Solomon M.

Nzioka (International Masters in Public Health (MPH), Israel Topic: Needs Assessment for Centralized Road Traffic Accidents Surveillance Unit As Basis For EvidenceBased Public Healthy Policy Management On Road Traffic Accidents In Nairobi, Kenya. Background: Kenya is located within the Africa continent at coordinates between latitude 30 North and 50 South and longitude 340 and 410 degrees East. The country lies across the equator on the East coast of Africa. It borders Somalia, Ethiopia and Sudan to the North, Uganda to the West, Tanzania to the South and the Indian Ocean to the East. Kenya covers about 582,500km² with its capital being Nairobi (10 170 S, 360 490 E). The administrative units are divided into 7 provinces and 1 area namely; Central, Coast, Eastern, Nairobi Area, North Eastern, Nyanza, Rift Valley, Western. (see annex 1). The provinces are further divided into Districts or constituencies. Villages are the smallest administrative structures while constituencies are the parliamentary electoral units with wards being the smallest constitutional organs. In Kenya, the literacy level (those with age 15 and over able to read and write) is rated at 85.1% in the total population (male: 90.6% and female: 79.7%) as per 2003 estimates (1). Notably, even though 98% of the of primary school entrants reach grade 5 as per the administrative data, between 2000-2005, secondary school enrolment ratio was 50% and 46% for gross male and female respectively. According to the same report, the 2006 estimates on GDP is US$ 40.77 billion and US$1,350 per head with a total expenditure on health being 8.3% of GDP and a per capita expenditure on health of $115. Problem Statement/Problem Definition: One of the current government visions is to transform Nairobi city into a metropolis by 2030. This will not only come with increased traffic flow but should also make road traffic accidents management a central concern for the health systems. Road traffic injuries are currently ranked 9th globally among the leading causes of disease burden, in terms of disability adjusted life years (DALYs) lost. In the year 2020, road traffic injuries are projected to become the 3rd largest cause of disabilities in the world (2). Developing countries bear the brunt of the fatalities and disabilities from road traffic crashes, accounting for more than 85% of the world’s road fatalities (2). An economic burden review by Jacobs et al (3) found that the annual cost of road crashes is in excess of US $500 billion. They acknowledged that due to the scarcity of costing data for African countries, it was difficult to make a precise cost of road crashes in Sub-Saharan Africa. However, the estimated costs as a percentage of the national Gross National Product (GNP) ranged from 0.8% in Ethiopia, 1% in South Africa, 2.3% in Zambia, 2.7% in Botswana and almost 5% in Kenya. 1 Epidemiological Basis for Decision Making in Health Administration

Solomon M. Nzioka (International Masters in Public Health (MPH), Israel This paper presents review of the current literature on linkages and challenges between health research and public healthy policy management on road traffic accidents (RTAs) in Kenya, provides an outline of the analytic framework for which evidence can contribute to public healthy policy on RTAs management and identifies data gaps that needs to be addressed within vision 2030 framework. Literature Review/Conceptual Framework: Nairobi is the most populous city in East Africa, with an estimated urban population of about 3.5 million in 2007 (1999 census). Nairobi is reputed to be the 4th fastest growing city in the world after Guadaloupe, Mexico City (Mexico) and Maputo (Mozambique). According to the 1999 Census, the city congestion was approximately 2925 persons/km². The Nairobi land use and transport Network has not been revised since its development in 1973 (see annex 2). According to a recent report (4), there are 7.5 million person trips per day translating to 2.1 trips per person per day (2007 population projection). The report further stated that home bound trips account for 46.5%, work 25%, school 9.8%, while other trips e.g. hospital account for 18.7%. The report further noted that 93% of traffic within Nairobi boundary at any day is destined to Nairobi while only 7% is a pass through traffic (see annex 3). The following figures summarize the Nairobi traffic as further presented in the report: Fig. 1: Nairobi Trip Composition by Travel Mode
Nairobi Trip Composition by Travel Mode
Others, 0.20%

