Epidemiological and clinical characteristics of road traffic accident cases admitted at the Connaught Teaching Hospital Freetown, 2020 -2022

Isata Theresa Kamara^1,2, Annah Jammeh^2,3, Umaru Sesay^1,2, Adel Hussein Elduma^2,3, Solomon Aiah Sogbeh^1,2, Amara Alhaji Sheriff^1,2, James Sylvester Squire^1,2, Joseph Sam Kanu^1,2, Gebrekrstos Negash Gebru^2,3

 

¹Ministry of Health, Freetown, Sierra Leone, ²Sierra Leone Field Epidemiology Training Program (SLFETP), Freetown, Sierra Leone, ³African Field Epidemiology Network (AFENET), Freetown, Sierra Leone

 

 

^&Corresponding author
Isata Theresa Kamara, Ministry of Health, Freetown, Sierra Leone, Sierra Leone Field Epidemiology Training Program (SLFETP), Freetown, Sierra Leone.

 

 

 

 

Worldwide, road traffic accidents are the leading cause of death among children and youth, resulting in an estimated 1.9 million fatalities, with 92% occurring in low and middle-income countries [1]. Vulnerable road users, including cyclists, motorcyclists, and pedestrians, constitute almost half of these deaths [1]. Road traffic accidents account for 3% of the Gross Domestic Product (GDP) in most countries and are projected to increase over the next ten years, resulting in more than 500 million injuries and 13 million deaths [2]. The Global Plan for the Decade of Action for Road Safety (GPDARS) was launched to reduce road traffic accident-related injuries and deaths by at least half between 2021 and 2030[3]. Despite the implementation of the GPDARS, there is a considerable risk of high injury and mortality rates in road traffic accidents due to poor road conditions, poor vehicle maintenance, and ineffective road safety policies, particularly in low-resource settings [4].

 

In Africa, although the data regarding road traffic accidents is suboptimal, studies show that the mortality rate is the highest in the world at 26.6 per 100,000 population, causing 21.6% of the total disability-adjusted life years lost [5] . In Sub-Saharan Africa, the burden of road traffic accidents has increased by over 80% in the past three decades [6] , making it the third leading cause of ‘disease’ in the region [7]. A study conducted in Guinea found that head injury and coma were factors associated with road traffic accident fatalities in children under 15 years of age [8].

 

Sierra Leone, a nation with a fragile healthcare system and poor health infrastructure, has experienced a disturbing rise in road traffic accidents in recent years. In 2013, the government of Sierra Leone launched a national road safety policy and strategic plan to curb the number of road traffic accidents and their fatalities [9]. Despite the implementation of this policy, Sierra Leone ranked 21st out of 185 countries globally in 2020 for road traffic accident-related deaths, with an age-adjusted death rate of 41.6 per 100,000 population [10]. At the time of writing this paper, road traffic accidents continue to be a significant public health issue in the country, but limited information exists on the burden, epidemiological, and clinical characteristics of road traffic accident cases in Sierra Leone. It is crucial to understand the magnitude of road traffic accidents, epidemiological, and clinical characteristics of road traffic accidents, and factors associated with deaths from road traffic accidents. Therefore, this study aimed to describe the clinical and epidemiological characteristics of road traffic accidents (RTA) and the factors associated with deaths due to road traffic accident at the Connaught Teaching Hospital in Freetown, Sierra Leone.

 

 

Study design and setting

 

This was a retrospective cross-sectional study conducted to analyze road traffic accident cases at Connaught Teaching Hospital Freetown, from 2020 to 2022. This study was conducted at the Connaught Teaching Hospital, the largest referral tertiary government hospital in Freetown, Sierra Leone. Located in the central part of Freetown, the hospital has a bed capacity of 287 beds, staffed by 149 doctors and 378 nurses, as well as administrative and support staff. The hospital has the highest number of specialized and sub-specialized doctors. The hospital consists of 25 departments and the Trauma Unit that manages accident and trauma cases is one of them.

 

Study population

 

We included all road traffic accident cases hospitalized at the Connaught Hospital from January 1, 2020, to December 31, 2022. Road traffic accident cases with no clinical chart available at the time of data collection were excluded. Additionally, other traumatic injury cases were excluded.

 

Data collection

 

We extracted data from the trauma unit patient and mortality files of road traffic accident cases, using a semi-structured checklist. Demographic and clinical data and details on the type of mobility involved in the accidents were collected. Demographic data included sex, age, occupation, victim class, address, month, year, time seen or admitted. Clinical data included the type of injury, body part injured, status on arrival at the facility, the outcome which was either died or live and number of days on admission. Missing variables on records of patients were considered as unknown.

