Pediatr Surg Int (2014) 30:625–632 DOI 10.1007/s00383-014-3516-8
ORIGINAL ARTICLE
Child pedestrian injury and fatality in a developing country Babatunde Akibu Solagberu • Roland I. Osuoji • Nasiru Akanmu Ibrahim Mobolaji A. Oludara • Rufai A. Balogun • Abdulwahab Olanrewaju Ajani Olufemi Emmanuel Idowu • Ibrahim A. Mustafa • Felix O. Sanni
• •
Accepted: 29 April 2014 / Published online: 8 May 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Child pedestrian injuries and fatalities in developing countries continue to increase. We examined child pedestrian injuries and fatalities in the most populated urban agglomeration in Africa in order to develop control measures. Methods Two-year prospective study of injured child pedestrians (B15 years) at the Surgical Emergency Room (SER) to determine demography, vehicles involved, road location, injury mechanism, pre-hospital transport, injuryarrival time, regions injured, injury severity and fatalities was done. Results Some 226 pedestrians (114 boys and 112 girls) comprising 42 children aged B4 years, 91 aged 5–9 years and 93 aged 10–15 years were seen with car collisions (83 pedestrians, 36.7 %), motorcycles (76, 33.6 %), buses (41, 18.1 %), others (15, 6.6 %) and 11 undetermined vehicles. Injuries on the highways were 147 (65 %); inner-city roads 77 (34.1 %) and two undetermined roads. Crossing the road was responsible for 168 (74.3 %) pedestrian injuries; while three other mechanisms produced 58 (25.7 %) patients. Regions injured were head (42.9 %), lower limbs (35.4 %) and others (21.7 %). Relatives, bystanders and police/ambulance brought 186 (82.3 %), 31 (13.7 %) and eight (3.5 %) children, respectively; and within 6 h (43.4,
B. A. Solagberu (&) R. I. Osuoji N. A. Ibrahim M. A. Oludara R. A. Balogun A. O. Ajani O. E. Idowu I. A. Mustafa Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria e-mail: [email protected] F. O. Sanni Academy of Traumatology and Medical Sciences, Lagos, Nigeria
11.5 and 2.2 %) and after (38.9, 2.2 and 1.3 %). Nineteen deaths (10 brought-in-dead, nine SER deaths) occurred; 15 of them girls, 15 had severe head injury, 15 were brought by relatives. However, fatality risks were truck collisions (OR 5.97), female child (OR 4.25), head injury (OR 4.18) and age B4 years (OR 3.7). Conclusion The equal sex incidence, worse female fatality despite similar exposure and injury severity with male, deserve further research. Improved pre-hospital and SER care is needed. Keywords Child Pedestrian Traffic injury Developing country Fatality Morbidity
Introduction Childhood road traffic injuries especially pedestrian injuries from the developed countries have been well documented. Evidence-based interventions have led to a steady reduction towards the end of the twentieth century [1, 2]. Some 98 % of all child injury deaths occur in low- and middle-income countries (LMIC) [3, 4]. Indeed, it has been estimated that pedestrian and pedal cycle injuries in 2000 would cost a total of $40 billion over the lifetimes of the injured [5]. In the United States, childhood traffic injuries result in one of five traffic deaths; pedestrians account for one-fourth of them [6]. Emerging reports from developing countries show unacceptable morbidity and fatality rates [7–9]. Child pedestrian injuries have continued to be significant because of two established contributory factors; the child’s small physical stature which contributes to the child’s vulnerability as it limits the ability of the child to see or be seen and the fact that the complex task of crossing the road is beyond the cognitive skill of the child. It was then thought that
123
626
improving the education of the child on road crossing and including this in the school curriculum along with some roadside simulations would make the difference [10]. Evidence gathered showed that education improved the knowledge of the child in handling the traffic but only in the short term did it contribute to a reduction in pedestrian traffic injuries [1]. Further research suggested the need for improved educational techniques to improve the dividends; nonetheless, engineering modifications on the road furniture were known to yield better outcomes [11]. Some differences in child pedestrian injuries globally include age, gender, geographical location, socio-economic status and possibly race [12, 13]. Recent evidence comparing effectiveness of traffic educational campaigns in African Americans and the white population in the US reported poorer results among the former due partly to the lack of cultural appeal of the message [14]. It is also known that human and economic factors are involved ranging from the socio-economic status of the parents who may not own a car, or a young mother with low education and low income, living in a highly densely populated area with heavy traffic [15, 16]. Some reports on pedestrians from some cities or semi-urban areas in Nigeria have addressed the child pedestrian but only as part of traffic or general injury research; and these have been few and far in between [9, 17– 19]. Indeed, more pedestrian injuries occur in urban than in rural dwellings [20]. This present study was done to document for the first time, to the best of our knowledge, the child pedestrian injury burden in the most densely populated city in Nigeria to add to existing global literature on the subject and identify possible areas of control and improvement.
Pediatr Surg Int (2014) 30:625–632
free healthcare, LASUTH SER receives an average of 1,000 patients every month. Demography The children’s ages were recorded and grouped into three for analysis— B4, 5–9 and 10–15 years; as well as the gender distribution. Other parameters studied
Methods
The vehicles which the child collided with, the regions of the body injured, the type of road where the collision occurred, whether highways or an inner-city road, were noted. Highways are major public roads within or leading to Lagos state with a median and two to three lanes on each side; speed limit is 80 km/h while inner-city roads are smaller roads with one or two lanes and single or dual traffic with speed limit of 30–50 km/h. The traffic is mixed with motorcycles, tricycles, cars, buses, trucks and some railway-road crossings—cars and motorcycles were predominant. The mechanism of injury depicting the activity as at the time of vehicle–pedestrian collision (crossing the road, standing by the bus stop, walking the pavement or side street, being in front of the house or street shop) was recorded. The method of bringing the child to the hospital was documented; whether by relations, police or ambulance and bystanders. The injury-arrival time was documented and grouped into arrivals within an hour, 1–6 h, more than 6–24 h and greater than 24 h. The injury severity was noted in the case of head injury using the Glasgow Coma Scale (GCS) score as mild (13–15), moderate (9–12) and severe (3–8); the pediatric Glasgow Coma Scale as adapted to children 4 years and younger was used as appropriate.
Setting
Outcome
A 2-year prospective study on the pedestrians covering 12 December 2011 to 11 December 2013 was done using a validated questionnaire at the Surgical Emergency Room (SER) of the Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria—a 750-bed hospital upgraded in 2002 to a University Teaching Hospital status mainly from General Hospital, Ikeja, which itself was an upgrade in 1967 of a cottage hospital established in 1955 by the British colonial government. It is the busiest of the four tertiary centres in Lagos State and the only one that is owned by the state government; the other three are federal government owned. Nigeria has a 36-state structure and Lagos State, with the smallest land size of all the states, has about 10 % of the 167 million population of Nigeria (2013 estimate). Due to its history, location in the confluence of many parts of Lagos and governmental policy of relatively
The outcome of injuries presenting to the SER was determined; patients who were treated and admitted, patients discharged, patients transferred to another hospital due mainly to bed constraints, patients who discharged against medical advice and those who died in SER or were brought-in-dead (BID). The results were analysed, where appropriate Odds Ratios (OR) were used to compare risks and probability of getting injured; and were further presented in tables and figures.
