Pedestrian injuries in the most densely populated city in Nigeria-an epidemic calling for control

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Current and Future Trends in Driver Behaviour and Traffic Safety Scholarship: An African Research Agenda

Road traffic accidents are strongly associated with driver behaviour. Africa, as a region, has the highest road accident fatality rate, but there is very little research dealing with this critical issue on the continent. This paper, therefore, sought to establish the state of driver behaviour and road safety scholarship in Africa to determine current research trends as well as potential future research directions. To this end, two bibliometric analyses were conducted, one which considered the issue from an African perspective and the other which considered the broader body of work. The analysis revealed a critical shortage of research related to driver behaviour in Africa. The existing body of research primarily focused on the identification of issues and tended to focus on narrow research problems within limited geographical areas. A need was identified for the collection of broader macro-level data and statistical analyses thereof to indicate regional traffic crash patterns; causes and effects; country-level studies, particularly countries with high traffic fatality rates and low levels of research; cross-country comparisons; and modelling. Future research directions should also include the link between driver behaviour, traffic safety and the sustainable developments goals, as well as policy-related research to determine current and potential future country-level policies.

Evaluating feasibility of a novel mobile emergency medical dispatch tool for lay first responder prehospital response coordination in Sierra Leone: A simulation-based study

INTRODUCTION

The global injury burden, driven by road traffic injuries, disproportionately affects low- and middle-income countries, which lack robust emergency medical services (EMS) to address injury. The WHO recommends training lay first responders (LFRs) as the first step toward formal EMS development. Emergency medical dispatch (EMD) systems are the recognized next step but whether small groups of LFRs equipped with mobile dispatch infrastructure can efficiently respond to geographically-dispersed emergencies in a timely fashion and the quality of prehospital care provided is unknown.

MATERIALS AND METHODS

We piloted an EMD system utilizing a mobile phone application in Sierra Leone. Ten LFRs were randomly selected from a pool of 61 highly-active LFRs trained in 2019 and recruited to participate in an emergency simulation-based study. Ten simulation scenarios were created matching proportions of injury conditions across 1,850 previous incidents (June-December 2019). Fifty total simulations were launched in randomized order over 3 months, randomized along 10 km of highway in Makeni. Replicating real-world conditions, highly-active LFR participants were blinded to randomized dispatch timing/scenario to assess response time and skill performance under direct observation with a checklist using standardized patient actors. We used novel cost data tracked during EMD pilot implementation to inform the calculation of a new cost-effectiveness ratio ($USD cost per disability-adjusted life year averted (DALY)) for LFR programs equipped with dispatch, following WHOCHOICE guidelines, which state cost-effectiveness ratios less than gross domestic product (GDP) per capita are considered "very cost-effective."

RESULTS

Median total response interval (notification to arrival) was 5 min 39 s (IQR:0:03:51, 0:09:18). LFRs initially trained with a 5-hour curriculum and refresher training provide high-quality prehospital care during simulated emergencies. Median first aid skill checklist completion was 89% (IQR: 78%, 90%). Cost-effectiveness equals $179.02USD per DALY averted per 100,000 people, less than Sierra Leonean GDP per capita ($484.52USD).

CONCLUSION

LFRs equipped with mobile dispatch demonstrate appropriate response times and effective basic initial management of simulated emergencies. Training smaller cohorts of highly-active LFRs equipped with mobile dispatch appears highly cost-effective and may be a feasible model to facilitate efficient dispatch to expand emergency coverage while conserving valuable training resources in resource-limited settings.

War surgery in Afghanistan: a model for mass causalities in terror attacks?

PURPOSE

The aim of the study was to identify solution strategies from a non-governmental (NGO) hospital in a war region for violence-related injuries and to show how high-income countries (HIC) might benefit from this expertise.

METHODS

NGO trauma hospital in Lashkar Gah, Afghanistan. Four hundred eighty-four war victims admitted in a three month period (February 2016-May 2016) were included. Patients´ characteristics were analyzed.