 

Statistical analysis

 

The data was imputed into an excel sheet, cleaned and analyzed using both MS Excel and Epi Info 7.2. Road traffic accident-related factors such as socio-demographic, clinical characteristics, and hospital stay were reported in percentages and proportions. Death due to road traffic accidents (yes/no) was considered as the outcome variable. Demographic, clinical, and type of vehicle were considered as independent variables. A forward stepwise strategy was used to develop logistic regression. Simple logistic regression was conducted to check for the association between independent variables and the outcome variable. A p-value cut-off of 0.2 was used to determine which variables would be included in the multiple logistic regression model. Adjusted odd ratio (aOR) at 95% confidence interval (CI) and p-value were calculated to identify independent variables associated with the outcome. Independent variables with a p-value of less than 0.05 were considered statistically associated with the outcome variables.

 

Ethical considerations

 

This study used secondary data from the hospital registers and records to extract data on the road traffic accidents. Approval to collect data from patient records was sought from the hospital management. Personally identifiable information was not included to maintain patients´ confidentiality.

 

 

Epidemiologic Characteristics

 

A total of 4839 road traffic accident cases were reported, of which 1539 were admitted. The median age of those admitted was 30 years (Interquartile range: 23 - 41). Among those admitted, 78.7% (1211) were males and 57.7% (889) were between the age group 20 and 39 years. Students/pupils accounted for 16.4% (253/1539) of all admitted cases followed by traders 15.9% (244/1539) and bike riders 12.1% (186/1539). Passengers accounted for 33.8% (520/1539), while pedestrians accounted for 31.8% (490/1539) of the admitted cases. The Western part of Freetown accounted for 28.3% (436/1539) of all admitted cases while the Northern province accounted for 6.5% (100/1539) of all admitted cases (Table 1). The year 2021 recorded 35.6% of the cases (548/1539) and the month of March recorded the highest number of admitted cases in 2021 and 2022 (4.1%, 63 in 2021 and 4.2%, 65 in 2022, respectively) and in 2020, the highest number of cases were recorded in February (4.4%, 68) (Figure 1).

 

Clinical Characteristics of Road Traffic Accident Cases

 

Lacerations were the most common type of injury among the admitted road traffic accident cases and accounted for 44.1% (679/1539) of all cases followed by fractures 41.3% (636/1539). The most common anatomical sites for injuries were the head which accounted for 53.5% (823/1539) and the lower limbs which accounted for 37.9% (584/1539). The most frequent injuries of the lower limbs were fractures, lacerations, and dislocations. Fracture of both fibula and tibia (tibio-fibula) of the lower limb accounted for 10.0% (154/1539) of all hospitalized road traffic accident cases. The commonest injuries of the head were lacerations accounting for 27.1% (417/1539) of all admitted cases and 50.7% (417/823) of all head injuries; followed by fractures accounting for 19.8% (304/1539) of all admitted cases and 36.9% (304/823) of all head injuries. Among the head fractures, basal skull fractures accounted for 29.9% (91/304) and mandibular fractures accounted for 10.2%, (31/304).

 

Of the admitted road traffic accident cases, 51.0% (785/1539) were stable upon arrival with a survival rate of 94.1% (1448/1539) and a case fatality rate (CFR) of 5.9% (91/1539). Males had a higher CFR of 6.5% (79/1211) compared to females at 3.7% (12/328).

 

Majority of the admitted cases 65.2% (1,003/1,539) were discharged and 26.1% (402/1,539) absconded or were discharged against medical advice (Table 2). The fatalities were highest among males (86.8%, 79/91), pedestrians (38.5%, 35/91), the age group over 40 years (53.8%, 49/91) and in 2021 (38.5%, 35/91) (Table 3). April and March recorded fatality of 13.2% (12/91) each.

 

Types of vehicles

 

Motorbikes accounted for 48.5% (747/1539) of the admitted road traffic accident cases at the Connaught hospital followed by cars which accounted for 38.1% (586/1539) (Figure 2). Cars accounted for the most fatalities 49.5% (45/91) followed by motorbikes 48.4% (44/91).

 

Factors associated with road traffic accident deaths

 

Variables associated with death due to road traffic accidents at bivariate analysis included having a head injury (cOR=3.52, 95% CI 2.10-5.89) and a laceration (cOR=2.23, 95% CI 1.44-3.45). Additionally, a stable clinical status (cOR=0.15, 965% CI 0.08-0.26), age group of 40 years or less (cOR=0.31, 95% CI 0.20-0.48), using a tricycle (cOR=0.08, 95% CI 0.01-0.57), fractures (cOR=0.55, 95% CI 0.34-0.88) and lower limb injury (cOR=0.33, 95%CI=0.19-0.56) had less odds of dying from road traffic accidents. Other factors associated with death from road traffic accidents were bruise (cOR=1.78, 95% CI=1.16-2.72), dislocation (cOR=2.03, 95% CI= 1.25-3.31), and head injury (cOR=3.52, 95%CI =2.10-5.89) (Table 4).