123
Results Demography There were 334 child road traffic injuries in the 2 years out of which 226 were pedestrians (67.7 %). Of the 226, 114
Pediatr Surg Int (2014) 30:625–632
Fig. 1 Age spectrum of child pedestrians. Male preponderance in the B4 years; female preponderance in the 5–9 years old and near equal distribution in the 10–15-year-old children
were boys and 112 were girls giving a M:F ratio of 1:1 with 42 (18.6 %) being B4 years, 91 (40.3 %) were 5–9 years old and 93 (41.1 %) were 10–15 years of age with mean ages 2.9 ± 1.1, 7.0 ± 1.5 and 12.8 ± 1.8, respectively. The male–female trend across the ages (Fig. 1) shows male preponderance in the B4 years; female preponderance in the 5–9 years old and near equal distribution in the 10–15-yearold children. The overall mean age was 8.6 ± 4.1 years. Location of the injury The highway recorded 147 collisions (65.0 %) with 59 injuries (about four in 10 injuries) due to cars, 37 due to motorcycles, 34 due to buses, five due to trucks, two due to tricycle and 10 undetermined; while the inner-city roads had 77 (34.1 %) pedestrian injuries with motorcycles responsible for a little more than half of them (39 pedestrians) followed by 22 injuries from cars, seven from buses, six from tricycles and one from a truck; and in two instances, the road type could not be ascertained. Of the 19 deaths recorded, 15 (79.0 %) were on the highway while the remaining 4 were in the inner-city roads. Majority of the highway injuries were in older children (B4 years old, 17 children; 5–9 years old, 60 children; and 10–15 years old, 70 children). There was nearly equal number of pedestrians injured on the inner-city roads in the three age groups (25, 29 and 23 children, respectively) but predominantly from motorcycles (39 pedestrians). Details are given in Table 1. The male–female variation was not visible on both the highways and inner-city roads (Table 2). Mechanism of injury Most children were knocked down while crossing the road; highways had 126 pedestrians while the inner-city roads had 41, and in one child, the road was undetermined. The 168 (74.3 %) crossing the road mechanism was the highest followed distantly by walking along the pavement (22
627
pedestrians, 11 equally on highway and inner-city roads). There were 19 children injured while standing at the bus stop when a vehicle would swerve to hit them and 17 others while in front of the house or shop and only in the innercity roads. Crossing the road also caused the highest regional injuries to the head in 75 patients and lower limbs in 59 others (more details in Table 1). When the mechanism was compared with the Glasgow Coma Score (GCS) of the head injury (HI), 40 were mild (GCS 13–15), 33 were moderate (GCS 9–12) while 35 were severe (GCS 3–8) HI. Crossing the road produced 30 of the 40, 27 of the 33 and 30 of the 35 mild, moderate and severe HIs, respectively. The male to female variation also was not visible on the mechanism of injury (see Table 2). Vehicles involved in collision Two vehicle types were predominant—cars (83 children, 36.7 %) and motorcycles (76, 33.6 %). Buses were a distant third in 41 children (18.2 %). Others were tricycles (eight children), trucks (six) and train at a railway crossing (one). The vehicles caused various regional injuries with majority in the head (96 pedestrians) and lower limb injuries (80). The vehicular collisions caused different outcomes: Car injuries led to 23 admissions, 31 referrals and 13 deaths while motorcycle injuries resulted in 41 admissions, 18 referrals but no deaths. There were six other deaths traced to buses (two), trucks (two) and train (one) and in one instance the vehicle involved was not ascertained. Effect of a new traffic law banning motorcycles from the highways from September 2012 A new traffic law was enacted in August 2012 banning motorcycles from plying the highways in Lagos State. The implementation began in September 2012. Figure 2 showing the monthly trends of injuries revealed nearly equal incidence in child pedestrian injuries from motorcycles and cars and buses. After the law, the latter surpassed the former (Fig. 2). Pre-hospital transport There were three categories of persons bringing patients to the hospital; relatives—persons who know the patient (186 pedestrians, 82.3 %); bystanders—persons who do not know the patient and are not statutorily responsible for transporting patients (31, 13.7 %); and the police or ambulance—persons who do not know the patients but whose statutory responsibility includes transporting injured patients (eight, 3.5 %). In one instance, the person could not be identified. Forty-one B4 years old (nearly all from
123
628
Pediatr Surg Int (2014) 30:625–632
Table 1 Showing the number of child pedestrian injuries at different age groups and the variables Variable
Sub-variable
B4 years old
5–9 years old
10–15 years old
Total number of child pedestrians (% of n = 226)
Sex
Male
25
42
47
114 (49.6 %)
Female
17
49
46
112 (50.4 %)
Highway
17
60
70
147 (65.0 %)
Inner-city road
25
29
23
Not determined
0
2
0
25
75
68
168 (74.3 %)
3 5
6 7
10 10
19 (8.4 %) 22 (9.7 %)
Location of injury
Mechanism of injury
Knocked crossing road Hit at the bus stop While walking along the pavement Situated in front of house/shop
Vehicle responsible
Regions injured
Glasgow Coma scale (HI severity)
77 (34.1 %) 2 (0.9 %)
9
3
5
17 (7.5 %)
Car
15
31
37
83 (36.7 %)
Motorcycle
16
35
25
76 (33.6 %)
Bus
6
17
18
Tricycle
0
5
3
8 (3.5 %)
Truck
1
2
3
6 (2.7 %)
Train
1
0
0
1 (0.4 %)
Undetermined
3
1
7
11 (4.9 %)
27
41
29
97 (42.9 %)
Lower limb injury (LLI)
8
35
37
80 (35.4 %)
Upper limb injury (ULI)
1
6
15
22 (9.7 %)
Head injury (HI)
41 (18.1 %)
Multiple region injury
3
4
6
13 (5.8 %)
Pelvis injury
1
1
3
5 (2.2 %)
Other regions 13–15 (mild)
2 11
4 14
3 15
9 (4.0 %) 40
9–12 (moderate)
6
16
11
33
3–8 (severe)
12
14
9
35
Relatives
41
82
40
Police
0
0
8
Bystanders
1
9
21
31 (13.7 %)
Undetermined
0
0
24
24 (10.6 %)
14
38
31
83 (36.7 %)
8
16
19
43 (19.0 %)
12
31
34
77(34.1 %)
DAMA
0
1
3
Brought in dead
3
1
6
10 (4.4 %)
Died
5
4
0
9 (4.0 %)
(108 HI pedestrians) Pre-hospital transport
Outcome
Admitted for further treatment Discharged Referred to another hospital
163 (72.1 %) 8 (3.5 %)
4 (1.8 %)
There were fewer \4-year-old pedestrians (18.6 %), yet they were in the majority of the dead (42.1 %)
this age group) were brought by relatives and the remaining one pedestrian of the 42 was brought by a bystander (see Table 1 for details). Six of the 10 brought-in-dead child pedestrians were transported by relatives, the remaining four by bystanders. All the nine deaths in SER were brought by relatives. No patient died among the nine brought by police or ambulance, although only one of them was severe HI compared to 27 severe HIs brought by relatives and seven severe HIs brought by bystanders.
