3.7 Supervision 7.3.8 Work environments 7.4 What can be done 7.4.1 Environmental and engineering approaches

59 59 59 59 61 61 61 61 62 62 62 62 62 62 63 63 63

CONTENTS V

7.4.2 Legislation and standards 7.4.3 Combined strategies 7.5 Conclusions 7.6 References

63 64 64 64

8. CONCLUSIONS AND POINTS FOR ACTION 8.1 Cross-cutting themes 8.1.1 Diversity 8.1.2 Change 8.1.3 Vulnerability 8.1.4 Child rights 8.1.5 Social determinants and poverty 8.1.6 Intersectoral action 8.1.7 Prevention and control 8.1.8 Potential lives saved 8.2 The way forward 8.2.1 Action points 8.3 Conclusions 8.4 References

67 67 67 67 67 68 68 69 69 70 70 71 72 72

APPENDIX Annex 1. Data sources Annex 2. Methods Annex 3. Conceptual approaches to injury prevention Annex 4. Additional results

75 75 78 80 82

VI EUROPEAN REPORT ON CHILD INJURY PREVENTION

ACRONYMS

APOLLO APSI CEHAPE CIS DALY ECMT EC EU EuroSafe GBD GDP HIC HFA-DB HFA-MDB HFA-DM ICD ICD-9 ICD-9 BTL ICD-10 ILO LMIC MKD NGO PFD RAPEX RTI RoSPA SMR UNECE UNICEF

Strategies and Best Practices for the Reduction of Injuries Portuguese Association for Child Safety Promotion Children’s Environment and Health Action Plan for Europe Commonwealth of Independent States disability-adjusted life-year European Conference of Ministers of Transport European Commission European Union (27 countries) European Association for Injury Prevention and Safety Global Burden of Disease (WHO study) Gross Domestic Product high-income countries WHO health for all database WHO health for all mortality database for 67 causes WHO health for all detailed mortality database WHO International Classification of Diseases ICD, ninth revision ICD-9 basic tabular list ICD, tenth revision International Labour Organization low- and middle-income countries The former Yugoslav Republic of Macedonia nongovernmental organization personal flotation device Rapid alert system for non-food consumer products road traffic injury Royal Society for the Prevention of Accidents standardized mortality rate United Nations Economic Commission for Europe United Nations Children’s Fund

ACRONYMS VII

ACKNOWLEDGEMENTS

Many international experts and WHO staff have contributed to the development of this book, and we are very thankful for their support and guidance. We are particularly grateful to the following WHO staff: t#JSUF'SFSJDLBOE'SBODFTDP.JUJTGPSUIFJSIFMQXJUIUIFEBUBBOBMZTJTBOEUP&OSJRVF-PZPMBGPSQSPWJEJOHBEWJDFBOE UIF&VSPQFBOEFUBJMFENPSUBMJUZEBUBCBTF t.BSHJF1FEFOGPSTIBSJOHUIFWorld report on child injury prevention and for thorough and patient comments on several ESBęT t,JEJTU#BSUIPMPNFPTGPSUIPSPVHIBOEQBUJFOUDPNNFOUTPOESBęT t7JWJBO#BSOFLPXGPSQSPWJEJOHWFSZVTFGVMDPNNFOUT t.BUIJBT#SBVCBDI -FEB/FNFSBOE'SBODFTDP;BNCPOBOEGPSIFMQXJUIDPOUSJCVUJPOTUPTFDUJPOTPGUIFCPPL t'SBODFTDB(JBNQJFSJBOE/JDPMFUUB%J5BOOPGPSIFMQJOPCUBJOJOHSFGFSFODFTBOEQIPUPHSBQITBOE t.BOVFMB(BMMJUUPGPSBENJOJTUSBUJWFTVQQPSU We are particularly grateful to our external peer reviewers for their very helpful comments, and for contributing to improving the completeness and accuracy of this publication: t.PSBH.BDLBZ &VSPQFBO$IJME4BGFUZ"MMJBODF &VSP4BGF ;PFUFSNFFS UIF/FUIFSMBOET t3PTB(PĕO )FEBTTBIo)FCSFX6OJWFSTJUZ +FSVTBMFN *TSBFM t+P4JCFSU $BSEJČ 6OJUFE,JOHEPN t1IJMJQQF-VOFUUB 6OJWFSTJUZPG)FMTJOLJ 'JOMBOE t,FOO%VOO *OUFSOBUJPOBM#VSO*OKVSZ%BUBCBTF .BODIFTUFS 6OJUFE,JOHEPN t/JDPMB$ISJTUJF 6OJWFSTJUZPG4VSSFZ (VJMEGPSE 6OJUFE,JOHEPN t%BWJE0SNBOEZ 6OJWFSTJUZPG8BSXJDL 6OJUFE,JOHEPN t*BO3PCFSUT -POEPO4DIPPMPG)ZHJFOFBOE5SPQJDBM.FEJDJOF 6OJUFE,JOHEPN t&MFOJ1FUSJEPVBOE&WJ(FSNFOJ "UIFOT6OJWFSTJUZ.FEJDBM4DIPPM (SFFDF t*BO4DPUU 5"4$ ćF"MMJBODFGPS4BGF$IJMESFO

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VIII EUROPEAN REPORT ON CHILD INJURY PREVENTION

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Dinesh Sethi, Elizabeth Towner, Joanne Vincenten, Maria Segui-Gomez and Francesca Racioppi

ACKNOWLEDGEMENTS IX

FOREWORD

Injuries are the leading cause of death in children aged 5–19 years in the WHO European Region, and send many millions of children to hospitals or emergency departments, possibly leading to lifelong disabilities. Injuries thus pose a huge drain on the resources of not only health systems but also society at large. The burden is unequally distributed in the Region, with most of it falling on low- and middle-income countries. Regardless of the level of country income, a disproportionate share of the burden of injuries falls on children from deprived backgrounds and minority groups. For many households, the loss is not just limited to a child’s pain and suffering; death or disability can be crippling both psychologically and financially. This inequity in child injury in Member States across the European Region is a cause of social injustice that needs to be addressed. Some Member States’ successes in reducing child mortality from injuries show that many of these deaths, and many injuries, could be prevented. If all countries in the Region matched the performance of the safest, nearly 3 out of 4 injury deaths could be prevented, along with many more non-fatal injuries and disabilities. These figures show the urgent need to take action to address this problem. Mounting a response to injuries requires more than one sector, and the lack of ownership and leadership of the task has led to fragmented activity and a lack of coordination. A wealth of evidence indicates that the way forward is to use a combination of approaches: environmental modification, engineering of safer products, legislation to require these changes and education to stress the importance of using safety equipment. Organized effort by society can prevent childhood injury, but this requires strong and sustained commitment across all levels of government and society, as well as the necessary resources, capacity and policy frameworks for effective multidisciplinary action. By giving child injury prevention greater priority, Member States will join a global effort to reduce a leading cause of child mortality, and creating a safer and more just society for children in the European Region. We at the WHO Regional Office for Europe hope that this report, which accompanies the 8PSMESFQPSUPODIJMEJOKVSZ prevention, will be used across the European Region to highlight the magnitude of the problem and support policy-makers, professionals and activists in mainstreaming the child injury prevention agenda both within and outside the health sector.

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FOREWORD XI

EXECUTIVE SUMMARY

*OKVSJFTBSFBMFBEJOHQVCMJDIFBMUIUISFBUUPDIJMESFOJOUIF8)0&VSPQFBO3FHJPO.BOZDIJMESFOEJFPSFYQFSJFODF QBJOBOEEJTBCJMJUZGSPNJOKVSZUISPVHIPVUUIF3FHJPO$IJMESFOBSFFTQFDJBMMZWVMOFSBCMFUPJOKVSJFTćFZOFFETQFDJBM DPOTJEFSBUJPOUPTBGFHVBSEUIFJSSJHIUUPIFBMUIBOEUPBTBGFFOWJSPONFOU GSFFGSPNJOKVSZBOEWJPMFODF BTFNQIBTJ[FECZ UIF6OJUFE/BUJPOT$POWFOUJPOPOUIF3JHIUTPGUIF$IJME&WFSZTPDJFUZJTSFTQPOTJCMFGPSFOTVSJOHUIBUUIJTGVOEBNFOUBM SJHIUJTGVMĕMMFE ćJTSFQPSUIJHIMJHIUTUIBUJOKVSJFTBSFBMFBEJOHDBVTFPGEFBUIBOEEJTBCJMJUZBNPOHDIJMESFO QSFTFOUTFWJEFODFPO IPXJOKVSJFTDBOCFQSFWFOUFEBOEDBMMTGPSHSFBUFSDPNNJUNFOUBOEBDUJPOBNPOHQPMJDZNBLFSTBOEQSBDUJUJPOFSTUP EFDSFBTFUIFCVSEFOPGJOKVSJFTćJTSFQPSUJTBDPNQBOJPOUPUIFWorld report on child injury prevention and focuses on UIF&VSPQFBOEJNFOTJPOPGUIFQSPCMFN 6OJOUFOUJPOBMJOKVSJFTBSFUIFMFBEJOHDBVTFPGEFBUIBNPOHDIJMESFOBHFEoZFBST*O DIJMESFOBOE BEPMFTDFOUTBHFEoZFBSTEJFEGSPNVOJOUFOUJPOBMJOKVSJFTJOUIF8)0&VSPQFBO3FHJPO#VUUIFJNQBDUPGJOKVSJFT JTNVDIHSFBUFS XJUINJMMJPOTPGIPTQJUBMJ[BUJPOTBOEFNFSHFODZDBSFWJTJUT"MUIPVHIJOKVSJFTBSFBMFBEJOHDBVTFPGUIF CVSEFOPGEJTFBTFBOETFSJPVTMZESBJOIFBMUIBOETPDJFUBMSFTPVSDFT UIFZIBWFOPUCFFOBIJHIQSJPSJUZBSFBGPSBDUJPOJO NPTUDPVOUSJFTVOUJMSFDFOUMZ"DBUBTUSPQIJDFWFOUTVDIBTBUSBJODSBTINBZDBQUVSFUIFQVCMJDTBUUFOUJPO CVUUIFEBJMZMPTT PGMJWFTPGDIJMESFOLJMMFECZJOKVSJFTJO&VSPQFJTTDBSDFMZOPUJDFEćFMBSHFTUMPTTPGMJGFJOUIF3FHJPOJTJOMPXBOE NJEEMFJODPNFDPVOUSJFT XIFSFĕWFPGTJYPGEFBUITGSPNJOKVSZBNPOHDIJMESFOPDDVSćFDPVOUSJFTXJUIUIFIJHIFTUBOE MPXFTUEFBUISBUFTGSPNVOJOUFOUJPOBMJOKVSZJOUIF3FHJPOEJČFSTFWFOGPMEćFMPXBOENJEEMFJODPNFDPVOUSJFTJOUIF &VSPQFBO3FHJPOIBWFVOEFSHPOFSBQJETPDJPFDPOPNJDBOEQPMJUJDBMDIBOHF BOEUIFIJHIFSJOKVSZNPSUBMJUZJTBTTPDJBUFE with this pace of change. ćFMFBEJOHNFDIBOJTNTPGEFBUIGSPNVOJOUFOUJPOBMJOKVSZJODIJMESFOBSFSPBEUSBďDDSBTIFT ESPXOJOH QPJTPOJOH UIFSNBM JOKVSJFT BOE GBMMT 'PS BMM NFDIBOJTNT UIF NBJO DBVTFT PG JOKVSZ BOE UIFJS VOEFSMZJOH TPDJPFDPOPNJD BOE FOWJSPONFOUBMEFUFSNJOBOUTBSFTUSJLJOHMZTJNJMBSćFCVSEFOGBMMTEJTQSPQPSUJPOBUFMZPOUIFNPTUEJTBEWBOUBHFEDIJMESFO BOEPOUIFDPVOUSJFTVOEFSHPJOHUIFHSFBUFTUTPDJPFDPOPNJDDIBOHF%FBUISBUFTGSPNVOJOUFOUJPOBMJOKVSZBNPOHDIJMESFO WBSZCZBTNVDIBTOJOFUJNFTCZTPDJPFDPOPNJDTUSBUVNJOTPNFDPVOUSJFTćJTVOFRVBMEJTUSJCVUJPOPGJOKVSJFTUISFBUFOT UPGVSUIFSXJEFOUIFHBQJOJOFRVBMJUZJOIFBMUICFUXFFOBOEXJUIJODPVOUSJFTBOEDBVTFTTPDJBMJOKVTUJDF/FWFSUIFMFTT TFWFSBM&VSPQFBODPVOUSJFTIBWFCFFOTVDDFTTGVMJOEFWFMPQJOHDPNQSFIFOTJWFBOEFWJEFODFCBTFEBQQSPBDIFTUPQSFWFOUJOH JOKVSZBOESBOLBNPOHUIFTBGFTUDPVOUSJFTJOUIFXPSMEćJTFYQFSJFODFJTBWBMVBCMFSFTPVSDFGPSUIF3FHJPOBOETIPXTUIBU TUSPOHBOETVTUBJOFEDPNNJUNFOUDBOSFTVMUJONBKPSQSPHSFTT*UTFSWFTUPFODPVSBHFBMMDPVOUSJFTUPFOHBHFJOBEESFTTJOH UIJTQSFWFOUBCMFDBVTFPGQSFNBUVSFEFBUIBOETVČFSJOH UIFSFCZSFEVDJOHJOFRVBMJUZJOTPDJFUZ ćJTSFQPSUEJTDVTTFTĕWFMFBEJOHNFDIBOJTNTGPSVOJOUFOUJPOBMJOKVSZBNPOHDIJMESFOJOUIF3FHJPO

