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					             Epidemiological Study of Road Traffic Accident Cases:
                        A Study from Eastern Nepal
                                                            By
                                    Nilambar Jha*, Chandra Shekhar Agrawal**


                                                         Abstract
      The reasons for the high burden of road traffic injuries in developing countries are: growth
      in the numbers of motor vehicles; higher number of people killed or injured per crash in
      low-income countries, poor enforcement of traffic safety regulations; inadequacy of health
      infrastructure, and poor access to health care. In Nepal as per estimates of morbidity and
      mortality for 1998-1999, injury contributed 9% to total mortality and was the third leading
      cause, with road accidents occupying the eighth position in the overall ranking. Fifty eight
      per cent of the injuries occurred in the 15-44 years age group with the male to female
      ratio of 3:1.
            This one-year study was conducted in two hospitals of eastern Nepal. A total of 870
      road traffic accidents (RTAs) victims were reported during the one-year study period. The
      highest (28.6%) percentage of these cases were in the age group of 20-29 years. The
      labourers constituted the largest group (27.6%) involved in RTAs, followed by students
      (24.1%). The highest number (126, 14.5%) of RTA victims were reported in the month of
      July followed by January. The highest number of accidents occurred on Sundays (30.5%)
      and Fridays (20.0%) respectively. In the present study, 16.9% drivers were found to have
      consumed alcohol 2-3 hours prior to the accident. Buses (31.4%), trucks (12.3%) and
      bicycles (11.3%) were the common vehicles involved in RTAs.
           There is lack of coordination between different ministries, departments and other
      agencies working in the field of injury including road traffic injury. Therefore, there is a
      need for the Ministry of Health to take the lead and coordinate the efforts of all agencies
      working for the prevention and control of road traffic injuries.




*
     Additional Professor, Department of Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
**
     Professor and Head, Department of Surgery, BP Koirala Institute of Health Sciences, Dharan, Nepal



Regional Health Forum – Volume 8, Number 1, 2004                                                                      15
Road Safety



Introduction                                     for nearly 60–70% of emergency room
                                                 registrations at the Bir Hospital (an apex
Member countries of the South-East Asia          hospital in the country). Road traffic accident
Region have been passing though a major          injuries were the principal (80 to 90%) cause
epidemiological transition, socio-demographic    of injuries.1
changes and technology revolution during
the past two decades. Countries are passing            In Nepal as per estimates of morbidity
though significant urbanization, motorization,   and mortality for 1998-1999, injury contri-
industrialization and changes in the socio-      buted 9% to total mortality and was the third
economic values of societies. Injuries on        leading cause, with road accidents occupying
roads, at homes, and in the workplace have       the eighth position in the overall ranking.
increased due to lack of safety-related          Fifty eight per cent of injuries were in the 15-
policies and programmes. The health sector       44 years age group with a male to female
in these countries bears the maximum brunt       ratio of 3:1.(3)
in terms of provision of acute care, and
short-term and long-term rehabilitation               Road traffic injures in developing
service.(1)                                      counties mostly affect pedestrians, pass-
                                                 engers and cyclists as opposed to drivers who
     In 2000 an estimated 5.1 million            are involved in most of the deaths and
people died due to injuries worldwide,           disabilities occurring in the developed
accounting for 10% of deaths due to all          world.(4) The reasons for the high burden of
causes. It is estimated that more than a         road traffic injuries in developing countries
quarter of injury-related deaths in the world    are: growth in the numbers of motor vehicles;
occurred in the South-East Asia Region in        higher number of people killed or injured per
2000. Children saved today from nutritional      crash in low-income countries; poor
and infectious diseases are killed and           enforcement of traffic safety regulations;
maimed by injuries in hundreds of thousands      inadequacy of health infrastructure, and poor
tomorrow. In fact, road traffic injuries alone   access to health care.(4)
ranked as the number one cause of the
burden of disease among children between
5-14 years, and as the number three cause        Methodology
among those in the age group 15 to 29            This study was conducted at the Sunsari
years in 2000. This heavy burden at such an      District Hospital (SDH) Ineruwa and the B.P.
early age has long-term implications on the      Koirala Institute of Health Sciences (BPKIHS)
quality of life and economy of the nations.(2)   Hospital, Dharan. The study period was from
                                                 May 1997 to April 1998. The study group
     As per the Annual Report of the
                                                 consisted of all the road traffic accident
Department of Health Services Nepal, falls,
                                                 victims reporting to these two hospitals of
burns and scalds, and dog bites were
                                                 Sunsari district during the above-mentioned
reported in large numbers. Injuries comprised
                                                 one-year period. For the purpose of the
2% of hospital admissions, occupying the
                                                 study, an RTA was defined as an accident
ninth leading position. They also accounted


