Introduction:
Road Traffic accidents (RTAs) are a major public health concern associated with significant morbidity and mortality. The objective of this study was to describe the epidemiological aspects of RTAs and their prognostic factors in the center east of Tunisia.
Methods:
This was a prospective cross sectional descriptive study conducted in the Emergency Medical Services area 03 of the center east of Tunisia for a period of 18 months from February 1 2020 to July 31 2021.
Results:
Three hundred forty five patients were included. Among them 82.8% were male (Mean age: 33±17.2 years). The injured patient was the driver in 57.1% of cases. Traffic accidents involving pedestrians and motorists were the most frequent types of accident (18.8%). Traffic accidents often occurred on Monday and Saturday (18.2% and 16.8%) between 6 p.m. and midnight (36.2%). In 54.4% of cases, injured patients did not meet effective safety measures such as helmet use and seat belt. Etiological events related to the patients that lead to traffic accident were, alcoholism is 29 cases (26.1%), excessive speed in 25 cases (22.5%). Etiological events related to the road were poor road conditions in 34 cases (39.5%). Etiological climate related events were rainy weather in 33 cases (47.1%). Thirty-one victims were died in the first 24 hours (8.9%). Univariate analysis of epidemiological factors of victims of RTAs showed 4 factors significant predicting mortality included in our study: location of the traffic accident in the city of “Kairouan” (p=0.005), road related factors: low-light areas (p=0.029), weather related factors: rainy weather (p=0.003) and patient related factors: alcoholism (p=0.044).
Conclusion:
Road Traffic accidents are of considerable socio-economic importance for our community. It is necessary to know how to manage a RTA‘s victim through the circumstances of the accident and its risk factors.
Key words: Emergency Medical Services, Epidemiology, Traffic accidents
Introduction:
Road Traffic accidents (RTAs) are a major public health problem; they are responsible of high rates of mortality and morbidity [1].
It is the leading cause of death in young people aged between 15 and 29 years. According to the July 2017 world health organization (WHO) Report, over 1.3 million of people dies, every year, from RTAs and 20-50 million people suffer from traumatic consequences [2].
Tunisia has the second highest mortality prevalence in the Maghreb region. RTAs are the fifth leading cause of death, responsible of 3.3% of all observed deaths in Tunisia [3]. The 2016 National Road Safety Observatory announced around 1,505 of deaths related to RTAs [3].
In Tunisia, there are around thirty accidents per day; these accidents are responsible of around four deaths and about forty serious and minor injuries per day. These figures are 50% higher than the European average [3].
This carnage strikes a considerable human heritage, which is thus destroyed with very heavy social and economic consequences. Indeed, for each person killed, injured or disabled by traffic accident, a whole group of other people including the family and the entourage of the person concerned are deeply affected [4].
However, we have noted a drop in the incidence of RTA since the SARS CoV2 pandemic, which could be explained by the confinement procedure imposed by several countries.
In Tunisia, the incidence of RTA has dropped reaching 23.4% during the confinement period; from March to June 2020. The epidemiological characteristics have also been modified [5].
We conducted this study to describe the epidemiology of RTAs in the east center of Tunisia and to investigate its associated and gravity factors. This study may help as a better health resource allocation and policymaking.
Material and method:
Type of study:
A cross-sectional descriptive study was carried out by the emergency medical services of the East Center of Tunisia (EMS 03) during a period of 18 months; from February 1, 2020 to July 31, 2021.
The study population:
Our study population was a non-probability sample of convenience.
We included all victims of RTAs occurring in the territory of the EMS 03 and which the regulation room played a part in the decision of transport. This territory of EMS 03 includes four governorates: Sousse, Monastir, Kairouan and Mehdia. It represents 8.16% of the total surface of Tunisia.
Victim of RTCs off territory, victims of other type of accidents and victims died before the intervention of the EMS03 were not included in this study.
Collection of data:
The data was collected from the regulation files and the intervention forms filled by the mobile intensive care unit (MICU) at the scene of the accident. The data has been aggregated on a pre-established data collection” sheet for the study.
We registered, on a the sheet, data about
- The socio-demographic characteristics of the victim: age, gender, comorbidities and type of road user.
- The epidemiological characteristics of the RTA (date and time, place of the RTA and type of accident).
- The circumstances of the RTA were grouped into three categories: related to the patient, related to the state of the road and related to the climate.
We did a 24-hour follow-up of victims who were transported to the emergency departments or to the intensive care unit (ICU).
Results:
The socio-demographic characteristics:
In our study, we included 345 RTA victims, 82.8% of them were male with a sex ratio H/F of 4.84.