Road traffic injury ćSPVHIPVUUIF3FHJPO SPBEUSBďDJOKVSJFTBSFUIFMFBEJOHNFDIBOJTN PGGBUBMJOKVSJFTćFZBSFBMTPBMFBEJOHDBVTFPGUSBVNBUJDCSBJOBOEMJNC JOKVSJFT SFTVMUJOH JO MPOHUFSN EJTBCJMJUZ BNPOH DIJMESFO 5SBWFMMJOH is an essential component of the daily lives of children on their way to TDIPPM IPNF BOE QMBZ $IJMESFO OFFE TQFDJBM DPOTJEFSBUJPO CFDBVTF UIFZBSFWVMOFSBCMFBOEJOFYQFSJFODFESPBEVTFST*O BOFTUJNBUFE DIJMESFOBOEBEPMFTDFOUTBHFEoZFBSTEJFEGSPNSPBEUSBďD JOKVSJFTćFSBUFTWBSZJOUIF3FHJPO XJUIBUISFFGPMEEJČFSFODFCFUXFFO UIFDPVOUSJFTXJUIUIFIJHIFTUBOEMPXFTUEFBUISBUFT$IJMESFOMJWJOH JOMPXBOENJEEMFJODPNFDPVOUSJFTIBWFBGPMEJODSFBTFESJTLPG EZJOHGSPNSPBEUSBďDJOKVSZDPNQBSFEXJUIDIJMESFOJOIJHIJODPNFDPVOUSJFT$IJMESFOGSPNEFQSJWFECBDLHSPVOETBSF BUJODSFBTFESJTL FTQFDJBMMZBTQFEFTUSJBOTBOEDZDMJTUT CFDBVTFPGFYQPTVSFUPVOTBGFFOWJSPONFOUT6OTBGFSPBEEFTJHO speed, excessive alcohol and failure to use safety devices are the leading risk factors. XII EUROPEAN REPORT ON CHILD INJURY PREVENTION

*GBMMDPVOUSJFTJOUIF3FHJPOIBEUIFTBNFNPSUBMJUZSBUFTBTUIPTFXJUIUIFMPXFTUSBUFT UIFOUIFMJWFTPGOFBSMZ DIJMESFODPVMECFTBWFEFBDIZFBSUIBUJT IBMGUIFEFBUITGSPNUIJTDBVTFBNPOHDIJMESFODPVMECFBWFSUFE$PVOUSJFTUIBU IBWFIBEDPOTJEFSBCMFTVDDFTTJOSPBETBGFUZIBWFTIPXOUIBUQSFWFOUJOHSPBEUSBďDJOKVSJFTSFRVJSFTBDUJPOCZEJČFSFOU BDUPSTBOEUIFJOUFHSBUJPOPGTBGFUZNFBTVSFTJOUPCSPBEFSUSBOTQPSUBOEVSCBOEFWFMPQNFOUQPMJDJFT*OBEEJUJPOUPTBGFS SPBEEFTJHOBOEDPOUSPMMJOHTQFFEBOEBMDPIPMVTF FČFDUJWFNFBTVSFTJODMVEFVTJOHTFBUCFMUT IFMNFUT DIJMEDBSSFTUSBJOUT DZDMFMBOFTBOEQFEFTUSJBOJ[FEBSFBT1SPWJEJOHTBGFFOWJSPONFOUTGPSDIJMESFOSFEVDFTSPBEUSBďDJOKVSZ BOEBUSBOTQPSU QPMJDZUIBUQSPNPUFTDZDMJOHBOEXBMLJOHIBTPUIFSIFBMUIBOEFOWJSPONFOUBMCFOFĕUTćFTFJODMVEFSFEVDJOHPCFTJUZ and reducing noise and emissions, which reduce the risk of ill health from noncommunicable disease and mitigate climate DIBOHFćFPWFSBMMCFOFĕUTPGJOUFHSBUFEQSPHSBNNFTGPSTBGFUZUIVTHPXFMMCFZPOESFEVDJOHJOKVSZ'BJMVSFUPTBGFHVBSE DIJMESFOXIPVTFUIFSPBETDPNQSPNJTFTDIJMESFOTGVOEBNFOUBMSJHIUUPTBGFUZćJTDIBMMFOHFQSFTFOUTBOPQQPSUVOJUZ UPBDLOPXMFEHFTPDJFUZTSFTQPOTJCJMJUZUPJUTDIJMESFOBOEUPUBDLMFUIFQSPCMFNVTJOHTUSVDUVSBMBOEDPNNVOJUZCBTFE interventions that will provide effective solutions for everyone regardless of background or income.

Drowning %SPXOJOHJTUIFTFDPOEMFBEJOHDBVTFPGJOKVSZEFBUITBNPOHDIJMESFOJOUIF8)0 &VSPQFBO3FHJPOBOEUIFMFBEJOHDBVTFPGDIJMEIPPEJOKVSZEFBUIJOTPNFDPVOUSJFT &BDIZFBS NPSFUIBODIJMESFOBOEBEPMFTDFOUTBHFEoZFBSTEJFGSPNESPXOJOH JOUIF3FHJPO*OBEEJUJPO DIJMESFOXIPBSFJOKVSFECZESPXOJOHNBZCFTFWFSFMZEJTBCMFE UISPVHI CSBJO EBNBHF BOE SFRVJSF MJGFMPOH ĕOBODJBM BOE IFBMUI DBSF TVQQPSU "T JO PUIFSNFDIBOJTNTPGJOKVSZ JOFRVBMJUZJTTVCTUBOUJBM BOEUIFNPSUBMJUZSBUFTCFUXFFO UIFDPVOUSJFTJOUIF3FHJPOXJUIUIFIJHIFTUBOEMPXFTUSBUFTEJČFSCZUXFOUZGPMEćJT JOFRVBMJUZJTBMTPTUSJLJOHXJUIJODPVOUSJFT XIFSFUIFQPPSFTUQFPQMFBSFNPSFWVMOFSBCMF UPEFBUIGSPNESPXOJOHCZVQUPUJNFT 8BUFSFOWJSPONFOUTTIPVMECFQPTJUJWFBOECFOFĕDJBMGPSCPUIDIJMESFOBOEBEVMUT BOEVOEFSUBLJOHQSFWFOUJWFBDUJPOUPFOIBODFTBGFUZJTUIFSFGPSFFTTFOUJBM*GNPSUBMJUZ SBUFTXFSFUIFTBNFBTUIPTFJOUIFDPVOUSJFTXJUIUIFMPXFTUSBUFT UIFOPGUIFTFEFBUITBNPOHDIJMESFODPVMECF BWFSUFEćJTFNQIBTJ[FTUIFWFSZHSFBUQPUFOUJBMGPSQSFWFOUJPO4VDIBDUJPOOFFETUPCFJOUFSTFDUPSBMUPFOTVSFTBGFXBUFS environments using the combined approaches of engineering and modifying the environment, legislation and education. 1SPWFOJOUFSWFOUJPOTUPSFEVDFESPXOJOHBNPOHDIJMESFOJODMVEFSFNPWJOHPSDPWFSJOHXBUFSIB[BSET JOTUBMMJOHGPVSTJEFE QPPMGFODJOH VTJOHQFSTPOBMĘPUBUJPOEFWJDFTBOEJOTUJUVUJOHJNNFEJBUFSFTVTDJUBUJPO

Poisoning 1PJTPOJOHSFNBJOTUIFUIJSEMFBEJOHDBVTFPGVOJOUFOUJPOBMJOKVSZEFBUIDIJMESFO BOE BEPMFTDFOU BHFE o ZFBST EJFE GSPN BDVUF QPJTPOJOH JO JO UIF 3FHJPO *OFRVBMJUZJTTVCTUBOUJBMJOUIF3FHJPOCPUICFUXFFODPVOUSJFTBOEXJUIJODPVOUSJFTćF DPVOUSJFTXJUIUIFIJHIFTUBOEMPXFTUSBUFTEJČFSCZUIJSUZGPME BOEPGQPJTPOJOH EFBUITPDDVSJOUIFMPXBOENJEEMFJODPNFDPVOUSJFTJOUIF3FHJPOćFIPNFJTUIF most common setting for childhood poisoning, and children are particularly at risk when IBSNGVMTVCTUBODFTBSFTUPSFEJOOPODIJMEQSPPGDPOUBJOFSTPSXJUIJOFBTZSFBDI*O UIF3FHJPO QIBSNBDFVUJDBMT IPVTFIPMEBHFOUT QFTUJDJEFTBOEQMBOUTDBVTFNPTUDBTFT PGGBUBMQPJTPOJOH"DVUFJOUPYJDBUJPOXJUIBMDPIPMBNPOHPMEFSDIJMESFOJTBHSPXJOH concern. *GBMMDPVOUSJFTJOUIF3FHJPOIBEUIFTBNFSBUFBTUIFDPVOUSZXJUIUIFMPXFTUSBUF UIFOPGEFBUITDPVMECFBWFSUFE &WJEFODFGSPNDPVOUSJFTXJUIMPXSBUFTTIPXTUIBUNPEJGZJOHUIFFOWJSPONFOU TVDIBTDIJMESFTJTUBOUDMPTVSFT TBGFTUPSBHF SFEVDJOHUIFBWBJMBCJMJUZPGUPYJDTVCTUBODFT EJTQFOTJOHNFEJDJOFTJOOPOMFUIBMRVBOUJUJFTBOEFTUBCMJTIJOHQPJTPODPOUSPM centres, is a good investment in prevention. However, obstacles remain in further reducing the incidence and morbidity of QPJTPOJOH5PFOTVSFDPPSEJOBUFEBDUJPO OBUJPOBMQMBOTGPSQSFWFOUJOHQPJTPOJOHOFFEUPCFEFWFMPQFEUIBUJODMVEFUIFTF JOUFSWFOUJPOT5BSHFUFEBDUJPOUPSFEVDFBDVUFBMDPIPMJOUPYJDBUJPOBNPOHDIJMESFOJTBMTPOFFEFE

Thermal injuries ćFSNBMJOKVSJFTBSFBMFBEJOHDBVTFPGEFBUIBOEEJTĕHVSFNFOUBNPOHDIJMESFO&BDIZFBS DIJMESFOBHFEoZFBST EJFGSPNUIFSNBMJOKVSJFTJOUIF3FHJPO BOENBOZPGUIPTFXIPTVSWJWFUIFSNBMJOKVSJFTBSFQFSNBOFOUMZTDBSSFEPSEJTBCMFE *OFRVBMJUZJTTVCTUBOUJBMCFUXFFOBOEXJUIJODPVOUSJFTJOUIF3FHJPOUIFEFBUISBUFTJOUIFDPVOUSJFTXJUIUIFIJHIFTUBOE EXECUTIVE SUMMARY XIII

MPXFTUSBUFTEJČFSCZUJNFT8JUIJODPVOUSJFT UIFQPPSFTUQFPQMFBSFNPSFWVMOFSBCMF CZVQUPUJNFT%FBUITBOEJOKVSJFTSFTVMUJOHGSPNUIFSNBMJOKVSJFTBSFTUSPOHMZMJOLFE to unsafe environments and products, especially in the home. .BOZ DPTUFČFDUJWF TUSBUFHJFT FYJTU UP QSFWFOU CVSOT BNPOH DIJMESFO BOE PG deaths could be averted if the rates were the same as those in the countries with the MPXFTUSBUFTćFSNBMJOKVSJFTDBOCFQSFWFOUFEPSDPOUSPMMFECZBWBSJFUZPGNFBTVSFT including legislation and regulations, modifying the environment and educating people BOESBJTJOHBXBSFOFTT4VDIBSFTQPOTFOFFETUPJOWPMWFBSBOHFPGTUBLFIPMEFSTGSPN EJWFSTF TFDUPST JODMVEJOH DPNNVOJUZ NFNCFST -BXT UP FOGPSDF UIF JOTUBMMBUJPO PG smoke alarms and to regulate hot water and standards for cigarette lighters are effective JOQSFWFOUJOHUIFSNBMJOKVSJFTBOEOFFEUPCFJNQMFNFOUFEXJEFMZ'JSTUBJEJOJUJBUJWFT BOEQSPWJEJOHIJHIRVBMJUZCVSODBSFBSFFČFDUJWFJOFOTVSJOHUIFCFTUQPTTJCMFPVUDPNFT for physical and mental health and need to be supported widely.

Falls 'BMMTPDDVSGSFRVFOUMZBOEDBOIBWFBUSFNFOEPVTFČFDUPODIJMESFO GBNJMJFT BOETPDJFUZ&BDIZFBSNPSFUIBODIJMESFOBHFEoZFBSTEJFGSPNGBMMT JOUIF3FHJPO$PVOUSJFTEJČFSWBTUMZJOSBUFT BOEUIFEFBUISBUFTCFUXFFO UIFDPVOUSJFTXJUIUIFIJHIFTUBOEMPXFTUSBUFTEJČ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managing safe environments and products for children are critical in reducing their exposure to and risk of serious falls. 1SPWFOTUSBUFHJFTFYJTUUPSFEVDFTFSJPVTGBMMTBNPOHDIJMESFOBOEJODMVEFNPEJGZJOHPSSFQMBDJOHVOTBGFQSPEVDUT SFRVJSJOH window guards, implementing playground standards and executing multifaceted community programmes.

The way forward ćJTSFQPSUIJHIMJHIUTUIFFOPSNPVTTDBMFPGUIFMPTTUPTPDJFUZGSPNJOKVSZBNPOHDIJMESFOJOUIF8)0&VSPQFBO3FHJPO BOEUIFIVHFQPUFOUJBMGPSQSFWFOUJPOCZBEESFTTJOHVOEFSMZJOHSJTLTBOEFYQPTVSFT*GBMMDPVOUSJFTJOUIF3FHJPOIBEUIF TBNFJOKVSZNPSUBMJUZSBUFTBNPOHDIJMESFOBTUIFDPVOUSJFTXJUIUIFMPXFTUSBUFT UIJTXPVMEBWPJEBOFTUJNBUFEPG UIFTFEFBUITćFFYQFSJFODFBDDVNVMBUFECZTFWFSBM&VSPQFBODPVOUSJFTTIPXTUIBUTVTUBJOFEBOETZTUFNBUJDBQQSPBDIFT UIBUBEESFTTUIFVOEFSMZJOHDBVTFTPGJOKVSJFT TVDIBTUIFJSTPDJPFDPOPNJDBOEFOWJSPONFOUBMEFUFSNJOBOUT DBONBLF BMMDPVOUSJFTJOUIF3FHJPOBNPOHUIFTBGFTUJOUIFXPSME4FWFSBMBDUJPOQPJOUTBSFSFDPNNFOEFEGPSUBLJOHUIJTGPSXBSE (MPCBMBOE&VSPQFBOQPMJDZEFWFMPQNFOUTVOEFSQJOUIJTBDUJPO Provide leadership in integrating the prevention of injury among children and adolescents into a comprehensive approach to their health and development"DPNQSFIFOTJWFTUSBUFHZGPSUIFIFBMUIBOEEFWFMPQNFOUPGDIJMESFOBOE BEPMFTDFOUTOFFETUPJODMVEFJOKVSZCFDBVTFJUJTBMFBEJOHDBVTFPGEFBUIBOEEJTBCJMJUZBNPOHDIJMESFOćJTSFQPSU QSPWJEFTFWJEFODFPGFČFDUJWFBDUJPO BOEJOUFHSBUJOHUIJTJOUPBDPNQSFIFOTJWFBQQSPBDIXJMMPQUJNJ[FIFBMUIHBJO Develop and implement a policy and plan for preventing injury among children that involves other sectors. *OUFSTFDUPSBMBDUJWJUJFTBSFFTTFOUJBMGPSTVDDFTTGVMMZQSFWFOUJOHJOKVSZBOELFZUPBQMBOGPSQSFWFOUJOHJOKVSZBNPOH DIJMESFO&ČPSUTTIPVMEJODMVEFTFDUPSTPGHPWFSONFOU UIFQSJWBUFTFDUPS OPOHPWFSONFOUBMPSHBOJ[BUJPOT UIFNBTT NFEJBBOEUIFHFOFSBMQVCMJD XJUIBDMFBSBMMPDBUJPOPGSFTQPOTJCJMJUJFTBOESFTPVSDFTćFTUSBUFHZTIPVMEJODMVEFBMM DIJMESFO FTQFDJBMMZ UIPTF JO MPXJODPNF BOE FUIOJD NJOPSJUZ DPNNVOJUJFT 4VDI B TUSBUFHZ TIPVME CF DPPSEJOBUFE with the promotion of physical activity through walking, cycling and swimming in safe environments and the safe use PGQVCMJDUSBOTQPSU"DPNQSFIFOTJWFQPMJDZGSBNFXPSLXPVMEBMTPPWFSDPNFUIFGSBHNFOUFEBQQSPBDIUPQSFWFOUJOH JOKVSZ