123
Injury-arrival time More than half of the pedestrians arrived within 6 h of vehicular collision—129 patients (57.1 %)—see Fig. 3. Another 51 patients (22.6 %) were brought after six but before 24 h while 32 (14.2 %) came in after 24 h. In 14 patients, the time recorded was not complete. Whether this had any effect on outcome could be seen when the results showed 13 of the 19 (68.4 %) pedestrian deaths were
Pediatr Surg Int (2014) 30:625–632
629
Table 2 Showing gender comparisons of boys and girls Variable
Sub-variable
Male
Female
Total
Location of injury
Highway
74
73
147
Inner-city road
39
38
77
Undetermined
1
1
2
Knocked crossing road
81
87
168
Hit at the bus stop
12
7
19
While walking along the pavement
12
10
22
9
8
17
Head injury (HI)
56
41
97
Lower limb injury (LLI)
38
42
80
Upper limb injury (ULI)
9
13
22
Multiple region injury
4
9
13
Pelvis injury
2
3
5
Mechanism of injury
Situated in front of house/ shop Regions injured
Glasgow Coma scale (HI severity)
Other regions
5
4
9
13–15 (mild)
26
14
40
9–12 (moderate)
18
15
33
3–8 (severe)
16
19
35
Admitted for further treatment
46
37
83
Discharged
19
24
43
Referred to another hospital
42
35
77
Discharged against medical advice
3
1
4
(108 HI pedestrians) Outcome
Brought in dead (BID)
1
9
10
Died (in Surgical Emergency Room)
3
6
9
Fig. 3 Injury arrival time based on pre-hospital transport. The burden of pre-hospital transport is still largely being born by the relatives (186, 82.3 %) and majority of the patients still got to the Surgical Emergency Room within 6 h (129, 57.1 %)
among those that arrived within 6 h—seven of these were BID and six were SER deaths. The remaining six (32.0 %), three each of BID and SER deaths, came in after 6 h. Outcome of injuries Of the 226 injured patients, 83 (36.7 %) were admitted, 77 (34.1 %) were referred to another hospital largely on account of lack of bed space, 43 (19.0 %) were discharged after treatment due to minor injuries sustained and four patients discharged against medical advice (DAMA). The remaining 19 (8.4 %) were deaths, 10 of who died before reaching the hospital (brought-in-dead, BID). Fourteen of the 19 deaths occurred from crossing the road, one at the bus stop, two each while walking along the pavement and being in front of the house. There is predominance of female mortality among those both BID and those that died in the SER (see Table 2). All the crude death rates along with their odds ratios are shown in Table 3. The alcohol influence both among pedestrians and drivers and the distraction from mobile phone use by pedestrians were not investigated.
Discussion Fig. 2 Comparison of child pedestrians before and after September 2012. A new traffic law banning motorcycles from plying the highways in Lagos State was enacted in August 2012 but the implementation began in September 2012. From October 2012 till end of this study in Dec 2013, child pedestrian injuries from cars and buses have surpassed those from motorcycles. Before September 2012, injuries were about equal in both motorcycles (two wheelers) and cars and buses (four wheelers)
In spite of the huge knowledge on pedestrian injuries largely from the developed world, the abysmal result from developing countries is evidence of lack of adapting the implementation of the available knowledge to control pedestrian injuries and possibly also from inadequate research that policy makers may utilize. This report has
123
630 Table 3 High risks of death and their odds ratios among child pedestrians
Pediatr Surg Int (2014) 30:625–632
Mortality risk Truck-hit and female Female child aged B4 years Truck-pedestrian collision
Odds ratio
2 of 4 = 50
12.0588 (95 % CI 1.5973–91.363)
7 of 17 = 41.2
11.4917 (95 % CI 3.7193-35.5066)
2 of 6 = 33.3
5.9706 (95 % CI 1.0189–34.9852)
Female child pedestrian
15 of 112 = 13.4
4.2526 (95 % CI 1.3652–13.247)
Car-pedestrian collision
13 of 83 = 15.7
4.2405 (95 % CI 1.5455–11.6346
Head injury
14 of 97 = 14.4
4.1831 (95 % CI 1.4537–12.0534)
8 of 42 = 19.0
3.7005 (95 % CI 1.3858–9.8811)
15 of 147 = 10.2
2.1307 (95 % CI 0.6823–6.6541)
Age B4 years Highway location of collision
clearly reported unique features that can contribute to existing global literature on pedestrian injuries; especially in the absence of gender variation in the incidence of child pedestrians. Most literature reported about twice the incidence among boys compared to girls [3, 4, 7]. Additionally, there was equal male female exposure on both the highway and inner-city roads and indeed in the mechanism of injury in road crossing or walking along the pavement. What then is responsible for the higher risks of death among the girls, in children 4 years and younger and in being hit by a truck or a car (Tables 2 and 3)? The odds ratio (OR) of a female pedestrian dying at 4.25 compared to a male pedestrian with OR 0.24 suggests that the probability of dying in the female child is 21 times higher. This calls for continuous or further research. The relevance of continuous research that is prospective is reinforced in this study where a new legislation was enacted 8 months into the research. The law [21] has banned movement of motorcycle from the highways in the entire state. The predominant vehicle changed from motorcycles to cars and buses as shown in Fig. 2. The reason for the law was to check the rising injuries from the motorcycle (two wheelers) but it appears this has shifted to the cars and buses (four wheelers). Certainly, the need to ensure holistic road safety implementation is desirable as this new law just showed that injuries did not abate but rather the incident vehicle just changed. Obviously no activity of a pedestrian appears safe whether crossing the road, walking along the pavement, standing by the bus stop or in front of one’s house or shop in the inner-city roads. This paper also reported the negative impact of truck related collisions as it produced the highest crude death rate and probability of dying; the need for new truck bumper designs that are pedestrian friendly is timely [22]. Trucks alone caused nearly six times higher risk of death while this risk was more than doubled when a truck hits a girl pedestrian. Despite having three quarters of the collisions, crossing the road presented a lower risk than standing in front of a house or shop. Indeed, city planning that exposes households to this injury should be revisited and where difficult due to the economics of urban renewal, traffic calming measures should be instituted wherever
123
Crude death rate %
there is very close proximity of roads and dwelling places. Of all the four mechanisms investigated, standing at the bus stop or walking along the pavement presented the lowest risks. Much safer still is the requirement to walk by facing the traffic; the benefit of this has recently been documented with 77 % decrease in fatal and in non-fatal pedestrian injuries [23]. The increasing motorization in developing countries has worsened the apparent safety of footpaths—, which are now being used by all sorts of vehicles, whether it is a motorcycle or a car—should be a great concern to all and sundry. This is one of the three factors documented by Berger and Mohan as reasons for higher pedestrian injury rates in the developing countries [24]. The debates on whether education of the child pedestrian had value or not appears settled as both education and engineering and indeed involvement of all stakeholders have led to higher safety records in the developed countries [11, 14, 25]. The life of every human being is precious but greater emotional attachment is given to children by almost all cultures of the world. This positive emotion should be translated to obtaining greater participation of the citizenry to all phases of efforts at improving safety records for all humans especially the child pedestrian. Adesunkanmi et al. in Ile Ife [13] and Shokunbi and Solagberu in Ibadan [14], reporting from two other cities in Nigeria documented 90 % pedestrian incidence and 75 % mortality due to HI, respectively in their studies. Abantaga et al. also documented 83 % pedestrian fatalities in Ghana. In a sub-urban study by one of us (BAS); three of the seven deaths recorded in children after injuries were pedestrian injuries, while another three were from burns and last from foreign bodies. Even when all these studies were not dedicated to pedestrians, the high incidence of pedestrian risks to injuries and mortalities lend credence to special focus on them as done here. Although Lagos population is the highest in density in Nigeria and indeed the highest in Africa (2011 report www.unpopulation.org) the significance of this report as an important prelude to a statewide study is obvious. However, the 8.4 % death rate is much lower than the 33 % reported from Ghana [26].
