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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 971-976

Auto tricycle injuries and the vulnerability of occupants and pedestrians in a developing Country: A multi-center study


1 Department of Surgery, Ebonyi State University/Federal Teaching Hospital, Ebonyi State, Abakaliki, Nigeria
2 Department of Orthopaedic, National Orthopaedic Hospital, Enugu, Nigeria
3 Department of Surgery, University of Nigeria Teaching Hospital, Enugu, Nigeria

Date of Acceptance15-Apr-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. N I Omoke
Department of Surgery, Ebonyi State University/Federal Teaching Hospital Ebonyi State, Abakaliki
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_571_18

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   Abstract 


Background: Auto tricycle is an emerging common means of public transport in Nigeria. This study aimed to determine the scope and type of collisions and injuries from auto tricycles crashes in Nigeria, and identify potential areas for interventions to facilitate injury prevention. Patients and Methods: This was a prospective study of all the patients with auto tricycle injuries that visited Emergency rooms of three Nigerian tertiary hospitals from 1st February 2015 to 31st July 2016. Results: There were 210 victims; auto tricycle - other vehicle collisions, lone auto tricycle collisions and auto tricycle- pedestrian collisions accounted for injuries in 67.2%, 19% and 13.8% of them respectively. Preponderance of collisions at nighttime (60%), and on intra-city roads (86.7%) was observed. The rate of severe injury was significantly higher on inter-city than intra-city roads (32.11% vs. 9.3%, P < 0.001), and in daytime than night time (16.7% vs. 6.0%, P < 0.043). The lower extremity (50%), head (38.6%) and upper extremity (30.4%) were the three top anatomical regions involved. The case fatality rate was 1.4%: head injury accounted for two-third of the mortality. Conclusion: In Nigeria, auto tricycle has come to stay as a means of public transport and vulnerable road users are not immune to auto tricycle related injuries and its associated morbidity and mortality. This calls for preventive strategies, based on the findings in this study, which may curb the menace of auto tricycle crash and resultant injuries.

Keywords: Auto tricycle, developing country, injuries, Nigeria, occupant, pedestrian


How to cite this article:
Omoke N I, Lasebikan O A, Onyemaechi N O, Ajali N. Auto tricycle injuries and the vulnerability of occupants and pedestrians in a developing Country: A multi-center study. Niger J Clin Pract 2019;22:971-6

How to cite this URL:
Omoke N I, Lasebikan O A, Onyemaechi N O, Ajali N. Auto tricycle injuries and the vulnerability of occupants and pedestrians in a developing Country: A multi-center study. Niger J Clin Pract [serial online] 2019 [cited 2019 Jul 20];22:971-6. Available from: http://www.njcponline.com/text.asp?2019/22/7/971/262528




   Introduction Top


The morbidity and mortality associated with road traffic crashes is a major problem in developing countries. The road traffic injury, though an important public health concern in developing countries, is a neglected epidemic due to lack of appropriate policy response or implementation of existing ones to prevent road traffic crashes and make the roads safer for vulnerable road users.[1] In low-income nations, auto tricycle related road traffic injury is a component of this neglected epidemic though under reported.

Auto tricycle (motorised rickshaw) known as “keke” in Nigeria local parlance is a lightweight, flexible and open vehicle designed to carry three adult passengers and a driver. Findings from biomechanical studies indicate that auto tricycle has limited crashworthiness, and at a crash speed as low as 30 km per hr, the occupants are at risk of severe injuries.[2] This risk of severe injury to the occupants is futher increased by being an open vehicle without safety device such as seat belt and airbag.[2] The pedestrians hit by auto tricycle are also at risk of injury of varying degrees of severity depending on the orientation of the pedestrian on impact.[2] The vulnerability of pedestrian and other road users is even higher in a setting, where most of the roads lack pedestrian walkways and disregard for traffic rules and safety measures is common among drivers as often the case in developing countries.[3]

Auto tricycle is a popular and common mode of transport in Asian countries,[4] it is an emerging means of public transport in some African countries. In Nigeria, it was introduced as a mode of transport about two decades ago; some years later, it was popularized to cushion the effect of ban on commercial two-wheeled motorcycles from urban roads (especially in capital territories and major cities) on the account of high prevalence of road traffic injuries and metropolitan security concerns associated with the latter.[5],[6] This development also resulted in metamorphosis of two-wheeled motorcycle drivers (known for, recklessness and hazardous driving on the road) into auto tricycle drivers without proper training and re-orientation.[5] Thus, an increasing number of auto tricycle injuries in the emergency rooms and recent reports in the media on myriad of challenges associated with commercial auto tricycle in our environment are emerging concerns.[5]