Fig. 2: Nairobi Daily Traffic Volume by Road Name
Nairobi Daily Traffic Volume By Main Road Networks to CBD
Langata Road 10% Waiyaki Way 10% Jogoo Road 16% Outering Road 17%

Walking, 47%

Matatu, 29% Bus, 3.70%

Mbagathi Road 10%

School or College Bus, 3.10% KR(Railway), 0.40%

Two – wheel mode, 1.20%

Private Car/Taxi/Truck, 15.30%

Haile Selassie Road 11% Mombasa Road 13%

Thika Road 13%

A Global Road Safety Project (GRSP) study (5) showed that 4% of global vehicles are registered in Sub-Saharan Africa and contributed about 10% of global road deaths in 1999. Comparatively, 60% of all globally registered vehicles are in developed world where only 14% of global road deaths occurred (4). From Odero et al (6) review of the GRSP study, they noted that the adjusted true estimate of total road deaths for all Sub-Saharan African countries for the year 2000, based on the police department’s records, ranged between 68,500 and 82,200. They further stated that the estimated fatality of 190,191 for Sub-Saharan Africa presented in the 2004 World Report, based on health care data was much higher, and reflected the magnitude of under-reporting in police statistics. They acknowledged that given the widely recognized problem of under-reporting of road deaths in Africa, "the true figures were likely to be much higher, as the police-reported road fatalities represent only the tip of the injury pyramid". 2 Epidemiological Basis for Decision Making in Health Administration

Solomon M. Nzioka (International Masters in Public Health (MPH), Israel Another related report on road traffic accidents and injury in Kenya (7) reported that people killed in road accidents increased by 578%, while non-fatal casualties rose by 506% between 1962 and 1992. In addition, fatality rate per 10,000 vehicles increased from 50.7 to 64.2, while fatality per 100,000 population ranged between 7.3 and 8.6. More over, the report stated that 66% of the accidents occurred during daytime. Regarding causes of road traffic accidents, the same report noted that human factors were responsible for 85% of all causes whereby vehicle-to-pedestrian collisions were most severe and had the highest case fatality rates of 24%. In addition, only 12% of injuries resulting from vehicle-to-vehicle accidents were fatal. In the said study, public service vehicles were involved in 62% of the injuries. In addition, of all traffic fatalities reported, pedestrians comprised 42%, passengers 38%, drivers 12%, and cyclists 8%. The report concluded that the high pedestrian and passenger deaths implied the need to investigate the underlying risk factors, operational and policy issues involved in the transport system, and to develop and implement appropriate responsive road safety interventions. A 2003 related publication (8) stated that a "four-fold increase in road fatalities had been experienced over the last 30 years with over 3,000 people being killed annually on Kenyan roads within whom more than 75% are economically productive young adults". It further noted that pedestrians and passengers were the most vulnerable accounting for 80% of the deaths. The report inferred that "road safety interventions have not made any measurable impact in reducing the numbers, rates and consequences of road crashes". It added that "despite the marked increase in road crashes in Kenya, little effort has been made to develop and implement effective interventions". The report adds that "impediments to road traffic injury prevention and control include ineffective coordination, inadequate resources and qualified personnel, and limited capacity to implement and monitor interventions". Acknowledging most of the drawbacks, the report recommended that "there is need to improve the collection and availability of accurate data to help in recognising traffic injury as a priority public health problem, raising awareness of policymakers on existing effective countermeasures and mobilizing resources for implementation. Establishment of an effective lead agency and development of stakeholder coalitions to address the problem are desirable". The above referenced reports are a sample of what has been documented and one will notice that some of the widely referenced publications are not only based on assumptions that conditions remained the same over the long comparative periods (like comparing 1962-1992) but others generalize sub-saharan Africa and developed countries and treat each of them as homogeneous societies and make strong comparative inferences. Notably, the utility of the combined evidence at policy level will be limited given the methodological weaknesses and inconsistency in variable definitions amongst researchers. 3

