Nonfatal childhood injuries: a survey at the Children's Hospital of eastern Ontario.

OBJECTIVE: To examine the types and severity of injuries seen in the Emergency Department of the Children''s Hospital of Eastern Ontario and the circumstances surrounding the events. DESIGN: Chart review. SETTING: A tertiary care hospital that serves a child population of 600,000 in eastern Ontario and western Quebec. PARTICIPANTS: Every sixth day''s charts of children up to 17 years of age who visited the Emergency Department because of injuries between Sept. 1, 1984, and Aug. 31, 1985, were examined retrospectively. RESULTS: A total of 2886 charts were reviewed. There were more boys than girls. Most (1354 [46.9%]) of the accidents had occurred at home. Falls and sports-related accidents were the leading causes of injury (in 1088 [37.7%] and 560 [19.4%] of the cases respectively). Most of the visits were for minor injuries (bumps, swellings, cuts, bruises and scrapes), and only 114 (4.0%) of the children were admitted to the hospital. Injuries from motor vehicle accidents accounted for the highest admission rate (17.4%). Important information regarding the circumstances surrounding the events (e.g., whether a seat belt or car seat was used) was frequently missing from the charts. CONCLUSIONS: Nonfatal injuries are common, especially in or around the home, and remain a significant problem in our society in terms of radiographic and consulting fees, time off from school or work and pain. Given the difficulties in obtaining information on the circumstances surrounding the events prospective studies are needed. Factors related to the occurrence and severity of childhood injury and whether these factors can be altered remain a high priority for research.     

School Playground Surfacing and Arm Fractures in Children: A Cluster Randomized Trial Comparing Sand to Wood Chip Surfaces

Background

The risk of playground injuries, especially fractures, is prevalent in children, and can result in emergency room treatment and hospital admissions. Fall height and surface area are major determinants of playground fall injury risk. The primary objective was to determine if there was a difference in playground upper extremity fracture rates in school playgrounds with wood fibre surfacing versus granite sand surfacing. Secondary objectives were to determine if there were differences in overall playground injury rates or in head injury rates in school playgrounds with wood fibre surfacing compared to school playgrounds with granite sand surfacing.

Methods and Findings

The cluster randomized trial comprised 37 elementary schools in the Toronto District School Board in Toronto, Canada with a total of 15,074 students. Each school received qualified funding for installation of new playground equipment and surfacing. The risk of arm fracture from playground falls onto granitic sand versus onto engineered wood fibre surfaces was compared, with an outcome measure of estimated arm fracture rate per 100,000 student-months. Schools were randomly assigned by computer generated list to receive either a granitic sand or an engineered wood fibre playground surface (Fibar), and were not blinded. Schools were visited to ascertain details of the playground and surface actually installed and to observe the exposure to play and to periodically monitor the depth of the surfacing material. Injury data, including details of circumstance and diagnosis, were collected at each school by a prospective surveillance system with confirmation of injury details through a validated telephone interview with parents and also through collection (with consent) of medical reports regarding treated injuries. All schools were recruited together at the beginning of the trial, which is now closed after 2.5 years of injury data collection. Compliant schools included 12 schools randomized to Fibar that installed Fibar and seven schools randomized to sand that installed sand. Noncompliant schools were added to the analysis to complete a cohort type analysis by treatment received (two schools that were randomized to Fibar but installed sand and seven schools that were randomized to sand but installed Fibar). Among compliant schools, an arm fracture rate of 1.9 (95% confidence interval [CI] 0.04–6.9) per 100,000 student-months was observed for falls into sand, compared with an arm fracture rate of 9.4 (95% CI 3.7–21.4) for falls onto Fibar surfaces (p≤0.04905). Among all schools, the arm fracture rate was 4.5 (95% CI 0.26–15.9) per 100,000 student-months for falls into sand compared with 12.9 (95% CI 5.1–30.1) for falls onto Fibar surfaces. No serious head injuries and no fatalities were observed in either group.

Conclusions

Granitic sand playground surfaces reduce the risk of arm fractures from playground falls when compared with engineered wood fibre surfaces. Upgrading playground surfacing standards to reflect this information will prevent arm fractures.

Trial Registration

Current Controlled Trials ISRCTN02647424 Please see later in the article for the Editors'' Summary     

Measuring exposure to injury risk in schoolchildren aged 11-14.