16                                               Regional Health Forum – Volume 8, Number 1, 2004
                          Epidemiological Study of Road Traffic Accident Cases: A Study from Eastern Nepal



which took place on the road between two or            Table 1. Age and sex distribution of Road Traffic
more objects, one of which had to be any                   Accident (RTA) victims in Eastern Nepal,
kind of a moving vehicle. Any injury on the                              1997-1998
road without involvement of a vehicle (e.g. a            Age          Males           Females           Total
person slipping and falling on the road and             Group       No.       %      No.    %      No.          %
sustaining injury) or injury involving a                0–9          89     13.4     46     22.1 135        15.5
stationary vehicle (e.g. person getting injured        10 – 19      116     17.5     33     15.9 149        17.1
while washing or loading a vehicle) were               20 – 29      202     30.5     47     22.6 249        28.6
excluded from the study.                               30 – 39      130     19.6     34     16.3 164        18.9
                                                       40 – 49       69     10.4     17      8.2   86           9.9
      The victims of the accidents were
                                                       50 – 59       34       5.1    16      7.7   50           5.7
interviewed to obtain information about the
                                                       60 – 69       14       2.1    12      5.8   26           3.0
circumstances leading to the accident. A pre-
tested proforma especially designed for this            70 and        8       1.2     3      1.4   11           1.3
                                                        above
purpose was used for interviewing the
                                                         Total      662    100.0 208       100.0 870       100.0
accident victims, either during the emergency
or in the wards of the SDH and BPKIHS                 Source: Hospital-based study
hospitals; where the condition of the victims               The highest number of victims (249,
did not warrant the interview, the relatives or       28.6%) were from 20-29 years of age
attendants were interviewed.                          followed by 164 (18.9%) in the age group
                                                      30-39 years. More than 80% of victims (697)
      The information collected comprised:            were under 40 years of age. Table 2
personal identification data; time data; day;         describes the educational status and
type of vehicle involved in RTA; protective           occupation of the RTA victims.
gear worn, and the category of road users. In           Table 2. Educational status and occupations of
addition, the type and severity of injury                  RTA victims, Eastern Nepal, 1997-1998
suffered by the victims and their management                          Frequency             Frequency
were also recorded. The medico-legal                    Education               Occupation
                                                                     No.    %              No.    %
records and case sheets of the victims were            Illiterate    195   22.4 Labourer   240 27.6
referred for collecting additional data and            Primary       199   22.9 Student    209 24.1
where necessary for cross-checking.                    School
                                                       High School 177        20.3 Housewife       104      11.9
                                                       Matriculate 104        12.0 Agriculturist    71       8.1
                                                       Intermediate 155       17.8 Govt.            58       6.6
Results                                                                            Service
                                                       Graduate       18       2.1 Employee         51          5.9
                                                       and above
A total of 870 RTA victims reported at both            Not            22          2.5 Unemployed    48          5.6
hospitals during the period: May 1997 to               applicable
April 1998. Out of these, 366 cases were                                       Not          34   3.9
registered at SDH and 504 cases at BPKIHS,                                     applicable
                                                                               Others       28   3.2
Dharan. There were 662 (76.1%) male and
                                                                               Businessman 27    3.1
208 (23.9%) female casualties (Table 1).               Total         870 100.0 Total       870 100.0



