Epidemiology of traumatic brain injury in a South African major trauma cohort

Background: South Africa has one of the highest trauma burdens globally, with unique contextual challenges around health system capacity. Traumatic brain injury (TBI) is a significant contributor to post-injury mortality and morbidity. We aimed to examine TBI prevalence and outcomes in adult major trauma patients. Methods: We conducted a secondary analysis of the Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study, a prospective observational study of adult major trauma patients presenting to public-sector health facilities in South Africa's Western Cape. Individuals injured from January 2022 to December 2024 with documentation of a head injury were included. We compared demographic, injury, and outcome variables across TBI categories: no TBI, mild (Glasgow Coma Scale (GCS) 13-15), moderate (GCS 9-12), severe (GCS 3-8). Logistic regression and Mantel-Haenszel analyses were used to examine mortality and neurofunctional disability. Results: We included 4815 patients within the EpiC database who had any head injury. Among those with TBI (n = 2297), 36.7% had mild, 39.6% moderate, and 23.7% severe TBI. A significantly higher percentage of severe TBI patients (n = 195; 35.8%) were transported directly to the tertiary facility. Overall, 7.2% of patients died before discharge from an EpiC site. Those with moderate (OR = 1.89; 95% confidence interval (CI) = 1.16-3.07) and severe (OR = 53.08; 95% CI = 37.61-74.91) TBI had higher odds of dying compared to those with no or mild TBI, controlling for age, multiple-trauma, and GCS qualifier. Among survivors, individuals with severe TBI (OR = 8.97; 95% CI = 5.45-14.74) had higher odds of poor neurofunctional recovery, measured by Glasgow Outcome at Discharge Scale, compared to those with no or mild TBI. Conclusions: TBI represents a significant burden in South Africa's Western Cape. Within this head injury cohort, there are significant differences in injury characteristics and transport patterns. Mortality and neurofunctional recovery vary significantly across TBI severity but remain significantly worse for those with TBI even when controlling for potential confounders.