XIV EUROPEAN REPORT ON CHILD INJURY PREVENTION

Implement evidence-based action to prevent and control injuries among childrenćFSFJTTVďDJFOUFWJEFODFUP TUBSUJNQMFNFOUJOHUIFTQFDJĕDBDUJPOTOFFEFEUPQSFWFOUBOEDPOUSPMJOKVSJFTBNPOHDIJMESFOBOEUPNJOJNJ[FUIFJS DPOTFRVFODFT,FZBQQSPBDIFTOFFEUPJODMVEFMFHJTMBUJPO SFHVMBUJPOBOEFOGPSDFNFOU NPEJGZJOHQSPEVDUT NPEJGZJOH the environment, education and developing skills and emergency health care. Strengthen health systems to address injuries among children. Health system responses need to incorporate both QSJNBSZQSFWFOUJPOBOEUIFQSPWJTJPOPGIJHIRVBMJUZFNFSHFODZUSBVNBDBSFUPJOKVSFEDIJMESFOBTXFMMBTSFIBCJMJUBUJPO BOETVQQPSUTFSWJDFTćFQSJODJQMFTPGFRVJUZBOEFWJEFODFCBTFEQSBDUJDFTIPVMEVOEFSQJOUIFTFBDUJPOT'PDBMQFPQMF GPSJOKVSZQSFWFOUJPOXJUIJOIFBMUINJOJTUSJFTBSFXFMMQMBDFEUPDPPSEJOBUFTVDIBDUJWJUJFT Build capacity and exchange best practice"OFTTFOUJBMQBSUPGBOBEFRVBUFIFBMUITZTUFNSFTQPOTFJTFOTVSJOHTVďDJFOU USBJOFEBOEFYQFSJFODFETUBČ$VSSJDVMBUIBUGPDVTPOQSFWFOUJOHJOKVSZOFFEUPCFJOUFHSBUFEJOUPIFBMUIQSPGFTTJPOBM DVSSJDVMB&YDIBOHJOHLOPXMFEHFCZEFWFMPQJOHQBSUOFSTIJQTBOEOFUXPSLTTUSFOHUIFOTDPVOUSZDBQBDJUZ$IJMESFOBOE BEPMFTDFOUTOFFEUPCFJODMVEFEBOEBDUJWFMZJOWPMWFEJOQSPHSBNNFTBOESFTFBSDI BOEJOKVSZQSFWFOUJPOBDUJWJUJFT should be introduced into school and university curricula. Enhance the quality and quantity of data for preventing injury among children(PPEEBUBPONPSUBMJUZ NPSCJEJUZ exposure, outcomes and costs are needed to provide a foundation on which to develop and monitor policies that promote DIJMETBGFUZ.PTUDPVOUSJFTOFFECFUUFSJOGPSNBUJPOPOUIFDJSDVNTUBODFTBOEBDUJWJUJFTTVSSPVOEJOHBOJOKVSZBOEUIF socioeconomic determinants, which are essential to understanding exposure and risk and to developing comprehensive responses. Define priorities for and support research and evaluation on the causes, effects, costs and prevention of injury among children"SFTFBSDIBHFOEBGPSJOKVSJFTBNPOHDIJMESFOOFFETUPCFEFWFMPQFEBUUIFSFHJPOBMBOEOBUJPOBM MFWFMT3FTFBSDITLJMMTTIPVMECFTUSFOHUIFOFEJOBWBSJFUZPGJOKVSZSFMBUFEĕFMET JODMVEJOHFQJEFNJPMPHZ FDPOPNJDT engineering, social sciences, human factor and behavioural psychology, product evaluation, clinical trials and policy analysis. Raise awareness and targeted investment for preventing injury among children3BJTJOHBXBSFOFTTBCPVUUIFBCJMJUZ UPQSFWFOUJOKVSZBNPOHDIJMESFOJTPGQBSBNPVOUJNQPSUBODF1SPNPUJOHTBGFSFOWJSPONFOUTGPSDIJMESFOJTBDSVDJBM QBSUPGUIJT5PEPUIJT IFBMUITZTUFNTOFFEUPBEWPDBUFGPSTBGFSCSPBEHPWFSONFOUQPMJDZPOFOTVSJOHTBGFSQIZTJDBM and social environments. Address inequity in injury among childrenćFIFBMUITFDUPSIBTBLFZSPMFUPQMBZJOBEWPDBUJOHGPSKVTUBDUJPOBDSPTT HPWFSONFOUBOEDBOEPUIJTCZQSPNPUJOHFRVJUZJOIFBMUIJOBMMQPMJDJFTBOECZIJHIMJHIUJOHJOKVSJFTBTBDPOTFRVFODF PGTPDJBMQPMJDJFT'VSUIFS UIFIFBMUITFDUPSOFFETUPJODPSQPSBUFUIFQSFWFOUJPOPGJOKVSZJOJUTQSPWJTJPOPGVOJWFSTBM QSJNBSZIFBMUIDBSFBOETVQQPSUPGDPNNVOJUZCBTFEBDUJPOBOEOFFETUPQBZQBSUJDVMBSBUUFOUJPOUPUBSHFUJOHUIFTPDJBM TUSBUJĕDBUJPOPGJOKVSJFT

Conclusion "DIJFWJOHHSFBUFSTPDJBMKVTUJDFJOUIF8)0&VSPQFBO3FHJPOSFRVJSFTFMJNJOBUJOHJOFRVJUZJOJOKVSJFTBNPOHDIJMESFO ćFHSFBUFTUCVSEFOPGJOKVSZJOUIF3FHJPOJTDPODFOUSBUFEJOMPXBOENJEEMFJODPNFDPVOUSJFT XJUISBUFTPGJOKVSZ NPSUBMJUZBNPOHDIJMESFONPSFUIBOUISFFUJNFTHSFBUFSUIBOJOIJHIJODPNFDPVOUSJFT*OIJHIJODPNFDPVOUSJFT EFQSJWFE DPNNVOJUJFTCFBSBEJTQSPQPSUJPOBUFMZIJHIFSTIBSFPGUIFCVSEFO/FWFSUIFMFTT GFXDPVOUSJFTIBWFEFWPUFEBEFRVBUF SFTPVSDFTUPQSFWFOUJOHVOJOUFOUJPOBMJOKVSJFTBNPOHDIJMESFOBOEBEPMFTDFOUT4PDJFUJFTIBWFBSFTQPOTJCJMJUZUPQSPUFDU DIJMESFOBOEBEPMFTDFOUTCZQSPWJEJOHTBGFFOWJSPONFOUT1SPHSBNNFTPODIJMESFOTIFBMUIUISPVHIPVUUIF3FHJPONVTU FOTVSFUIBUUIFZJODMVEFQSFWFOUJOHBOEDPOUSPMMJOHJOKVSZBNPOHDIJMESFOćJTJNQPSUBOUQSPCMFNSFRVJSFTBUUFOUJPO commitment, resources and action now.

EXECUTIVE SUMMARY XV

CHAPTER 1 OVERVIEW: CHILD INJURIES IN THE WHO EUROPEAN REGION 1.1 Introduction "DSPTT UIF MFOHUI BOE CSFBEUI PG UIF 8)0 &VSPQFBO 3FHJPO JOKVSJFTLJMMDIJMESFOPSMFBWFUIFNJOQBJOPSXJUI EJTBCJMJUJFT /P DPVOUSZ JT JNNVOF GSPN UIJT QSPCMFN CVU UIF SBUFT PG GBUBM BOE OPOGBUBM JOKVSZ WBSZ XJEFMZ SFĘFDUJOHUIFEJWFSTFDPOEJUJPOTJOUIF3FHJPOćFNBJO DBVTFTPGJOKVSZBOEUIFJSVOEFSMZJOHTPDJPFDPOPNJDBOE environmental determinants, however, are strikingly similar. ćFCVSEFOGBMMTEJTQSPQPSUJPOBUFMZPODIJMESFOGSPNUIF most disadvantaged groups and in the countries undergoing UIFHSFBUFTUTPDJPFDPOPNJDDIBOHFćJTVOFRVBMEJTUSJCVUJPO PG JOKVSJFT UISFBUFOT UP GVSUIFS XJEFO UIF HBQ JO IFBMUI JOFRVBMJUJFTCFUXFFOBOEXJUIJODPVOUSJFT BOEDBVTFTTPDJBM JOKVTUJDF /FWFSUIFMFTT TFWFSBM &VSPQFBO DPVOUSJFT IBWF EFWFMPQFEDPNQSFIFOTJWFBOEFWJEFODFCBTFEBQQSPBDIFT UP JOKVSZ QSFWFOUJPO BOE SBOL BNPOH UIF TBGFTU JO UIF XPSMEćJTFYQFSJFODFJTBWBMVBCMFSFTPVSDFGPSUIF3FHJPO showing that strong and sustained commitment can result JO NBKPS QSPHSFTT ćJT DPVME FODPVSBHF BMM DPVOUSJFT UP address this preventable cause of premature death and TVČFSJOH UIFSFCZSFEVDJOHJOFRVBMJUJFTJOTPDJFUZ ćJTSFQPSUJTBDPNQBOJPOUPUIFWorld report on child injury prevention (1)BOEGPDVTFTPOUIF&VSPQFBOEJNFOTJPO PGUIFJTTVF*UUIFSFGPSFIJHIMJHIUTUIFJNQPSUBODFPGJOKVSJFT as a leading cause of death and disability in children in the 8)0&VSPQFBO3FHJPO QSFTFOUTFWJEFODFPOIPXUIFZDBO CFQSFWFOUFEBOEDBMMTGPSHSFBUFSBDUJPOGSPNQPMJDZNBLFST and practitioners to decrease the burden. 5IJT GJSTU DIBQUFS FYBNJOFT UIF CVSEFO EFTDSJCFT JOFRVBMJUJFT UIF TPDJBM EFUFSNJOBOUT PG JOKVSJFT BOE UIF SJTL GBDUPST BOE QSFTFOUT TPNF PG UIF FWJEFODF PO XIBU XPSLT GPS QSFWFOUJPO $IBQUFS GPDVTFT PO UIF PWFSBMM CVSEFOGSPNBMMJOKVSJFTBOETFUTUIFTDFOFGPSUIF3FHJPO ćFTVCTFRVFOUDIBQUFSTEFTDSJCFUIFCVSEFOBOEEFBMXJUI QSFWFOUJOH UIF MFBEJOH VOJOUFOUJPOBM JOKVSZ DBVTFT ćF ĕOBMDIBQUFSTVNNBSJ[FTUIFFWJEFODFBOEDBMMTPOQPMJDZ makers, practitioners and researchers from all sectors to QSPUFDU &VSPQFT DIJMESFO GSPN UIJT QVCMJD IFBMUI UISFBU using solutions based on the best evidence.

1.2 The concept of childhood and why children need special attention ćJTSFQPSUFYBNJOFTJOKVSJFTJODIJMESFOBOEBEPMFTDFOUT BHFEoZFBSTćFDPODFQUPGDIJMEIPPEWBSJFTCFUXFFO DVMUVSFT BOEJTJOĘVFODFEOPUPOMZCZBHFBOEEFWFMPQNFOUBM

stage but also by gender, family and social background, school and work (2,3)ćJTOFFETUPCFUBLFOJOUPBDDPVOU XIFOFYQPTVSFT SJTLGBDUPSTBOEUIFEFWFMPQNFOUPGJOKVSZ prevention strategies are considered for different settings in UIF3FHJPO ćJT SFQPSU GPDVTFT PO DIJMESFO CFDBVTF UIFZ BSF OPU TNBMM BEVMUT $IJMEIPPE FODPNQBTTFT EJČFSFOU TUBHFT PG emotional, physical and brain development, ranging from OFXCPSOCBCJFTUPBEPMFTDFOUT*OKVSJFTSFRVJSFBEJČFSFOU response at each stage (4). "TDIJMESFOEPOPUIBWFBQMBUGPSNGPSFYQSFTTJOHUIFJS views, they need advocates of safer environments on the road, BUMFJTVSFBOEJOUIFIPNF&OWJSPONFOUTBSFCFUUFSBEBQUFE to the needs of adults than children, and children may not know how to respond appropriately to risky situations. 1PMJDZNBLFST BOE QSBDUJUJPOFST OFFE UP UBLF BDDPVOU PG these special circumstances when promoting safety for UIJT WVMOFSBCMF HSPVQ 'BJMVSF UP EP TP DPNQSPNJTFT UIF fundamental rights of children and young adults to safety BOEGVMMBOEQSPEVDUJWFMJWFT JOBDDPSEBODFXJUIUIF6OJUFE /BUJPOT $POWFOUJPO PO UIF 3JHIUT PG UIF $IJME (5) *U JT VOKVTUUIBUDIJMESFOMBSHFMZCFBSUIFFYUFSOBMDPTUTPGJOKVSJFT ćFZIBWFBSJHIUUPTBGFFOWJSPONFOUT BOEUIJTSJHIUNBZ be denied in segments of society or whole countries.

