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ORIGINAL RESEARCH ARTICLE
Epidemiology of injuries presenting to the national hospital
in Kampala, Uganda: implications for research and policy
Renee Y. Hsia &Doruk Ozgediz &Milton Mutto &
Sudha Jayaraman &Patrick Kyamanywa &
Olive C. Kobusingye
Received: 23 May 2009 / Accepted: 31 May 2010 /Published online: 20 July 2010
#Springer-Verlag London Ltd 2010
Abstract
Background Despite the growing burden of injuries in LMICs,
there are still limited primary epidemiologic data to guide
health policy and health system development. Understanding
the epidemiology of injury in developing countries can help
identify risk factors for injury and target interventions for
prevention and treatment to decrease disability and mortality.
Aim To estimate the epidemiology of the injury seen in
patients presenting to the government hospital in Kampala, the
capital city of Uganda.
Methods A secondary analysis of a prospectively collected
database collected by the Injury Control Centre-Uganda at
the Mulago National Referral Hospital, Kampala, Uganda,
2004-2005.
Results From 1 August 2004 to 12 August 2005, a total of
3,750 injury-related visits were recorded; a final sample of
3,481 records were analyzed. The majority of patients
(62%) were treated in the casualty department and then
discharged; 38% were admitted. Road traffic injuries (RTIs)
were the most common causes of injury for all age groups
in this sample, except for those under 5 years old, and
accounted for 49% of total injuries. RTIs were also the most
common cause of mortality in trauma patients. Within
traffic injuries, more passengers (44%) and pedestrians
(30%) were injured than drivers (27%). Other causes of
trauma included blunt/penetrating injuries (25% of injuries)
and falls (10%). Less than 5% of all patients arriving to the
emergency department for injuries arrived by ambulance.
Conclusions Road traffic injuries are by far the largest
cause of both morbidity and mortality in Kampala. They are
the most common cause of injury for all ages, except those
younger than 5, and school-aged children comprise a large
proportion of victims from these incidents. The integration
of injury control programs with ongoing health initiatives is
an urgent priority for health and development.
Keywords Road traffic .Injuries .Developing country .
Trauma .Uganda
Introduction
Injuries are responsible for an increasing share of morbidity
and mortality in low- and middle-income countries
(LMICs) where they currently account for 11% of the total
The views expressed in this paper are those of the author(s) and not
those of the editors, editorial board or publisher.
R. Y. Hsia (*)
Department of Emergency Medicine,
University of California at San Francisco,
1001 Potrero Avenue, 1E21,
San Francisco, CA 94110, USA
e-mail: rhsia@post.harvard.edu
D. Ozgediz
Department of Surgery, University of Toronto,
Hospital for Sick Children,
Toronto, ON, Canada
M. Mutto
Injury Control Center- Uganda,
Kampala, Uganda
S. Jayaraman
Department of Surgery, University of California at San Francisco,
San Francisco, CA, USA
P. Kyamanywa
Department of Surgery, Faculty of Medicine,
National University of Rwanda,
Butare, Rwanda
O. C. Kobusingye
Regional Office for Africa, World Health Organization,
Harare, Zimbabwe
Int J Emerg Med (2010) 3:165–172
DOI 10.1007/s12245-010-0200-1
disability-adjusted life years [1]. Injuries also have an
enormous socioeconomic impact both at the household and
national level. There are great disparities in the prevention
and care of injuries worldwide,with1to2million
preventable deaths in severely injured patients and 90% of
deaths from road traffic injuries occurring in low- and
middle-income countries [2,3]. Children are disproportion-
ately affected as well. In sub-Saharan African children over
5, injuries account for more deaths than HIV, tuberculosis,
and malaria combined [4].