The mean age of the victims was 33 +- 17.2 years with extremes ranging from 2 to 81 years. Victims were mainly young subjects aged between 15 and 29 years with a prevalence of 36.2%.
The majority of victims had no medical history (72.1%). Diabetes represented the most common comorbidity among victims with past medical history (35.4%).
Most of the identified victims were drivers (57.1%) followed by pedestrians (24.6%) then vehicle passengers (18.3%).
Table 1
Socio-demographic characteristics of the study population.
|
Injured n (%) |
Deceased n (%) |
P |
Age < 15 years 15 – 29 year 30 – 59 year >60 year |
70 (20.2) 125 (36.2) 115 (33.5) 35 (10.1) |
3 (9.6) 10 (32.2) 12 (38.7) 6 (19.3) |
0.656 0.723 0.919 0.917 |
Sexe male female |
286 (82.8) 59 (17.2) |
28 (90.3) 3 (9.7) |
0.116 0.102 |
comorbidities No Yes Diabetes Cardiovascular hypertension Neurological Psychiatric Others Unknown |
249 (72.1) 96 (27.9) 34 (35.4) 23 (23.9) 9 (9.3) 9 (9.3) 7 (7.2) 5 (5.6) 9 (9.3) |
22 (70.9) 9 (29.1) 2 (22.2) 1 (11.1) 0 1 (11.1) 0 4 (44.4) 1 (11.1) |
0.841 0.286 0.845 0.586
0.586
0.336 0.586 |
Type of road user Pedestrians Drivers Passengers |
85 (24.6) 197 (57.1) 63 (18.3) |
6 (19.3) 22 (70.9) 4 (12.9) |
0.714 0.569 0.189 |
The city of Sousse had the highest prevalence of RTA with a rate of 57.1%. In the governorate of Sousse, “Sahloul” region had the highest prevalence of RTAs (16.7%).
In our study, we noted that the prevalence of RTAs was higher on Monday (18.2%) and Saturday (16.8%), however, it was the lowest on Wednesday (12.4%).
According to the hours of occurrence of RTA, we found that the highest rate of RTAs was during the time interval between 6 p.m. and midnight (36.2%).
Regarding the flow of accident victims, we found that the peak of accidents was in the month of February 2020 with a percentage of 27% while the lowest accident rate was in the month of April 2020 with a percentage of 9.2 %.
The most prevalent type of accident was a crash between light vehicles (VL) against pedestrian with a prevalence of 18.8%, followed by two wheels -VL (17.9%).
Table 2
Epidemiological characteristics of RTA
|
|
Injured n (%) |
Deceased n (%) |
p |
Hour 06h-12h 12h-18h 18h-00h 00h-06h Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday |
|
71 (20.5) 114 (33) 125 (36.2) 35 (10.3)
63 (18.2) 44 (12.7) 43 (12.4) 44 (12.7) 48 (13.9) 58 (16.8) 45 (13.3) |
7 (22.5) 8 (25.3) 13 (41.9) 3 (9.6)
4 (12.9) 3 (9.6) 6 (19.3) 4 (12.9) 4 (12.9) 7 (22.8) 3 (9.6)
|
0.832 0.823 0.489 0.479
0.616 0.624 0.324 0.227 0.227 0.345 0.624
|
Place Governorate Sousse Monastir Mahdia Kairouan Urban Rural |
|
197 (57.1) 41 (11.8) 49 (14.2) 58 (16.9) 238 (68.9) 107 (31.3) |
10 (32.2) 5 (16.1) 4 (12.9) 12 (38.4) 15 (48.3) 16 (51.7) |
0.071 0.116 0.189 0.005 0.187 0.194 |
Type of RTA Pedestrian – light vehicle Two wheels - light vehicle Two wheels Light vehicle Light vehicle - light vehicle Pedestrian - two wheels Two wheels - two wheels Light vehicle - heavy vehicle Light vehicle – van Two wheels – van Two wheels - heavy vehicle Heavy vehicle Pedestrian - heavy vehicle Pedestrian – bus bus |
65 (18.8) 62 (17.9) 56 (16.2) 47 (13.6) 49 (14.2) 16 (4.6) 14 (4) 15 (4.3) 6 (1.7) 4 (1.1) 5 (1.4) 2 (0.5) 2 (0.5) 1 (0.2) 1 (0.2) |
4 (12.9) 7 (22.5) 1 (3.22) 6 (19.3) 5 (16.1) 0 2 (6.4) 2 (6.4) 2 (6.4) 0 1 (3.22) 0 1 (3.22) 0 0 |
0.196 0.140 0.199 0.148 0.096
0.646 0.646 0.646
0.199
0.199
|
In our study, we have studied the circumstances of the RTAs and we grouped them into three categories; factors related to the victim, weather-related factors and factors related to the road condition.