There are numerous published reports on motorcycle related road traffic injuries but almost all of them focused on pattern of injuries and crash characteristic of two- wheeled motorcycle.[3],[7],[8],[9],[10],[11],[12] Overall, there is very limited data on auto tricycle injuries and vulnerability of its occupants, and pedestrians.[4],[12],[13] The almost non-existence of published report on auto tricycles injuries in the sub- region necessitated this study for a data that can facilitate interventions aimed at prevention and optimum care of victims. Therefore, this study aimed to determine the scope and type of collisions and injuries from auto tricycles crashes among victims (drivers, passengers and pedestrians) visiting three tertiary hospitals in Nigeria, and identify potential areas of intervention to reduce morbidity and mortality associated with auto tricycle injury.


   Patients and Methods Top


This was a multi-center prospective study of all the patients (occupants of auto tricycle involved in a crash or pedestrians hit by auto tricycle) with auto tricycle injuries presenting at the Emergency room of three Nigerian tertiary hospitals, Federal Teaching Hospital Abakaliki Ebonyi State, National Orthopaedic Hospital Enugu and University of Nigeria Teaching Hospital Ituku- Ozala from 1st February 2015 to 31st July 2016. The Federal Teaching hospital Abakaliki and University of Nigeria Teaching Hospital Ituku- Ozala Enugu are two of the major University teaching hospitals in Nigeria. National Orthopaedic Hospital Enugu is a regional orthopaedic and trauma centre located in Enugu southeast Nigeria. These three centres serve the Southeast, South-South and part of the North-Central geopolitical zones of Nigeria, a population of about 30 million people.

Data collected on a proforma included, demographic characteristics of road user category, injury host status (driver, passenger or pedestrian), number of occupants, type of road (intra-city or inter-city road), time and type of collision, type and anatomical site of injury, helmet use, pre-hospital care, the duration between injury and presentation to the hospital, trauma score parameters. The other outcome variables using trauma scores were injury severity score (ISS) and probability of survival

(TRISS), and dead or alive. The alive were futher grouped into treated and discharged and self- discharge against medical advice (DAMA). Data collected also included the reason for DAMA, the duration of time between injury and death, and duration of admission by the time of death. The time of injury was grouped into four, 12-5.59 am, 6 am-11.59 am, 12 noon-5.59 pm and 6 pm-11.59 pm. In Nigeria, night-time refers to 6 pm-11.59 pm and 12 am-5.59 am while day- time refers to 6 am-11.59 am and 12 noon-5.59 pm.

All the occupants of other types of motor vehicles that collided with auto tricycle were excluded from this study.

With the approval of Ethics and Research Committee of the hospitals, Resident doctors in each of these three centers collected the data from within hours of arrival to the end of admission in the hospital.

Data was analyzed using Statistical package for Social Sciences (SPSS) version 20 (SPSS Chicago IL, USA) statistical soft ware for graphs, frequency tables and cross tabulation. Chi squared test was used for statistical test of significance and P value <0.05 was considered significant.


   Results Top


Within the period of this study, there were 210 patients with auto tricycle injury. Amongst these patients, 181 (86.2%) sustained injures as occupants (52 drivers and 129 passengers) of auto tricycle whereas 29 (13.8%) were pedestrians hit by auto tricycle giving a driver, passenger and pedestrian ratio of 1.8: 4.5:1. The male to female ratio was 2:1 and the age range was 3 months to 76 years with a mean of 31.2 ± 12.9 years and peak age incidence of 21-30 years. In [Table 1], the incidence of auto tricycle injury involving the occupants was significantly (P < 0.008) more in the young and middle aged compared to other age groups whereas the incidence of pedestrian injury was more in children and elderly than other age categories.
Table 1: Occupants and pedestrians by socio-demographic characteristics

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The three top occupational groups involved in injury as either occupants or pedestrians were students (28.6%), traders (25.7%) and commercial cyclist and drivers (20.5%) as shown in [Table 1].