Solomon M. Nzioka (International Masters in Public Health (MPH), Israel The problem of consistency and comparability is compounded by the fact that there is no single accepted indicator that accurately describes the overall road safety in a particular country. As pointed out by Odero (7), the number of fatal crashes per million vehicle kilometres travelled per annum (as a measure of exposure to motor vehicle traffic) is the most common method often used in highly motorized countries. The report acknowledged that "because of the absence of accurate data on vehicle usage in most African countries, it is not possible to apply this method. Instead, fatality rates, the number of reported fatalities per 10,000 registered motor vehicles, or calculated as the number of deaths per 100,000 population per annum, is the indicator commonly used by the WHO and the ministries of health sector to report diseases and causes of death". As pointed out in the report, these rates are subject to several errors, including variations in the definition of road accident deaths, under-reporting of crashes, the resulting injuries and deaths, lack of uniform definition of variables (e.g. what constitutes a case) amongst others (7). Agreeing with Odero's concerns, it is notable that fatality rates are biased indicators since they depend on quality of emergency and post-trauma services which are definitely superior in developed countries and comparison with developing countries is misleading. At best, healthy policy management will benefit from standardized rates. The methodological challenges mentioned previously not withstanding, it was necessary to review publications that had temporality as required in a cause-effect inference. In one "prospective" study in Kenya lasting 3 months (9), 240 injury patients were analysed, it was reported that road injury admissions formed 31% of all injury admissions, the mean pre-hospital time was 2.56 hours and the Emergency Department disposition time was 3.36 hours with the pace of care not matching severity of the injuries as determined by injury severity score (ISS). In addition, only 17.5% reached their areas of definitive care within 1 hour. The study concluded that though injuries following road traffic accidents are common in Nairobi, the response to injury is slow and haphazard and that the institution of a care incorporating the city's health centres and pre-hospital triage may improve post accident care outcomes. Notably, these time lapses are not near acceptable international standards. In a related study (10) in Kenya, it was found out that males comprised 63.1% of the injured, predominantly, vehicle occupant was frequently the road user injured (70%) whereas pedestrians constituted only 21.3%. Major city roads or highways were the commonest scenes of injury (38.3%). It further highlighted that most of the responsible vehicles were small personal cars (65.8%) whereas the public service vehicles caused 20% of the injuries. The report consistently with previous publications found that even though most of the injuries were mild, transport of the injured to hospital was uniformly haphazard. In addition, it was noted that trauma documentation was poor with less than 30% accuracy in most parameters and the report concluded that pre-hospital and initial care of the injured is not systematized and called for re-orientation of trauma care departments to the care of the injured. 4