1.3 Reason to focus on child injuries in the European Region *OKVSJFTBČFDUQFPQMFPGBMMBHFT CVUUIFZBSFUIFMFBEJOHDBVTF PGEFBUIJOUIPTFBHFEoZFBSTJOUIF8)0&VSPQFBO 3FHJPOćFZBSFBMTPBNBKPSDBVTFPGQBJO TVČFSJOHBOE EJTBCJMJUZ XIJDI DBO IBWF GBSSFBDIJOH DPOTFRVFODFT GPS DIJMESFOTQIZTJDBM QTZDIPMPHJDBMBOETPDJBMEFWFMPQNFOU 'VSUIFS DIJMEJOKVSJFTBSFBIVHFESBJOPOIFBMUIBOETPDJFUBM resources in the short and longer terms (6,7). 0OMZJOUIFMBTUGFXEFDBEFTIBWFJOKVSJFTCFFOSFDPHOJ[FE as a problem that coordinated public health action can QSFWFOUćJOLJOHIBTTIJęFEUPBDDFQUJOKVSZQSFWFOUJPO BTBTPDJFUBMSFTQPOTJCJMJUZBOEUPSFDPHOJ[FUIBUFWJEFODF based systemic prevention is a more effective response than SFHBSEJOH JOKVSJFT BT SBOEPN BOE VOBWPJEBCMF BDDJEFOUBM FWFOUTNPEJĕBCMFUISPVHIFEVDBUJPOćFIFBMUITFDUPSDBO play a central role in this new approach by documenting the CVSEFO EJTUJMMJOHUIFFWJEFODFPGXIBUXPSLT QSJPSJUJ[JOH actions and engaging other sectors in partnerships to develop prevention plans. OVERVIEW: CHILD INJURIES IN THE WHO EUROPEAN REGION 1

$PVOUSJFT JO UIF 3FHJPO WBSZ XJEFMZ JO DJSDVNTUBODFT BOE DVMUVSF 'PS FYBNQMF TPNF XFTUFSO BOE OPSUIFSO .FNCFS4UBUFTIBWFTIPXFETUSPOHBOETVTUBJOFEQPMJUJDBM DPNNJUNFOUBOEBMMPDBUFESFTPVSDFTUPUBDLMFDIJMEJOKVSZ PWFSBOVNCFSPGZFBSTUIFTFIBWFTPNFPGUIFMPXFTUJOKVSZ SBUFTJOUIFXPSME*ODPOUSBTU DFOUSBMBOEFBTUFSODPVOUSJFT JODMVEJOHUIF$PNNPOXFBMUIPG*OEFQFOEFOU4UBUFT $*4

BSFBEKVTUJOHUPSBQJEMZDIBOHJOHQPMJUJDBM FDPOPNJDBOE TPDJBMSFBMJUJFTBOEIBWFWFSZIJHIDIJMEJOKVSZSBUFT ćVT UIF TPDJFUBM DPNNJUNFOU BOE DPODFSUFE QVCMJD health action that result in safer environments and behaviour EPOPUCFOFĕUBMMDIJMESFOJOUIF3FHJPOćJTSFQPSUBJNT to stimulate action that will make the less privileged as TBGF BT UIPTF JO UIF NPTU QSJWJMFHFE TPDJFUJFT 1MFOUZ PG opportunities are available for strengthening collaboration, so that good practice can be adapted and transferred from one country to another, as well as to different segments of society (8,9).

$IBOHF JT OPXIFSF NPSF WJTJCMF UIBO JO UIF MPX BOE NJEEMFJODPNF DPVOUSJFT -.*$T JO UIF 3FHJPO ćFZ are undergoing both political change and rapid transition UP NBSLFU FDPOPNJFT 1PMJUJDBM BOE TPDJBM VODFSUBJOUZ IBT DBVTFE JODSFBTFE TUSFTT GPS GBNJMJFT )JHI JOĘBUJPO VOFNQMPZNFOUBOEQPWFSUZ SJTJOHJODPNFJOFRVBMJUZBOE social disintegration, exacerbated by some of the highest alcohol consumption levels in the world, have increased exposure to risk and weakened the safety and support OFUXPSLTUIBUNJUJHBUFUIFFČFDUTPGJOKVSJFT(10–14)ćFTF DIBOHFTDPOUSJCVUFEUPBQFBLJODIJMEJOKVSZNPSUBMJUZJOUIF FBSMZT 'JH

XJUIUIFTVCTFRVFOUEFDMJOFBUUSJCVUFEUP the relative price increase of alcohol and decrease of motor USBďDMJOLFEUPUIFFDPOPNJDTMPXEPXOJOTPNFUSBOTJUJPO countries (14)5PEBZ VOJOUFOUJPOBMJOKVSZNPSUBMJUZSBUFT JOUIF$*4 BMUIPVHIEFDMJOJOH SFNBJOUISFFUJNFTIJHIFS UIBOUIPTFJOUIF&VSPQFBO6OJPO &6

1.4 A changing Region with social inequalities

1.5 Injury prevention: an issue of social and environmental justice in the European Region

$PVOUSJFTJOUIF3FHJPOOPUPOMZBSFEJWFSTFCVUBMTPDIBOHF SBQJEMZ "MMGFFMUIFFČFDUTPGHMPCBMJ[BUJPO XJUINBUFSJBM BOETPDJBMFOWJSPONFOUTDPNJOHVOEFSOFXTUSFTTFTćFTF stresses are felt unevenly, however, and increasing evidence indicates that the losers in this process are falling behind. )FBMUIJOFRVBMJUJFTBSFSJTJOHJOUIFNPTUWVMOFSBCMFHSPVQT XJUIDIJMESFOGPSFNPTUBNPOHUIFN*OFRVBMJUJFTJODIJME NPSUBMJUZGSPNJOKVSZIBWFXJEFOFEJONBOZDPVOUSJFTBOE BSF B CBSPNFUFS PG UIJT DIBOHF ćJT JT BO JTTVF PG TPDJBM KVTUJDF BOE FRVBM PQQPSUVOJUJFT GPS TBGF FOWJSPONFOUT TIPVMECFFOTVSFEUISPVHIPVUUIFXIPMF3FHJPO

"TBNBUUFSPGTPDJBMBOEFOWJSPONFOUBMKVTUJDF BMMDPVOUSJFT JO UIF 8)0 &VSPQFBO 3FHJPO TIPVME BEESFTT UIF MJOL CFUXFFOQPWFSUZ JOFRVBMJUZBOEJOKVSJFT(16)ćF5BMMJOO $IBSUFS)FBUI4ZTUFNTGPS)FBMUIBOE8FBMUI(17), adopted CZUIF3FHJPOT.FNCFS4UBUFTJO QSPNPUFTUIFWBMVFT PG TPMJEBSJUZ FRVJUZ BOE QBSUJDJQBUJPO UISPVHI IFBMUI policies and resource allocation, and calls for attention to be paid to the needs of the poor and vulnerable groups. ćF6OJUFE/BUJPOT$IJMESFOT'VOE 6/*$&' TUBUFEUIBU i1PWFSUZDPNQSPNJTFTDIJMESFOTMJWFTBOEIBTBDVNVMBUJWF and negative impact on their future” (18)4PDJPFDPOPNJD

Fig. 1.1 Trends in standardized mortality rates for unintentional injury in children aged 1–19 years in the WHO European Region CIS

European Region

EU

45 40

Deaths per 100 000 population

35 30 25 20 15 10 5 0 1980

1982

1984

1986

Source: Mortality by 67 causes of death, age and sex (15).

2 EUROPEAN REPORT ON CHILD INJURY PREVENTION

1988

1990

1992

1994

1996

1998

2000

2002

2004

class and poverty are intertwined with physical, social, psychological, educational and occupational variables, as well as social capital and social networks (19–22)"MMUIFTF JOĘVFODFUIFQBUUFSOTPGBOEDPOTFRVFODFTPGJOKVSZ TFF #PY *OUIFDPVOUSJFTJOTPVUIFBTUFSO&VSPQFBOEUIF$*4 JODIJMESFOMJWFTJOBCTPMVUFQPWFSUZ BOEDIJMESFOIBWF BIJHIFSQSPCBCJMJUZPGCFJOHQPPSUIBOBEVMUT1PWFSUZJT concentrated in some regions: more than half the child QPQVMBUJPOTJODFOUSBM"TJB UIF$BVDBTVTBOEUIF3FQVCMJD of Moldova live in poverty (18). 1PPSDIJMESFONBZCFFYQPTFEUPIB[BSEPVTFOWJSPONFOUT oJODMVEJOHGBTUUSBďD MBDLPGTBGFQMBZBSFBTBOEDSPXEFE homes with unsafe structures such as stairs without rails or gates or windows without bars and locks (20) 1PPS GBNJMJFTNBZOPUCFBCMFUPBČPSETBGFUZFRVJQNFOU TVDI as child car restraints, smoke alarms or bicycle helmets (11)4VQFSWJTJPONBZCFEJďDVMUJOGBNJMJFTIFBEFECZPOF QBSFOUPSXIFSFQBSFOUTIBWFDPOĘJDUJOHEFNBOETPOUIFJS UJNF BOE OP BEFRVBUF DIJMEDBSF GBDJMJUJFT 0ODF JOKVSFE QPPSDIJMESFONBZIBWFMFTTBDDFTTUPIJHIRVBMJUZNFEJDBM BOESFIBCJMJUBUJPOTFSWJDFTćFDPTUTPGIFBMUIDBSFBOEMPTU FBSOJOHDBQBDJUZNBZTFWFSFMZEBNBHFBGBNJMZTĕOBODJBM position (22) 'VSUIFS DIJMESFO JO SVSBM BSFBT NBZ CF BU HSFBUFSSJTLPGSPBEUSBďDJOKVSJFT 35*T

ESPXOJOH ĕSFT and contact with pesticides (24). $FSUBJOHSPVQTNBZGBDFNVMUJQMFEJTBEWBOUBHFTBOEUIVT CFQBSUJDVMBSMZWVMOFSBCMFUPJOKVSJFT JODMVEJOHUIF3PNB

BOX 1.1

Recent findings of a systematic review of injury inequalities Childhood injuries show some of the steepest social gradients in mortality in the WHO European Region. Studies from Greece, Ireland, Spain, Sweden, the Netherlands and the United Kingdom demonstrate that children from less affluent areas suffer and die from injuries much more than their more affluent peers. Studies of the mechanisms contributing to this social patterning show that one of the major risk factors is the unsafe home, play and road environments of children in deprived areas. This contributes greatly to the risk differentials in death and injuries. Making children’s environments inherently safer by using passive safety countermeasures can reverse the social inequities in injury. These interventions tackle the physical exposures that put children at risk. For example, ameliorating material deprivation at home by providing better housing and modifying the traffic environment to ensure that children are not exposed to dangerous situations have been shown to result in fewer injuries, thereby reducing the safety differentials between different social groups. Policy-makers and opinion leaders are increasingly concerned that the current trend in social inequalities in health constitutes a major threat to health. In particular, existing health targets, such as those for improved life expectancy and reduced child mortality, may not be achieved. Equityoriented policies and interventions have been proposed as responses. Safety for all is their cornerstone, and they should be enacted within and outside the health sector (23).

community, displaced people and refugees (25)ćF3PNB DPNNVOJUZJTPOFPG&VSPQFTMBSHFTUBOENPTUWVMOFSBCMF NJOPSJUJFT.BOZ3PNBDIJMESFOMJWFJOPWFSDSPXEFEBOE dilapidated housing and are forced to work to help their families survive (26). "OPUIFS DPODFSO JO UIF 3FHJPO JT UIBU PG DIJMESFO BU XPSL:PVOHXPSLFSTSVOBIJHIFSSJTLPGJOKVSJFTBSJTJOH from lack of experience, limited awareness of existing or potential risks, or immaturity (27). Working methods, tools BOEFRVJQNFOUBSFOPSNBMMZEFTJHOFEGPSBEVMUT BOEEPOPU UBLFBDDPVOUPGDIJMEXPSLFSTTNBMMFSTJ[F(28). $IJME MBCPVS JT B SFMBUJWFMZ VOEFSSFQPSUFE JTTVF BOE reliable information about the number of child workers in UIF3FHJPOJTMBDLJOH(28)$IJMEMBCPVS IPXFWFS DBOSFTVMU JOEFBUITBOEJOKVSJFTBOEMPTTPGPQQPSUVOJUJFTGPSFEVDBUJPO BOETPDJBMEFWFMPQNFOU6OBDDFQUBCMFXPSLJOHDPOEJUJPOT DBOJODMVEFFYQPTVSFPGZPVOHXPSLFSTUPIB[BSETBUDPBM NJOFT GBSNTBOEDPOTUSVDUJPOTJUFT$IJMESFOPęFOQFSGPSN work that is regarded as helping out, in domestic settings, TFBTPOBMKPCTBOETUSFFUUSBEJOH(28).