Factors related to victims were found in 32.2% of cases. The factor with the highest prevalence of RTA injuries was alcohol consumption (26.1%) followed by speeding (22.5%), drug intake (neuroleptics, opiates: codeine, anxiolytics) (15.3%), fatigue (12.6%) and mental state (8.1%).
Regarding weather, related factors, rainy weather had the highest prevalence of RTAs (47.1%), followed by foggy weather (27.1%) then other weather conditions such as the presence of clouds or storms (25.8%). Weather related factors were found in 20.3% of cases.
As for factors related the road condition which were present in 25% of cases, RTAs were more likely to happen when driving on a road with bas condition (39.5%). Poor lighting was involved in 34.8% of cases and in 18.6% of cases, the road surface was slippery. Other road conditions were present in 7.1% such as traffic and roadwork.
Concerning safety measures among the drivers, only 45.4% of them wore helmets or wore the seat belt.
We have studied RTAs according to “vittel” criteria, regarding kinetic elements; 54.6% of victims did not respect safety measures (no helmet or seat belt), 22.5% of RTAs were associated to high speed, 11.8% of victims were ejected, 7.6% of RTAs were deadly for other passenger in the same accident and in 4.4% of RTAs, the car was significantly deformed.
.
According to victim’s type of transport, 58.5% of victims were transported by the mobile care unit team, 31.1% of theme were transported by civil protection and 10.4% by a type B ambulance or by simple means.
Tableau 3
Special circumstances related to RTAs
Factors |
Injuried n (%) |
Deceased n (%) |
P |
Related to the victim No particular factor With particular factor Alcohol consumption Speeding Medication Mental state Fatigue Others |
234 (67.8) 111 (32.2) 29 (26.1) 25 (22.5) 17 (15.3) 14 (8.1) 9 (12.6) 17 (15.3) |
18 (58) 13 (42) 2 (15.3) 1 (7.6) 3 (23) 1 (7.6) 3 (23) 3 (23)
|
0.274 0.454 0.044 0.668 0.945 0.668 0.945 0.945 |
Related to weather No particular factor With particular factor Rainy Foggy Others (clouds, storms) |
275 (79.7) 70 (20.3) 33 (47.1) 19 (27.1) 18 (25.8) |
24 (77.4) 7 (22.6) 7 (100) 0 0 |
0.012 0.018 0.003
|
Related the road condition No particular factor With particular factor Poor lighting Bad road state Slippery surface Others (Traffic, roadworks) |
259 (75) 86 (25) 30 (34.8) 34 (39.5) 16 (18.6) 6 (7.1) |
19 (61.2) 12 (38.8) 2 (16.6) 9 (75) 1 (8.3) 0 |
0.004 0.013 0.029 0.278 0.378
|
In our study we had 31 (8.9%) victims died in the first 24 hours after the accident.
The most of them are young (38.7% aged between 30-59 years ) ;male (90.3%) ; drivers (70.9%) and the most of the drivers deceaded (16 victims) did not respect safety measures (72.7%).
We conducted an analytical study focused on mortality risk factors based on the statistical significance of Pearson's chi-squared test.
The univariate analysis of the epidemiological factors of road accident victims showed only 4 statistically significant predictors of death in our population, which are
- Place of occurrence of the accident according to the governorate: Kairouan.
- Road related factor: Poor lighting.
- Weather condition: Rainy.
- Circumstances related to the victim: Alcohol consumption
Discussion
In our study, we found that men are 4 times more exposed to the risk of RTAs than women are. Such a predominance has been reported in several studies: according to the road safety in France in the report on accident rates of the year 2018, death on the road occurred three times more in men (2,492) than in women (756). This ratio was found in other occidental countries [6].
Similarly, to most countries in the world, we found that the young population was the one to pay the heaviest price in terms of traffic accidents. In our series of studies, the average age was 33 years and the most affected age group was between 15 and 29 years. In the "road safety in France "report on accident rates for the year 2018, in terms of the number of deaths and injuries, people aged between 20-24 years were the most affected by road accidents; followed by the ones aged between 15-19 year and between 25-29 years [6].
Regarding the flow of accident victims, we found that the peak of accidents was in the month of February 2020 with a percentage of 27% while the lowest accident rate was in the month of April 2020 with a percentage of 9.2 %.