Solomon M. Nzioka (International Masters in Public Health (MPH), Israel One will further notice that most of these studies were rather cross-sectional in design (gathering of cases) with prolective timing of data collection rather than prospective as stated in their published reports which would imply follow-up of exposed and non-exposed groups for the outcome of interest. These included some publications that reported random sampling of blood alcohol concentration of drivers (11) while others reported pattern of alcohol use in subjects admitted following RTAs (12). Justification/Analytic Framework on Why Systematic Data is required: In one of the most documented studies outside Kenya on analysis of temporal distribution of deaths done by San Francisco group (13), it was reported that there were three occasions in which trauma patients die after the road crash. It is a classical trimodal distribution with first peak comprising immediate deaths (45%) primarily due to central nervous system (CNS) and major vascular trauma. The second peak included the early hospital deaths (34%), which occurred within a few hours after injury, principally caused by CNS injuries and exsanguinations1. The third peak of deaths (20%) were late deaths (occur after one week) caused by sepsis-related multi-organic failure (MOF). This evidence was used in supporting the need for interventions in the post-event phase related with the physical environment including improved access to the medical systems and improvement in trauma units (14). This reduced the incidence of preventable2 deaths within trauma units to a lower incidence of 2% of preventable deaths as compared to 8% of incidence of preventable deaths amongst the non-trauma hospitals (14). In a related study, the Denver group for trauma (15), found out that out of all deaths, 34% occurred in the pre-hospital setting, out of the remaining 66% patients that were transported to the hospital, 84% died in the first 48 hours (acute), 5% within three to seven days (early) and 11% after seven days (late). In Kenya, the above framework is not feasible due to data inconsistencies coupled by the fact that most of the published reports are cross-sectional and hence not strong methodology for cause-effect relationship. Consequently, informational evidence for RTAs related policy management was found to be wanting. A more informative and less biased measure for causality inference is the use of case/incidence reports coupled by case cross-over study methodology with the accidents victims providing control and hazard periods. This can only be possible if there is a coordinated mechanism to define the operational variables across the various agencies currently involved in record keeping and reporting. Such efforts will produce more reliable data bank for long-term use in monitoring of interventions including policies so as to produce evidence-based management of RTAs for Nairobi city that can be scaled up to other towns in the country as well as in sub-saharan Africa.
1 Mode of death in which blood loss exceeds the body's ability to compensate and provide adequate tissue perfusion and oxygenation, frequently is due to trauma. Bozeman, W. Shock, Hemorrhagic. [online] http://www.emedicine.com/emerg/TOPIC531.HTM. [Cited: May 25 2008]. 2 “Preventable death was defined as any death that might have been prevented if optimal care had been delivered: The following three implicit criteria should be met before a death is assessed as preventable: 1) the injury or sequelae of injury must be survivable; 2) the care delivered must be judged suboptimal; and 3) identified errors in delivery of care must be directly and indirectly affected on the death.” (13).

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Solomon M. Nzioka (International Masters in Public Health (MPH), Israel Sustainability of such interventions will require community oriented road safety policy development and reviews, good surveillance and information system and coordinated monitoring and reporting of trends. These efforts will be in line with the 2004 WHO appeal to Member States to institute concrete measures aimed at reducing road traffic injuries and the pledged support for implementing effective interventions (16). The following section outlines the objectives, data requirements and sources for such a centralized surveillance and information system. Aim: To provide evidence basis for public healthy road safety policy management within Nairobi city. Broad Objective: To identify information gaps and undertake ongoing systematic collection, analysis, interpretation and dissemination of health information on RTAs for public healthy policy management in Nairobi. Specific Objectives: 1. Identify baseline indicators on the epidemiology and management of injuries in Nairobi city a. Number of cases of road traffic accidents and related injuries by type and severity b. Proportional morbidity and mortality by time, age group and gender c. The populations at risk specified by age, occupation and cause of accident d. Proportionate use of WHO recommended RTAs management protocol e. Barriers in adherence to use of WHO recommended RTAs management protocol 2. To reduce road accidents by monitoring cause-specific trends and compliance to policy-based prevention measures: a. Increase proportion of drivers adhering to speed limits, safety belt use and pedestrian crossing codes. b. Reduce proportion of drunk-driving drivers c. Increase proportionate road safety adherence by pedestrians and cyclists d. Reduce proportion of road accidents by cause 3. To reduce RTAs related preventable deaths by increasing use of WHO recommended treatment protocol on RTAs: a. Increase proportion of trained Basic Life Support (BLS) personnel b. Increase proportionate adherence to standardize severity score system for injuries c. Increase proportion of RTAs receiving BLS within 5 minutes (pre-hospital services) d. Increased proportion of RTAs registered at ER within 15 minutes of road crash. e. Increase proportion of people accessing post-road accidents rehabilitation services 4. Provide continuous information feedback loop on information and knowledge gaps for public healthy policy management based on proportional occurrence and severity of various types of injuries over-time. 6

