Pattern of road traffic injuries in Yemen: a hospital-based study

Introduction Road traffic injuries (RTIs) are the eighth leading cause of death globally and the leading cause of death for young people. This study aimed to present time-limited trial surveillance in two referral hospitals to describe the pattern of RTIs in Sana'a, Yemen and determine road traffic crashes (RTCs) associated factors. Methods All RTIs presented to Emergency Departments (ED) of the two Sanaa city hospitals between August and October, 2015 were studied and described. Data were collected everyday by trained data collectors. A pretested questionnaire modified from WHO injury surveillance form was used for data collection. Results A total of 156 casualties from 128 RTCs had attended the two study hospitals during the study period. About 73% of victims were less than 30 years old. Only 13% of casualties were transported by ambulance. None of the victims wore the seat belt in case of 4-wheeled vehicles' users nor the helmet in case of 2-wheeled vehicles' users. Poor driving skills were involved in 133 (85%) casualties. Factors related to the vehicles contributed to 12% of RTCs. Of the 156 casualties, 17% had severe injuries and needed ICU admission. After 48 hours of the accident, 38% of patients ended with disability due to fractured limbs, 29% were not improving and their conditions were deteriorating, 18% had recovered and 5% died. Conclusion Several personal, behavioral, environmental and vehicles related factors had contributed to RTIs in Yemen. The burden of RTIs in Yemen in terms of disability and mortality is high.


Introduction
Road traffic injuries (RTIs) are the eighth leading cause of death globally and the leading cause of death for young people aged 15-29 [1]. Over million people worldwide died because of road traffic injuries [2]. More than 90% of all road traffic injuries' deaths occurred in the low and middle-income countries [3], with about one third was among pedestrians and cyclists. However, less than 35% of low-and middle-income countries have policies in place to protect road users [4]. Eighty-eight countries have reduced the number of deaths on their roads-but the total number of road traffic deaths remains unacceptably high at 1.24 million per year. There are large disparities in road traffic death rates between WHO regions. The Eastern Mediterranean region comes next to the African region with a death rate of 19.9/100,000 population compared to 26.6/100,000 in the African region [4]. Only 28 countries, representing 449 million people (7% of the world's population), have adequate laws addressing the most important related factors, namely speed, drink-driving, helmets, seat-belts and child restraints [4]. According to the global status report on road safety (2013) [2], the road traffic death rate in Yemen was 23.7 deaths per 100,000 population. Unfortunately, there were no data available for deaths by road-user category [4]. Furthermore, the source of these estimates was the Ministry of Interior (MOI) not the Ministry of Public Health and Population (MOPHP) as there is no well-established surveillance system in the MOPHP. Moreover, there are no established committees or bodies to address injuries issue in general and to prevent their occurrence and manage their consequences. This study aimed to present time-limited trial surveillance in two referral hospitals to describe the pattern of RTIs in Sana'a, Yemen. Moreover, the study aimed to determine road traffic crashes (RTCs) associated factors. The results of this study will be necessary for surveillance planning in MOPH.

Methods
This study was conducted in Aljomhoury General Hospital and Science and Technology Private Hospital, between 24 th August 2015 and 8 th October 2015. All traffic injuries attended the two selected hospitals during the day and the night shifts of the study period were included unless overwhelmed by the number of the crashes coming at once; in such case, the first one at least was included.
Data were collected everyday by the trained data collectors in the Emergency Departments (EDs) of the selected hospitals. The study questionnaire was developed based on the WHO injury surveillance form [5,6] and was used for interviewing the study subjects. Where condition of victims did not permit the interview, the relatives of the victim were interviewed. During the interview, the purpose of study was explained to each respondent. Case-sheets of the victims were referred for cross-checking. The collected information consisted of personal identification data, history of road traffic crashes, human and environmental risk factors, clinical history and examination. The type and severity of injury suffered by the victims was graded using the injury severity scoring used by WHO guideline for injury surveillance [5]. The injury outcomes were also recorded for each case. For the purpose of study, RTC was defined as a collision or incident that may or may not lead to injury, occurring on a public road and involving at least one moving vehicle. RTI was defined as any injury due to crashes originating, terminating or involving a vehicle partially or fully in a public pathway [5]. A declaration about the researcher, the study objectives and its anticipated benefits was manifested at the beginning of each questionnaire. Oral informed consent was obtained from each conscious injured and, from the available accompanied relative, in case of unconsciousness or deceased. Along with that in case of child victims, asset was obtained. Confidentiality was protected for all participants. The study was approved by the ethical committee in the MOPHP. Data were described and analyzed using SPSS IBM version 20. Data were described using means for continuous variables and percentages for categorical variables.