Understanding the epidemiology of injury can help
identify risk factors for injury and target interventions for
prevention and treatment to decrease disability and mortal-
ity. Despite the growing burden of injuries in LMICs,
however, there remain limited primary epidemiologic data
to guide health policy and health system development [5,
6]. Even if a health facility capable of providing quality
emergency care exists, the absence of formal prehospital
care in resource-constrained settings, along with multiple
barriers to care such as social, educational, cultural, and
financial factors, prevents access to these facilities.
To improve epidemiologic surveillance of injuries in
Uganda, the Injury Control Centre-Uganda established a
trauma registry in 1998, after piloting and validating an
instrument for data collection. This registry has been used in
five Ugandan hospitals since 1998 [7,8]. Similar registries
have also been established in other countries in the region
[9]. Since then, a number of injury prevention interventions
such as seat belt laws in motor vehicles, helmet laws for
motorcyclists, speed bumps, improved street lighting, and
school and household-based interventions for children have
been implemented. Efforts to improve trauma care have
included trauma courses for hospital-based personnel and
some first aid courses for police [10]. In addition, a national
injury policy has been drafted by the Ministry of Health [11].
There has, however, been no formal epidemiologic analysis
of the potential collective impact of these interventions since
the trauma registry was first implemented.
The goal of this study was to estimate the current
epidemiology of injury in the capital city of Kampala by
using data at Mulago National Referral Hospital, especially
the most common causes of injury, and the prevalence of
intentional and unintentional injury.
Methods
The database for this study was constructed from prospec-
tively collected data from the Injury Control Centre-
Uganda, which is a private organization that is funded by
both public and private sources; trained nurses, clinical
officers, or doctors in the casualty (or emergency) depart-
ment of the Mulago National Referral Hospital completed a
one-page form (described previously in the literature [8]) on
each patient presenting to the casualty department, recording
information on the patient condition, status, demographics
(age, sex, residence, occupation), several clinical variables
(blood pressure, pulse, respiratory rate, and neurological
status), as well as causes and place of injury, severity of
injury, and outcome. Two weeks after initial presentation, the
health care providers or records clerks completed the patient
disposition from the casualty (treated and discharged from
casualty, admitted, transferred to higher level facility, died in
casualty, dead on arrival) as well as the disposition for those
admitted (discharged, died, still in the hospital, transferred,
or other). This registry was checked for accuracy by a
hospital surgeon or senior doctor, and the data were entered
into Excel (Microsoft, 2005), cleaned, and managed by the
Injury Control Centre-Uganda.
The most current full year of data available at this time is
from July 2004 to August 2005. Prospective injury data
were no longer recorded after 2005 due to lack of funding,
and at this time, these data represent the most recent injury
epidemiology seen at Mulago National Referral Hospital, a
government hospital. Since 2008, efforts to restart the
hospital trauma registry have been revived.
All patients seen at Mulago National Referral Hospital
that were recorded in the database in the 12-month period
from 1 July 2004–1 August 2005 were included in the data
set, which was queried for descriptive statistics of all
injuries to characterize patients by age, gender, type of
injury, location of injury, intent, mode of arrival, distance,
injury severity, and disposition.
The Kampala Trauma Score (KTS) was chosen to
categorize severity of injury. This score has been validated
and was revised in 2004, where previous definitions of
mild, moderate, and severe injuries (which were KTS
scores of 14–16, 11–13, and <11, respectively) were
simplified to fit on a 10-point scale, with mild injury
defined as KTS 8–10, moderate injury as KTS 5–7, and
severe injury as KTS <5.
This study protocol was approved by the Mulago
National Referral Hospital Research Committee, the Uganda
National Council of Science and Technology, and the
Institutional Review Board of the University of California,
San Francisco.
Results
From 1 August 2004 to 12 August 2005, a total of 3,750
injury-related visits were recorded. We excluded those that
had no disposition from the casualty department (n = 51)
and those with missing values for disposition at 2 weeks
(n=218), together representing 7% of our sample. A total of
3,481 records were analyzed.
166 Int J Emerg Med (2010) 3:165–172
General characteristics
Injured patients seen at this hospital had a mean age of
25 years, and 74% were male. Figure 1shows the age
distribution of injured patients.