Solomon M. Nzioka (International Masters in Public Health (MPH), Israel Variables, Data Items and Sources:
Result/ Variable Broad Objective: Outcome 1: Identify number of cases of road traffic accidents and related injuries by type and severity Outcome 2: Identify proportional morbidity and mortality by time, age group and gender Outcome 3: Identify populations at risk specified by age, occupation and cause of accident Outcome 4: Identify proportionate use of WHO recommended RTAs management protocol Outcome 5: Identify barriers in adherence to use of WHO recommended RTAs management protocol Outcome 6: Increase proportion of drivers adhering to speed limits, safety belt use and pedestrian crossing codes. Outcome 7: Reduce proportion of drunkdriving drivers Outcome 8: Increase proportionate road safety adherence by pedestrians and cyclists Outcome 9: Reduce proportion of road accidents by cause Outcome 10: Increase proportion of trained Basic Life Support (BLS) personnel Outcome 11: Increase proportionate adherence to standardize severity score system for injuries Outcome 12: Increase proportion of RTAs receiving BLS within 5 minutes (pre-hospital services) Outcome 13: Increased proportion of RTAs registered at ER within 15 minutes of road crash. Outcome 14: Increase proportion of people accessing post-road accidents rehabilitation services Outcome 15: Proportional occurrence and severity of various types of injuries over-time Objective Verifiable Indicator Source of Data Means of verification and (OVI) (Baseline) frequency To identify information gaps and undertake ongoing systematic collection, analysis, interpretation and dissemination of health information on RTAs for public healthy policy management in Nairobi. X number of cases of road traffic Emergency/casualty Repeat cross-sectional study accidents and related injuries by department records review on records in major hospitals type and severity in major hospitals within within Nairobi Nairobi X% morbidity and mortality by Emergency/casualty and Repeat cross-sectional study time, age group and gender in-patient department on records in major hospitals records review in major within Nairobi hospitals within Nairobi X% cases of road traffic accidents Emergency/casualty Repeat cross-sectional study and related injuries by type and department records review on records in major hospitals severity in major hospitals within within Nairobi Nairobi X% of BSL and ER personnel Emergency/casualty and 3 month prospective study at using WHO recommended RTAs in-patient department interval times management protocol records review in major hospitals within Nairobi Tabulate barrier type and ER/casualty staff peer Focus group discussions and frequency by source performance review reports plenary reviews with in major hospitals within ER/casualty staff Nairobi X% of drivers adhering to speed Drivers in major roads to Repeat cross-sectional study limits, safety belt use and and within Nairobi CBD at in major roads to and within pedestrian crossing codes per unit rush peak time. Nairobi CBD at baseline. hour at rush peak time. X% drunk-driving drivers per unit hour at late night X% of pedestrians and cyclists adhering to road safety requirements per unit hour at rush peak time X% of road accidents by cause Drivers in major roads to and within Nairobi CBD at late night. Pedestrians and cyclists in major roads to and within Nairobi CBD at rush peak time RTAs cases registered at ER/casualty units in major hospitals within Nairobi Trained Basic Life Support (BLS) personnel in major hospitals within Nairobi Personnel adhering to standardize severity score system for injuries in major hospitals within Nairobi Ambulance department records review in major hospitals within Nairobi Emergency/casualty department records review in major hospitals within Nairobi Physiotherapy department records review in major hospitals within Nairobi Centralised surveillance unit based on standardised data collection forms Repeat cross-sectional study in major roads within and outside Nairobi CBD at baseline. Repeat cross-sectional study in major roads within and outside Nairobi CBD at baseline. Case-cross over study of RTAs cases for hazard and control periods Repeat cross-sectional study on personnel in major hospitals within Nairobi Repeat cross-sectional study on personnel in major hospitals within Nairobi Repeat cross-sectional study on ambulance records in major hospitals within Nairobi Repeat cross-sectional study on Emergency/ casualty records in major hospitals within Nairobi Repeat cross-sectional study Physiotherapy department records in major hospitals within Nairobi RTAs stakeholders steering committee reports on trends over-time

X% of trained Basic Life Support (BLS) personnel

X% of personnel adhering to standardize severity score system for injuries X% of RTAs receiving BLS within 5 minutes (pre-hospital services)

X% of RTAs registered at ER within 15 minutes of road crash.