1.6 Global and European policy initiatives *OKVSJFT BSF JODSFBTJOHMZ SFDPHOJ[FEUPCFBQSFWFOUBCMF cause of premature death, CVU DPVOUSJFT JO UIF 3FHJPO vary widely in the patterns of policies and initiatives for child JOKVSZ QSFWFOUJPO SBOHJOH from intense activity to limited DPNNJUNFOU"TFBSMZBT UIF8)03FHJPOBM0ďDFGPS &VSPQFSFDPHOJ[FEJOKVSJFTBT the leading cause of childhood EFBUIJO&VSPQF(29). 4JODF UIFO GPVS 8PSME )FBMUI "TTFNCMZ SFTPMVUJPOT IBWFFNQIBTJ[FEUIFQVCMJDIFBMUIBQQSPBDIUPQSFWFOUJOH JOKVSJFT BOEDBMMFEPO.FNCFS4UBUFTUPUBLFBDUJPOćFTF resolutions include children as one of the target groups for intervention: tSFTPMVUJPO8)"POQSFWFOUJPOPGWJPMFODFB public health priority (30) t SFTPMVUJPO 8)" PO QSFWFOUJPO PG WJPMFODF (31) t SFTPMVUJPO 8)" PO JNQMFNFOUJOH UIF recommendations of the World report on violence and health (32) t SFTPMVUJPO 8)" PO SPBE USBďD TBGFUZ BOE health (33). ćF 6OJUFE /BUJPOT $POWFOUJPO PO UIF 3JHIUT PG UIF $IJME (5) underlines the social responsibility to protect DIJMESFOVQUPUIFBHFPGZFBSTBOEUPQSPWJEFUIFNXJUI BQQSPQSJBUF TVQQPSU BOE TFSWJDFT *U UIFSFGPSF TVQQPSUT DIJMESFOT SJHIU UP IFBMUI BOE B TBGF FOWJSPONFOU GSFF GSPN JOKVSZ BOE WJPMFODF ćF GPVSUI PG UIF .JMMFOOJVN OVERVIEW: CHILD INJURIES IN THE WHO EUROPEAN REGION 3

%FWFMPQNFOU (PBMT BEPQUFE CZ UIF (FOFSBM "TTFNCMZ PGUIF6OJUFE/BUJPOT DBMMTGPSBUXPUIJSETSFEVDUJPOJO NPSUBMJUZJODIJMESFOVOEFSZFBSTCFUXFFOBOE (34)"MUIPVHIJUEPFTOPUNFOUJPOJOKVSJFT UIJTUBSHFUXJMM only be achieved if concerted efforts are made to reduce JOKVSZNPSUBMJUZ BTJUJTPOFPGUIFMFBEJOHDBVTFTPGEFBUI JODIJMESFOPWFSZFBSPGBHF *O &VSPQF 3FHJPOBM 1SJPSJUZ (PBM ** PG UIF $IJMESFOT &OWJSPONFOUBOE)FBMUI"DUJPO1MBOGPS&VSPQF $&)"1& GPDVTFTPOJOKVSJFTBTBMFBEJOHDBVTFPGQSFWFOUBCMFEFBUI from environmental factors (35) BOE UIF &VSPQFBO strategy for child and adolescent health and development (36) IJHIMJHIUT UIF OFFE GPS QSFWFOUJPO 8)0 3FHJPOBM $PNNJUUFFGPS&VSPQFSFTPMVUJPO3$3DBMMTPO.FNCFS 4UBUFTUPUBLFDPODFSUFEQVCMJDIFBMUIBDUJPOUPSFEVDFEFBUI BOEEJTBCJMJUZGSPNJOKVSJFTJOUIF&VSPQFBO3FHJPO(37). 4JNJMBSMZ UIF &VSPQFBO $PNNJTTJPO &$ DPOTVMUBUJPO POBSFDPNNFOEBUJPOUPUIF$PVODJMPOUIFQSFWFOUJPOPG JOKVSJFT BOE QSPNPUJPO PG TBGFUZ (38) singles out groups, JODMVEJOHDIJMESFO UIBUSFRVJSFHSFBUFSBUUFOUJPO *ODSFBTJOHMZSBQJEEJTTFNJOBUJPOPGJEFBTBOELOPXMFEHF in public health (39) DBO TUSFOHUIFO QFPQMFT BCJMJUZ UP BWPJEJOKVSZćFHSPXUIPGBHMPCBMDJWJMTPDJFUZ(40) with OFUXPSLTPGGPSNBMBOEJOGPSNBMHSPVQTDBOJOĘVFODFIFBMUI issues where national structures may be weak: examples JODMVEFUIF*OUFSOBUJPOBM4PDJFUZGPS$IJMEBOE"EPMFTDFOU *OKVSZ1SFWFOUJPO UIF&VSPQFBO$IJME4BGFUZ"MMJBODF UIF &VSPQFBO"DBEFNZPG1BFEJBUSJDTBOEUIF4BGF$PNNVOJUJFT NPWFNFOU #PY 0UIFS PSHBOJ[BUJPOT IBWF B HMPCBM HPWFSOBODFSPMF TVDIBT6/*$&' UIF*OUFSOBUJPOBM-BCPVS 0SHBOJ[BUJPO *-0 BOE OPOHPWFSONFOUBM PSHBOJ[BUJPOT /(0T

JODMVEJOHUIF*OUFSOBUJPOBM'FEFSBUJPOPG7JDUJNT PG5SBďD*OKVSJFT/(0TBUUIFDPVOUSZMFWFMNBZDPPSEJOBUF BOE TUJNVMBUF JOKVSZ QSFWFOUJPO BDUJWJUJFT &YBNQMFT JODMVEFUIF$IJME"DDJEFOU1SFWFOUJPO5SVTUJOUIF6OJUFE ,JOHEPNBOEUIF1PSUVHVFTF"TTPDJBUJPOGPS$IJME4BGFUZ 1SPNPUJPO

1.7 Overcoming the problem *OKVSJFT SFTVMU GSPN B DPNQMFY JOUFSBDUJPO CFUXFFO UIF JOEJWJEVBM BOE UIF QIZTJDBM BOE TPDJBM FOWJSPONFOU "T mentioned, thinking has shifted from focusing on the JOEJWJEVBM UP FNQIBTJ[JOH UIF TPDJFUBM SFTQPOTJCJMJUZ UP provide inherently safer environmental contexts to prevent JOKVSJFTGSPNPDDVSSJOHćFTDPQFGPSJOUFSWFOUJPOUIFSFGPSF JOWPMWFT EJČFSFOU TFDUPST o JODMVEJOH /(0T BDBEFNJB BOE JOEVTUSZ o DPODFSOFE XJUI FOTVSJOH TBGFS EPNBJOT FYQPTVSFT BOE CFIBWJPVS *OKVSZ QSFWFOUJPO #PY UIFSFGPSFSFRVJSFTBTZTUFNBUJDBQQSPBDI &YQFSJFODFGSPNUIFDPVOUSJFTXJUIUIFCFTUTBGFUZSFDPSET shows that positive leadership, along with widespread efforts to provide safer physical and social environments, can result JOTVTUBJOFESFEVDUJPOTJOJOKVSZNPSUBMJUZBOENPSCJEJUZ (10) BTXFMMBTIFBMUIJOFRVBMJUJFT4XFEFOXBTUIFĕSTUUP SFDPHOJ[F UIF JNQPSUBODF PG JOKVSJFT BT B UISFBU UP DIJME IFBMUIBOEUPUBDLMFUIFQSPCMFNJOBDPPSEJOBUFENBOOFS JUTVTUBJOFEUIJTDPNNJUNFOUPWFSZFBST(42)4XFEJTI TPDJFUZT TFOTF PG DPSQPSBUF SFTQPOTJCJMJUZ NFBOU UIBU B culture of safety could be nurtured and the protection of DIJMESFOCFDBNFBNBKPSTPDJFUBMHPBMćFJNQMFNFOUBUJPO PGFČFDUJWFJOUFSWFOUJPOTBSPVOEUIF&VSPQFBO3FHJPOXPVME

BOX 1.3

Preventing injuries Injury prevention involves primary, secondary and tertiary prevention. Primary prevention aims to prevent the injury event in the first place through, for example, stair gates to prevent falls or drink–driving legislation to reduce the risk of road traffic injury. Secondary prevention seeks to reduce the risk of injury once an event has occurred. A smoke alarm will not prevent a fire but may enable occupants to escape a building before they are overcome by smoke or burned. Tertiary prevention aims to minimize the consequences of an injury, for example, by providing first aid and emergency trauma care.

BOX 1.2

Collective action in Europe to develop and implement national child safety action plans As injury is the leading cause of death for children in every Member State in the European Region, having a government-endorsed plan to address this critical health issue is an essential step in meeting children’s rights to safety. More than 30 countries are developing such plans within the framework of the Child Safety Action Plan initiative, led and coordinated by the European Child Safety Alliance of the European Association for Injury Protection and Safety Promotion (EuroSafe), with the support of the EC, WHO and UNICEF. This European project is undertaking joint action and uses standard indicators and other tools to assess the state of child injury in participating countries, identify gaps and priority issues, and select evidence-based good practices to outline multisectoral plans with clear commitments and action steps. The assessments undertaken by each country form the basis of national-level child safety report cards and profiles, which allow benchmarking in and between countries at baseline and as implementation proceeds. Seeking participation and endorsement from the governments of each country is designed to enhance plan uptake and gain further commitment to leadership, infrastructure and capacity commensurate with the size of the issue. Participating countries are making progress, with several now implementing plans, and all have indicated that the process has placed child injury higher on the political agenda and led to a more coordinated approach to child injury prevention for those that have moved beyond the assessment stage. Further information is available from EuroSafe (41). 4 EUROPEAN REPORT ON CHILD INJURY PREVENTION

save many thousands of lives and considerable amounts in health care costs. ćJTSFQPSUFYBNJOFTUIFQSFWFOUJPOPGĕWFNBKPSJOKVSZ UZQFT USBďD ESPXOJOH CVSOT GBMMT BOE QPJTPOJOH 'PS each type, evidence indicates that a range of different BQQSPBDIFT o MFHJTMBUJPO SFHVMBUJPO BOE FOGPSDFNFOU QSPEVDU BOE FOWJSPONFOUBM NPEJĕDBUJPO FEVDBUJPO BOE TLJMMT EFWFMPQNFOU BOE FNFSHFODZ NFEJDBM DBSF o DBO QSFWFOUPSSFEVDFUIFJNQBDUPGJOKVSJFT

1.8 Defining a child and an injury 5IJT SFQPSU GPMMPXT "SUJDMF PG UIF 6OJUFE /BUJPOT $POWFOUJPOPOUIF3JHIUTPGUIF$IJMEJOEFĕOJOHBDIJME BTBOZIVNBOCFJOHCFMPXUIFBHFPG(5). However much of the data presented in this report are for children and BEPMFTDFOUTBHFE¦ZFBSTCFDBVTFFYJTUJOHEBUBTPVSDFT provide information in this age group. "OJOKVSZJTUIFQIZTJDBMEBNBHFUIBUPDDVSTXIFOUIF IVNBOCPEZJTTVEEFOMZTVCKFDUFEUPBNPVOUTPGFOFSHZ that exceed the physiological threshold or is deprived of vital FMFNFOUT TVDI BT PYZHFO ćF FOFSHZ DBO CF NFDIBOJDBM thermal, chemical or radiant (43) *OKVSJFT BSF VTVBMMZ EFĕOFE CZ JOUFOUJPO ćF NBJO DBVTFT PG VOJOUFOUJPOBM JOKVSJFT UIF GPDVT PG UIJT SFQPSU BSF SPBE USBďD JOKVSJFT poisoning, drowning, falls and burns.

1.9 References 1FEFO.FUBMWorld report on child injury prevention(FOFWB 8PSME)FBMUI0SHBOJ[BUJPO JOQSFTT 5BNCVSMJOJ($IJMESFOTTQFDJBMWVMOFSBCJMJUZUPFOWJSPONFOUBM IFBMUIIB[BSETBOPWFSWJFX*O5BNCVSMJOJ( WPO&ISFOTUFJO 0 #FSUPMMJOJ 3 FET Children’s health and environment: a review of evidence $PQFOIBHFO &VSPQFBO &OWJSPONFOU "HFODZ &OWJSPONFOUBM*TTVF3FQPSU -BOTEPXO ( The evolving capacities of the child 'MPSFODF 6/*$&' *OOPDFOUJ 3FTFBSDI $FOUSF IUUQXXX VOJDFGJSDPSHQVCMJDBUJPOTQEGFWPMWJOHFOHQEG BDDFTTFE 0DUPCFS "ZOTMFZ(SFFO " FU BM 8IP JT TQFBLJOH GPS DIJMESFO BOE adolescents and for their health at policy level. BMJ o Convention on the Rights of the Child/FX:PSL /: 6OJUFE /BUJPOT "3&4 IUUQXXXVOIDISDIIUNM NFOVCLDSDIUN BDDFTTFE0DUPCFS ,SVH& 4IBSNB( -P[BOP3ćFHMPCBMCVSEFOPGJOKVSJFT American Journal of Public Health o 4FUIJ%FUBM3FEVDJOHJOFRVBMJUJFTGSPNJOKVSJFTJO&VSPQF Lancet o #SVTTPOJ . 5PXOFS & )BZFT . &WJEFODF JOUP QSBDUJDF DPNCJOJOH UIF BSU BOE TDJFODF PG JOKVSZ QSFWFOUJPO Injury Prevention o 'PSKVPI4 (VPIVB -"SFWJFXPGTVDDFTTGVMUSBOTQPSUBOE IPNF JOKVSZ JOUFSWFOUJPOT UP HVJEF EFWFMPQJOH DPVOUSJFT Social Science and Medicine o 4FUIJ%FUBMInjuries and violence in Europe: why they matter and what can be done$PQFOIBHFO 8)03FHJPOBM0ďDFGPS &VSPQF IUUQXXXFVSPXIPJOUEPDVNFOU& QEG BDDFTTFE0DUPCFS 5PXOFS & *OKVSZ BOE JOFRVBMJUJFT CSJEHJOH UIF HBQ