Patient disposition
The majority of patients (n = 2,144, 62%) were treated in the
casualty department and then discharged. Thirty-eight
percent (n=1,315) were admitted. The proportion of
admitted patients to all presenting patients was similar for
all age groups. Although 2 patients were dead on arrival, 15
patients (0.4%) were alive when presenting to the casualty
ward but died before being admitted. Five patients (0.1%)
were transferred (although the data do not indicate where or
why).
Most common causes of injury
Road traffic injuries were the most common causes of
injury for all age groups in this sample except for those
under 5, and accounted for 49% of total injuries. Blunt
injuries accounted for 15% and accounted for the second
most common cause of injury in all patients 15 years and
above. Penetrating injury was seen more often in patients
between the ages of 15 and 64. Poisonings, choking or
hanging, drowning, and sexual assault were rarely reported
(all less than 1%). Figure 2describes the top three causes of
injury by age group. Within traffic injuries (Fig. 3), more
passengers (44%) and pedestrians (30%) were injured than
were drivers (27%).
Occupation
Students (20%) and casual laborers (17%) were the most
frequent victims of trauma. Civil servants and private
employees comprised 11% of victims and small business
owners 10%.
Place of injury
Fifty-nine percent of injuries occurred on the road or street,
and 25% occurred in the home. This pattern was similar for
both sexes. Roads or streets were named as the most
common place of injury for all ages, except those aged less
than 15, for whom the home was the most common place of
injury. For women, 35% of injuries occurred at home
compared to 21% for men (p < 0.05).
Intent
Seventy-two percent of injuries were unintentional. After
excluding animal/snakebites, blunt force (56%) and stabs or
cuts (19%) comprised the majority of intentional injuries,
with a similar pattern for both genders. Nine victims sought
care for sexual assault. Five of the nine patients were
treated and discharged at the casualty department, and four
were admitted, three of whom were subsequently dis-
charged. One died in the hospital. Five of the assaults were
alcohol-related incidents.
Nine cases of domestic violence were reported. Given
that domestic violence is rarely reported, possible
domestic violence cases were noted if injuries occurred
at home and were reported to be intentional. Based on
these two criteria, 328 injuries were identified, com-
pared with the actual reported number of nine victims
of domestic violence. Some of these injuries were
reported as animal or snakebites, which have been
shown to be associated in published literature [12].
Even when these injuries were excluded, 223 cases
remained with 58% from blunt force, 20% from penetrat-
ing injuries such as stabs/cuts, and the rest from falls,
burns, and other causes.
Mode of arrival
Less than 5% of all patients arriving to the emergency
department for injuries arrived by ambulance. The majority
of patients (50%) came by private vehicle, and 22% were
brought in by the police. Twelve percent came by bicycle or
motorcycle, and 10% came by foot. Patients with more
severe injuries as determined by a low initial Kampala
Trauma Score (KTS, see Table 1) were more likely (p<
0.01) to arrive by ambulance than those who were less
severely injured (higher KTS).
For patients that were eventually admitted, 9.8% (95%
CI 8.2, 11.4) came by ambulance. Of these admitted
patients, more severely ill patients had 1.2 times the
likelihood (95% CI 1.1, 1.4) of being taken to the hospital
Fig. 1 Age distribution of injured patients presenting to the hospital
Int J Emerg Med (2010) 3:165–172 167
in an ambulance compared to those with lower severity
(higher KTS).
Distance
Sixty-five percent of injured people brought to Mulago
Hospital were from the district of Kampala. Of those who
were injured in Kampala and brought to Mulago Hospital,
33% were admitted as compared to 46.7% of those who
were injured outside of Kampala (p < 0.01 for difference).