 

After controlling for confounding in multiple logistics regression, the odds of death were statistically significantly higher among patients that had lacerations, head injuries, and dislocations. On the other hand, there were statistically significantly lower odds of death among patients who had lower limb injuries, were aged 40 years or below, stable at admission and injured in or by a tricycle. The odds of death were highest among patients with lacerations at aOR=2.35 (95% CI: 1.44-3.84), 2.33 times higher among patients with head injuries (aOR=2.33. 95% CI 1.33-4.10) and 1.79 times higher among patients with dislocations (aOR=1.79, 95%CI:1.04-3.09). Among the RTA cases that were hospitalized, those in the age group of 40 years and less had 60% less odds of death compared to patients in the above 40 years´ age group (aOR= 0.4, 95% CI: 0.22-0.55). The odds of death were 56% less among patients with lower limb injuries (aOR=0.44, 95% CI 0.24-0.81,), 84% less among patients with stable clinical status (aOR= 0.16, 95% CI: 0.09-0.30,) and 91% less among patients riding tricycle (aOR= 0.09, 95% CI: 0.01-0.64,), respectively (Table 3).

 

 

This study aimed to describe the clinical and epidemiological characteristics of road traffic injuries and factors associated with deaths due to road traffic accident cases at the Connaught Teaching Hospital in Freetown. A total of 1,539 RTA cases were admitted at hospital out of 4,839 cases that were reported during the three-year study period. A three years (2015-2017) study conducted in Guinea by Kourouma et al in 2019, recorded 3,140 from police stations. This was lower compared to this study which is a hospital-based study.

 

Our findings indicated that the case fatality rate was slightly high. A study conducted in South Africa reported a similar fatality rate [11]. On the other hand, a study conducted in Malawi reported a higher case fatality rate (34%) as a result of road traffic accidents prior to hospitalization. This is probably because a lot of cases may have died before they are taken to the hospital, unlike this study which is hospital based deaths. [12]. The high case fatality rate we recorded could likely be due to more than half of the accidents involving head injuries. This finding was similar to a study conducted in Ghana, where head injuries accounted for 58.3% of all injuries [13].

 

Head injuries were the most common possibly because most people do not use protective gears like helmets and seat belts. This was supported by findings from a study by Kourouma in Guinea 2019 [8] and Malik Muneeb Abid in Pakistan in 2022 [14].

 

Epidemiologic characteristics

 

The findings of this study also showed that males were more involved in road traffic accidents. This could likely be because males tend to ride or drive at higher speeds than females. Additionally, this could be attributed to long-distance driving and more time spent by men on the road. A study that reviewed the global burden of road traffic accidents revealed that the majority of those involved in road traffic accidents were males [15].

 

This study also revealed that, the age group 20-40 years were more involved in road traffic accidents. This could likely be due to their involvement in driving commercial vehicles, being less experienced in road traffic rules, and being at risk of exposure to alcohol and drugs. The Global Status Report on Road Safety reported that two-thirds of road traffic crash deaths occur among people aged 18 - 59 years [16]. A study conducted in Nepal showed that the majority of road traffic accidents occurred among the age group 20-40 years [17].

 

It was also observed that students/pupils and traders were the most affected. This may be due to them frequently using vehicles to travel to and from school or business centers or due to walking along roads from home to school or hawking and back daily. A study conducted in Ethiopia reported that students were the second most recorded group among the majority of road traffic accident victims [18]. Additionally, our study found that passengers and pedestrians were among the most vulnerable victims. The 2023 WHO fact sheet on road traffic accidents [1] indicated that pedestrians were more vulnerable to road traffic accidents.

 

Cases who resided in Freetown West were more involved in road traffic accidents probably because victims from this part of the town may be more likely to be taken to the hospital because of its proximity to the accident sites. Additionally, this may be due to a high population density, heavy economic activity, more traffic and frequent use of motor bikes in this part of Freetown. A study by Aati et al in Pakistan [19] revealed similar findings in which he stated that dense city roadways are plagued with a high frequency of traffic accidents.