International Journal of Injury Control and Safety Promotion, o Transition. The first ten years: analysis and lessons for eastern Europe and the former Soviet Union8BTIJOHUPO %$ 8PSME #BOL .D,FF. /PMUF&-FTTPOTGSPNIFBMUIEVSJOHUIFUSBOTJUJPO from communism. BMJ o .D,FF . "MDPIPM JO UIF 3VTTJBO 'FEFSBUJPO Alcohol and Alcoholism o Mortality by 67 causes of death, age and sex (off-line version), supplement to the European health for all database (HFAMDB) $PQFOIBHFO 8)0 3FHJPOBM 0GGJDF GPS &VSPQF IUUQXXXFVSPXIPJOUIGBEC BDDFTTFE 0DUPCFS 4UFQIFOT$ #VMMPDL4&OWJSPONFOUBMKVTUJDF"OJTTVFGPSUIF IFBMUIPGUIFDIJMESFOPG&VSPQFBOEUIFXPSME*O5BNCVSMJOJ ( WPO&ISFOTUFJO0 #FSUPMMJOJ3 FETChildren’s health and environment: a review of evidence $PQFOIBHFO &VSPQFBO &OWJSPONFOU "HFODZ o &OWJSPONFOUBM *TTVF 3FQPSU The Tallinn Charter: Health Systems for Health and Wealth. $PQFOIBHFO 8)03FHJPOBM0ďDFGPS&VSPQF IUUQ XXXFVSPXIPJOUEPDVNFOU&QEG BDDFTTFE 0DUPCFS Understanding child poverty in south-eastern Europe and the Commonwealth of Independent States 'MPSFODF 6/*$&' *OOPDFOUJ3FTFBSDI$FOUSF *OOPDFOUJ4PDJBM.POJUPS 8JMLJOTPO3 .BSNPU.Social determinants of health. The solid facts. Second edition. $PQFOIBHFO 8)0 3FHJPOBM 0ďDFGPS&VSPQF IUUQXXXFVSPXIPJOUEPDVNFOU FQEG BDDFTTFE0DUPCFS $VCCJO$ 4NJUI(4PDJPFDPOPNJDJOFRVBMJUJFTJOJOKVS y critical issues in design and analysis. Annual Reviews of Public Health o $VCCJO$ 4NJUI(4PDJPFDPOPNJDJOFRVBMJUJFTJOJOKVS y Annual Reviews of Public Health 9o ;XJ"*OKVSJFT JOFRVBMJUJFTBOEIFBMUIGSPNQPMJDZWBDVVN UPQPMJDZBDUJPO*O-FPO% 8BMU( FETPoverty, inequality and health0YGPSE 0YGPSE6OJWFSTJUZ1SFTT o Socioeconomic differences in injury risks. A review of findings and a discussion of potential countermeasures$PQFOIBHFO 8)03FHJPOBM0ďDFGPS&VSPQF JOQSFTT #PMBOE . FU BM 6SCBOoSVSBM WBSJBUJPO JO NPSUBMJUZ BOE IPTQJUBMBENJTTJPOSBUFTGPSVOJOUFOUJPOBMJOKVSZJO*SFMBOE Injury Prevention o $PMMJOT.FUBMAt risk. Roma and the displaced in south east Europe#SBUJTMBWB 6OJUFE/BUJPOT%FWFMPQNFOU1SPHSBNNF 3FHJPOBM#VSFBVGPS&VSPQF Breaking the cycle of exclusion. Roma children in South East Europe#FMHSBEF 6/*$&'4FSCJB 3VOZBO $8 ;BLPDT 3$ &QJEFNJPMPHZ BOE QSFWFOUJPO PG JOKVSJFTBNPOHBEPMFTDFOUXPSLFSTJOUIF64"Annual Review of Public Health o &VSPQFBO &OWJSPONFOU BOE )FBMUI *OGPSNBUJPO 4ZTUFN &/)*4 Work injuries in children and young people. $PQFOIBHFO 8)03FHJPOBM0ďDFGPS&VSPQF 'BDU 4IFFU/P The prevention of accidents in childhood. Report of a seminar, Spa, Belgium 16–25 July 1958$PQFOIBHFO 8)03FHJPOBM 0ďDFGPS&VSPQF World Health Assembly resolution WHA49.25 on prevention of violence: a public health priority (FOFWB 8PSME )FBMUI 0SHBOJ[BUJPO IUUQQPMJDZXIPJOUDHJCJOPN@JTBQJEMM BEWRVFSZ8)"BOEJOGPCBTFXIBBOESFDPSE\"#^ BOETPęQBHF#SPXTF@'SBNF@1HBOEYBOEZBOE[[ OVERVIEW: CHILD INJURIES IN THE WHO EUROPEAN REGION 5

BDDFTTFE0DUPCFS World Health Assembly resolution WHA50.19 on prevention of violence(FOFWB 8PSME)FBMUI0SHBOJ[BUJPO IUUQ XXXXIPJOUFOUJUZTVCTUBODF@BCVTFFO8)"QEG BDDFTTFE0DUPCFS World Health Assembly resolution WHA56.24 on implementing the recommendations of the World report on violence and health (FOFWB 8PSME )FBMUI 0SHBOJ[BUJPO IUUQ QPMJDZXIPJOUDHJCJOPN@JTBQJEMM BEWRVFSZ8)"B OEJOGPCBTFXIBBOESFDPSE\"^BOETPęQBHF#SPXTF@ 'SBNF@1HBOEYBOEZBOE[[ BDDFTTFE 0DUPCFS World Health Assembly resolution WHA57.10 on road safety and health(FOFWB 8PSME)FBMUI0SHBOJ[BUJPO IUUQ QPMJDZXIPJOUDHJCJOPN@JTBQJEMM BEWRVFSZ8)"B OEJOGPCBTFXIBBOESFDPSE\#%"^BOETPęQBHF#SPXTF@ 'SBNF@1HBOE[[ BDDFTTFE0DUPCFS United Nations Millennium Declaration/FX:PSL /: 6OJUFE /BUJPOT "3&4 IUUQXXXVOPSHNJMMFOOJVN EFDMBSBUJPOBSFTFIUN BDDFTTFE0DUPCFS $IJMESFOT&OWJSPONFOUBOE)FBMUI"DUJPO1MBOGPS&VSPQF $&)"1& <XFCTJUF>$PQFOIBHFO 8)03FHJPOBM0ďDF GPS &VSPQF IUUQXXXFVSPXIPJOUDIJMEIFBMUIFOW QPMJDZ@ BDDFTTFE0DUPCFS European strategy for children and adolescent health and development$PQFOIBHFO 8)03FHJPOBM0ďDFGPS&VSPQF IUUQXXXFVSPXIPJOUEPDVNFOU&QEG BDDFTTFE0DUPCFS WHO Regional Committee for Europe resolution EUR/RC55/


R9 on prevention of injuries in the WHO European Region. $PQFOIBHFO 8)0 3FHJPOBM 0GGJDF GPS &VSPQF IUUQXXXFVSPXIPJOUFQSJTFNBJO8)0"CPVU8)0 (PWFSOBODFSFTPMVUJPOT@ BDDFTTFE 0DUPCFS Consultation of the Member States on elements for a proposal for a Commission Communication and Council recommendation on injury prevention and safety promotion -VYFNCPVSH &VSPQFBO $PNNJTTJPO IUUQXXXFVJOUDPNN IFBMUIQI@EFUFSNJOBOUTFOWJSPONFOU*11FW@@ FOIUN BDDFTTFE0DUPCFS #FUUDIFS % 8JQGMJ ) 5PXBSET B NPSF TVTUBJOBCMF HMPCBMJ[BUJPOUIFSPMFPGUIFQVCMJDIFBMUIDPNNVOJUZJournal of Epidemiology and Community Health o #FUUDIFS% -FF,(MPCBMJ[BUJPOBOEQVCMJDIFBMUIJournal of Epidemiology and Community Health o IUUQKFDICNKDPNDHJDPOUFOUGVMM BDDFTTFE 0DUPCFS &VSP4BGF &VSPQFBO "TTPDJBUJPO GPS *OKVSZ QSPUFDUJPO BOE 4BGFUZ 1SPNPUJPO <XFC TJUF> "NTUFSEBN &VSP4BGF IUUQXXXFVSPTBGFFVDPNDTJFVSPTBGFOTG XXX7X$POUFOUMFVSPQFBODIJMETBGFUZBMMJBODFIUN BDDFTTFE 0DUPCFS 1MFTT * 5PXOFS & 1SBDUJUJPOFST BOE QPMJDZNBLFST *O "ZOTMFZ(SFFO"FUBM FETUnintentional injury in childhood and adolescence-POEPO #BJMMJFSF5JOEBMM o #BLFS 41 FU BM FET The injury fact book (2nd edition). -FYJOHUPO ." -FYJOHUPO#PPLT

CHAPTER 2 BURDEN OF UNINTENTIONAL INJURIES 2.1 Introduction This chapter describes the burden and causes of unintentional injuries in children aged 0–19 years in the WHO European Region (Box 2.1).

2.2 Variations in the burden In 2004, 42 000 Europeans younger than 20 years died from unintentional injuries (1). While injuries are the leading cause of death in those aged 5–19 years, three causes –road traffic, drowning and poisoning – rank among the top 15 causes of death in those aged 0–19 years (Table 2.1). The ranks of different injury types vary with victims’ ages. Road traffic injury is the leading cause of death for those aged 5–19, while drowning holds this rank for the group aged 1–4 years (Annex 4, Table 1). The average age-standardized mortality rate for the group aged 0–19 years in the Region – 18.4 per 100 000 population – masks great variation between countries. When taken together, the rates in LMICs (25.4 per 100 000 population) are more than three times those for HICs (7.9 per 100 000). Comparisons between countries show even greater inequality. Deaths in the countries with the highest rates are almost seven times those in the countries with the lowest rates (Fig. 2.1). Death rates are highest in the Russian Federation, Kazakhstan and the Republic of Moldova and lowest in the Netherlands, Israel and Switzerland. Some countries, such as those in the Caucasus and Balkan region, have less reliable data for the period studied, which are more difficult to interpret (2).

2.3 Leading causes of injury The leading causes of fatal unintentional injuries were road traffic (39%), drowning (14%), poisoning (7%), fires and falls (4% each) (Fig. 2.2). Other causes – including deaths from suffocation, choking, strangulation, hypoand hyperthermia, animal bites, natural disasters, etc. – account for a high proportion of deaths (32%). As the leading causes change with age, those for children aged under 10 years are drowning and road traffic injuries (both 21%), followed by poisoning (8%), while those for older children are RTIs (51%), drowning (9%) and poisoning (7%) (Annex 4, Fig. 5).

BOX 2.1

Key facts about unintentional injuries in children t *OKVSJFTBSFUIFMFBEJOHDBVTFPGEFBUIJODIJMESFOBHFEoZFBSTJO the Region. t 5IFSFBSFEFBUITJODIJMESFOBHFEoZFBSTBOOVBMMZPVU of 6 of these occur in LMICs, where death rates are three times higher than in high-income countries (HICs). t #PZTTVòFSUISFFPVUPGGPVSJOKVSZEFBUIT t 5IFSFBSFBTFWFOGPMEEJòFSFODFCFUXFFODPVOUSJFTXJUIUIFIJHIFTU BOEMPXFTUJOKVSZEFBUISBUFT BOEVQUPOJOFGPMEEJòFSFODFTJOUIF WBSJBUJPOTXJUIJODPVOUSJFT t *OKVSJFTDBVTFBIVHFESBJOPOIFBMUISFTPVSDFT XJUIBOFTUJNBUFE BOOVBMNJMMJPOIPTQJUBMBENJTTJPOTBOENJMMJPOWJTJUTUPFNFSHFODZ departments in the Region. t 5IFMPXJOKVSZSBUFTJO)*$TTVHHFTUMJWFTDBOBMTPCFTBWFEJOPUIFS settings.

Table 2.1 Ranking of 15 leading causes of death in people aged 0–19 years in the WHO European Region, 2004 Rank 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Cause of death Perinatal causes Lower respiratory infections Diarrhoeal diseases Congenital anomalies Road traffic injuries Self-inflicted injuries Meningitis Drowning Leukaemia Violence Upper respiratory infections Poisoning Endocrine disorders HIV/AIDS Epilepsy

Source: The global burden of disease: 2004 update (1).

BURDEN OF UNINTENTIONAL INJURIES 7

Fig. 2.1 Average standardized mortality rates for all unintentional injuries in children aged 0–19 years in the WHO European Region 2003–2005, or most recent three years HIC

LMICa

Russian Federation Kazakhstan Republic of Moldova Ukraine Belarus Latvia Kyrgyzstan Lithuania Romania Estonia Uzbekistan Croatia Portugal Greece Azerbaijan Slovakia Poland Czech Republic Belgium Italy Spain Bulgaria Finland Austria Slovenia France Denmark Hungary Norway Germany Albania United Kingdom Sweden Switzerland Israel Georgia Netherlands MKDb 0

5

10

15

20

25

30

35

40

DEATHS PER 100 000 POPULATION a

Income levels are those defined by the World Bank. The International Organization for Standardization acronym for the former Yugoslav Republic of Macedonia is used in figures throughout this publication. Source: European detailed mortality database (3). b

2.4 Variations by age and sex ćF EFBUI SBUFT GSPN VOJOUFOUJPOBM JOKVSJFT BSF IJHIFTU JODIJMESFOVOEFSZFBSPME 'JH

GPMMPXFECZUIPTF BHFEoZFBST"UBMMBHFT NBMFTIBWFIJHIFSSBUFTUIBO females, though this difference is minimal for infants and SJTFTTIBSQMZJOoZFBSPMETćFFYQMBOBUJPOGPSUIJT difference lies more in environmental factors for infants, BOEJOEJČFSFODFTJOFYQPTVSFT TPDJBMJ[BUJPOBOESJTLGBDUPST 8 EUROPEAN REPORT ON CHILD INJURY PREVENTION

GPS UFFOBHFST ćJT QPJOUT UP UIF OFFE GPS FWFO TUSPOHFS protective environmental measures to address these factors, FTQFDJBMMZGPSJOGBOUTBOEPMEFSCPZT*OKVSZSBUFTBSFIJHIFS in males than females, irrespective of the cause, but the EJČFSFODF JO SJTL PG EFBUI CZ HFOEFS JT HSFBUFTU GPS 35*T ESPXOJOH BOE GBMMT BOE TNBMMFTU GPS ĕSFT BOE QPJTPOJOH 'JH

Fig. 2.2 Proportion of unintentional injury deaths among people aged 0–19 years in the WHO European Region (total deaths: 42 000)

Fig. 2.3 Age- and sex-specific death rates for all unintentional child injuries in the WHO European Region Males

Females

45 40 RTIs (39%)

Drowning (14%)

Poisonings (7%)

Fire (4%)

35 Deaths per 100 000 population

Other (32%)

Falls (4%)

30 25 20 15 10 5

Source: The global burden of disease: 2004 update (1).

0

Under 1

"TIJHIMJHIUFEJO'JH JOKVSZNPSUBMJUZJOUIFDPVOUSJFT with the highest rates is more than eight times that in those XJUI UIF MPXFTU SBUFT *O GBDU ĕWF PVU PG TJY EFBUIT GSPN JOKVSJFTJODIJMESFOBOEUFFOBHFSTPDDVSJO-.*$T0GUIF EFBUITJOUIF3FHJPOJO XFSFJO)*$TBOE JO-.*$T$PNQBSJTPOPGBHFTUBOEBSEJ[FEEFBUI SBUFTGPSVOJOUFOUJPOBMJOKVSJFTGPSUIFHSPVQBHFEoBT BXIPMFTIPXTUIBUUIFMJLFMJIPPEPGEZJOHGSPNJOKVSJFTJT UJNFTIJHIFSJO-.*$TUIBOJO)*$T"OBMZTFTPGUIJT EJČFSFODFCZBHFDBUFHPSZTIPXUIBUJOKVSZSBUFTBSFIJHIFTU JOUIPTFBHFEoZFBSTJO)*$T BOEJOJOGBOUTJO-.*$T ćFJOKVSZEFBUISBUJPTBSFUIFSFGPSFIJHIFTUJOUIFZPVOHFS BHFT XJUISBUJPTGPSDIJMESFOVOEFSZFBSPGBHFPWFS UJNFTIJHIFSJO-.*$TUIBOJO)*$T 5BCMF 'PSUIPTF BHFEo UIJTSBUJPJTUJNFTIJHIFSJO-.*$TUIBOJO )*$T "TXJUIPUIFSIFBMUIDPOEJUJPOT DIJMEIPPEEFBUITGSPN JOKVSZ TIPX B TPDJBM HSBEJFOU (4), irrespective of cause and strongly associated with poverty, single parenthood, low maternal education, low maternal age at birth, poor IPVTJOH MBSHF GBNJMZ TJ[F BOE QBSFOUBM BMDPIPM VTF PS ESVH BCVTF 6OJOUFOUJPOBM JOKVSJFT BSF UIF MFBEJOH DBVTF PG JOFRVBMJUZ JO DIJMEIPPE EFBUI UIJT XBT DPOĕSNFE CZ BOBOBMZTJTPG4DPUUJTIEBUB BOEJTUSVFGPSCPUINBMFTBOE females (5)%BUBTIPXUIBUUIFHSFBUFTUJOFRVBMJUJFTBSFJO DIJMESFO SBUIFSUIBOPUIFSBHFHSPVQT SFFNQIBTJ[JOHUIFJS WVMOFSBCJMJUZUPTPDJPFDPOPNJDGBDUPSTćFSFJTBOJOFGPME EJČFSFODFJOEFBUITGSPNVOJOUFOUJPOBMJOKVSZJODIJMESFO whose parents are unemployed when compared to those with parents in the highest occupations (6). ćFTFJOFRVBMJUJFTBSFCPUIBUISFBUBOEBOPQQPSUVOJUZ to adapt and transfer good practice and to report experience from countries with lower mortality rates to those with IJHIFSSBUFTćFFYQFSJFODFPGDPVOUSJFTUIBUHBWFQSJPSJUZ

5–9

10–14

15–19

AGE GROUP (YEARS) Source: The global burden of disease: 2004 update (1).