Injury classification, severity, and outcome
Table 2shows that 92% of the patients were mildly injured
and only 1% of the sample severely injured. At 2 weeks,
67% of admitted patients had been discharged, 26% were
still in the hospital, 6% had died, and 1% had left against
medical advice. Seventy-five percent of the patients who
died of trauma in the hospital had head injury. Chest injury
accounted for 17% of trauma deaths. A total of 72 patients
died, which comprised 2% of the admitted patients. For
those who died, the most common cause was road traffic
injuries (n=41) (Table 3), which constituted over half of the
fatalities. A multivariable regression (including age, sex,
mechanism, occupation, place of injury, mode of arrival,
and distance) looking at outcome of death in the hospital
didnotshowanycorrelationwithanyvariablesexcept
for KTS, where each lower KTS point was correlated
with a decrease of 5% in the chance of survival (95% CI,
4.9%–5.7%).
Limitations
The goal of this study was to analyze the injuries of patients
that presented to the tertiary care hospital of the capital city
of Uganda. For a broader view of injury, it would be
preferable to include data from all hospitals in Kampala;
Fig. 2 Most common causes of
injuries by age group
0 200 400 600 800 1000 1200
Vehicle
Motorcycle
Bicycle
Type of vehicle
Number of patients
Driver
Passenger
Pedestrian
Fig. 3 Patients presenting to the
hospital from road traffic
injuries by type of vehicle and
status in vehicle
168 Int J Emerg Med (2010) 3:165–172
however, such data are not available since there is no
systematic data collection across these facilities for trauma.
Although Mulago Hospital receives 75% of injured victims
in Kampala [8], most of the other hospitals in city are
private and better resourced than the National Hospital,
although they do not as reliably have the 24-h coverage of
the National Hospital. It would be possible that they have
better injury outcomes. In addition, limitations in facility-
based care that could have affected outcomes were not
evaluated in this study. Furthermore, we were unable to
assess the number, characteristics, and types of trauma
patients that did not present to this hospital because of the
lack of a formal prehospital emergency system in Kampala.
Discussion
Several findings are notable in this study. Earlier reports of
trauma registries in Uganda show that the young male
population is most affected by trauma, and the findings of
this more updated study confirm the impact on this age
group. Similar to previous studies, the data also show that
road traffic injuries are the most common cause of injury
overall, except for in children aged 5 and younger [13].
Worldwide, road traffic injuries account for approximately
30% of all childhood injury deaths [14], which mirrors our
finding of overall injured people presenting to the hospital.
While these results are no doubt partly a reflection of the
underlying demographic patterns in sub-Saharan Africa,
with a relatively younger population compared to more
developed countries, these findings still have important
potential implications for public health and for poverty
eradication.
First, children and the economically productive segments
of the population are most affected by injury, but the
precise impact on household poverty (e.g., income forgone,
impact on family members, household wealth lost) is
poorly characterized, even in other sub-Saharan African
nations with a similar burden of injury [15]. Though there
was no specific variable to capture wealth or socioeconom-
ic status, the preponderance of students and casual laborers
that were injured suggests that poorer and more vulnerable
groups are affected by injury, keeping with prior reports
[16]. This could be further analyzed either through closer
evaluation of patients hospitalized with injuries or as part of
community surveys or ongoing demographic surveillance
programs. Previous work has suggested that injury costs
Uganda 2% of the GDP per year; however, the prevention
and care of injuries has not been highlighted by the Poverty
Eradication Action Plan of the Ministry of Finance or
recognized as a key health-related aspect of Uganda’s
progress toward the Millennium Development Goals [11].
