Canadian Journal of Public Health

, Volume 96, Issue 5, pp 328–332 | Cite as

Quantifying the Iceberg Effect for Injury

Using Comprehensive Community Health Data
  • Vic S. Sahai
  • Mary S. Ward
  • Tim Zmijowskyj
  • Brian H. RoweEmail author



Injury is the leading cause of preventable morbidity and mortality in Canada. The “iceberg” effect in injuries was proposed to address the injury statistics that are often poorly documented. The aim of this investigation was to quantify the severity and magnitude of iceberg effect in Ontario, Canada.


Data from Vital Statistics (1999, mortality), Canadian Institute for Health Information (2001, hospitalizations), Census (2001, demographic information), National Ambulatory Care Reporting System (2001, emergency department visits), and the Canadian Community Health Survey (2000/01, other injuries) were used to construct the Ontario injury iceberg for ages 12 years and older.


There were 79,577 fatalities in Ontario in 1999; 2,645 were attributable to injuries (crude rate: 2.3 per 10,000). Of the 913,540 hospitalizations (2001), 67,301 were caused by injuries. There were 3,520,253 emergency department (ED) visits (2001) and 959,278 were attributable to injuries. For injuries treated elsewhere, the most common treatment site was the physician’s office (23.3%). The most common cause of injuries (CCHS) was falls (37.4%) and exertion/movement (20.5%). There were 1,928,000 injuries causing functional impairment (one injury to five individuals in the population).


The high ratio of injury-related ED visits to deaths illustrated the high volume of injuries that present to the ED. The ratio of injuries resulting in functional impairment to the population demonstrates that such injuries can be problematic, even if not resulting in hospitalization. Constructing the injury iceberg using valid data should assist researchers and decision-makers in priority setting.

MeSH terms

Wounds and injuries health services public health accidents 



Les blessures corporelles constituent la principale cause de morbidité et de mortalité au Canada. On a proposé la théorie de l’effet « iceberg » pour mieux comprendre les données statistiques relatives aux blessures, souvent peu documentées. Cette étude vise à quantifier la gravité et l’importance de l’effet iceberg dans la province de l’Ontario, au Canada.


Les statistiques de l’état civil (1999, mortalité), de l’Institut canadien d’information sur la santé (2001, hospitalisations), et du recensement (2001, données démographiques), du Système national d’information sur les soins ambulatoires (2001, nombre de visites aux services d’urgence) et de l’Enquête sur la santé dans les collectivités canadiennes (ESCC) (2000–2001, autres blessures) ont servi à la construction de l’effet iceberg en Ontario, pour les personnes de 12 ans et plus.


En 1999, on a signalé 79 577 décès en Ontario, dont 2 645 attribuables à des blessures (taux brut: 2,3 pour 10 000). Des 913 540 hospitalisations relevées (2001), 67 301 étaient attribuables à des blessures. De même, des 3 520 253 visites des services d’urgence (SU) (2001), 959 278 étaient dues à des blessures. Les blessures qui ne sont pas traitées dans les services d’urgence l’étaient de façon prédominante dans un cabinet de médecin (23,3 %). Les chutes représentaient la principale cause de blessures (ESCC) (37,4 %), suivie de la fatigue et des mouvements (20,5 %). On constate que 1 928 000 blessures ont entraîné une invalidité fonctionnelle (dans la population, une personne sur cinq a subi des blessures).