X% of people accessing post-road accidents rehabilitation services

Standard data collecting format at various points of RTAs services

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Solomon M. Nzioka (International Masters in Public Health (MPH), Israel References:
1. Kenya statistics (2004). Available at: http://www.unicef.org/infobycountry/kenya_statistics.html#0. Accessed on 8/6/08. 2. Murray CJL, Lopez AD. The global burden of disease. World Health Organization/ Harvard school of Public Health/World Bank. Harvard University Press, 1996. 3. Jacobs G, Aeron-Thomas A. (TRL Limited). Africa Road Safety Review: Final Report. Global Road Safety Partnership; 2000. Available at: www.safety.fhwa.dot.gov/fourthlevel/toc.htm. Accessed on 31/5/08. 4. King’ori Z.I. nairobi urban transportation challenges – learning from Japan. JICA Training Course Final report. 2007. Available at: http://www.scribd.com/doc/2369220/FINAL-REPORTNAIROBI-CITY. Accessed 27/6/08 5. World Report 2004 on Road Traffic Injuries. World Health Organization/World Bank. Geneva. Available at: www.who.int/violence_injury_prevention. 6. Odero W, Garner P, Zwi A. Road traffic injuries in developing countries: a comprehensive review of epidemiological studies. Tropical Medicine & International Health, 1997: 2(5);445-460. 7. Odero W. Road traffic accidents in Kenya: an epidemiological appraisal. East Afr Med J. 1995 May;72(5):299-305. 8. Odero W, Khayesi M, Heda PM. Road traffic injuries in Kenya: magnitude, causes and status of intervention. Inj Control Saf Promot. 2003 Mar-Jun;10(1-2):53-61. 9. Saidi H. S. Initial injury care in Nairobi, Kenya: A call for trauma care regionalisation. East Afr Med J. 2003;80 (9):480-483 10. Saidi H.S, Kahoro P. Experience with road traffic accident victims at The Nairobi Hospital. East Afr Med J. 2001 Aug;78(8):441-444. 11. Odero W, Zwi AB. Drinking and driving in an urban setting in Kenya. East Afr Med J. 1997 Nov;74(11):673-679. 12. Hassan S, Macharia WM, Atinga J. Self reported alcohol use in an urban traffic trauma population in Kenya. East Afr Med J. 2005 Mar;82(3):144-147. 13. Baker C, Oppenheimer L, Stephens B, Lewis F, Trunkey D. Epidemiology of Trauma Deaths. Am J Surg. 1980; 140(1):144-150 14. Haddon W. The changing approach to the epidemiology prevention and amelioration of trauma: Transition to approaches etiologically rather than descriptive based. Inj. Prev. 1999; 5;231-235. 15. Sauaia, A, Moore F, Moore E, Moser K, Brennan R, Read R, Pons P. Epidemiology of Trauma Deaths: A Reassessment. The Journal of Trauma Injury, Infection and Critical Care. 1995;38(2):185-193 16. WHO/AFRO Statement to mark 2004 WHO day. Availlable from http://www.afro.who.int/press/2004/pr20040406.html. Accessed on 8/6/08.

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Solomon M. Nzioka (International Masters in Public Health (MPH), Israel Annex 1: Kenya Location Map

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Solomon M. Nzioka (International Masters in Public Health (MPH), Israel Annex 2: Land use and transport network for Nairobi Central Business District (CBD) (developed in 1973 and no revision to date).

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Solomon M. Nzioka (International Masters in Public Health (MPH), Israel Annex 3: Main Road Network To Nairobi Central Business City (CBD)

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