Distribution of injuries according the road user categories
and the type of accident crash: About 38% of injured people were occupants of vehicles other than drivers, 32% were pedestrians and the rest were the drivers. Of the drivers, 55% were motorized 2-wheeler drivers, 26% were 4-wheeler drivers and the rest were bicyclists. More than half (55%) of the casualties befell on urban highways, while 28% occurred on highways outside the main cities. The vehicle-person mechanism of crash represents the highest percent (37%) followed by vehicle-object (33%). Vehiclevehicle crashes were manifested in 30%.  The most common injury were bruises and superficial wounds (74%), followed by fractures in 32% of the cases and internal organs injuries in 16% of them. Fractures occurred in 50 cases.

Transportation of injured
However, the total number of fractures resulted from the accidents was 57 fractured bones as some patients had more than one fractured bone. Lower limbs fractures represented the main injury in 2-wheeled users. The number of casualties with internal organs injuries were 25. However, the total organs affected was 27 as some patients had multi-organs injuries. Figure 2 shows that the most affected internal organ was the brain (52%) followed by the spleen (22%).
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Discussion
The study captured 156 casualties from 128 accidents. The total number of the casualties affected by those accidents was 266. Of those, 156 presented to the study site. The total number deaths from the mentioned accidents was 18. The majority (78%) of deaths occurred at the site of the accidents. A similar finding was reported in Kenya study [6]. Since most deaths occurred prehospital, many might be preventable if they got the proper first-aid services. The mean age of victims in our study was 23 years, which is less than that noticed in other studies where the mean age was more than 30 [7][8][9].This study revealed that the highest number of casualties were 20-29 years old (34%), a finding that is consistent with the results of other studies in India and Nepal [7,8,10]. The next most affected age groups were the younger age groups (10)(11)(12)(13)(14)(15)(16)(17)(18)(19) years old (20%) and less than 10 years old (19%). This finding was not seen in other studies that found fewer casualties in the extremes of age [7][8][9][10][11][12][13][14]. However, all the mentioned studies agreed with our study on that people less than 40 years old were at high risk of being injured. This finding reflects that people in productive age were mostly affected by RTIs, which adds a serious economic loss to the community. The high incidence in children raises the issue of parental care to their kids. The current study showed those males were more likely to be affected than females (male-female ration of 4.6:1). The same ratio was reported by hospital-based studies from Western Maharashtra, India [7,15]. Although different ratios were reported by other studies, all agreed that male are more likely to be affected than females by more than three times [8,[16][17][18][19], probably due to more exposure and their risk taking behaviors.
However, the outcomes were more severe in females due to many factors; most probable one is that the majority of severe cases were among 4-wheeled passengers and those were tending to be females most often. This study showed that the working groups; employed (24%), laborers and farmers (19%) and business owners (5%) represent the most affected populations. Many other studies stated that laborers are the most affected working groups while other studies stated that business owners have higher risk (201). Risky driving behaviors contributed to 85% of the casualties. Furious driving represented 37% of these behaviors. A recent study from UAE ranked speed as the first unsafe behavior among drivers13. For pedestrians and passengers, their risky behaviors contributed to 19% of the casualties. The most risky behavior reported was pedestrians' carelessness. Head injuries were more common among the drivers and the passengers of 4-wheeled cars, while lower limbs injuries were more common among motorcycles riders and passengers. The same pattern was reported in many studies from different countries [8,10,19,20]. It is evident that traffic-related trauma exerts a considerable burden on the already constrained health care resources in developing countries [6]. It was estimated by WHO that 100% of severe, 50% of moderate and10% of mildly injured persons need long-term rehabilitation services. A few hospital-based studies revealed that disabilities persist for a long time among 20%-40% of people discharged after an RTI [6,15].

Conclusion
In conclusion, several personal, behavioral, environmental, and vehicles related factors had contributed to RTIs in Yemen. The burden of RTIs in Yemen in terms of disability and mortality is high.
A critical first step toward improving road safety conditions is establishment of a multi-sectorial injury surveillance system. In