Pediatr Surg Int (2014) 30:625–632
The pre-hospital transport revealed the absence of emergency medical services in the country but the diligence of the relatives and some bystanders to render transport without any knowledge of resuscitation efforts [27]. The availability of relatives in bringing injured child pedestrians most of the times also gives room for questioning where they were just before the child-vehicle impacts. Could this be negligence in whatever forms or recklessness of the drivers despite the precarious traffic situation in the city? It is expected that children should get all the assistance they need at road crossing ventures. Future research should explore how many children are being supervised by one single individual at a time as it is not uncommon to find an older child in need of help himself being the expected ‘adult’ to guide much younger children across the road on the way to school. At the SER, resuscitation equipment for children are often lacking especially appropriately sized endotracheal tubes for small size babies. Improvement in all levels of care would improve the abysmal mortality figures [28]. Recommendations The literature is not short of recommendations; therefore, what is needed may be further research into why what is known is not being implemented. No doubt, the multifaceted approach to pedestrian traffic injury prevention has worked in the developed countries partly due to evidencebased, strategically focused implementation including a closer working relationship between researchers and policy makers which studied the complex web of social, economic, environmental, criminal and behavioral factors that are involved in injury morbidity and mortality [29]. Nothing less than this is desirable for developing countries. Additionally, emerging evidence of how to adapt educational messages to suit cultural realities of races and tribes or geographical areas should be taken seriously. No doubt, research efforts from the affected areas are the ways forward to locate these lacunae of differences so that recommendations are not taken hook, line and sinker without adapting it to local relevance [14]. The role of non-governmental organisations like Safe Kids Worldwide with useful roles in several small countries like New Zealand (population 4.4 million 2012 estimate) in a country like Nigeria with 167 million population (2013 estimate) can only be more effective to spur local efforts at supporting governmental intervention in reducing injuries [30].
Conclusions Pedestrian injuries among children presented in this paper have shown new and important differences from global
631
literature in the risks to the female child-pedestrian and the under 5-year-old child. The perennial absence of emergency medical services (EMS) and the insufficient supporting roles of the relatives and bystanders in providing pre-hospital transport have proved once again the need to train all adults in resuscitation while the planning for the establishment of EMS would continue. Further research is needed as regards alcohol impact and distraction from the use of mobile gadgets by child pedestrians which this report has not studied.
References 1. Child Pedestrian Safety Education. Applying learning and developmental theories to develop safe street-crossing behaviors. National Highway Traffic Safety Administration NHTSA 2009 Report 2. Pan SY, Ugnat A-M, Semenclw R, Desmeules M, Mao Y, MacLeod M (2006) Trends in childhood injury mortality in Canada 1979–2002. Inj Prev 12:155–160 3. Bartlett SN (2002) The problem of children’s injuries in lowincome countries: a review. Health Policy Plan 17(1):1–13 4. World report on child injury prevention (2008) World Health Organization, Geneva 5. Miller TR, Zaloshnja E, Lawrence BA, Crandall J, Ivarsson J, Finkelstein AE (2004) Pedestrian and pedalcyclist injury costs in the United States by age and injury severity. Annu Proc Assoc Adv Automot Med 48:265–284 6. Schieber RA, Vegera ME (2002) Reducing childhood pedestrian injuries. Inj Prev 8(Suppl 1):i3–i8 7. Abantanga FA, Mock CN (1998) Childhood injuries in an urban area of Ghana: a hospital based study of 677 cases. Pediatr Surg Int 13:515–518 8. Abantanga FA, Mock CN, Quansah RE (2004) Paediatric deaths after injury at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Ghana Med J 38(2):56–61 9. Solagberu BA (2002) Trauma deaths in children: a preliminary report. Nigerian J Surg Res 4(3):98–102 10. Demetre JD, Lee DN, Pitcairn TK, Grieve R, Thomson JA, Ampofo-Boateng K (1992) Errors in young children’s decisions about traffic gaps: experiments with roadside simulations. Br J Psychol 83:189–202 11. Schieber R, Vegega M (2002) Education versus environmental countermeasures. Inj Prev 8:10–11 12. Naci H, Chisholm D, Baker TD (2009) Distribution of road traffic deaths by road user group: a global comparison. Inj Prev 15(1):55–59 13. National Highway Traffic Safety Administration (NHTSA) (2012) Traffic Safety Facts 2010 Data US Department of Transportation 14. Daniels F, Moore W, Conti C, Norville Perez LC, Gaines BM, Hood RG, Swain IJ, Williams R, Burgess CT (2002) The role of African-American physicians in reducing traffic-related injury and death among African Americans: consensus report of the National Medical Association. J Natl Med Assoc 94(2):108–118 15. Durkin MS, Davidson LL, Kuhn L, O’Connor P, Barlow B (1984) Low-income neighborhoods and risk of severe pediatric injury: a small-area analysis in Northern Manhattan. Am J Public Health 84:587–592 16. Statter M, Schubble T, Harris-Rosado M, Liu D, Quinlan K (2011) Targetting pediatric pedestrian injury prevention efforts: teasing the information through spatial analysis. J Trauma 71(5 Suppl 2):S511–S516
123
632 17. Adesunkanmi ARK, Oginni LM, Oyelami AO, Badru OS (1998) Epidemiology of childhood injury. J Trauma 44:506–511 18. Shokunbi MT, Solagberu BA (1995) Mortality in childhood head injury in Ibadan. Afr J Med Med Sci 24:159–163 19. Nasir AA, Bello JO, Ofoegbu CKP, Abdur-Rahman LO, Yakub S, Solagberu BA (2011) Childhood motorcycle-related injuries in a Nigerian city—prevalence, spectrum and strategies for control. South Afr J Child Health 5(2):48–50 20. Zhu M, Cummings P, Chu H, Xiang H (2008) Urban and rural variation in walking patterns and pedestrian crashes. Inj Prev 14:377–380 21. Lagos State Road Traffic Law (2012) Lagos State government. http://www.lagosstate.gov.ng/images/pageimages/downloadfiles/ docs/Road_Traffic_Law_2012.pdf. Accessed 25 Mar 2014 22. Roudsari BS, Mock CN, Kaufman R, Grossman D, Henary BY, Crandall J (2004) Pedestrian crashes: higher injury severity and mortality rate for light vehicles compared with passenger vehicles. Inj Prev 10:154–158 23. Luoma J, Peltola H (2013) Does facing traffic improve pedestrian safety? Accid Anal Prev 50:1207–1210 24. Berger LR, Mohan D (1996) Injury control: a global view. Oxford University Press, Oxford
123
Pediatr Surg Int (2014) 30:625–632 25. Retting RA, Ferguson SA, McCartt AT (2003) A review of evidence-based traffic engineering measures designed to reduce pedestrian-motor vehicle crashes. Am J Public Health 93(9):1456–1463 26. Damsere-Derry J, Ebelb BE, Mock CN, Afukaar F, Donkor P (2010) Pedestrians injury patterns in Ghana. Accid Anal Prev 42(4):1080–1088 27. Solagberu BA, Ofoegbu CKP, Nasir AA, Ogundipe KO, Adekanye AO, Abdur-Rahman LO (2009) Prehospital care in a country without emergency medical services. Niger J Clin Pract 12(1):29–33 28. Mock CN, Tiska M, Adu-Ampofo M, Boakye G (2002) Improvements in pre-hospital trauma care in an African country with no formal emergency medical services. J Trauma 53:90–97 29. Pressley JC, Barlow B, Durkin M, Jacko SA, Dominiguez DR, Johnson L (2005) A national program for injury prevention in children and adolescents: the injury free coalition for kids. J Urban Health 82(3):389–402 30. Safe Kids New Zealand (2014) Traffic related child pedestrian injury. www.safekids.org.nz. Accessed 15 Mar 2014
ORIGINAL ARTICLE
Child pedestrian injury and fatality in a developing country Babatunde Akibu Solagberu • Roland I. Osuoji • Nasiru Akanmu Ibrahim Mobolaji A. Oludara • Rufai A. Balogun • Abdulwahab Olanrewaju Ajani Olufemi Emmanuel Idowu • Ibrahim A. Mustafa • Felix O. Sanni