OBJECTIVE--To apply a measure of exposure to injury risk for schoolchildren aged 11-14 across a population and to examine how risk factors vary with sex, age, and affluence. DESIGN--Self completion questionnaire survey administered in schools in May 1990. SETTING--24 schools in Newcastle upon Tyne. SUBJECTS--5334 pupils aged 11-14, of whom 4637 (87%) completed the questionnaire. RESULTS--Boys were exposed to greater risk than girls in journeys to places to play outdoors; they took longer trips and were more likely to ride bicycles (relative risk 5.30 (95% confidence interval 4.23 to 6.64)) and less likely to travel by public transport or car. Younger pupils (aged 11-12) were less exposed to traffic during journeys to and from school: their journeys were shorter, they were less likely to walk (trip to school, relative risk 0.88 (0.83 to 0.94)), and they were more likely to travel by car (trip to school, relative risk 1.33 (1.13 to 1.56)) or school bus (1.33 (1.10 to 1.62)). Poorer children were exposed to greater risk than affluent children (from families that owned a car and a telephone): they were less likely to travel to school by car (relative risk 0.26 (0.20 to 0.33)) or to be accompanied by an adult (0.39 (0.32 to 0.48)). CONCLUSION--Injury risk data can provide useful information on child injury prevention and can be used to identify priorities and target resources for injury prevention on a citywide scale or for an individual school.     

Effectiveness of bicycle helmets in preventing head injury in children: case-control study.

OBJECTIVE--To examine the risk of injury to the head and the effect of wearing helmets in bicycle accidents among children. DESIGN--Case-control study by questionnaire completed by the children and their carers. SETTING--Two large children''s hospitals in Brisbane, Australia. SUBJECT--445 children presenting with bicycle related injuries during 15 April 1991 to 30 June 1992. The cases comprised 102 children who had sustained injury to the upper head including the skull, forehead and scalp or loss of consciousness. The controls were 278 cyclists presenting with injuries other than to the head or face. A further 65 children with injuries to the face were considered as an extra comparison group. MAIN OUTCOME MEASURES--Cause and type of injury, wearing of helmet. RESULTS--Most children (230) were injured after losing control and falling from their bicycle. Only 31 had contact with another moving vehicle. Children with head injury were significantly more likely to have made contact with a moving vehicle than control children (19 (19%) v 12 (4%), P < 0.001). Head injuries were more likely to occur on paved surfaces than on grass, gravel, or dirt. Wearing a helmet reduced the risk of head injury by 63% (95% confidence interval 34% to 80%) and of loss of consciousness by 86% (62% to 95%). CONCLUSIONS--The risk of head injury in bicycle accidents is reduced among children wearing a helmet. Current helmet design maximises protection in the type of accident most commonly occurring in this study. Legislation enforcing helmet use among children should be considered.     

The effect of safer play equipment on playground injury rates among school children

Background

Changes to Canadian Standards Association (CSA) standards for playground equipment prompted the removal of hazardous equipment from 136 elementary schools in Toronto. We conducted a study to determine whether applying these new standards and replacing unsafe playground equipment with safe equipment reduced the number of school playground injuries.

Methods

A total of 86 of the 136 schools with hazardous play equipment had the equipment removed and replaced with safer equipment within the study period (intervention schools). Playground injury rates before and after equipment replacement were compared in intervention schools. A database of incident reports from the Ontario School Board Insurance Exchange was used to identify injury events. There were 225 schools whose equipment did not require replacement (nonintervention schools); these schools served as a natural control group for background injury rates during the study period. Injury rates per 1000 students per month, relative risks (RRs) and 95% confidence intervals (CIs) were calculated, adjusting for clustering within schools.

Results

The rate of injury in intervention schools decreased from 2.61 (95% CI 1.93–3.29) per 1000 students per month before unsafe equipment was removed to 1.68 (95% CI 1.31–2.05) after it was replaced (RR 0.70, 95% CI 0.62–0.78). This translated into 550 injuries avoided in the post-intervention period. In nonintervention schools, the rate of injury increased from 1.44 (95% CI 1.07–1.81) to 1.81 (95% CI 1.07–2.53) during the study period (RR 1.40, 95% CI 1.29–1.52).