RESULTS

The mean age was 23.5 years. Four hundred thirty-four (89.9%) were male, and 50 (10.1%) were female. The most common cause of injury was bullet injuries, shell injuries, and mine injuries. The most common injured body region was the lower extremity, upper extremity, and the chest or the face. Apart from surgical wound care and debridements, which were performed on every wound in the operation theatre, laparotomy was the most common surgical procedure, followed by installation of a chest drainage and amputation.

CONCLUSION

The surgical expertise and clear pathways outweigh modern infrastructure. In case of a mass casualty incident, fast decision-making with basic diagnostic means in order to take rapid measurements for life-saving therapies could make the difference.

Global Incidence and Mortality Patterns of Pedestrian Road Traffic Injuries by Sociodemographic Index, with Forecasting: Findings from the Global Burden of Diseases, Injuries, and Risk Factors 2017 Study

(1) Background: Pedestrian injuries (PIs) represent a significant proportion of road traffic injuries. Our aim was to investigate the incidence and mortality of PIs in different age groups and sociodemographic index (SDI) categories between 1990 and 2017. (2) Method: Estimates of age-standardized incidence and mortality along with trends of PIs by SDI levels were obtained from the Global Burden of Disease from 1990 to 2017. We also forecasted the trends across all the SDI categories until 2040 using the Statistical Package for the Social Sciences (SPSS Statistics for Windows, version 23.0, Chicago, IL, USA) time series expert modeler. (3) Results: Globally, the incidence of PIs increased by 3.31% (−9.94 to 16.56) in 2017 compared to 1990. Men have higher incidence of PIs than women. Forecasted incidence was 132.02 (127.37 to 136.66) per 100,000 population in 2020, 101.52 (65.99 to 137.05) in 2030, and reduced further to 71.02 (10.62 to 152.65) by 2040. Globally across all SDI categories, there was a decreasing trend in mortality due to PIs with the global estimated percentage reduction of 37.12% (−45.19 to −29.04). (4) Conclusions: The results show that PIs are still a burden for all SDI categories despite some variation. Although incidence and mortality are expected to decrease globally, some SDI categories and specific vulnerable age groups may require particular attention. Further studies addressing incidence and mortality patterns in vulnerable SDI categories are needed.

Road traffic injured patients with severe GCS and organ injury had a poor prognosis: a retrospective cohort study

Background

Ethiopia had an increasing trend of morbidity and mortality due to road traffic injury. Road traffic injured patient’s recovery rate is affected by many different factors. Those factors might affect the duration of time to recovery. Therefore studying the median time to recovery and its predictors of road traffic injured patients will be needed to act upon the patient’s hospital provided service.

Method

A retrospective cohort study design was employed. The study population was all admitted road traffic injured patients in Ayder tertiary hospital. We have used the total of all three-year RTI patients’ chart from 2015 to 2017 found in the hospital. After excluding incomplete charts for major variables the sample size was 322. Descriptive statistics, life table, Kaplan-Meier, log-rank test and assumptions of the Cox proportional hazard model was applied. Bi and multivariate Cox regression analysis, hazard ratios and associated 95% CI were estimated.

Result

Male to female RTI patient ratio was 3:1. Of the total 258(80.1%) had been recovered and the median survival time to recovery was 15 days (interquartile range 7–29). From those recovered, 104(40.3%) had been referred from other health facilities. Availability of referral form linkage [adjusted hazard ratio = 1.5, CI (1.1–1.9)], mild and moderate glass coma scale [adjusted hazard ratio = 2.3, CI (1.3–3.9)], conservative management [adjusted hazard ratio = 1.6, CI (1.2–2.1)], and not having organ injury [adjusted hazard ratio = 1.6, CI (1.1–2.3)] were associated with time to recovery in multivariate analysis.

Conclusion

Median time to recovery of road traffic injured patients was relatively good. Being referred from another health facility, mild and moderate glass coma scale, conservative management and without organ injury was positively associated with time to recovery of road traffic injured patients. We would like to recommend for future prospective studies to determine the time to return to work of road traffic injured patients and quality of life after the injury.

Trauma demography and clinical epidemiology of motorcycle crash-related head injury in a neurosurgery practice in an African developing country

OBJECTIVE

Though motor vehicle crashes (MVCs) were the main cause of head trauma from road traffic injuries (RTIs), motorcycle crashes (MCCs) are now a major cause of RTI-related head injury (HI) in many developing countries.