• •
Accepted: 29 April 2014 / Published online: 8 May 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Child pedestrian injuries and fatalities in developing countries continue to increase. We examined child pedestrian injuries and fatalities in the most populated urban agglomeration in Africa in order to develop control measures. Methods Two-year prospective study of injured child pedestrians (B15 years) at the Surgical Emergency Room (SER) to determine demography, vehicles involved, road location, injury mechanism, pre-hospital transport, injuryarrival time, regions injured, injury severity and fatalities was done. Results Some 226 pedestrians (114 boys and 112 girls) comprising 42 children aged B4 years, 91 aged 5–9 years and 93 aged 10–15 years were seen with car collisions (83 pedestrians, 36.7 %), motorcycles (76, 33.6 %), buses (41, 18.1 %), others (15, 6.6 %) and 11 undetermined vehicles. Injuries on the highways were 147 (65 %); inner-city roads 77 (34.1 %) and two undetermined roads. Crossing the road was responsible for 168 (74.3 %) pedestrian injuries; while three other mechanisms produced 58 (25.7 %) patients. Regions injured were head (42.9 %), lower limbs (35.4 %) and others (21.7 %). Relatives, bystanders and police/ambulance brought 186 (82.3 %), 31 (13.7 %) and eight (3.5 %) children, respectively; and within 6 h (43.4,
B. A. Solagberu (&) R. I. Osuoji N. A. Ibrahim M. A. Oludara R. A. Balogun A. O. Ajani O. E. Idowu I. A. Mustafa Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria e-mail: [email protected] F. O. Sanni Academy of Traumatology and Medical Sciences, Lagos, Nigeria
11.5 and 2.2 %) and after (38.9, 2.2 and 1.3 %). Nineteen deaths (10 brought-in-dead, nine SER deaths) occurred; 15 of them girls, 15 had severe head injury, 15 were brought by relatives. However, fatality risks were truck collisions (OR 5.97), female child (OR 4.25), head injury (OR 4.18) and age B4 years (OR 3.7). Conclusion The equal sex incidence, worse female fatality despite similar exposure and injury severity with male, deserve further research. Improved pre-hospital and SER care is needed. Keywords Child Pedestrian Traffic injury Developing country Fatality Morbidity
Introduction Childhood road traffic injuries especially pedestrian injuries from the developed countries have been well documented. Evidence-based interventions have led to a steady reduction towards the end of the twentieth century [1, 2]. Some 98 % of all child injury deaths occur in low- and middle-income countries (LMIC) [3, 4]. Indeed, it has been estimated that pedestrian and pedal cycle injuries in 2000 would cost a total of $40 billion over the lifetimes of the injured [5]. In the United States, childhood traffic injuries result in one of five traffic deaths; pedestrians account for one-fourth of them [6]. Emerging reports from developing countries show unacceptable morbidity and fatality rates [7–9]. Child pedestrian injuries have continued to be significant because of two established contributory factors; the child’s small physical stature which contributes to the child’s vulnerability as it limits the ability of the child to see or be seen and the fact that the complex task of crossing the road is beyond the cognitive skill of the child. It was then thought that
123
626
improving the education of the child on road crossing and including this in the school curriculum along with some roadside simulations would make the difference [10]. Evidence gathered showed that education improved the knowledge of the child in handling the traffic but only in the short term did it contribute to a reduction in pedestrian traffic injuries [1]. Further research suggested the need for improved educational techniques to improve the dividends; nonetheless, engineering modifications on the road furniture were known to yield better outcomes [11]. Some differences in child pedestrian injuries globally include age, gender, geographical location, socio-economic status and possibly race [12, 13]. Recent evidence comparing effectiveness of traffic educational campaigns in African Americans and the white population in the US reported poorer results among the former due partly to the lack of cultural appeal of the message [14]. It is also known that human and economic factors are involved ranging from the socio-economic status of the parents who may not own a car, or a young mother with low education and low income, living in a highly densely populated area with heavy traffic [15, 16]. Some reports on pedestrians from some cities or semi-urban areas in Nigeria have addressed the child pedestrian but only as part of traffic or general injury research; and these have been few and far in between [9, 17– 19]. Indeed, more pedestrian injuries occur in urban than in rural dwellings [20]. This present study was done to document for the first time, to the best of our knowledge, the child pedestrian injury burden in the most densely populated city in Nigeria to add to existing global literature on the subject and identify possible areas of control and improvement.
Pediatr Surg Int (2014) 30:625–632
free healthcare, LASUTH SER receives an average of 1,000 patients every month. Demography The children’s ages were recorded and grouped into three for analysis— B4, 5–9 and 10–15 years; as well as the gender distribution. Other parameters studied
Methods
The vehicles which the child collided with, the regions of the body injured, the type of road where the collision occurred, whether highways or an inner-city road, were noted. Highways are major public roads within or leading to Lagos state with a median and two to three lanes on each side; speed limit is 80 km/h while inner-city roads are smaller roads with one or two lanes and single or dual traffic with speed limit of 30–50 km/h. The traffic is mixed with motorcycles, tricycles, cars, buses, trucks and some railway-road crossings—cars and motorcycles were predominant. The mechanism of injury depicting the activity as at the time of vehicle–pedestrian collision (crossing the road, standing by the bus stop, walking the pavement or side street, being in front of the house or street shop) was recorded. The method of bringing the child to the hospital was documented; whether by relations, police or ambulance and bystanders. The injury-arrival time was documented and grouped into arrivals within an hour, 1–6 h, more than 6–24 h and greater than 24 h. The injury severity was noted in the case of head injury using the Glasgow Coma Scale (GCS) score as mild (13–15), moderate (9–12) and severe (3–8); the pediatric Glasgow Coma Scale as adapted to children 4 years and younger was used as appropriate.
Setting
Outcome
A 2-year prospective study on the pedestrians covering 12 December 2011 to 11 December 2013 was done using a validated questionnaire at the Surgical Emergency Room (SER) of the Lagos State University Teaching Hospital (LASUTH), Ikeja, Nigeria—a 750-bed hospital upgraded in 2002 to a University Teaching Hospital status mainly from General Hospital, Ikeja, which itself was an upgrade in 1967 of a cottage hospital established in 1955 by the British colonial government. It is the busiest of the four tertiary centres in Lagos State and the only one that is owned by the state government; the other three are federal government owned. Nigeria has a 36-state structure and Lagos State, with the smallest land size of all the states, has about 10 % of the 167 million population of Nigeria (2013 estimate). Due to its history, location in the confluence of many parts of Lagos and governmental policy of relatively
The outcome of injuries presenting to the SER was determined; patients who were treated and admitted, patients discharged, patients transferred to another hospital due mainly to bed constraints, patients who discharged against medical advice and those who died in SER or were brought-in-dead (BID). The results were analysed, where appropriate Odds Ratios (OR) were used to compare risks and probability of getting injured; and were further presented in tables and figures.
