ForumDistribution and Characteristics of Severe Traumatic Brain Injury at Mulago National Referral Hospital in Uganda
Introduction
From 2015 to 2030, road traffic injuries will become the fifth-leading cause of death (47). Current approximations suggest 90% of deaths from injuries occur in low- and middle-income countries (LMICs) (46). Traumatic brain injury (TBI) outcomes are among the worst in LMICs and the incidence is greater; the Sub-Saharan Africa (SSA) region has an incidence of 150−170 per 100,000 compared with a global average of 106 per 100,000 (18). The incidence is likely an underestimate because of the typically nascent or nonexistent trauma care infrastructure, which leaves many patients presenting late at referral hospitals. Moreover, TBI deaths are underreported because victims are likely routed first to mortuaries, as 50% of TBI mortality occurs within the first 2 hours from the moment of primary injury (14). Rapid infrastructure growth and motorization in the SSA region is likely to exacerbate this trend. In the United States, TBI has long been recognized as a “silent” epidemic, with immense public health impact with annual costs estimated at USD 76.5 billion (9). Countries in the SSA region carries a disproportionate burden with greater mortality, worsened outcomes, and greater impact from ensuing disability. In terms of capacity, human resources are lacking. There is 1 neurosurgeon per 10,000,000 average for the African continent compared with 102 per 10,000,000 in Europe and 56 per 10,000,000 globally (45).
The evidence base for TBI in SSA countries has been enriched within the previous 10 years as the result of increased descriptive studies, establishment of prospective databases, and expansion of sites for the international cohort study, Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH) trials 1, 8, 28, 35, 36, 48. CRASH trial results of 8927 patients predict that a TBI victim in a LMIC has twice the odds of dying after severe TBI (odds ratio [OR] 2.23, 95% confidence interval [CI] 1.51−3.30). In Uganda, head injury is one of the top 4 common admission diagnoses, contributing to a total 45.3% mortality rate in one study of intensive care unit patients and 75% head injury−specific mortality rate in another study of all casualty department admissions 17, 24. Head/neck injury is associated with 65% of all injury-related fatalities in urban Uganda (19). The literature from SSA countries specifically related to severe TBI is scarce. We undertook this retrospective analysis to describe distribution of severe TBI at Mulago Hospital, the national referral hospital of Uganda. Secondary objectives were to identify associations between outcomes and patient characteristics in order to potentiate platforms for more effective prevention and inform future research efforts at Mualgo Hospital.
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Methods
This was a single-institution study at Mulago Hospital, which has an immediate catchment area of the Kampala Capital City (estimated population 1,516,210 in 2014), but patients are referred from throughout the country (44). Injuries are triaged and treated in the Casualty Department; more severe injuries are admitted and many are referred to the Surgery Department. Mulago Hospital has 1500 beds and admits 130,000−140,000 patients per year. The Neurosurgery Unit employs 4 of Uganda's 5 formally
Results
One hundred twenty patients met the inclusion criteria within the 1-year period (July 1, 2008 to June 30, 2009). Thirty-one of 120 patients died, yielding an in-hospital mortality rate of 25.8%. Demographics are depicted in Table 1 and Figure 1A.
Discussion
Within the study period, Mulago Hospital's cumulative incidence of admissions was 89 per 100,000, and compared with other tertiary hospitals in the region, the high incidence suggests a concentration of severe TBI cases. A tertiary university hospital in Durban treated 32 severe TBI patients in 6 months; Nigeria's Lagos State University Hospital's treated 32 severe TBI patients in 7 months; Kamuzu Central Hospital in Milawi treated 15 severe TBI cases in 4 months; and 2 major Cape Town
Conclusions
Our study demonstrated that severe TBI was a common condition for injury-related hospital admissions at Mulago Hospital. Surprisingly, the in-hospital mortality rate was comparable to hospitals in developed countries. Males in their adolescence to middle age range were most likely to present with severe TBI. Initial GCS score, changes in GCS, and CT pathologies were most significantly associated with outcome. Clinical capacity building in neurosurgery and formal residency education at Mulago
Acknowledgments
The authors thank Dr. Joseph Egger of the Duke Global Health Institute Biostatistics Core for insights and review of the manuscript. The authors acknowledge the tremendous efforts in caring for patients with severe TBI by the Mulago Hospital Neurosurgery Unit's clinical staff. The authors thank Dr. Samuel Kaggwa, Chair of the Department of Surgery, and Dr. Byarugaba Baterana, the former Executive Director of Mulago Hospital, for their support for the collaboration between Makere University
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Conflict of interest statement: This research was supported by evaluation grant number: H22-Policy-031; Research on Intractable Diseases grant number: H23-Nanchi-032.