METHODS

Using a prospective database of HIs from a neurosurgical practice in a sub-Saharan African developing country, a cross-sectional survey was conducted for the trauma demography and clinical epidemiology of this MCC-related HI.

RESULTS

Motorcycle crashes accounted for 57% (473/833) of all RTI-related HIs in this registry. The victims, with a mean age of 33.1 years (SD = 18.3), consisted mainly of males (83.1%), those of low socioeconomic status (>90%), and those aged between 20 and 40 years old (56%). MCCs involved only riders in 114 cases (114/473, 32.1%), of which 69% were motorcycle-motorcycle crashes. The HI was moderate-severe in 50.8%; clinical symptomatology of significant HI included loss of consciousness (92%), anisocoria (35%), Abbreviated Injury Scale head (AIS-head) score > 3 (28%), and CT-Rotterdam score > 3 (30%). Extracranial systemic injury involved the limbs most frequently, with an Injury Severity Score (ISS) >25 in 49%. The fatality rate was 24%. MCC-related HI among pedestrian victims involved more vulnerable age groups (the young and elderly) but have lower mean ISS compared to motorcycle passengers (mean ISS = 23.5 [11.6] vs. 27.4 [13.0]; 95% confidence interval [CI], 1.27-6.49; P = .004). In addition, compared to a contemporary cohort of MVC-related HIs in our registry, MCC victims were older (mean age 34.8 years [18.0] vs. 30.8 [18.4]; P = .002); had higher proportions of certain extracranial trauma like long bone fractures (71 vs. 29%; P = .02); and suffered fewer surgical brain lesions (25.5 vs. 17.2%; P = .004).

CONCLUSIONS

Motorcycle crashes are now a significant threat to the heads, limbs, and lives of vulnerable road users in developing countries.

Clinical Epidemiology of Head Injury from Road-Traffic Trauma in a Developing Country in the Current Era

Objectives

Africa and other Asian low middle-income countries account for the greatest burden of the global road-traffic injury (RTI)-related head injury (HI). This study set out to describe the incidence, causation, and severity of RTI-related HI and associated injuries in a Nigerian academic neurosurgical practice.

Methods

This is a retrospective cross-sectional analysis of RTI-related HI from a prospective HI registry in an academic neurosurgery practice in Nigeria.

Results

All-terrain RTI accounted for 80.6% (833/1,034) of HI over a 7-year study period. All age groups were involved, mean 33.06 years (SD 18.30), mode 21–30, 231/833 (27.7%). The male:female ratio was 631:202, ≈3:1. The road trauma occurred exclusively from motorcycle-and motor-vehicle crash (MCC/MVC), MCC caused 56.8% (473/833) of these; the victims were vulnerable road users (VRU) in 74%, and >90% belong in the low socioeconomic class. Using the Glasgow Coma Scale grading, the HI was moderate/severe in 52%; loss of consciousness occurred in 93%, the Abbreviated Injury Severity-head > 3 in 74%, and computed tomography (CT) Rotterdam score > 3 in 52%. Significant extracranial injuries occurred in many organ systems, 421/833 (50.5%) having Injury Severity Score (ISS) > 25. Surgical lesions included extensive brain contusions in 157 (18.8%); acute extradural hematoma in 34 (4.1%); acute subdural hematoma in 32 (3.8%); and traumatic intracerebral hemorrhage in 27 (3.2%), but only 97 (11.6%) received operative care for various logistic reasons. The in-hospital outcome was good in 71.3% and poor in 28.7%; the statistically significant (p < 0.001) determinants of this outcome profile were the severity of the HI, the CT Rotterdam score, and the ISS.

Conclusion

In this study from Nigeria, RTI-related HI emanates from significant trauma to vulnerable road users and are caused exclusively by motorcycles and motor vehicles.

Road traffic injury in sub-Saharan African countries: A systematic review and summary of observational studies

OBJECTIVE

The aim of this study is to evaluate, through a systematic review of hospital-based studies, the proportion of road traffic injuries and fatalities in sub-Saharan Africa (SSA).