Interpretation

The CSA standards were an effective tool in identifying hazardous playground equipment. Removing and replacing unsafe equipment is an effective strategy for preventing playground injuries.Playgrounds provide a recreational refuge for children, away from traffic and other outdoor hazards. In addition, playground activities can enhance children''s cognitive, physical and psychosocial skills. Playground safety is of concern to physicians, parents and injury prevention advocates. Of all playground injuries that result in a visit to a hospital emergency department, 27%–40% are fractures and 17% require hospital admission — a greater frequency of admission than that associated with any other cause of pediatric injury except traffic.^1,2,3,4 The results of an observational study in Wales showed that 90% of all playground injuries resulting in a visit to an emergency department were related to the playground equipment.¹ As might be expected, playgrounds are the location within elementary schools with the highest injury rates and the most severe injuries.⁵ In a study conducted in Kingston, Ont., children were 12 times more likely to be injured in school playgrounds than in municipal playgrounds.³Standards for playgrounds have been developed both in Canada⁶ and internationally.^{7,8,9,10,11,12} The Canadian Standards Association (CSA) standards for the design, installation and maintenance of playgrounds and equipment were most recently revised in 1998.⁶ No published data exist on the relation between equipment standards and injury rates. If applying standards can identify unsafe playgrounds and, more importantly, reduce the rate of child injury, such standards would be a useful tool for school and municipal authorities responsible for playgrounds.We sought to determine the effect of replacing unsafe playground equipment (as determined using the new CSA standards) on injury rates among school children.     

Unusual injury? Recent injury in normal children and children with suspected non-accidental injury.

Four hundred normal children aged between 2 weeks and 11 years were examined to determine the prevalence and site of recent injury of any type. There was evidence of injury in 37% with a steady increase in prevalence to 60% by the end of the third year of life. Bruising of the hands and feet and of the lower legs was the most frequent type of injury. Head and facial injuries were most common between 18 months and 3 years (17% of children) but were rare at other ages. Injury to the lumbar region was unusual before 5 years but was present in 14% of children of school age. In 84 children of similar age where non-accidental injury was proved or suspected a different pattern of injury was present. Sixty per cent had injuries to the head and face; this increase in prevalence was seen at all ages. These children also had more frequent injuries in the lumbar region, particularly before the age of 5 years.     

Asthma in primary schools.

Seven schools in the Lewes area were visited to identify which children were using inhalational treatment for asthma. The attitudes of the parents and schools were assessed, as was the children''s skill in using inhalers. Five per cent of all children were receiving inhalational treatment with bronchodilator drugs. On average they had missed seven school days in the past year. The opinions of the parents about treatment appeared to be determined by the severity of the child''s asthma. Most schools coped well with giving bronchodilators, though there was no real understanding of the nature of the disease or treatment. Most children who had received pressurised inhalers could not use them satisfactorily.     

High-resolution measurements of face-to-face contact patterns in a primary school

Background

Little quantitative information is available on the mixing patterns of children in school environments. Describing and understanding contacts between children at school would help quantify the transmission opportunities of respiratory infections and identify situations within schools where the risk of transmission is higher. We report on measurements carried out in a French school (6–12 years children), where we collected data on the time-resolved face-to-face proximity of children and teachers using a proximity-sensing infrastructure based on radio frequency identification devices.

Methods and Findings

Data on face-to-face interactions were collected on Thursday, October 1^st and Friday, October 2^nd 2009. We recorded 77,602 contact events between 242 individuals (232 children and 10 teachers). In this setting, each child has on average 323 contacts per day with 47 other children, leading to an average daily interaction time of 176 minutes. Most contacts are brief, but long contacts are also observed. Contacts occur mostly within each class, and each child spends on average three times more time in contact with classmates than with children of other classes. We describe the temporal evolution of the contact network and the trajectories followed by the children in the school, which constrain the contact patterns. We determine an exposure matrix aimed at informing mathematical models. This matrix exhibits a class and age structure which is very different from the homogeneous mixing hypothesis.

Conclusions

We report on important properties of the contact patterns between school children that are relevant for modeling the propagation of diseases and for evaluating control measures. We discuss public health implications related to the management of schools in case of epidemics and pandemics. Our results can help define a prioritization of control measures based on preventive measures, case isolation, classes and school closures, that could reduce the disruption to education during epidemics.     