123
Results Demography There were 334 child road traffic injuries in the 2 years out of which 226 were pedestrians (67.7 %). Of the 226, 114
Pediatr Surg Int (2014) 30:625–632
Fig. 1 Age spectrum of child pedestrians. Male preponderance in the B4 years; female preponderance in the 5–9 years old and near equal distribution in the 10–15-year-old children
were boys and 112 were girls giving a M:F ratio of 1:1 with 42 (18.6 %) being B4 years, 91 (40.3 %) were 5–9 years old and 93 (41.1 %) were 10–15 years of age with mean ages 2.9 ± 1.1, 7.0 ± 1.5 and 12.8 ± 1.8, respectively. The male–female trend across the ages (Fig. 1) shows male preponderance in the B4 years; female preponderance in the 5–9 years old and near equal distribution in the 10–15-yearold children. The overall mean age was 8.6 ± 4.1 years. Location of the injury The highway recorded 147 collisions (65.0 %) with 59 injuries (about four in 10 injuries) due to cars, 37 due to motorcycles, 34 due to buses, five due to trucks, two due to tricycle and 10 undetermined; while the inner-city roads had 77 (34.1 %) pedestrian injuries with motorcycles responsible for a little more than half of them (39 pedestrians) followed by 22 injuries from cars, seven from buses, six from tricycles and one from a truck; and in two instances, the road type could not be ascertained. Of the 19 deaths recorded, 15 (79.0 %) were on the highway while the remaining 4 were in the inner-city roads. Majority of the highway injuries were in older children (B4 years old, 17 children; 5–9 years old, 60 children; and 10–15 years old, 70 children). There was nearly equal number of pedestrians injured on the inner-city roads in the three age groups (25, 29 and 23 children, respectively) but predominantly from motorcycles (39 pedestrians). Details are given in Table 1. The male–female variation was not visible on both the highways and inner-city roads (Table 2). Mechanism of injury Most children were knocked down while crossing the road; highways had 126 pedestrians while the inner-city roads had 41, and in one child, the road was undetermined. The 168 (74.3 %) crossing the road mechanism was the highest followed distantly by walking along the pavement (22
627
pedestrians, 11 equally on highway and inner-city roads). There were 19 children injured while standing at the bus stop when a vehicle would swerve to hit them and 17 others while in front of the house or shop and only in the innercity roads. Crossing the road also caused the highest regional injuries to the head in 75 patients and lower limbs in 59 others (more details in Table 1). When the mechanism was compared with the Glasgow Coma Score (GCS) of the head injury (HI), 40 were mild (GCS 13–15), 33 were moderate (GCS 9–12) while 35 were severe (GCS 3–8) HI. Crossing the road produced 30 of the 40, 27 of the 33 and 30 of the 35 mild, moderate and severe HIs, respectively. The male to female variation also was not visible on the mechanism of injury (see Table 2). Vehicles involved in collision Two vehicle types were predominant—cars (83 children, 36.7 %) and motorcycles (76, 33.6 %). Buses were a distant third in 41 children (18.2 %). Others were tricycles (eight children), trucks (six) and train at a railway crossing (one). The vehicles caused various regional injuries with majority in the head (96 pedestrians) and lower limb injuries (80). The vehicular collisions caused different outcomes: Car injuries led to 23 admissions, 31 referrals and 13 deaths while motorcycle injuries resulted in 41 admissions, 18 referrals but no deaths. There were six other deaths traced to buses (two), trucks (two) and train (one) and in one instance the vehicle involved was not ascertained. Effect of a new traffic law banning motorcycles from the highways from September 2012 A new traffic law was enacted in August 2012 banning motorcycles from plying the highways in Lagos State. The implementation began in September 2012. Figure 2 showing the monthly trends of injuries revealed nearly equal incidence in child pedestrian injuries from motorcycles and cars and buses. After the law, the latter surpassed the former (Fig. 2). Pre-hospital transport There were three categories of persons bringing patients to the hospital; relatives—persons who know the patient (186 pedestrians, 82.3 %); bystanders—persons who do not know the patient and are not statutorily responsible for transporting patients (31, 13.7 %); and the police or ambulance—persons who do not know the patients but whose statutory responsibility includes transporting injured patients (eight, 3.5 %). In one instance, the person could not be identified. Forty-one B4 years old (nearly all from
123
628
Pediatr Surg Int (2014) 30:625–632
Table 1 Showing the number of child pedestrian injuries at different age groups and the variables Variable
Sub-variable
B4 years old
5–9 years old
10–15 years old
Total number of child pedestrians (% of n = 226)
Sex
Male
25
42
47
114 (49.6 %)
Female
17
49
46
112 (50.4 %)
Highway
17
60
70
147 (65.0 %)
Inner-city road
25
29
23
Not determined
0
2
0
25
75
68
168 (74.3 %)
3 5
6 7
10 10
19 (8.4 %) 22 (9.7 %)
Location of injury
Mechanism of injury
Knocked crossing road Hit at the bus stop While walking along the pavement Situated in front of house/shop
Vehicle responsible
Regions injured
Glasgow Coma scale (HI severity)
77 (34.1 %) 2 (0.9 %)
9
3
5
17 (7.5 %)
Car
15
31
37
83 (36.7 %)
Motorcycle
16
35
25
76 (33.6 %)
Bus
6
17
18
Tricycle
0
5
3
8 (3.5 %)
Truck
1
2
3
6 (2.7 %)
Train
1
0
0
1 (0.4 %)
Undetermined
3
1
7
11 (4.9 %)
27
41
29
97 (42.9 %)
Lower limb injury (LLI)
8
35
37
80 (35.4 %)
Upper limb injury (ULI)
1
6
15
22 (9.7 %)
Head injury (HI)
41 (18.1 %)
Multiple region injury
3
4
6
13 (5.8 %)
Pelvis injury
1
1
3
5 (2.2 %)
Other regions 13–15 (mild)
2 11
4 14
3 15
9 (4.0 %) 40
9–12 (moderate)
6
16
11
33
3–8 (severe)
12
14
9
35
Relatives
41
82
40
Police
0
0
8
Bystanders
1
9
21
31 (13.7 %)
Undetermined
0
0
24
24 (10.6 %)
14
38
31
83 (36.7 %)
8
16
19
43 (19.0 %)
12
31
34
77(34.1 %)
DAMA
0
1
3
Brought in dead
3
1
6
10 (4.4 %)
Died
5
4
0
9 (4.0 %)
(108 HI pedestrians) Pre-hospital transport
Outcome
Admitted for further treatment Discharged Referred to another hospital
163 (72.1 %) 8 (3.5 %)
4 (1.8 %)
There were fewer \4-year-old pedestrians (18.6 %), yet they were in the majority of the dead (42.1 %)
this age group) were brought by relatives and the remaining one pedestrian of the 42 was brought by a bystander (see Table 1 for details). Six of the 10 brought-in-dead child pedestrians were transported by relatives, the remaining four by bystanders. All the nine deaths in SER were brought by relatives. No patient died among the nine brought by police or ambulance, although only one of them was severe HI compared to 27 severe HIs brought by relatives and seven severe HIs brought by bystanders.