Le taux élevé de visites aux services d’urgence pour cause de blessures et de mortalité témoignent du nombre important de blessures traitées par les services d’urgence. Le taux de blessures entraînant des invalidités fonctionnelles permet de conclure que les blessures peuvent poser problème et ce, même si elles ne donnent pas lieu à une hospitalisation. La construction de l’effet iceberg, à l’aide de données valides, devrait aider les chercheurs et les décideurs dans l’établissement des priorités.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Northern Health Information Partnership. Injuries and Poisonings in Northern Ontario–2000. Sudbury, ON: NHIP, 2000.Google Scholar
  2. 2.
    Queen’s Printer for Ontario. Provincial Health Planning Database. Health Planning Branch, Ontario Ministry of Health and Long-Term Care, 2000.Google Scholar
  3. 3.
    Northern Health Information Partnership. An overview of health status in Northern Ontario, 2004.Google Scholar
  4. 4.
    Health Canada. Economic burden of injury in Canada, 1998. 2002.Google Scholar
  5. 5.
    McClure R, Douglas R. The public health impact of minor injuries. Accid Anal Prev 1996;28(4):443–51.CrossRefPubMedGoogle Scholar
  6. 6.
    Loimer H, Driur M, Guarnier M. Accidents and acts of God: A history of the terms. Am J Public Health 1996;86(1):101–7.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Davis R, Pless B. BMJ bans “accidents”: Accidents are not unpredictable. BMJ 2001;322(7298):1320–21.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Last, JM. The iceberg: Completing the clinical picture in general practice. Lancet 1963;6:28–31.CrossRefGoogle Scholar
  9. 9.
    World Health Organization. International Classification of Diseases, Injuries, and Causes of Death, 9th Revision. Geneva, Switzerland, 1977.Google Scholar
  10. 10.
    Northern Health Information Partnership. Injuries and Poisonings in Northern Ontario–2004. Sudbury, ON: NHIP, 2004.Google Scholar
  11. 11.
    Burt CW, Fingerhut, LA. Injury visits to hospital emergency departments: United States, 1992–95. Vital Health Statistics 1998;13(131):1–76.Google Scholar
  12. 12.
    Pickett W, Hartling L, Brison, RJ. A populationbased study of hospitalized injuries in Kingston, Ontario, identified via the Canadian Hospitals Injury Reporting and Prevention Program. Chron Dis Can 1997;18(2):61–69.Google Scholar
  13. 13.
    Wadman MC, Muelleman RL, Coto JA, Kellerman, AL. The pyramid of injury: Using ecodes to accurately describe the burden of injury. Ann Emerg Med 2003;42(4):468–78.CrossRefPubMedGoogle Scholar
  14. 14.
    Centers for Disease Control and Prevention. Leads from the Morbidity and Mortality Weekly Report, Atlanta, GA: Deaths resulting from firearm- and motor-vehicle-related injuries— United States, 1968–1991. JAMA 1994;271(7):495–96.CrossRefGoogle Scholar
  15. 15.
    Sahai VS, Pitblado JR, Bota GW, Rowe BH. Factors associated with seat belt use: An evaluation from the Ontario Health Survey. Can J Public Health 1998;89(5):320–24.PubMedGoogle Scholar
  16. 16.
    Irvine A, Rowe BH, Sahai V. Bicycle helmetwearing variation and associated factors in Ontario teenagers and adults. Can J Public Health 2002;93(5):368–73.PubMedGoogle Scholar
  17. 17.
    Demorest RA, Posner JC, Osterhoudt KC, Henretig, FM. Poisoning prevention education during emergency department visits for childhood poisoning. Pediatric Emerg Care 2004;20(5):281–84.CrossRefGoogle Scholar
  18. 18.
    Reeson C, Wafer M. Falls in accident and emergency departments. Nursing Standard 2001;15(50):33–37.CrossRefPubMedGoogle Scholar
  19. 19.
    Leigh JP, Markowitz SB, Fahs M, Shin C, Landrigan, PJ. Occupational injury and illness in the United States: Estimates of costs, Morbidity, and mortality. Arch Intern Med 1997;157(14):1557–68.CrossRefPubMedGoogle Scholar
  20. 20.
    Bastida JL, Aguilar PS, Gonzalez, BD. The economic costs of traffic accidents in Spain. J Trauma: Injury, Infection, Critical Care 2004;56(4):883–89.CrossRefGoogle Scholar
  21. 21.
    Northern Health Information Partnership. Northern Ontario Child and Youth Health Report. Sudbury, ON: NHIP, 2003.Google Scholar
  22. 22.
    MacMillan HL, MacMillan AB, Offord DR, Dingle, JL. Aboriginal health. CMAJ 1996;155(11):1569–78.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Scott J. Homelessness and mental health. Br J Psychiatry 1993;162:314–24.CrossRefPubMedGoogle Scholar

Copyright information

© The Canadian Public Health Association 2005

Authors and Affiliations

  • Vic S. Sahai
    • 1
    • 2
    • 3
  • Mary S. Ward
    • 1
    • 3
  • Tim Zmijowskyj
    • 2
    • 3
  • Brian H. Rowe
    • 4
    Email author
  1. 1.Northern Health Information PartnershipSudburyCanada
  2. 2.Northeastern Ontario Medical Education CorporationCanada
  3. 3.Northern Ontario Medical SchoolUniversity of OttawaSudburyCanada
  4. 4.Departments of Emergency Medicine and Public Health Sciences, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonCanada

Personalised recommendations