One hundred and eighty two patients (86.7%) sustained injury on the intra city road whereas 38 (13.3%) patient were injured on the intercity road. Majority of the patients (55.2%) sustained injury from auto tricycle ≥4 wheeled vehicles collision as shown in [Table 2]. Lone auto tricycle collision was due to, loss of control/overturning (17, 41.5%), fall into ditch/pothole (10, 24.4%), over speeding (5, 12.2%), burst tyre (4, 9.8%), tyre pull out (4, 9.8%) and break failure (1, 2.4%). None of these casualties was wearing a helmet at the time of injury. In 41 (19.5%) victims, injury was sustained from collision that involved overloaded auto tricycle. The incidence of injury from overloaded auto tricycle was significantly highest in lone auto tricycle collision (31.1%) compared to auto tricycle collisions with ≥4 vehicles (19.7%), auto tricycle (18.2%) and two-wheeled motorcycle (14.3%) (P = 0.048).
Table 2: Distribution of casualties by Collision and Road type involved

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A hundred and twenty six patients (60%) sustained injury at nighttime whereas 84 patients (40%) sustained injury in the daytime. The peak period of incidence varies with respect to the type of collision; it was 12 noon -5:59 pm for auto tricycle- ≥4 wheeled collision, and 6 pm-11:59 pm for collisions involving auto tricycle-auto tricycle, lone auto tricycle and auto tricycle -pedestrians as shown in [Figure 1].
Figure 1: Auto tricycle injury by type of collision and time if injury

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The lower extremity (50%), head (38.6%) and upper extremity (30.4%) were the three top anatomical regions involved as shown in [Figure 2]. There were no significant differences in the incidence of injuries in the extremities and head region between occupants and pedestrians. The incidence of chest injury was about twice among the occupants compared to the pedestrian [Figure 2]. Sixty (28.6%) of the patients sustained multiple injuries.
Figure 2: Distribution of data tricycle injuries by body region and road user type

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There were 93 fractures in 64 (30.5%) of the casualties. In [Figure 3]: the tibia, maxillofacial bones and the femur were the three top bones fractured and the shoulder joint accounted for half of six joint dislocations observed. There were 243 soft tissue injuries in 161 (76%) of the patients. Lacerations, abrasions/friction burns and contusions accounted for 82 (34%), 80 (33%) and 37 (15.2%) of these soft tissue injuries respectively. There are about 29 (13.8%) of the patients sustained traumatic brain injury whereas eight (3.8%) had organ/visceral injury [Figure 3].
Figure 3: Auto tricycle injuries by type and anatomical sites

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The mean duration between injury and arrival to the hospital was 2.5 hours. The majority of the patients arrived within 1 hour (156, 74.3%); 41 patients (19.5%) arrived 1 hour to 6 hours; 8 patients (3.8%) arrived between 7 and 24 hours, and 5 patients (2.4%) arrived after 24 hours.

The majority of the patients (183, 87.1%) had no pre hospital care. The mode of transportation of the patient to the hospital was car (98, 46.7%), auto tricycle (88, 41.9%), bus (17, 8.1%), van (4, 1.9%), ambulance (2, 1.0%) and two -wheeled motor cycle (1, 0.5%).

The injury severity score, ISS of the casualties was in a range of 1-27 with a mean of 6.1 ± 0.39. One hundred and eighty four patients (87.6%) sustained mild-moderate injury whereas the rest (12.4%) were severely injured. In [Table 3]: there was no significant difference in the severity of injury among the occupants and the pedestrians (P = 0.879), the incidence of moderate to severe injury was higher on inter-city than intra-city road (P = 0.001) and the incidence of severe injury was significantly higher in the day than at nighttime (0.043). Majority of the patients (97.1%) had TRISS ≥95% probability of survival. Three patients, all of whom had probability of survival (TRISS) >50% died, giving a case fatality rate of 1.4%. One of them (a passenger) that died had severe head injury (TRISS, 66.7%); one (a driver) had severe head and chest injury (TRISS, 95.5%) and the other one (a pedestrian) had abdominal injury (TRISS, 93.7%). All the patients that died presented within the first one hour of injury and each died in1 hr, 48 hrs and 6 days of hospital admission respectively.
Table 3: Auto tricycle injury severity by road user category, road type and period of injury

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Of the 207 survivors (98.6%), 196 (93.3%) were treated and discharged (131 from emergency room and 66 from surgical ward admission), 6 (2.9%) discharged self against medical advised (reasons for DAMA were traditional bonesetter preference and financial constraint in 5 and 1 patients respectively) and 2 (1%) transferred. There was no post mortem conducted for any of the mortalities.