 

Based on this study, a peak in road traffic accident cases was observed in the month of March which is the peak of the dry season and the month with the sunniest days in Sierra Leone. This was followed by a decline from April to September, which is the rainy season in this country. The decrease in road traffic accident cases during the rainy months could be attributed to fewer people using roads during the rainy season. Another reason may be fewer people using motorbikes, which is a common type of vehicle during rain. A study by Karacasua M et al, on ‘Variations in Traffic Accidents on Seasonal, Monthly, Daily and Hourly Basis’, reported that road traffic accidents were common on sunny days of the month [20]. Our study also observed that more accidents were reported during the day. This could be because most people travel during the day, particularly in the morning hours when people rush to work, school, or other engagements. A similar finding was reported in a study conducted in Nepal where more cases of road traffic accidents occurred during the day, particularly from 12 noon to 6 pm [21].

 

Motorbike accidents accounted for the highest number of vehicles involved in road traffic accidents. This may be because motorbikes are the most commonly used means of transportation, often operated by personnel with less training who may not fully understand traffic rules and signs. This finding is consistent with a study conducted in Ghana [22] which reported a high incidence of road traffic accidents involving motorbikes and their riders, particularly in urban and peri-urban settings [22].

 

Clinical characteristics

 

Lacerations were the most observed injuries which may be a result of the crash on soft tissues. This finding is similar to a study conducted in India which also indicated that lacerations were the most common injuries in road traffic accidents [23]. Fractures of the limbs and facial bones were common and may be attributed to the impact of falls direct blunt trauma and the force of gravity as well as not wearing protective gear. This is similar to a study conducted by Singh´s et al which showed that the most common site of fracture was the lower limb followed by the upper limb and skull/maxillofacial bones [23].

 

The study revealed that head injuries were more predominant affecting more than half of the cases. This finding was similar to a study conducted in Ghana, where head injuries accounted for 58.3% of all injuries [24]. This may be because most people do not use protective gear like helmets and seat belts. This finding was supported by similar results from a study by Kourouma in Guinea [25] and Malik Muneeb Abid in Pakistan in 2022 [14]. Our study observed that cases who had head injuries were more likely to die from road traffic accidents. This could be likely since head injuries can cause severe trauma, especially when drivers, riders, or passengers do not use protective gear. A similar finding was observed in a study conducted by Sharma et al [26]who stated that severe head injury, with or without peripheral trauma, is the main cause of death and/or disability [27] hence the need for the use of protective gears onboard vehicles. Lower limb injuries were also observed to be common next to head injuries. This may be because lower limbs are closer to the point of impact, have less protection and the impact of the force of gravity on the limbs. This finding is similar to that from the global burden of injuries from road traffic accidents by Ngunde P J et al 2019 in Cameroon [27]. Ngunde´s findings were also consistent with our findings of fractures and lacerations being the most common injuries of the lower limb. Fractures of the tibia and fibula were the most common probably because these bones carry the weight of the body and prone to the impact of direct trauma. This is similar to a study by Otte and Haasper which stated that more than half of the cases (53.8%) had fractures of both bones of the lower leg, tibia and fibula [28]. Our findings also showed that cases with lower limb injuries were less likely to die from road traffic accidents. This could be because most of the cases were successfully managed by the orthopedic team at the hospital. Similarly, a study conducted in Egypt reported that the management of lower limb injuries showed a significant improvement with fewer complications [29]. More than half of the cases were stable on arrival at the facility. This is contrary to a finding from a study conducted by Mamo DE et al 2023, a hospital-based study in Ethiopia [30].

 

Most of the cases were discharged from the facility (65%) and only 5.9% died due to road traffic accidents. A similar finding was reported by Deresse et al 2021[31], who stated that only 5.3% died due to road traffic accident. However, his study found that about 90% of the cases were discharged which is higher than our findings. Our findings showed that a considerable number of cases absconded or discharged against medical advice. This may be attributed to patients going home to seek alternative care possibly with traditional healers for whom they believe recovery is faster and the service is cheaper. A study conducted in Nigeria reported a similar finding [32,27].

 

Factors associated with death among admitted RTA cases

 

Additionally, road traffic accident cases that had lacerations were more likely to die compared to those without lacerations. This could be attributed to severe bleeding from the wound. Our findings showed that older people aged over 40 were more likely to die due to road traffic accidents. This might be attributed to their slow physical activity in maneuvering and higher susceptibility to injury among older people. In contrast to this finding a study conducted in Iran concluded that young people contributed to higher road traffic mortality rates [33]. This study showed that cases with lacerations, bruises, and dislocation had higher odds of dying from road traffic accidents. Joya Debnath et al also discovered that 34% of deaths had bruises [34] Additionally, road traffic accident cases that had lacerations were more likely to die compared to those without lacerations. This could be attributed to severe bleeding from the wound.