Regional Health Forum – Volume 8, Number 1, 2004                                                                17
Road Safety



      Almost an equal percentage (23%) of                                  Among the drivers of different types of
victims were either illiterate or had had only                        vehicles, 80 (37.7%) were bicyclists, followed
primary-level education. Victims with a higher                        by 70 (33%) motorcyclists (Table 3).
education were fewer in proportion. There
were 240 (27.6%) students involved in RTA.                             Table 3. Different types of drivers, occupants and
This was followed by agriculturists (18.7%).                               vehicles involved in RTA, Eastern Nepal,
                                                                                           1997-1998
The maximum number (126, 14.5%) of RTA
cases reported in the month of July followed                               Type of          Drivers         Occupants     Vehicles
by January (Figure. 1).                                                    vehicle      No.          %      No.   %      No.    %
                                                                      Bicycle           80           37.7   34     8.5 104     11.2
     A greater number of accident cases
(37%) were registered in three rainy months                           Two-wheelers      70           33.0   55    13.8 237     25.6
of July, August and September, and also in                            Three -               6         2.8    6     1.5   71     7.7
                                                                      wheelers
winter months (33.5%). The highest number
                                                                      Car, Jeep,        18            8.5   35     8.8 100     10.8
265 (30.5%) of victims was reported on
                                                                      Van
Sundays followed by Fridays. The categories
                                                                      Bus               25           11.8 200     50.0 290     31.4
of road users involved in these accidents
                                                                      Truck                 4         1.9   61    15.2 114     12.3
were occupants of different vehicles (46%),
                                                                      Bullock cart          9         4.3    9     2.2    9     1.0
drivers (24.4%) and pedestrians (29.6%).
                                                                      Total            212       100.0 400 100.0 925 100.0



                                Figure 1. No. of RTA cases in different months, Eastern Nepal, 1997-1998


                                 140
                                                                              126
                                           120

                                 120
                                                                                      102
                                                                                                94                96
                                 100

                                                  76
              No. of Patients




                                  80

                                                       54
                                                                 50   53
                                  60
                                                            38
                                                                                                            30
                                  40                                                                  31



                                  20


                                   0
                                          Jan    Feb Mar Apr     May Jun      Jul    Aug Sept Oct Nov Dec

         Source: Hospital-based study



18                                                                    Regional Health Forum – Volume 8, Number 1, 2004
                                     Epidemiological Study of Road Traffic Accident Cases: A Study from Eastern Nepal



      Of the 212 drivers involved in RTAs, 80                    Discussion
were bicyclists and nine were bullock cart
drivers, who do not require a driving license.                   Crude estimates suggest that the annual cost
The remaining 123 drivers had a valid                            of road crashes is about 1% of the Gross
driving license. All the motorized two-wheeler                   National Product (GNP) in developing
drivers (70) used protective helmets during                      countries, 1.5 in transitional countries and
RTAs. No seat belts were found to have been                      2% in highly motorized countries. The global
used by the car, jeep and van drivers and the                    estimate of US$ 518 billion was produced by
occupants. Out of 212 drivers, 36 (16.9%)                        Transport Research Laboratories.(5)
were found to have consumed alcohol 2-3
hours prior to the accident. These included                            Although     limited    information     is
18 (50%) bicyclists, 10 (27.8%) motorized                        available in health research and develop-
two wheelers, six (16.7%) bullock cart drivers                   ment on motor vehicle safety it is safe to say
and (5.5%) truck drivers. Among the                              that the lack of such investment contributes to
occupants of buses, 200 (50%) comprised                          the growing seriousness of the problem and
the highest number of victims involved in                        the widening gap between the low- and
RTAs followed by 61 occupants of trucks                          middle-income countries, and the high-
(15.2%). Since RTA usually involve more than                     income countries. In fact, the economic data
one vehicle, the total number of vehicles                        show that only US$ 1 was spent for every
involved were 925. Of these, 290 (31.4%)                         Disability Adjusted Life Year (DALY) caused
were buses, 225 (24.3%) were motorcycles                         by road traffic collisions in 1990 despite the
and 114 (12.3%) were trucks. Falling down                        fact that projections indicate that road traffic
was the more common mode of accident                             collisions will be the third biggest cause of
claiming 322 victims (37%), followed by the                      DALY by the year 2000.(6)
knocked-down category (Fig. 2). A total of
89 (10.2%) animals; 40 (4.6%) trees and                                Eight hundred and seventy RTI cases
31 (3.6%) electric poles were also involved in                   were reported from two hospitals in Sunsari
160 (18.4%) RTAs.                                                district of eastern Nepal (Table 1).