Injuries,Death, and Disability Associated with 11 Years of Conflict in Baghdad,Iraq: A Randomized Household Cluster Survey

Background

The objective of this study was to characterize injuries, deaths, and disabilities arising during 11 years of conflict in Baghdad.

Methods

Using satellite imagery and administrative population estimated size for Baghdad, 30 clusters were selected, proportionate to population size estimates. Interviews were conducted during April and May 2014 in 900 households containing 5148 persons. Details about injuries and disabilities occurring from 2003 through May 2014 and resultant disabilities were recorded.

Findings

There were 553 injuries reported by Baghdad residents, 225 of which were intentional, and 328 unintentional. For intentional injuries, the fatality rate was 39.1% and the disability rate 56.0%. Gunshots where the major cause of injury through 2006 when blasts/explosions became the most common cause and remained so through 2014. Among unintentional injuries, the fatality rate was 7.3% and the disability rate 77.1%. The major cause of unintentional injuries was falls (131) which have increased dramatically since 2008, followed by traffic related injuries (81), which have steadily increased. The proportion of injuries ending in disabilities remained fairly constant through the survey period.

Interpretation

Intentional injuries added substantially to the burden of unintentional injuries for the population. For Baghdad, the phases of the Iraqi conflict are reflected in the patterns of injuries and consequent deaths reported. The scale of injuries during conflict is most certainly under-reported. Difficulties recalling injuries in a survey covering 11 years is a limitation, but it is likely that minor injuries were under-reported more than severe injuries. The in- and out-migration of Baghdad populations likely had effects on the events reported which we could not measure or estimate. Damage to the health infrastructure and the flight of health workers may have contributed to mortality and morbidity. Civilian injuries as well as mortality should be measured during conflicts, though not currently done.     

道路交通事故致胫腓骨骨折的特点及救治

目的：总结交通事故伤中胫腓骨骨折的流行病学分类、特点及救治注意事项。方法：对136例交通事故伤中胫腓骨骨折患者的临床资料进行回顾性分析。结果：交通事故致胫腓骨骨折以多发伤及复合伤多见,经早期彻底清创、恰当的骨折固定、抗生素应用等,治愈77例,截肢2例,伤口浅表感染6例,骨髓炎1例。结论：交通事故伤中胫腓骨骨折大多伤情严重,感染率高,且开放性居多,早期及时选择合适的治疗方法是取得良好预后的关键。     

Epidemiology of rheumatic heart disease in black shcoolchildren of Soweto,Johannesburg.

A survey to determine the prevalence of rheumatic heart disease (R.H.D.) in Black children was conducted in the creeches and primary schools of the South Western Townships of Johannesburg (Soweto). A total of 12 050 Black children were examined by 10 cardiologists in May to October 1972. The overal prevalence rate of R.H.D. was 6.9 per 1000, with a peak rate of 19.2 per 1000 in children of the seventh school grade. The maximal age incidence was 15-18 years and there was a female preponderance of 1 6:1. A rise in prevalence occurred with increasing family size. Most children (92%) were asymptomatic, and in 82.5% R.H.D. was diagnosed for the first time during the school survey. The commonest valve lesion was mitral regurgitation, which was present in 93% and occurred as an isolated lesion in 47.5%. Lancefield''s group A beta-haemolytic streptococcus was isolated from the throats of 52 per 1000 Soweto children. The auscultatory features of a non-ejection systolic click and late systolic murmur were prevalent (13.9 per 1000) and had several epidemiological factors in common with R.H.D. A comprehensive preventative campaign is urgently needed in South Africa, directed at both primary and secondary prophylaxis of R.H.D. The socioeconomic status of the community must be improved if optimal prevention is to be achieved.     

Advisability of carrying out mass prevention of infectious hepatitis with gamma globulin

In Vilnius 15,183 pupils in 20 schools were observed for two years; in October, 1966, gamma globulin prophylaxis of infectious hepatitis was carried out among all the pupils of these schools. 17.062 pupils in 27 schools, who received no gamma globulin, were used for control. At the end of the first year of observation morbidity rate among the immunized children was found to be considerably lower than among the school children of the control group. During the second year of observation morbidity rate among the children of the "old" immunized group increased 3.5-fold and did not significantly differ from morbidity rate among the children of the control group. The latter increased 1.8-fold. The authors have come to the conclusion that the effect of gamma globulin prophylaxis on the epidemic process depends on the method of such prophylaxis. The method of prophylaxis by introducing gamma globulin immunization with universal coverage, as the use of the former method is not followed by an increase in total morbidity (i.e. among both immunized and nonimmunized children) during the second year after immunization, which is observed after prophylaxis by universal immunization.     