 

Cases of road traffic accidents that were in a stable condition upon admission at the facility were less likely to die than those who were unstable. This could be because they experienced minor accidents and were not in severe clinical condition. A study conducted in Ethiopia observed that car accident victims admitted to the hospital in stable condition were less likely to die due to the accident [27].

 

Our findings showed that cases with lower limb injuries were less likely to die from road traffic accidents. This could be because most of the cases were successfully managed by the orthopedic team at the hospital. Similarly, a study conducted in Egypt reported that the management of lower limb injuries showed a significant improvement with fewer complications [25].

 

Based on our results, cases who drove tricycles were less likely to die from road traffic accidents. This could be attributed to them having less speed compared to other types of vehicles. It was also observed that there was a high likelihood of injury when using a motorbike compared to other types of transportation including tricycles. Similar findings were reported in studies conducted in Nigeria in 2011 and 2020 respectively [31, 34].

 

Limitations to the study

 

This study is facility-based therefore findings cannot be generalized to the entire Freetown or the country. However, since it was conducted in the largest referral tertiary government hospital in Freetown, these findings are fairly representative of a majority of RTA cases that happen in Freetown and its neighborhood. There may be a selection bias in this study as RTA cases who may have died before arrival at the hospital were not included, and some characteristics of cases may have been missed because this is a secondary data analysis. The study did not collect data on some known risk factors associated with road traffic accidents such as road infrastructure, level of speed and type of crash.

 

Implications of study findings

 

Short-term implications: Immediate interventions should focus on improving emergency medical response and enhancing trauma care facilities. Efforts should be made to increase awareness on safe driving practices and the benefits of using safety gear in reducing RTA associated morbidities and mortalities. Immediate measures should be taken to enforce regulations regarding the use of protective gear, especially helmets and seat belts, to prevent head injuries which are the most fatal consequence and other severe consequences of road traffic accidents.

 

Medium-term implications: Policy changes and enforcement strategies are necessary to address the high incidence of motorbike accidents, possibly through improved training for riders on traffic rules and regulations and policies for stricter adherence to traffic rules and regulations. Health education campaigns should be initiated to discourage patients from absconding or self-discharge against medical advice, emphasizing the importance of receiving proper medical care following road traffic accidents to reduce complications and fatalities. Targeted interventions are needed to address the vulnerability of certain demographics, such as young adults aged 20-40, students/pupils, those above 40 and traders, through education programs promoting road safety and responsible behavior.

 

Long-term implications: Comprehensive road safety strategies should be developed and implemented, considering seasonal variations in accident rates and factors such as weather conditions and road usage patterns. Investments in healthcare infrastructure and trauma care facilities are necessary to improve outcomes for road traffic accident victims, particularly those with severe injuries such as head trauma. Sustainable measures should be taken to reduce the overall incidence of road traffic accidents, such as promoting alternative modes of travel to reduce reliance on motorbikes and other high-risk vehicles.

 

 

The findings of this study showed that males, the age group of 20-40 years, school students or pupils, passengers, and motorbike riders were more involved in road traffic accidents. Factors associated with death due to road traffic accidents included patients presenting with lacerations, head injuries and dislocations as well as persons older than 40 years of age. We recommend enhancing road safety preventive measures, and prompt medical intervention for road traffic accident cases to reduce fatalities.

 

 

The authors declare no competing interest.

 

 

Conceptualization and design: ITK, AJ. Data Collection: ITK. Analysis, and Interpretation: ITK, AJ, AHE, US, GNG. Drafting and Review of Manuscript: TK, AJ, AHE, US, SAS, AAS, JSS, JSK. The final approval was made by all authors.

 

 

We render sincere thanks and appreciation to the staff and management of the Connaught Teaching Hospital especially staff at the records office, AFENET, US-CDC and the Ministry of Health Sierra Leone.

 

 

Table 1: Demographic characteristics of road traffic accident cases Connaught Teaching Hospital, 2020-2022 N=1539

Table 2: Clinical characteristics of road traffic accident cases Connaught Teaching Hospital, 2020-2022, N=1539

Table 3. Distribution of the sociodemographic and clinical characteristics of admitted road traffic accident cases by their outcome, Connaught Teaching Hospital, Freetown 2020-2022

Table 4: Factors associated with road traffic accident deaths at the Connaught Teaching Hospital, Freetown, Sierra Leone 2020-2022

Figure 1: Monthly distribution of road traffic accident cases at Connaught Teaching Hospital, 2020-2022

Figure 2: Types of vehicles involved in accidents among road traffic accident cases admitted at Connaught Teaching Hospital, 2020-2022

 

 

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