Figure 2. Mode of road traffic accident, Eastern Nepal,
                                                                      The highest (28.6%) percentage of these
                     1997-1998                                   were cases in the age group of 20-29 years.
                                                                 Similar findings were observed in other
                 Others
                          8.6%                  Fall
                                               37.0%
                                                                 studies.(7, 8,9) A higher number of cases in this
 Hitting an object 7.2%
                                                                 age group can probably be explained on the
 Over-turning 5.4%                                               basis that this is the most active period of life
  Run over   6.1%                                                during which there is a tendency to take risk.
                                                                 It was observed that 57.4% of victims were in
   Collision 6.4%
                                                                 the age group of 20 to 49 years. This shows
                                                                 that people from the most active and
             Knocked down 29.3%                                  productive age groups are more involved in
                          Total Victims= 870
                                                                 RTAs. This causes a serious economic loss to



Regional Health Forum – Volume 8, Number 1, 2004                                                                  19
Road Safety



the community. Similar observations were                The highest number (126, 14.5%) of
also made in other studies.(7,10,11)              RTA victims who reported to these hospitals
                                                  was recorded in the month of July followed
      It was noticed that below and above the     by January (Fig. 1). A possible reason for this
age of 20 and 49 years respectively, there is     could be the increased number of accidents
a decrease in accident cases. The reason for      in these months, due to rains in July and fog
this may be that children are taken care of by    in January. More accidents were observed in
elders and are less likely to use vehicles. The   rainy months like August (11.7%), and
lower proportion of RTAs in those aged 60         September (10.8%), and in winter months
years and above could be due to the               like December (11.0%). A similar observation
generally less mobility of these population       was also reported by others.(7,8,9)
groups. The male/female ratio observed in
this study was 3.2:1. The predominance of               In the present study, the highest number
males was also observed by many                   of reported accident cases occurred on
authors.(7,8,12,13) This may be due to the fact   Sundays (30.5%) and Fridays (20.0%). In
that females lead a less active life and mostly   Nepal, Sundays and Fridays are the first and
                                                  last working days of the week: this could be
remain indoors.
                                                  the possible reason for the large number of
                                                  accidents on these days. People celebrate
     Furthermore, it was observed that more
                                                  Friday as weekend and possibly are in a
people with lower levels of education were
                                                  hurry to go to various places to join their
involved in RTAs (Table 2).
                                                  working places on the following Sunday.
                                                  Ghosh(9) also observed the highest number of
      Similar results were also observed by
                                                  RTAs on the first working day i.e. Monday in
others.(8,14) However this relationship between
                                                  India. Mehta(8) and Stallones(15) observed
education and RTA may not be causal. In this
                                                  more accident cases on a weekend Saturday.
study, labourers constituted the largest group    These observations are similar to those of the
(27.6%) involved in RTAs, followed by             present study. Accidents were reported on
students (24.1%). One study(14) has also          Mondays (10.9%), Tuesdays (12.3%),
reported that more accidents were seen in         Wednesdays (11.6%), Thursdays (11.0%) and
the low economic group of people whereas          Saturdays (3.7%). The number of accidents
another study(8) has reported the students        was the lowest on Saturdays. The possible
group to be the highest, followed by              reason for this could be that Saturdays are a
labourers. The reason for this may be that        weekly holiday in Nepal. The other reason
labourers travel in trucks carrying bricks,       could be that Nepalese do not like to start
sand, heavy materials and other goods,            their journey on a Saturday because of a
which are usually loaded in an improper           religious belief.
manner. It is interesting to note that among
the type of motorized vehicles, trucks were            In this study the pedestrians constituted
involved in a large number of accidents, and      29.6% of the main road users involved in
labourers often travelled in trucks as part of    RTA, followed by bicyclists (37.7%) and two-
their work.                                       wheeler drivers (33.0%) among the drivers
                                                  category. Similar results were also observed