Fig. 2.4 Unintentional injury death rates per 100 000 people aged 0–19 years by cause and sex in the European Region Males

Females

12 Deaths per 100 000 population

2.5 Inequalities in the Region by country income

1–4

10 8 6 4 2 0

RTIs

Drownings Poisoning

Falls

Fires

Other

CAUSES Source: The global burden of disease: 2004 update (1).

Table 2.2 Age-specific death rates and death rate ratios for people aged under 20 years in LMICs and HICs Age groups (years) Rates and rate ratio

"MNBUZ (B[FUBL[JOUFSOFUBHFODZ IUUQFOHHB[FUBL[ BDDFTTFE/PWFNCFS 4VMLFT4 WBOEFS+BHU&4PMBSQPPMCMBOLFUTBOPUIFSXBUFS IB[BSEPediatrics o Opinion on the Safety of Child Bath Aids (bath seats, bath rings, reclining bath seats, bath hammocks, bath pads, bathtubs for children). Consumer Code, and Specifically Articles L.224–1, L.224–4, R.224 – 4 and R.224–7 to R.224–12, petition no. 00–038 and 01–052 1BSJT $POTVNFS 4BGFUZ $PNNJTTJPO IUUQXXXTFDVSJUFDPOTPPSHPSHBSUJDMFIUNM BDDFTTFE/PWFNCFS #ZBSE 3 %POBME 5 *OGBOU CBUI TFBUT ESPXOJOH BOE OFBS drowning. Journal of Paediatric Child Health o

CHAPTER 5 POISONING 5.1 Introduction

5.2 Burden in the Region

1PJTPOJOH UIFUIJSEMFBEJOHDBVTFPGVOJOUFOUJPOBMJOKVSZ EFBUITJODIJMESFOJOUIF&VSPQFBO3FHJPO JTSFTQPOTJCMFGPS EFBUITQFSZFBSPGBMMVOJOUFOUJPOBMJOKVSZEFBUIT (1)/POGBUBMQPJTPOJOHTBSFFWFONPSFOVNFSPVTBOEBO JNQPSUBOUDBVTFPGJMMIFBMUIBOEMPOHMBTUJOHEJTBCJMJUZ&WFSZ year, millions of calls are made to poison control centres and tens of thousands of children are admitted to emergency departments because they have inadvertently consumed TPNF UZQF PG UPYJD TVCTUBODF .BOZ EJWFSTF TVCTUBODFT o ranging from medications to household chemicals, solvents, GVFMT BOE QFTUJDJEFT o BSF UPYJD JG JOHFTUFE JO TVďDJFOU RVBOUJUJFT (2) ćVT UIF IPNF BOE JUT TVSSPVOEJOHT DBO CF B EBOHFSPVT QMBDF GPS DIJMESFO NPTU VOJOUFOUJPOBM QPJTPOJOHT IPXFWFS DBOCFQSFWFOUFE #PY ćFUFSNQPJTPOJOHSFGFSTUPBOJOKVSZTVTUBJOFEEVFUP FYQPTVSFUPBTVCTUBODFUIBUDBVTFTDFMMVMBSJOKVSZPSEFBUI (2,3)1PJTPOTDBOCFJOHFTUFE JOIBMFE JOKFDUFEPSBCTPSCFE &YQPTVSFNBZCFBDVUFPSDISPOJD CVUUIJTDIBQUFSBEESFTTFT BDVUFFYQPTVSFćFTFWFSJUZPGQPJTPOJOHJODJEFOUTWBSJFT BOEJTJOĘVFODFECZGBDUPSTTVDIBTUIFOBUVSFPGUIFQPJTPO its formulation, the dose taken, the route of exposure and UIFBHFPGUIFDIJMEćFSBQJEJUZPGUIFĕSTUBJEPSIFBMUI care response is a critical factor in reducing absorption PSOFVUSBMJ[JOHUIFUPYJDTVCTUBODFćJTDIBQUFSEPFTOPU deal with food poisoning, since it is generally treated as an infectious disease, or bites from venomous animals, as they BSFSFMBUJWFMZVODPNNPOJOUIF&VSPQFBO3FHJPO

5.2.1 Mortality

BOX 5.1

Key facts on unintentional poisoning t 1PJTPOJOHJTUIFUIJSEMFBEJOHDBVTFPGVOJOUFOUJPOBMJOKVSZEFBUI with 3000 deaths from acute poisoning in the WHO European Region in 2004. t 5IFSFJTBUIJSUZGPMEEJòFSFODFCFUXFFODPVOUSJFTXJUIUIFIJHIFTUBOE lowest rates, and 9 out of 10 poisoning deaths occur in the LMICs in the Region. t *GBMMDPVOUSJFTIBEUIFTBNFSBUFBTUIFDPVOUSZXJUIUIFMPXFTU PVU 10 deaths could be averted. t &OWJSPONFOUBMNPEJöDBUJPOToTVDIBTVTJOHDIJMESFTJTUBOUDMPTVSFT and safe storage, reducing the availability of toxic substances – and establishing poison control centres are good investments for prevention.

1PJTPOJOHNPSUBMJUZWBSJFTXJEFMZJOUIF3FHJPOUIJSUZGPME between the countries with the lowest and the highest rates 'JH ćF-.*$TJOUIF3FHJPOTVČFSPGQPJTPOJOH EFBUITBOEEFBUISBUFTGPSUIPTFVOEFSUIBUBSFUJNFT UIPTFJO)*$T 5BCMF ćSPVHIPVUUIF3FHJPO UIFSBUF SBUJPGPSEFBUITJTIJHIFTUJOUIPTFBHFEVOEFSZFBSBOE decreases with age (1). Table 5.1 Age-standardized death rates from drowning by age group with rate ratios for LMICs and HICs, WHO European Region Age groups (years) Rates and rate ratio

(FOFWB 8PSME )FBMUI 0SHBOJ[BUJPO IUUQXXXXIPJOU IFBMUIJOGPHMPCBM@CVSEFO@EJTFBTF@SFQPSU@VQEBUFFO JOEFYIUNM BDDFTTFE/PWFNCFS &VSPQFBO EFUBJMFE NPSUBMJUZ EBUBCBTF %.%# $PQFOIBHFO 8)03FHJPOBM0ďDFGPS&VSPQF IUUQXXXFVSPXIPJOU*OGPSNBUJPO4PVSDFT %BUB@ BDDFTTFE/PWFNCFS 1BQQ " FU BM 1BFEJBUSJD *$6 CVSOT JO 'JOMBOE o Burns o )BEKJJTLJ0FUBM&QJEFNJPMPHJDBMTVSWFZPGDIJMESFOTCVSOTJO #VMHBSJBBOEBCVSOQSFWFOUJPOQSPHSBNNFAnnals of Burns and Fire Disasters (PMENBO 4 FU BM $IJMEIPPE CVSOT JO *TSBFM " ZFBS epidemiological review. Burns o (SJďUIT)FUBMćFDPTUPGBIPUESJOLTDBMEBurns o Consumer safety research: Burns and scalds in the home. -POEPO %FQBSUNFOUPG5SBEFBOE*OEVTUSZ +PTFQI , FU BM 1BSFOUBM DPSSFMBUFT PG VOJOUFOUJPOBM CVSO JOKVSJFTJOJOGBODZBOEDIJMEIPPECVSOTBurns o 8JMTPO.FUBMSaving children: a guide to injury prevention. 0YGPSE 0YGPSE6OJWFSTJUZ1SFTT /HVZFO%FUBM*OGBOUTVOEFSZFBSPGBHFIBWFBTJHOJĕDBOU SJTLPGCVSOJOKVSZBurns o

4BLBMMPʓMV"FUBM#VSOTJO5VSLJTIDIJMESFOBOEBEPMFTDFOUT nine years of experience. Burns o 5VSOFS $ FU BM $PNNVOJUZCBTFE JOUFSWFOUJPOT GPS UIF prevention of burns and scalds in children. Cochrane Database of Systematic Reviews 2004, *TTVF VQEBUFE$% %0*$%QVC #FLFSFDJPHMV.FUBM5BOEJSBOPMEBOEXFMMLOPXODBVTFPG CVSOJOKVSZJOUIF.JEEMF&BTUBurns o 4FFEBU . FU BM 5IF BQQMJDBUJPO PG TUJMM QIPUPHSBQIZ JO NBSTIBMMJOH EBUB GPS DPNNVOJUZCBTFE JOJUJBUJWFT African Journal of Psychology o 8BSEB-FUBM)PVTFĕSFQSFWFOUJPOVQEBUF1BSU"SFWJFX PG SJTL GBDUPST GPS GBUBM BOE OPOGBUBM IPVTF GJSFT Injury Prevention o 5PXOFS& 8BSE)1SFWFOUJPOPGJOKVSJFTUPDIJMESFOBOE ZPVOHQFPQMFUIFXBZBIFBEGPSUIF6,Injury Prevention, 4 #BSUMFUU4ćFQSPCMFNPGDIJMESFOTJOKVSJFTJOMPXJODPNF countries: a review. Health Policy and Planning o A league table of child deaths by injury in rich nations'MPSFODF 6/*$&' *OOPDFOUJ 3FTFBSDI $FOUSF IUUQXXX VOJDFGJDEDPSHQVCMJDBUJPOTQEGSFQDBSEFQEG BDDFTTFE /PWFNCFS 3PCFSUT*$BVTFTQFDJĕDTPDJBMDMBTTNPSUBMJUZEJČFSFOUJBMTGPS DIJMEJOKVSZBOEQPJTPOJOHJO&OHMBOEBOE8BMFTJournal of Epidemiology and Community Health o &EXBSET 1 FU BM %FBUIT GSPN JOKVSZ JO DIJMESFO BOE employment status in family: analysis of trends in class TQFDJĕDEFBUISBUFTBMJ o 3FJNFST " -BĘBNNF - /FJHICPVSIPPE TPDJBM BOE TPDJP FDPOPNJD DPNQPTJUJPO BOE JOKVSZ SJTLT Acta Paediatrica, o )JQQJTMFZ$PY+FUBM$SPTTTFDUJPOBMTVSWFZPGTPDJPFDPOPNJD WBSJBUJPOTJOTFWFSJUZBOENFDIBOJTNPGDIJMEIPPEJOKVSJFTJO 5SFOUoBMJ o $IFO(FUBM*ODJEFODFBOEQBUUFSOPGCVSOJOKVSJFTBNPOH children with disabilities. Journal of Trauma o 4QJU[.*OKVSJFTBOEEFBUIBTBDPOTFRVFODFPGTFJ[VSFTJO people with epilepsy. Epilepsia o %FNQTFZ. 0SS%"SFQBFEJBUSJDCVSOTNPSFDPNNPOJO BTZMVNTFFLFST "OBOBMZTJTPGQBFEJBUSJDCVSOBENJTTJPOT Burns o $BSMTTPO"FUBM#VSOJOKVSJFTJOTNBMMDIJMESFO BQPQVMBUJPO CBTFE TUVEZ JO 4XFEFO Journal of Clinical Nursing o 7BTTJMJB,'JSFXPSLSFMBUFEDIJMEIPPEJOKVSJFTJO(SFFDFB national problem. Burns o "SHZSJBEPV 4 FU BM ,OPXMFEHF BOE CFIBWJPVS PG UPVSJTUT UPXBSETUIFTVO BTTUVEJFEJOBSFHJPOPGOPSUIFSO(SFFDF Rural and Remote Health &VSPQFBO &OWJSPONFOU BOE )FBMUI *OGPSNBUJPO 4ZTUFN &/)*4 Policies to reduce the excessive exposure of children to ultraviolet radiation$PQFOIBHFO 8)03FHJPOBM0ďDF &VSPQF 'BDUTIFFU/P $BTTVUP+ćFEJTDPUIFRVFĕSFJO(PUIFOCVSH"USBHFEZ among teenagers. Burns o 5BSOPX1FUBM'JSFEJTBTUFSJO(PUIFOCVSHoTVSHJDBM treatment of burns. Burns o 3VOZBO $ FU BM 3JTL GBDUPST GPS GBUBM SFTJEFOUJBM ĕSFT New England Journal of Medicine o %J(VJTFQQJ$ )JHHJOT+4ZTUFNBUJDSFWJFXPGDPOUSPMMFEUSJBMT of interventions to promote smoke alarms. Archives of Diseases in Children o #BMMFTUFSPT . FU BM 8PSLJOH UPXBSET UIF FMJNJOBUJPO PG