123
Injury-arrival time More than half of the pedestrians arrived within 6 h of vehicular collision—129 patients (57.1 %)—see Fig. 3. Another 51 patients (22.6 %) were brought after six but before 24 h while 32 (14.2 %) came in after 24 h. In 14 patients, the time recorded was not complete. Whether this had any effect on outcome could be seen when the results showed 13 of the 19 (68.4 %) pedestrian deaths were
Pediatr Surg Int (2014) 30:625–632
629
Table 2 Showing gender comparisons of boys and girls Variable
Sub-variable
Male
Female
Total
Location of injury
Highway
74
73
147
Inner-city road
39
38
77
Undetermined
1
1
2
Knocked crossing road
81
87
168
Hit at the bus stop
12
7
19
While walking along the pavement
12
10
22
9
8
17
Head injury (HI)
56
41
97
Lower limb injury (LLI)
38
42
80
Upper limb injury (ULI)
9
13
22
Multiple region injury
4
9
13
Pelvis injury
2
3
5
Mechanism of injury
Situated in front of house/ shop Regions injured
Glasgow Coma scale (HI severity)
Other regions
5
4
9
13–15 (mild)
26
14
40
9–12 (moderate)
18
15
33
3–8 (severe)
16
19
35
Admitted for further treatment
46
37
83
Discharged
19
24
43
Referred to another hospital
42
35
77
Discharged against medical advice
3
1
4
(108 HI pedestrians) Outcome
Brought in dead (BID)
1
9
10
Died (in Surgical Emergency Room)
3
6
9
Fig. 3 Injury arrival time based on pre-hospital transport. The burden of pre-hospital transport is still largely being born by the relatives (186, 82.3 %) and majority of the patients still got to the Surgical Emergency Room within 6 h (129, 57.1 %)
among those that arrived within 6 h—seven of these were BID and six were SER deaths. The remaining six (32.0 %), three each of BID and SER deaths, came in after 6 h. Outcome of injuries Of the 226 injured patients, 83 (36.7 %) were admitted, 77 (34.1 %) were referred to another hospital largely on account of lack of bed space, 43 (19.0 %) were discharged after treatment due to minor injuries sustained and four patients discharged against medical advice (DAMA). The remaining 19 (8.4 %) were deaths, 10 of who died before reaching the hospital (brought-in-dead, BID). Fourteen of the 19 deaths occurred from crossing the road, one at the bus stop, two each while walking along the pavement and being in front of the house. There is predominance of female mortality among those both BID and those that died in the SER (see Table 2). All the crude death rates along with their odds ratios are shown in Table 3. The alcohol influence both among pedestrians and drivers and the distraction from mobile phone use by pedestrians were not investigated.
Discussion Fig. 2 Comparison of child pedestrians before and after September 2012. A new traffic law banning motorcycles from plying the highways in Lagos State was enacted in August 2012 but the implementation began in September 2012. From October 2012 till end of this study in Dec 2013, child pedestrian injuries from cars and buses have surpassed those from motorcycles. Before September 2012, injuries were about equal in both motorcycles (two wheelers) and cars and buses (four wheelers)
In spite of the huge knowledge on pedestrian injuries largely from the developed world, the abysmal result from developing countries is evidence of lack of adapting the implementation of the available knowledge to control pedestrian injuries and possibly also from inadequate research that policy makers may utilize. This report has
123
630 Table 3 High risks of death and their odds ratios among child pedestrians
Pediatr Surg Int (2014) 30:625–632
Mortality risk Truck-hit and female Female child aged B4 years Truck-pedestrian collision
Odds ratio
2 of 4 = 50
12.0588 (95 % CI 1.5973–91.363)
7 of 17 = 41.2
11.4917 (95 % CI 3.7193-35.5066)
2 of 6 = 33.3
5.9706 (95 % CI 1.0189–34.9852)
Female child pedestrian
15 of 112 = 13.4
4.2526 (95 % CI 1.3652–13.247)
Car-pedestrian collision
13 of 83 = 15.7
4.2405 (95 % CI 1.5455–11.6346
Head injury
14 of 97 = 14.4
4.1831 (95 % CI 1.4537–12.0534)
8 of 42 = 19.0
3.7005 (95 % CI 1.3858–9.8811)
15 of 147 = 10.2
2.1307 (95 % CI 0.6823–6.6541)
Age B4 years Highway location of collision
clearly reported unique features that can contribute to existing global literature on pedestrian injuries; especially in the absence of gender variation in the incidence of child pedestrians. Most literature reported about twice the incidence among boys compared to girls [3, 4, 7]. Additionally, there was equal male female exposure on both the highway and inner-city roads and indeed in the mechanism of injury in road crossing or walking along the pavement. What then is responsible for the higher risks of death among the girls, in children 4 years and younger and in being hit by a truck or a car (Tables 2 and 3)? The odds ratio (OR) of a female pedestrian dying at 4.25 compared to a male pedestrian with OR 0.24 suggests that the probability of dying in the female child is 21 times higher. This calls for continuous or further research. The relevance of continuous research that is prospective is reinforced in this study where a new legislation was enacted 8 months into the research. The law [21] has banned movement of motorcycle from the highways in the entire state. The predominant vehicle changed from motorcycles to cars and buses as shown in Fig. 2. The reason for the law was to check the rising injuries from the motorcycle (two wheelers) but it appears this has shifted to the cars and buses (four wheelers). Certainly, the need to ensure holistic road safety implementation is desirable as this new law just showed that injuries did not abate but rather the incident vehicle just changed. Obviously no activity of a pedestrian appears safe whether crossing the road, walking along the pavement, standing by the bus stop or in front of one’s house or shop in the inner-city roads. This paper also reported the negative impact of truck related collisions as it produced the highest crude death rate and probability of dying; the need for new truck bumper designs that are pedestrian friendly is timely [22]. Trucks alone caused nearly six times higher risk of death while this risk was more than doubled when a truck hits a girl pedestrian. Despite having three quarters of the collisions, crossing the road presented a lower risk than standing in front of a house or shop. Indeed, city planning that exposes households to this injury should be revisited and where difficult due to the economics of urban renewal, traffic calming measures should be instituted wherever
123
Crude death rate %
there is very close proximity of roads and dwelling places. Of all the four mechanisms investigated, standing at the bus stop or walking along the pavement presented the lowest risks. Much safer still is the requirement to walk by facing the traffic; the benefit of this has recently been documented with 77 % decrease in fatal and in non-fatal pedestrian injuries [23]. The increasing motorization in developing countries has worsened the apparent safety of footpaths—, which are now being used by all sorts of vehicles, whether it is a motorcycle or a car—should be a great concern to all and sundry. This is one of the three factors documented by Berger and Mohan as reasons for higher pedestrian injury rates in the developing countries [24]. The debates on whether education of the child pedestrian had value or not appears settled as both education and engineering and indeed involvement of all stakeholders have led to higher safety records in the developed countries [11, 14, 25]. The life of every human being is precious but greater emotional attachment is given to children by almost all cultures of the world. This positive emotion should be translated to obtaining greater participation of the citizenry to all phases of efforts at improving safety records for all humans especially the child pedestrian. Adesunkanmi et al. in Ile Ife [13] and Shokunbi and Solagberu in Ibadan [14], reporting from two other cities in Nigeria documented 90 % pedestrian incidence and 75 % mortality due to HI, respectively in their studies. Abantaga et al. also documented 83 % pedestrian fatalities in Ghana. In a sub-urban study by one of us (BAS); three of the seven deaths recorded in children after injuries were pedestrian injuries, while another three were from burns and last from foreign bodies. Even when all these studies were not dedicated to pedestrians, the high incidence of pedestrian risks to injuries and mortalities lend credence to special focus on them as done here. Although Lagos population is the highest in density in Nigeria and indeed the highest in Africa (2011 report www.unpopulation.org) the significance of this report as an important prelude to a statewide study is obvious. However, the 8.4 % death rate is much lower than the 33 % reported from Ghana [26].