20                                                Regional Health Forum – Volume 8, Number 1, 2004
                           Epidemiological Study of Road Traffic Accident Cases: A Study from Eastern Nepal



by others.(8,9,12,16) Bus drivers (11.8%) were         organizations are actively interested in road
observed to be involved in RTA in large                safety issues, but all this has not yet
numbers: a possible reason for this could be           translated into a cohesive strategy or into a
that buses are the most common mode of                 set of well-coordinated actions. Moreover,
transportation used by people. This is                 there are gaps in the proposed national
reflected by the fact that bus occupants               traffic safety action plans, which lack clear
constituted the highest number 200 (50%) of            priorities based on a strategic analysis of the
RTA victims.                                           situation. Alcohol for example, appears to be
                                                       a larger problem than is officially acknow-
      In the present study 16.9% drivers were          ledged throughout Nepal. Yet there are
found to have consumed alcohol 2-3 hours               virtually no countermeasures such as public
prior to the accident. This is a higher                education,      and     anti-drunken    driving
proportion than 4.6%, 8% and 14.9%                     campaigns, nor even the legal ability to deter
reported respectively by others.(9,17,18) The role     drunk drivers. Worldwide experience has
of alcohol in impairing driving ability is well        shown that tough but fair and targeted
documented. Also the impairment increases              enforcement of measures against unsafe
as the blood alcohol level rises. In addition,         behaviours, along with mass behaviour
the risk of accidents is higher in youngsters          modification and education are crucial to the
and elderly people for similar blood alcohol           rapid     improvement      of    road    safety.
levels.(19)                                            Regrettably, enforcement is not a high
                                                       enough priority in Nepal. At the same time
     Buses (31.4%), trucks (12.3%) and                 the implementation of all aspects of any road
bicycles (11.3%) were vehicles commonly                safety plans are ultimately necessary. But the
involved in RTAs. More or less similar                 more pressing reality is that current
observations were reported by others(8,9,16,18)        allocations for road safety are inadequate
from India. Among the motorized vehicles,              and allocations for educational programmes
buses and trucks were involved in RTAs the             are even more deficient.
most. Rough driving, over-speeding and
heavily-loaded vehicles offering poor control                 The national policy for injury prevention
were the possible reasons for the vehicles             and control in Nepal is in its final stage.
involvement in RTAs. The common (37%)                  However, there are big challenges ahead for
mode of sustaining accidents was by falling            the implementation of such policy throughout
down from a moving vehicle (Fig. 2). But               the country in an effective manner. There is
Ghosh(9) reported getting knocked down by a            lack of coordination between different
vehicle as the common mode of accidents in             ministries, departments and various agencies
Delhi.                                                 working in the field of injury including road
                                                       traffic injury. The data are kept separately
                                                       and not shared for developing immediate
Conclusion                                             and future plans. Therefore, there is a need
Nepal has comprehensive safety plans for               for the Ministry of Health to take the lead and
tackling traffic problems, but they are under-         coordinate the efforts of all agencies working
funded and poorly coordinated. Ministries,             for the prevention and control of road traffic
donors, and business and nongovernmental               injuries, and also in road safety.



Regional Health Forum – Volume 8, Number 1, 2004                                                        21
Road Safety



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