These results were not found in the literature; In fact, the traffic accident rate is classically higher during summer. A study carried out in France in 2001 found that the winter months (January to March) were at a low level of accidents followed by a rise in the spring that culminates during the summer with a gradual descent during the fall [7].
The differences between our results and those found in the literature can be explained by the lockdown implemented in April 2020 for the fight against the covid-19 pandemic; therefore, the month of February 2020 represents the most accident-prone month in our study.
The days of the week with the highest numbers of traffic accidents was Monday and Saturday.
The most accident-prone time interval during the day was from 6 p.m. to midnight, while the time interval with the lowest number of accidents was from 6 a.m. to 12 p.m.
Similar results have been found in other studies: in fact, a study carried out in France by Gayrard A et al; showed that the days at the start of the week had a lower average number of deceased accident victims at 17 deaths per day. Weekends had an average of 27 deaths per day [7]. The 2018 study by Bernagaud AS et al; showed that there was an increase of 18% in the number of accidents during the morning rush hour (7 a.m. to 9 a.m.) and of 52 % during the evening rush hour (5 p.m. to 7 p.m.) [6].
In our study, the third of the RTAs had special circumstances: the most important one was alcohol consumption in 26.1% of cases, and excessive speed in 22.5% of cases, several others studies have found similar results [8-9-10].
The subject of the contributing factors to RTAs is both complicated and recurrent in the field of road safety [11]. In fact, in the search for the causal factors of RTAs, there are several factors related to both the driver and the environment. The contribution of human factors in traffic accidents is far from being easy to isolate in accidental mechanisms. In fact, among the main human factors contributing to road accidents, we typically find speeding and alcohol consumption. Each of these variables has been the subject of abundant literature, which has largely proven their harmful effect on driving activity.
In our sample, it was found that 24% of RTAs occurred under poor weather conditions and 29.5% of RTAs were influenced by road-related factors. Among the road deaths in our study, 36.8% were associated with particular weather conditions, and 21% were associated with road-related conditions.
Several other studies showed the impact of these conditions on the incidence and severity of road accidents; A Finnish study published in 2018 assessed the relative accident risk of different road and weather conditions. The study analyzed traffic accidents on 43 major Finnish roads between the years 2014-2016 [12]. To simplify the analysis, the potentially dangerous conditions were combined into five categories: slippery road, very slippery road, poor visibility, icy rain and slush. All road weather conditions had an increased relative crash risk of more than 50%
In our study, 54.6% of victims did not respect safety measures (no helmet or seat belt). Among the deceased victims, the most of them (16 victims ) did not take road safety measures, in particular wearing a helmet or a seat belt.
Similar results have been found in the literature: It was the case of the accident rate report for 2018 in France, which insisted on the importance of wearing seat belts as well as helmets. In the period 2013-2017 [6], 1,779 people who died in road accidents were not wearing their seatbelts.
Limits of the study
Our study was conducted during the COVID-19 lock down, for that reason; the size of our sample was small. This may influence research findings by making p-values stray from significance affecting the ability to study associations. It is more difficult to distinguish between a real effect and random variation.
Despite these limitations, this study offers a picture on the epidemiology of RTAs and its associated factors in Tunisia, which may aid in identifying factors suitable for the development of preventive programs and the allocation of resources by Tunisian health authorities.
Conclusion
Our study focused on a series of 345 victims of RTAs in the territory of EMS 03 in the Center East of Tunisia. We described the epidemiological and prognostic characteristics of the RTAs. The results showed the circumstances and etiological factors of RTAs as well as the epidemiological and clinical profiles most frequently found.
In fact, the majority of victims were males (82.8%), and young with an age between 15 and 29 years (36.2%). In 18.8 % of cases, the victim was a pedestrian hit by VL and in 17.9% of cases; the victim was a driver of a two-wheeled vehicle hit by a light vehicle. Safety measures were taken only in 45.4 % of drivers victims.
Weather related factors were found in 20.3% of cases. Road-related factors were found in 25% of cases.
Accidents took place most frequently in Sousse (57.1%), on Monday and Saturday (18.1 and 16.8%) of cases. The injured person was taken to the emergency department by the mobile care unit team in almost half of the cases.
Through this study, we were able to identify the severity and the mortality predictive factors. Thus, all measures that can preserve life must be implemented, such as adapting the traffic environment to users and educating and training drivers and pedestrians to change their behavior in the desired direction.
Declaration of Competing Interest
The authors declared no conflict of interest.
Acknowledgements
I would like to thank all the staff of the emergency medical service 03 for the data collection.
References
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