SFTJEFOUJBMĕSFEFBUITUIF$FOUFSTGPS%JTFBTF$POUSPMBOE 1SFWFOUJPOTTNPLFBMBSNJOTUBMMBUJPOBOEĕSFTBGFUZ 4"*'& program. Journal of Burn Care and Rehabilitation o Working to prevent and control injury in the United States – Fact book for the year 2000"UMBOUB /BUJPOBM$FOUFSGPS*OKVSZ 1SFWFOUJPOBOE$POUSPM Home fire protection. Residential fire sprinkler systems [FA–43]. 8BTIJOHUPO %$ 'FEFSBM&NFSHFODZ.BOBHFNFOU"HFODZ IUUQXXXNPEFTUPĕSFDPN%PDVNFOUT#SPDIVSFT IGQSFETQSJOLMFSTQEG BDDFTTFE/PWFNCFS 4IBJ % *ODPNF IPVTJOH BOE ĕSF JOKVSJFT B DFOTVT USBDU analysis. Public Health Reports o .BD"SUIVS$&WBMVBUJPOPG4BGF,JET8FFL1SFWFOUJPO PG 4DBME BOE #VSO *OKVSJFT JO :PVOH $IJMESFO Injury Prevention o ,FOESJDL%FUBM3BOEPNJTFEDPOUSPMMFEUSJBMPGUIFSNPTUBUJD mixer valves in reducing bath hot tap water temperature in GBNJMJFTXJUIZPVOHDIJMESFOJOTPDJBMIPVTJOH"QSPUPDPM Trials Recommendation on the danger of burns presented by domestic hot water 10/031BSJT $POTVNFS4BGFUZ$PNNJTTJPO IUUQ XXXTFDVSJUFDPOTPPSHOPUJDFIUNM JE@BSUJDMF BDDFTTFE /PWFNCFS 4DIJFCFS3FUBM-FHJTMBUJWFBOESFHVMBUPSZTUSBUFHJFTUPSFEVDF DIJMEIPPE VOJOUFOUJPOBM JOKVSJFT The Future of Children, o -BJOH 3 #SZBOU 7 1SFWFOUJPO PG CVSO JOKVSJFT UP DIJMESFO involving nightwear. New Zealand Medical Journal o 64$POTVNFS1SPEVDU4BGFUZ$PNNJTTJPO Children’s sleepwear regulations 8BTIJOHUPO %$ 64 $POTVNFS 1SPEVDU4BGFUZ$PNNJTTJPO0ďDFPG$PNQMJBODF -ZPOT3FUBM4PDJPFDPOPNJDWBSJBUJPOJOJOKVSZJODIJMESFO and older people: a population based study. Injury Prevention, 'FMENBO , FU BM 5BQ XBUFS TDBME CVSOT JO DIJMESFO Injury Prevention o )BO3 6OHBS8 .BDBSUIVS$$PTUoFČFDUJWFOFTTBOBMZTJT PGBQSPQPTFEQVCMJDIFBMUIMFHJTMBUJWFFEVDBUJPOBMTUSBUFHZUP SFEVDFUBQXBUFSTDBMEJOKVSJFTJODIJMESFOInjury Prevention, o 64 $POTVNFS 1SPEVDU 4BGFUZ $PNNJTTJPO 0ďDF PG $PNQMJBODF 3FRVJSFNFOUT GPS $JHBSFUUF -JHIUFST $'3 1BSU <XFCTJUF> IUUQXXXDQTDHPWCVTJOGP SFHTVNMJHIUFSTQEG BDDFTTFE/PWFNCFS 4NJUI - FU BM 4UVEZ PG UIF FČFDUJWFOFTT PG UIF 64 TBGFUZ standard for child resistant cigarette lighters. Injury Prevention, o Decision 2006/502/EC Commission Decision of 11 May 2006 requiring Member States to take measures to ensure that only lighters which are child-resistant are placed on the market and to prohibit the placing on the market of novelty lighters. #SVTTFMT 0ďDFPGUIF0ďDJBM1VCMJDBUJPOTPGUIF&VSPQFBO $PNNVOJUJFT IUUQFDFVSPQBFVDPOTVNFSTTBGFUZ QSPE@MFHJTQSPE@MFHJTMBUJPO@MJHIUFST@FOIUN BDDFTTFE /PWFNCFS .BD,BZ . FU BM Child safety good practice guide: Good investments in unintentional child injury prevention and safety promotion "NTUFSEBN &VSPQFBO $IJME 4BGFUZ "MMJBODF &VSPTBGF %"SHFOJP 1 FU BM $BQPEBOOP 4FO[B %BOOP UIF FČFDUT PG BO JOUFSWFOUJPO QSPHSBN PO ĕSFXPSLT JOKVSJFT JO /BQMFT American Journal of Public Health o ,FOESJDL%FUBMi3JTL8BUDIwDMVTUFSSBOEPNJ[FEDPOUSPMMFE USJBM FWBMVBUJOH BO JOKVSZ QSFWFOUJPO QSPHSBN Injury THERMAL INJURIES 55

Prevention o 8BSEB- #BMMFTUFSPT.*OUFSWFOUJPOTUPQSFWFOUSFTJEFOUJBM ĕSF JOKVSZ *O %PMM - FU BM FET Handbook of injury and violence prevention"UMBOUB 4QSJOHFS o 'PSKVPI4 (VPIVB -"SFWJFXPGTVDDFTTGVMUSBOTQPSUBOE IPNF JOKVSZ JOUFSWFOUJPOT UP HVJEF EFWFMPQJOH DPVOUSJFT Social Science and Medicine o (JFMFO"$FUBM"SBOEPNJ[FEUSJBMPGFOIBODFEBOUJDJQBUPSZ HVJEBODF GPS JOKVSZ QSFWFOUJPO Archives of Pediatric and Adolescent Medicine o


(JFMFO "$ FU BM ć F FČFDUT PG JNQSPWFE BDDFTT UP TBGFUZ DPVOTFMJOH QSPEVDUT BOE IPNF WJTJUT PO QBSFOUT TBGFUZ practices. Archives of Pediatric and Adolescent Medicine o /HVZFO / FU BM ć F JNQPSUBODF PG JNNFEJBUF DPPMJOH o B DBTF TFSJFT PG DIJMEIPPE CVSOT JO 7JFUOBN Burns o 5VSOFS $ FU BM $PNNVOJUZCBTFE JOUFSWFOUJPOT GPS UIF prevention of burns and scalds in children. Cochrane Database of Systematic Reviews VQEBUFE $%

If all countries in the Region had the same injury mortality rates among children as the countries with the lowest rates, this would avoid an estimated 75% of these deaths. The experience accumulated by several European countries shows that sustained and systematic approaches that address the underlying causes of injuries, such as their socioeconomic and environmental determinants, can make all countries in the Region among the safest in the world.

CHAPTER 7 FALLS 7.1 Introduction $IJMESFOMFBSOCZFYQMPSJOHUIFJSTVSSPVOEJOHFOWJSPONFOUT BOE BTUIFZXBML SVO DMJNCBOEKVNQGSPNQMBDFUPQMBDF they often fall. Most falls are not serious, and children continue on their way with a better understanding of what UIFZ DBO BOE DBOOPU EP 'BMMT GSPN IFJHIUT PS POUP IBSE TVSGBDFT IPXFWFS DBOSFTVMUJOTFSJPVTJOKVSZ EJTBCJMJUZPS EFBUI$IJMESFOBSFFTQFDJBMMZWVMOFSBCMF BTUIFZNBZOPU SFDPHOJ[F UIF SJTLT PS DPSSFDUMZ KVEHF UIFJS QIZTJDBM BOE mental ability to carry out an activity safely. 4PNF DPVOUSJFT JO UIF 8)0 &VSPQFBO 3FHJPO IBWF XPSLFE UP QSFWFOU GBMMT (PPE QSBDUJDFT o TVDI BT redesigning products for children, improving stair design BOEJOUSPEVDJOHBOEFOGPSDJOHTBGFXJOEPXEFTJHOoIBWF DPOUSJCVUFE UP UIF SFEVDUJPO PG DIJMESFOT JOKVSJFT BOE fatalities from falls. ćJTDIBQUFSEFĕOFTBGBMMBTBOFWFOUUIBUSFTVMUTJOB QFSTPODPNJOHUPSFTUJOBEWFSUFOUMZPOUIFHSPVOEPSĘPPS or other lower level (1) #PY *OKVSJFTGSPNGBMMTBSFUIF SFTVMUPGUIFBCSVQUEJTTJQBUJPOPGNFDIBOJDBMFOFSHZćSFF factors are important in the outcome: tUIF BNPVOU PG FOFSHZ HFOFSBUFE PS SFMFBTFE CZ UIF GBMM XJUIUIFTFWFSJUZPGUIFJOKVSZTVTUBJOFECFJOHHPWFSOFE largely by the height from which a child falls (2) tIPXNVDIFOFSHZJTUSBOTNJUUFE XIJDIEFQFOETPOUIF PCKFDUPSTVSGBDFUIFDIJMEGBMMTPOUP GPSFYBNQMF BHSBTTZ TVSGBDFBCTPSCTNPSFJNQBDUUIBODPODSFUF BOE tUIFQPJOUTPGFOFSHZUSBOTNJTTJPOJGUIFGPSDFTPGUIFGBMM are spread over a large part of the body, the chance of JOKVSZJTSFEVDFE(3).

7.2 Burden in the Region 7.2.1 Mortality .PSFUIBOQFPQMFVOEFSZFBSTPGBHFEJFBTBSFTVMU PGTFWFSFGBMMTFBDIZFBSJOUIF&VSPQFBO3FHJPONPSFUIBO EFBUITQFSEBZ(4)'BMMTSBOLBTUIFGPVSUIMFBEJOHDBVTF PGJOKVSZEFBUIGPSUIJTBHFHSPVQ8IJMFGBMMTEPOPUSBOL JOUIFUPQDBVTFTPGEFBUIGPSDIJMESFOBHFEoZFBST UIFZ SBOL FJHIUI BT B MFBEJOH DBVTF PG CVSEFO PS %"-:T MPTU 5BCMF 'BMMTBSFBOJNQPSUBOUTPVSDFPGEJTBCJMJUZ CFDBVTFUIFZBSFDPNNPOBOENBZIBWFTFSJPVTMPOHUFSN IFBMUIDPOTFRVFODFT %FBUISBUFTGPSGBMMTWBSZXJEFMZJOUIF3FHJPO$IJMESFO JOUIFDPVOUSJFTXJUIUIFIJHIFTUNPSUBMJUZSBUFT UIF3VTTJBO 'FEFSBUJPO ,ZSHZ[TUBOBOE#FMBSVT IBWFUJNFTUIFSJTL

BOX 7.1

Key facts for falls in the WHO European Region t .PSFUIBODIJMESFOBHFEoZFBSTEJFGSPNGBMMTJOUIF3FHJPO each year. t 'BMMTBSFPGUFOUIFNPTUDPNNPODBVTFPGGBUBMBOETFSJPVTIFBEJOKVSJFT to young children. t *OFRVBMJUJFTFYJTUDIJMESFOJOUIFDPVOUSJFTXJUIUIFIJHIFTUSBUFTIBWF 22 times the risk of death of those in the countries with the lowest rates. If all countries matched the lowest rate in the Region, 9 out of 10 deaths could be averted. t 1SPWFOTUSBUFHJFTUPSFEVDFTFSJPVTGBMMTJODIJMESFOJODMVEFNPEJGZJOH or replacing unsafe products, legislation requiring window guards, and implementing playground standards and multifaceted community programmes.

of dying from a fall of children in the countries with the MPXFTUSBUFT 4XFEFO /FUIFSMBOETBOEUIF6OJUFE,JOHEPN 'JH 4PNFPGUIFQPTTJCMFFYQMBOBUJPOTGPSTVDIHSFBU differences include environment and housing conditions, SFHVMBUJPO PG DIJMESFMBUFE QSPEVDUT BOE DPNNVOJUZ BOE family attention to safety issues. *G BMM DPVOUSJFT JO UIF &VSPQFBO 3FHJPO NBUDIFE UIF DPVOUSZXJUIPOFPGUIFMPXFTUGBMMEFBUISBUFJOUIF3FHJPO 4XFEFO

PVU PG EFBUIT DPVME CF QSFWFOUFE TBWJOH BCPVUMJWFTFBDIZFBS 5BCMF %FBUISBUFTJO-.*$T JOUIF3FHJPOBSFUISFFUJNFTUIPTFJO)*$T3BUFTGPSJOGBOUT BSFFJHIUUJNFTIJHIFSJO-.*$T 5BCMF 'BMMTLJMMNPSFCPZTUIBOHJSMT QBSUJDVMBSMZJOUIFHSPVQ BHFEoZFBSTJOXIJDICPZTBSFGPVSUJNFTNPSFMJLFMZUP EJF 'JH 5ZQFTPGGBMMSFMBUFEJOKVSZEJČFSGPSEJČFSFOU BHFHSPVQT*OGBOUTBSFNPTUMJLFMZUPGBMMGSPNGVSOJUVSFPS Table 7.1 Age-standardized death rates for falls by age group with rate ratios for LMICs and HICs in the European Region Age groups (years) Rates and rate ratio

(FOFWB 8PSME)FBMUI0SHBOJ[BUJPO IUUQXXXXIPJOUIFBMUIJOGP HMPCBM@CVSEFO@EJTFBTF(#%@SFQPSU@VQEBUF@GVMMQEG BDDFTTFE/PWFNCFS "10--0)PTQJUBM%JTDIBSHF%BUBCBTF1BNQMPOB 6OJWFSTJUZPG/BWBSSB IUUQTXXXVOBWFTFDJQBQPMMP BTJTUFOUF BDDFTTFE/PWFNCFS 4FHVJ(PNF[.Injury-related hospitalizations in Europe, 2004/BWBSSB &VSPQFBO$FOUFSGPS*OKVSZ1SFWFOUJPO 1PMJOEFS4FUBMAPOLLO: the economic consequences of injury. Final report"NTUFSEBN $POTVNFS4BGFUZ*OTUJUVUF $PVOUSZ DMBTTJĕDBUJPO <XFC TJUF> 8BTIJOHUPO %$ 8PSME #BOL IUUQHPXPSMECBOLPSH,$,.$$ BDDFTTFE /PWFNCFS

DATA SOURCES 77

ANNEX 2 METHODS Standardized mortality rates and rate ratios Mortality data by age and sex provide a convenient and essential measure of disease or injury estimates of lives lost. The first analytical step in any estimation of the burden of disease or injury is to assess the age-specific death rates, by sex, for a given population for the reference year chosen for the study. This last should be chosen to be the most recent year for which data are available and might coincide with the census year or one for which extensive epidemiological and demographic data are accessible from other sources (1). In this report, two mortality indicators were calculated for further analysis: 1. Age-specific crude mortality rates (CDR) were calculated as follows: ,w with D = deaths; P = population; and i = age group.

2. Standardized mortality rates use a set of weights from a standard population, the reference population (European or world population structure) to compare different mortality profiles inside the WHO European Region. The formula is as follows (1):

,w with D = deaths; P = population; i = age group; and N = last age group; W = weight g =

Reference populationi R Total reference populationi

Age-standardized rates were calculated using the direct method and the European standard population structure (Table 3). TTable 1 European standard population weights Age (years)

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