Can morbidity associated with untreated asthma in primary school children be reduced?: a controlled intervention study.

OBJECTIVE--To determine whether an intervention programme based on existing school and community resources can reduce school absence and improve participation in games lessons and sport in children with unrecognised or undertreated asthma. DESIGN--Parallel group controlled intervention study. SETTING--102 primary schools in Nottingham: 49 were randomised to receive the intervention and 53 to be control schools. SUBJECTS--All children aged 5 to 10 years with parent reported absence from school because of wheezing in the previous year and taking no treatment or beta agonists only. INTERVENTIONS--Children with asthma were referred to their general practitioner for assessment of symptoms and treatment. Teachers were given education on asthma by the school nurse in 44 of the 49 intervention schools. MAIN OUTCOME MEASURES--Changes in school absence and missed games and swimming lessons because of wheezing, and schools'' policy towards management of asthma in school. RESULTS--Of 17,432 children screened, 451 met the entry criteria--228 in intervention schools and 223 in control schools. 152 (67%) children in intervention schools visited their general practitioner, of whom 39 (26%) were given a new diagnosis of asthma and 58 (38%) had treatment for asthma increased or changed. Over the next academic year mean (SE) parent reported school absence due to wheezing fell significantly, but to a similar extent, in both intervention and control schools (0.82 (0.11) and 1.09 (0.21) weeks respectively). There was little change in school recorded absence or participation in games lessons and swimming lessons in either group. At the end of the study intervention schools were more likely to have improved aspects of management of asthma in school. CONCLUSION--The intervention resulted in a majority of children being assessed by their general practitioner and improved teachers'' understanding and management of asthma, but it did not result in any appreciable reduction in morbidity.     

Injuries to primary school pupils and secondary school students during physical education classes and in their leisure time

The study aimed to establish the frequency of injuries in primary and secondary schools during leisure time and physical education classes in school as well as in group and individual sports. The sample included 2842 pupils from nine primary schools and 1235 students from five secondary schools in Slovenia. The data were processed with the SPSS statistical software package and the frequencies and Crosstabs were calculated. The results showed that substantially more pupils and students were injured in their leisure time than during physical education classes. Girls were more frequently injured in group and individual sports practiced during physical education classes and in individual sports practiced in their leisure time, whereas boys suffered more injuries in group sports practiced in their leisure time. As regards group sports, pupils and students were most frequently injured while playing football in their leisure time whereas, during physical education classes, they suffered most injuries in volleyball, followed closely by basketball and football; as regards individual sports, pupils and students were most frequently injured while cycling and rollerblading in their leisure time, whereas during physical education classes they suffered most injuries in athletics.     

Occupational Injury Risk Assessment Using Injury Severity Odds Ratios: Male Falls from Heights in the Danish Construction Industry, 1993-1999

To allow for an improved targeted approach to occupational injury research and prevention, detailed risk analyses of fatal, serious, and minor occupational injuries were completed with a focus on male falls from heights in construction. Reported lost-time injuries in Denmark (1993 to 1999) were analyzed for proportions, relative rates, and an injury severity odds ratio to assess relative hazards and reporting. Different types of injury risks, such as elevation falls through surfaces, were identified by contrasting fatal, serious and minor injuries. Trade-specific analyses provided evidence that the carpentry-trade group merits increased attention, as this group has excessively high proportions, rates and hazards for falls from heights, compared to the entire construction industry. Age-specific analyses of workers aged 20 to 59 revealed that the rates of serious-injury falls from heights increase with increasing age. This relationship was inverted for elevation fall injuries from roof surfaces. A focus on construction and falls from heights is necessary not only in terms of fatal injuries, but also for serious injuries. The use of an injury severity odds ratio to assess relative hazards and reporting is a useful supplement to proportions and injury rates in contributing to more precise targeting of subgroups for primary injury prevention.     