   Discussion Top


The result of this study indicate that auto tricycle occupants, and pedestrians are vulnerable to road traffic injury, a neglected epidemic, in developing country setting such as Nigeria. The driver passenger pedestrian ratio in this study indicates passenger bias and is at variance with pedestrian bias reported by Schmuker et al. in Hyderabad, India.[4] The reason for this variation is not evident. The predominance of young and male victims in this study is similar to the finding reported by Schmuker et al.[4] The socio-demographic characteristic of the victims is also similar to that of the victims of two-wheel motorcycle in a previous published report from Nigeria:[3] this suggests a switch over to auto tricycle by the same category of the population (age, gender, and occupational distribution wise) that patronized the former.

In Nigeria, auto tricycle is mostly in use as means of public transport in cities; this perhaps explains the predominance of the victims that sustained injury on intra-city roads.

The types of collisions observed in this study indicate the vulnerability of auto tricycle to crash into other vehicles, and the vulnerability of pedestrian to auto tricycle on the roads. Furthermore, injury from collisions involving overloaded auto tricycle was common and its incidence significantly related to the type of collision. Abiding by the principles of loading in auto tricycle could have prevented a third of the injuries in lone auto tricycle collision, and injuries from other overloading related collisions.

In this study, the peak period (evening and early night hours) incidence of auto tricycle injuries involving auto tricycle collisions with pedestrians, auto-tricycle, and lone auto tricycle collisions is similar to the findings reported by Schmuker et al.[4] Auto tricycle collisions with ≥4-wheel vehicles incidence though peaked from midday to early evening hour dropped a little and remained high up to early hours of the night. The reason for evening and night period bias in the temporal distribution of types of collision is not evident. Silvia and co workers reported that in Sri Lanka over a two-third of auto tricycle accidents at night was alcohol related.[12] We were unable to obtain reliable information on alcohol consumption and this may be a limitation of this study. However, improved visibility (use of constant running light and reflective labels on auto tricycle body) may reduce the high incidence of evening and night related collisions and injuries.

The three top anatomical regions (lower extremity, head and upper extremity) involved in auto tricycle injury in this series are similar to the finding reported by Muzzammil et al. in Pakistan.[13] The distribution of superficial open wound in the body region in this series is also similar to the finding reported by Schmuker et al. in India.[4] In the event of collision, the occupants of auto tricycle (an open vehicle without seat belt) can easily be thrown out [5] or dive unto the road in a fear and flight response. This can result in injuries of varying degrees of severity especially head injury and superficial open wounds, and perhaps explains the high incidence of abrasions, friction burns and lacerations observed in head and extremities in this study. This also emphasizes the importance of adding seat belt to the design of auto tricycle to improve its crash worthiness; a previous recommendation based on findings from biomechanical studies.[2]

In Nigeria, there is no mandatory crash helmet law for auto tricycle occupants as applicable to two-wheeled motorcycle: none of the casualties wore crash helmet at the time of injury. The involvement of head region in injury (38.7%), traumatic brain injury in 29 (13.8%) of the patients, and the preponderance of head injury- related mortality in this study is a clear evidence to emphasis the use of crash helmet for auto tricycle occupants.

The mean injury severity score and the lack of significant difference in the severity of injury between auto tricycle occupants and the pedestrian observed in this study is similar to the findings reported by Schmuker and co-workers.[4] In the setting of this study, intercity roads give more room for higher speed compared to intra city ones that are often congested. Thus, collisions are more likely to occur at a higher speed on inter-city roads compared to intra -city ones. This perhaps explains the significantly more severe injury in the former than the later in this study. The reason for the significantly higher incidence of severe injury in the daytime compared to nighttime in this study is not evident.