Pediatr Surg Int (2014) 30:625–632
The pre-hospital transport revealed the absence of emergency medical services in the country but the diligence of the relatives and some bystanders to render transport without any knowledge of resuscitation efforts [27]. The availability of relatives in bringing injured child pedestrians most of the times also gives room for questioning where they were just before the child-vehicle impacts. Could this be negligence in whatever forms or recklessness of the drivers despite the precarious traffic situation in the city? It is expected that children should get all the assistance they need at road crossing ventures. Future research should explore how many children are being supervised by one single individual at a time as it is not uncommon to find an older child in need of help himself being the expected ‘adult’ to guide much younger children across the road on the way to school. At the SER, resuscitation equipment for children are often lacking especially appropriately sized endotracheal tubes for small size babies. Improvement in all levels of care would improve the abysmal mortality figures [28]. Recommendations The literature is not short of recommendations; therefore, what is needed may be further research into why what is known is not being implemented. No doubt, the multifaceted approach to pedestrian traffic injury prevention has worked in the developed countries partly due to evidencebased, strategically focused implementation including a closer working relationship between researchers and policy makers which studied the complex web of social, economic, environmental, criminal and behavioral factors that are involved in injury morbidity and mortality [29]. Nothing less than this is desirable for developing countries. Additionally, emerging evidence of how to adapt educational messages to suit cultural realities of races and tribes or geographical areas should be taken seriously. No doubt, research efforts from the affected areas are the ways forward to locate these lacunae of differences so that recommendations are not taken hook, line and sinker without adapting it to local relevance [14]. The role of non-governmental organisations like Safe Kids Worldwide with useful roles in several small countries like New Zealand (population 4.4 million 2012 estimate) in a country like Nigeria with 167 million population (2013 estimate) can only be more effective to spur local efforts at supporting governmental intervention in reducing injuries [30].
Conclusions Pedestrian injuries among children presented in this paper have shown new and important differences from global
631
literature in the risks to the female child-pedestrian and the under 5-year-old child. The perennial absence of emergency medical services (EMS) and the insufficient supporting roles of the relatives and bystanders in providing pre-hospital transport have proved once again the need to train all adults in resuscitation while the planning for the establishment of EMS would continue. Further research is needed as regards alcohol impact and distraction from the use of mobile gadgets by child pedestrians which this report has not studied.
References 1. Child Pedestrian Safety Education. Applying learning and developmental theories to develop safe street-crossing behaviors. National Highway Traffic Safety Administration NHTSA 2009 Report 2. Pan SY, Ugnat A-M, Semenclw R, Desmeules M, Mao Y, MacLeod M (2006) Trends in childhood injury mortality in Canada 1979–2002. Inj Prev 12:155–160 3. Bartlett SN (2002) The problem of children’s injuries in lowincome countries: a review. Health Policy Plan 17(1):1–13 4. World report on child injury prevention (2008) World Health Organization, Geneva 5. Miller TR, Zaloshnja E, Lawrence BA, Crandall J, Ivarsson J, Finkelstein AE (2004) Pedestrian and pedalcyclist injury costs in the United States by age and injury severity. Annu Proc Assoc Adv Automot Med 48:265–284 6. Schieber RA, Vegera ME (2002) Reducing childhood pedestrian injuries. Inj Prev 8(Suppl 1):i3–i8 7. Abantanga FA, Mock CN (1998) Childhood injuries in an urban area of Ghana: a hospital based study of 677 cases. Pediatr Surg Int 13:515–518 8. Abantanga FA, Mock CN, Quansah RE (2004) Paediatric deaths after injury at Komfo Anokye Teaching Hospital, Kumasi, Ghana. Ghana Med J 38(2):56–61 9. Solagberu BA (2002) Trauma deaths in children: a preliminary report. Nigerian J Surg Res 4(3):98–102 10. Demetre JD, Lee DN, Pitcairn TK, Grieve R, Thomson JA, Ampofo-Boateng K (1992) Errors in young children’s decisions about traffic gaps: experiments with roadside simulations. Br J Psychol 83:189–202 11. Schieber R, Vegega M (2002) Education versus environmental countermeasures. Inj Prev 8:10–11 12. Naci H, Chisholm D, Baker TD (2009) Distribution of road traffic deaths by road user group: a global comparison. Inj Prev 15(1):55–59 13. National Highway Traffic Safety Administration (NHTSA) (2012) Traffic Safety Facts 2010 Data US Department of Transportation 14. Daniels F, Moore W, Conti C, Norville Perez LC, Gaines BM, Hood RG, Swain IJ, Williams R, Burgess CT (2002) The role of African-American physicians in reducing traffic-related injury and death among African Americans: consensus report of the National Medical Association. J Natl Med Assoc 94(2):108–118 15. Durkin MS, Davidson LL, Kuhn L, O’Connor P, Barlow B (1984) Low-income neighborhoods and risk of severe pediatric injury: a small-area analysis in Northern Manhattan. Am J Public Health 84:587–592 16. Statter M, Schubble T, Harris-Rosado M, Liu D, Quinlan K (2011) Targetting pediatric pedestrian injury prevention efforts: teasing the information through spatial analysis. J Trauma 71(5 Suppl 2):S511–S516
123
632 17. Adesunkanmi ARK, Oginni LM, Oyelami AO, Badru OS (1998) Epidemiology of childhood injury. J Trauma 44:506–511 18. Shokunbi MT, Solagberu BA (1995) Mortality in childhood head injury in Ibadan. Afr J Med Med Sci 24:159–163 19. Nasir AA, Bello JO, Ofoegbu CKP, Abdur-Rahman LO, Yakub S, Solagberu BA (2011) Childhood motorcycle-related injuries in a Nigerian city—prevalence, spectrum and strategies for control. South Afr J Child Health 5(2):48–50 20. Zhu M, Cummings P, Chu H, Xiang H (2008) Urban and rural variation in walking patterns and pedestrian crashes. Inj Prev 14:377–380 21. Lagos State Road Traffic Law (2012) Lagos State government. http://www.lagosstate.gov.ng/images/pageimages/downloadfiles/ docs/Road_Traffic_Law_2012.pdf. Accessed 25 Mar 2014 22. Roudsari BS, Mock CN, Kaufman R, Grossman D, Henary BY, Crandall J (2004) Pedestrian crashes: higher injury severity and mortality rate for light vehicles compared with passenger vehicles. Inj Prev 10:154–158 23. Luoma J, Peltola H (2013) Does facing traffic improve pedestrian safety? Accid Anal Prev 50:1207–1210 24. Berger LR, Mohan D (1996) Injury control: a global view. Oxford University Press, Oxford
123
Pediatr Surg Int (2014) 30:625–632 25. Retting RA, Ferguson SA, McCartt AT (2003) A review of evidence-based traffic engineering measures designed to reduce pedestrian-motor vehicle crashes. Am J Public Health 93(9):1456–1463 26. Damsere-Derry J, Ebelb BE, Mock CN, Afukaar F, Donkor P (2010) Pedestrians injury patterns in Ghana. Accid Anal Prev 42(4):1080–1088 27. Solagberu BA, Ofoegbu CKP, Nasir AA, Ogundipe KO, Adekanye AO, Abdur-Rahman LO (2009) Prehospital care in a country without emergency medical services. Niger J Clin Pract 12(1):29–33 28. Mock CN, Tiska M, Adu-Ampofo M, Boakye G (2002) Improvements in pre-hospital trauma care in an African country with no formal emergency medical services. J Trauma 53:90–97 29. Pressley JC, Barlow B, Durkin M, Jacko SA, Dominiguez DR, Johnson L (2005) A national program for injury prevention in children and adolescents: the injury free coalition for kids. J Urban Health 82(3):389–402 30. Safe Kids New Zealand (2014) Traffic related child pedestrian injury. www.safekids.org.nz. Accessed 15 Mar 2014