The relationship between violent video games,acculturation, and aggression among Latino adolescents

Multiple factors are involved in the occurrence of aggressive behavior. The purpose of this study was to evaluate the hypotheses that Latino middle school children exposed to higher levels of video game playing will exhibit a higher level of aggression and fighting compared to children exposed to lower levels and that the more acculturated middle school Latino children will play more video games and will prefer more violent video games compared to less acculturated middle school Latino children. This study involved 5,831 students attending eight public schools in Texas. A linear relationship was observed between the time spent playing video games and aggression scores. Higher aggression scores were significantly associated with heavier video playing for boys and girls (p < 0.0001). The more students played video games, the more they fought at school (p < 0.0001). As Latino middle school students were more acculturated, their preference for violent video game playing increased, as well as the amount of time they played video games. Students who reported speaking more Spanish at home and with their friends were less likely to spend large amounts of time playing video games and less likely to prefer violent video games (p < 0.05).     

Traffic Deaths—A Preliminary Study of Urban and Rural Fatalities in California

An analysis by the California Department of Public Health of California Highway Patrol reports for 1961 showed that traffic accidents injured one and one-half times as many people per 1,000 population in rural California counties (under 50,000 people) as in urban counties (over 500,000 people), also persons injured in rural counties were almost four times as likely to die of their injuries as those injured in urban counties.A death certificate study was undertaken of 782 traffic deaths (excluding pedestrians) occurring in rural and urban California counties during 1961. Accidents occurring in rural counties tended to be single vehicle accidents which resulted in less severe injuries, while those in urban counties tended to be two vehicle and multiple vehicle accidents resulting in more serious injuries. The anatomic distribution of injuries was the same for both urban and rural accidents. However, people dying in rural accidents more frequently died at the scene of the accident, died sooner after injury, and died of less serious injuries than did those injured in urban accidents. For injuries where theoretically few lives should be salvaged by prompt emergency care, the time between injury and death was about the same in urban as in rural counties. Where such care should delay or prevent death because the injury was possibly or probably salvageable, those injured in rural counties died more quickly.Thirty-two per cent of fatalities in rural counties happened to urban and out-of-state residents, while only 12 per cent of fatalities in urban counties were to rural or out-of-state residents, suggesting that traffic accidents to non-residents may place an excessive load upon medical care resources in rural areas.     

Retrospective injury epidemiology of one hundred one competitive Oceania power lifters: the effects of age, body mass, competitive standard, and gender

The injury epidemiology of competitive power lifters was investigated to provide a basis for injury prevention initiatives in power lifting. Self-reported retrospective injury data for 1 year and selected biographical and training information were obtained via a 4-page injury survey from 82 men and 19 women of varying ages (Open and Masters), body masses (lightweight and heavyweight), and competitive standards (national and international). Injury was defined as any physical damage to the body that caused the lifter to miss or modify one or more training sessions or miss a competition. A total of 118 injuries, which equated to 1.2 +/- 1.1 injuries per lifter per year and 4.4 +/- 4.8 injuries per 1,000 hours of training, were reported. The most commonly injured body regions were the shoulder (36%), lower back (24%), elbow (11%), and knee (9%). More injuries appeared to be of a sudden (acute) (59%) rather than gradual (chronic) nature (41%). National competitors had a significantly greater rate of injury (5.8 +/- 4.9 per 1,000 hours) than international competitors (3.6 +/- 3.6 per 1,000 hours). The relative proportion of injuries at some body regions varied significantly as a function of competitive standard and gender. No significant differences in injury profile were seen between Open and Masters or between lightweight and heavyweight lifters. Power lifting appears to have a moderately low risk of injury, regardless of the lifter's age, body mass, competitive standard, or gender, compared with other sports. Future research should utilize a prospective cohort or case-controlled design to examine the effect of a range of other intrinsic and extrinsic factors on injury epidemiology and to assess the effects of various intervention strategies.     

Hand Sanitiser Provision for Reducing Illness Absences in Primary School Children: A Cluster Randomised Trial

Background

The potential for transmission of infectious diseases offered by the school environment are likely to be an important contributor to the rates of infectious disease experienced by children. This study aimed to test whether the addition of hand sanitiser in primary school classrooms compared with usual hand hygiene would reduce illness absences in primary school children in New Zealand.