Table 1 Kampala trauma score
Category Value
a. Age
≤51
6-55 2
>55 1
b. Number of serious injuries
03
12
2 or more 1
c. Systolic blood pressure (mmHg)
>89 4
0-89 3
1-49 2
Undetectable 1
d. Respiratory rate (breaths/min)
10-29 3
≥30 2
≤91
e. Neurological status (AVPU system*)
Alert 4
Responds to verbal stimuli 3
Responds to painful stimuli 2
Unresponsive 1
KTS total = a+b+c+d+e
Notes: Possible range for KTS is 5–16
5 = Most severely injured
16 = The least severely injured
*The AVPU system is a simplified version of the Glasgow Coma
Scale
Table 3 Fatal causes of injury
Cause Number Percent
Road traffic 41 56.9%
Burn 12 16.7%
Blunt/penetrating injury 11 15.2%
Fall 7 9.7%
Sexual assault 1 1.4%
Total 72 100.0%
Table 2 Injury severity of patients seen in casualty
Category KTS score Number % Sample
Mild 8-10 3,135 92%
Moderate 5-7 235 7%
Severe <5 33 1%
3,403 100%
Int J Emerg Med (2010) 3:165–172 169
In addition, the impact on school-age children suggests
that more coherent policies for the prevention and care of
injuries must be integrated into child health programs, as
has been previously suggested from prospective studies in
children and reviews of surgical conditions in the region
[14,17–19]. In the under-5-years age group, the prepon-
derance of burns and falls points to areas of further research
for prevention and care. Since the majority of child injuries
occurred at home, one might consider how a household-
based injury prevention program could be designed and
implemented. In addition, though prior reviews suggest that
school-based education programs for injury prevention
have limited effectiveness, this may need to be reconsid-
ered. Multiple randomized controlled trials have shown that
safety education can change pedestrian behavior in high-
income countries, although the effects on injury rates are
not known. However, there have been no large-scale studies
on pedestrian education in low and middle-income
countries. Such interventions may need to be considered
potentially in combination with other, more effective
interventions at the household and primary care level to
address the injury epidemic in Kampala [20].
Second, our findings also show that, within road traffic
injuries, more passengers are injured compared to drivers in
both motorcycle and vehicular injuries in Kampala. Not
only are road traffic injuries the most common cause of
injury, they are also responsible for the majority of fatal
injuries that occurred in this study. This is in contrast to
previous findings showing that pedestrians were the most
commonly injured in road traffic injuries in urban Uganda.
Prior studies have also shown the high impact on
vulnerable road users such as pedestrians and motorcycle
drivers [16,21]. The increased numbers of non-driver
injuries reflect the pattern of transport in Uganda, where
few individuals own their own vehicles, and most use large
vehicles that ferry numerous passengers at a time. This
pattern provides a strong argument for interventions that
increase the road safety of these large transportation
vehicles.
This is also in keeping with prior work documenting that
more passengers per crash are injured in LMICs compared
to higher income countries. The authors have also noted
that multiple casualty injuries are more the norm than the
exception, and this has implications for the design of
prehospital systems and the training and protocols in the
casualty ward, which must be ready to receive several
severely injured patients at a time.
Third, very few patients (less than 5%) were brought to
the hospital by ambulance, with the majority of injured
patients brought in private cars, by the police, and by
bystanders. This rate has not changed significantly since
earlier reports from the registry, suggesting that there has
been limited progress in the development of a formal
prehospital system. Though ambulances do exist in Kam-
pala, they are privately run, and families must be able to
afford the cost, which the majority cannot. Others have
suggested that the majority of potentially avertable deaths
in severely injured patients occur in the prehospital setting
[2]. In Kampala, records of fatalities from the prehospital
setting are captured by the police or by the public city
mortuary. An analysis of trauma-related deaths from
mortuary data may help to clarify the proportion of deaths
and disabilities that may have been preventable by
improved prehospital care. In the absence of an
ambulance-based prehospital system, prior work has sug-
gested that in regions of high injury incidence, initiatives to
improve knowledge and skills of lay responders may be a
feasible, cost-effective, and critical first step towards
developing a formal emergency system [22]. These initia-
tives deserve further study [23,24].
Finally, a primary finding of prior analysis is the
preponderance of minor injuries presenting to the National
Hospital, congesting the hospital and perhaps impeding the
care of more severely injured patients. Our findings show a
similar pattern and suggest that a more organized preho-
spital system might triage patients with less severe injuries
to other health centers to decongest the tertiary care facility.