The case fatality rate in this study is less than the 2% in Siri Lanka and 12% in India reported by Silva et al.[12] and Schmuker et al.[4] respectively. However, all the patients that died had a probability of survival greater than 50 percent, which implies preventable deaths. The high probability of survival of these patients that died is a reflection of inadequacies of the emergency health care services in Nigeria, which other previous study documented.[3],[14]

The strength of this study is in being a multi-center and prospective one. To the best of our knowledge, it is the first study to highlight auto tricycle injuries and the vulnerability of drivers, passengers and pedestrian in Nigerian setting. Thus, the finding in this study can facilitate preventive strategies as well as form the basis for comparison in future studies in the sub region. The limitation of this study is in being a hospital based one and may not be a representation of entire population of auto tricycle related injury: fatal and non-fatal injuries that did not present to the hospital were not captured in the study.


   Conclusion Top


In Nigeria, auto tricycle has come to stay as a common means of transport and vulnerable road users are not immune to auto tricycle related injuries and its associated morbidity and mortality. This calls for preventive strategies, based on the findings in this study, which may curb the menace of auto tricycle crash and resultant injuries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Nantulya VM, Reich M R. The neglected epidemics: Road traffic injuries in developing countries. BMJ 2002;324:1139-42.  Back to cited text no. 1
    
2.
Chawla A, Mukherjee S, Mohan D, Singh J, Rizvi N. Crash Simulation of Three Wheeled Scooter Taxi (TST). New Delhi: Indian Institute of Technology; 2003. p. 1-14.  Back to cited text no. 2
    
3.
Solegberu BA, Ofegbu CPK, Nasir AA, Ogundipe OK, Adekanye AO, Abdur-Rahman LO. Motorcycle injuries in a developing country and the vulnerability of riders, passengers, and pedestrians. Inj Prev 2006;12:266-8.  Back to cited text no. 3
    
4.
Schmuker U, Dandona R, Kumar GA, Dandona L. Crashes involving motorised rickshaws in urban India: Characteristics and injury pattern. Injury 2011;42:104-11.  Back to cited text no. 4
    
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Idialu B. Nigeria's tricycle of trauma. Available from http://nigeriaobservernews.com/2016/12/nigerias-tricycles-of-trauma/. [Last accessed on 2018 Jul 22].  Back to cited text no. 5
    
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Babatunde A. Ban of Okada and security situations in Delta state. Available from http://dailyindependenting.com/2013/11/ban-of-okada-and-security-in-delta-state/. [Last Accessed on 2014 Jan 27].  Back to cited text no. 6
    
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Ofonime EJ. Prevalence and pattern of road traffic accidents among commercial motorcyclist in a city in Southern Nigeria. Educ Res 2012;3:537-42.  Back to cited text no. 7
    
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Chichom-Mefire A, Atashili J, Isiagadigui JG, Fon-Awah C, Ngowe-Ngowe MA. Prospective pilot cohort analysis of crash characteristics and pattern of injuries in riders and pillion passengers involved in motorcycle crashes in urban area in Cameroon: Lessons for prevention. BMC Public Health 2015;15:915.  Back to cited text no. 8
    
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Nwadiaro HC, Ekwe KK, Akpayak I C, Shitta H. Motorcycle injuries in north-central Nigeria. Nig J Clin Pract 2011;14:186-9.  Back to cited text no. 9
    
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Sisimwo PK, Mwaniki PK, Bii C. Crash characteristics and injury pattern among commercial motorcycle users attending Kitale level IV district hospital, Kenya. Pan Afr Med J 2014;19:296.  Back to cited text no. 10
    
11.
Fitzharris M, Dandona R, Kumar GA, Dandona L. Crash characteristics and pattern of injury among hospitalised motorised two-wheeled vehicle users in Urban India. BMC Public Health 2009;9:11.  Back to cited text no. 11
    
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Silva M, Nellihala LP, Fernando D. Pattern of accidents and injury involving three-wheelers. Ceylon Med J 2001;46:15-6.  Back to cited text no. 12
    
13.
Muzzammil M, Minhas MS, Effendi J, Jahanzeb S, Mughal A, Qadir A. Qing-qi rickshaw: A boon or bane for public transportation? A study of road traffic injury patterns involving Qing-qi rickshaw in Karachi Pakistan. J Ayub Med Coll Abbottabad 2017;29:289-92.  Back to cited text no. 13
    
14.
Omoke NI, Chukwu COO, Madubueze CC, Oyakhilome OP. Outcome of road traffic injury received in the emergency room of a teaching hospital South east Nigeria. Trop Doct 2012;42:18-22.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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