Methods and Findings

This parallel-group cluster randomised trial took place in 68 primary schools, where schools were allocated using restricted randomisation (1∶1 ratio) to the intervention or control group. All children (aged 5 to 11 y) in attendance at participating schools received an in-class hand hygiene education session. Schools in the intervention group were provided with alcohol-based hand sanitiser dispensers in classrooms for the winter school terms (27 April to 25 September 2009). Control schools received only the hand hygiene education session. The primary outcome was the number of absence episodes due to any illness among 2,443 follow-up children whose caregivers were telephoned after each absence from school. Secondary outcomes measured among follow-up children were the number of absence episodes due to specific illness (respiratory or gastrointestinal), length of illness and illness absence episodes, and number of episodes where at least one other member of the household became ill subsequently (child or adult). We also examined whether provision of sanitiser was associated with experience of a skin reaction. The number of absences for any reason and the length of the absence episode were measured in all primary school children enrolled at the schools. Children, school administrative staff, and the school liaison research assistants were not blind to group allocation. Outcome assessors of follow-up children were blind to group allocation. Of the 1,301 and 1,142 follow-up children in the hand sanitiser and control groups, respectively, the rate of absence episodes due to illness per 100 child-days was similar (1.21 and 1.16, respectively, incidence rate ratio 1.06, 95% CI 0.94 to 1.18). The provision of an alcohol-based hand sanitiser dispenser in classrooms was not effective in reducing rates of absence episodes due to respiratory or gastrointestinal illness, the length of illness or illness absence episodes, or the rate of subsequent infection for other members of the household in these children. The percentage of children experiencing a skin reaction was similar (10.4% hand sanitiser versus 10.3% control, risk ratio 1.01, 95% CI 0.78 to 1.30). The rate or length of absence episodes for any reason measured for all children also did not differ between groups. Limitations of the study include that the study was conducted during an influenza pandemic, with associated public health messaging about hand hygiene, which may have increased hand hygiene among all children and thereby reduced any additional effectiveness of sanitiser provision. We did not quite achieve the planned sample size of 1,350 follow-up children per group, although we still obtained precise estimates of the intervention effects. Also, it is possible that follow-up children were healthier than non-participating eligible children, with therefore less to gain from improved hand hygiene. However, lack of effectiveness of hand sanitiser provision on the rate of absences among all children suggests that this may not be the explanation.

Conclusions

The provision of hand sanitiser in addition to usual hand hygiene in primary schools in New Zealand did not prevent disease of severity sufficient to cause school absence.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12609000478213 Please see later in the article for the Editors'' Summary     

Health and Exercise-Related Medical Issues among 1,212 Ultramarathon Runners: Baseline Findings from the Ultrarunners Longitudinal TRAcking (ULTRA) Study

Regular exercise is associated with substantial health benefits; however, little is known about the health impact of extreme levels of exercise. This study examined the prevalence of chronic diseases, health-care utilization, and risk factors for exercise-related injuries among ultramarathon runners. Retrospective, self-reported enrollment data from an ongoing longitudinal observational study of 1,212 active ultramarathon runners were analyzed. The most prevalent chronic medical conditions were allergies/hay fever (25.1%) and exercise-induced asthma (13.0%), but there was a low prevalence of serious medical issues including cancers (4.5%), coronary artery disease (0.7%), seizure disorders (0.7%), diabetes (0.7%), and human immunodeficiency virus (HIV) infection (0.2%). In the year preceding enrollment, most (64.6%) reported an exercise-related injury that resulted in lost training days (median of 14 days), but little nonattendance of work or school due to illness, injury, or exercise-related medical conditions (medians of 0 days for each). The knee was the most common area of exercise-related injury. Prior year incidence of stress fractures was 5.5% with most (44.5%) involving the foot. Ultramarathon runners who sustained exercise-related injuries were younger (p<0.001) and less experienced (p<0.01) than those without injury. Stress fractures were more common (p<0.01) among women than men. We conclude that, compared with the general population, ultramarathon runners appear healthier and report fewer missed work or school days due to illness or injury. Ultramarathon runners have a higher prevalence of asthma and allergies than the general population, and the prevalence of serious medical issues was nontrivial and should be recognized by those providing medical care to these individuals. Ultramarathon runners, compared with shorter distance runners, have a similar annual incidence of exercise-related injuries but higher proportion of stress fractures involving the foot, and it is the younger and less experienced ultramarathoners who appear most at risk for injury.