This would require more thorough evaluation of the
capacity of lower level health facilities to receive and care
for injured patients. Qualitative interviews with Kampala
residents during this study indicated that most patients
prefer to attend Mulago Hospital because it is a government
hospital with highly subsidized health care, unlike the only
other options in the city, which are all private hospitals.
Nevertheless, many injured patients still do not seek care
because of other barriers to access to care, whether these are
cultural, social, economic, or geographic. Prior work has
suggested that up to 80% of patients with fractures present
first to a traditional healer before coming to a hospital [25,
26]. Causes of this health-seeking behavior need to be
further identified.
Hospital-based registries are limited because they do
not capture injured patients who do not interact with the
health system. A community survey in Ghana showed that
30% of patients with severe injuries did not access formal
care [27]. Prior community surveys in Kampala have
demonstrated that large proportion of injured patients die
without reaching care, with a mortality rate of 2.2/1,000 per
year, which is higher than that seen in this data [28]. There
were 72 deaths recorded in the trauma registry, which is
likely to be a gross underestimate of total deaths from
injuries since a large proportion of deaths are likely to have
occurred in the prehospital setting. Hospital-based death
data should be analyzed with police and city mortuary data
to calculate a better estimate of injury mortality in
Kampala.
170 Int J Emerg Med (2010) 3:165–172
A large proportion of trauma deaths was due to head
injuries in this study. Improving access to emergency
neurosurgical care may have the potential to prevent a
substantial proportion of these deaths. Prior reports have
suggested that the human resources and infrastructure
for neurosurgical care are very limited in sub-Saharan
Africa. A more detailed mortality audit at the hospital
level may help to determine how to improve care for
patients with head injuries who reach the hospital [29].
Other strategies to decrease trauma mortality in similar
settings have included the introduction of a trauma
education course for health personnel [30]. This interven-
tion is currently underway in Uganda, and an understand-
ing of its effectiveness will add greatly to the provision of
injury care in Kampala.
Conclusion
Road traffic injuries are by far the largest cause of both
morbidity and mortality seen in the government hospital in
Kampala. They are the most common cause of injury for all
ages except those less than 5, and school-aged children
comprise a large proportion of victims from these incidents.
The preponderance of minor injuries seen at the National
Hospital suggests that lower level facilities could be better
equipped to handle these injuries to decongest the National
Hospital. The development of prehospital trauma care
should be a high priority area given that less than 5% of
patients arrived by ambulance. Our data show that injuries
of the head, face, and neck account for a large proportion of
injured patients, and is the most common body part injured
in both discharged and admitted (and those who died in the
hospital) patients. While more research needs to be done on
appropriate and effective interventions, our findings point
to patterns of injury that should be targeted in future injury
control programs. The integration of injury control pro-
grams with ongoing health initiatives is an urgent priority
for health and development.
Acknowledgement None
Conflicts of interest None.
Funding None
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Dr. Renee Hsia is an emergency physician who has worked
extensively in sub-Saharan Africa both clinically and for research,
and is currently an Assistant Professor of Emergency Medicine at the
University of California, San Francisco (UCSF). This relationship
with the Mulago Hospital was first developed by Dr. Doruk Ozgediz,
who was Assistant Professor of Surgery at UCSF, and spent over a
year living in Uganda to help collect this data from the trauma
registry. Mr. Milton Mutto was the executive director of the Injury
Control Center- Uganda at the time, which was originally started
under the aegis of Dr. Olive C. Kobusingye, who went from the ICC-
U to the Regional Office for Africa at the World Health Organization,
based in Harare, Zimbabwe. Drs. Sudha Jayaraman (UCSF) and
Patrick Kyamanywa have spent significant periods of time in Kampala
also helping analyze the data and develop this study.
172 Int J Emerg Med (2010) 3:165–172