METHODS

In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology guidelines, we searched the following electronic databases: PubMed, Embase, Africa-Wide Information, Global Health, and Web of Science. Articles were eligible if they measured proportion of road traffic injuries (RTIs) in SSA by using hospital-based studies. In addition, a reference and citation analysis was conducted as well as a data quality assessment.

RESULTS

Up to 2015, there were a total of 83 hospital-based epidemiologic studies, including 310,660 trauma patients and 99,751 RTI cases, in 13 SSA countries. The median proportion of RTIs among trauma patients was 32% (4 to 91%), of which the median proportion of death for the included articles was 5% (0.3 to 41%).

CONCLUSION

The number of studies evaluating RTI proportions and fatalities in SSA countries is increasing but without the exponential rise expected from World Health Organization calls for research during the Decade of Action for Road Traffic Injuries. Further research infrastructure including standardization of taxonomy, definitions, and data reporting measures, as well as funding, would allow for improved cross-country comparisons.

Risk Factors for Road Traffic Injuries among Different Road Users in the Gambia

We identified risk factors for road traffic injuries among road users who received treatment at two major trauma hospitals in urban Gambia. The study includes pedestrians, bicyclists, motorcyclists, and drivers/passengers of cars and trucks. We examined distributions of injury by age, gender, collision vehicle types and vehicle category, and driver and environment factors. Two hundred and fifty-four patients were included in the study. Two-thirds were male and one-third female. Two-thirds (67%) of road traffic injuries involved pedestrians, bicyclists, and motorcyclists; and these were more common during weekdays (74%) than weekends. Nearly half (47%) of road traffic injuries involved pedestrians. One-third (34%) of injured patients were students (mean age of students was less than 14 years), more than half (51%) of whom were injured on the roadway as pedestrians. Head/skull injuries were common. Concussion/brain injuries were 3.5 times higher among pedestrians, bicyclists, and motorcyclists than vehicle occupants. Crashes involving pedestrians were more likely to involve young people (<25 years; aOR 6.36, 95% CI: 3.32–12.17) and involve being struck by a motor car (aOR 3.95, 95% CI: 2.09–7.47). Pedestrians contribute the largest proportion of hospitalizations in the Gambia. Young pedestrians are at particularly high risk. Prevention efforts should focus on not only vehicle and driver factors, but also protecting pedestrians, bicyclists, and motorcyclists.

Injury pattern, outcome and characteristics of severely injured pedestrian

Background

Pedestrians who are involved in motor vehicle collisions present with a unique trauma situation. The aim of this study was to demonstrate the specific clinical characteristics of this patient population in comparison to injured motor vehicle occupants in the medical emergency setting.

Methods

A total of 4435 pedestrian traffic collision victims admitted to hospitals participating at TraumaRegister DGU® between 2002 and 2012 (primary admission, Injury Severity Score, ISS ≥ 9; age ≥ 2 years) was assessed and compared to 16,042 severely injured motor vehicle occupants. Analyses included features such as demographic distribution, injury patterns, treatment course, subsequent complications and overall clinical outcome.

Results

Severely injured pedestrians more commonly were female (42 % vs. 34 % of motor vehicle occupants) and children below 16 years (12 % vs. 2 %) or seniors above 60 years of age (39 % vs. 17 %). Pedestrians were injured more severely (ISS: 26 vs. 25; NISS 32 vs. 30) with higher rates of head injuries (64 % vs. 47 %), pelvic injuries (32 % vs. 23 %) and lower extremity injuries (52 % vs. 43 %). Accordingly, pedestrians more commonly presented with Glasgow Coma Scale <9 (36 % vs. 28 %) and a systolic blood pressure below 90 mmHg (18 % vs. 13 %) accumulating in a worse prognosis (RISC-Score 24 % vs. 15 %) despite of a shorter on-scene treatment time (26 min vs. 38 min) and a shorter period from the collision until hospital admission (61 min vs. 78 min). Finally, pedestrians showed a higher mortality (22 % vs. 12 %).

Conclusion

Severely injured pedestrians represent a challenging patient population with unique injury patterns and high subsequent mortality. Emergency team members should be sensitized to the trigger term “pedestrian” in order to improve the initial emergency management and thus the overall clinical outcome.