Injury epidemiology has become a major public health concern 1. An injury affects more than just the person injured; it affects everyone involved in the injured person’s life. Injury, with all its consequences of death, life-long disabilities, physical disfigurement, and financial harms, can cause family destruction and community devastation 2,3. Worldwide estimates show that 16 000 die from injuries daily, accounting for 9% of the world’s deaths 2.
Injury affects the most productive earning group; it was reported to be the leading cause of all deaths for the age group 1 to <45 years. Moreover, 73% of individuals who die from accidents are men, which contributes to the financial burden of families, especially low-income ones 4.
Deaths due to unintentional injuries include many causes such as motor vehicle/road traffic accidents (RTA), falls, and burns, whereas intentional injuries (suicidal or homicidal) are often discussed separately for injury prevention 2,5,6.
More than 90% of deaths due to injury occur in low-income and middle-income countries, where preventive efforts are often nonexistent, and healthcare systems are least prepared to meet the challenge, the highest percentage of which is RTA deaths 4.
Road traffic injuries and deaths are a major public health concern worldwide. Appropriate safety measures are urgently required to avoid worsening of the problem globally. Without appropriate action, by 2020, road traffic injuries are predicted to become the third leading contributor to the global burden of disease and injury instead of ninth in 1990 7.
This should be mainly considered in developing countries, where rapid motorization is likely to occur over the next two decades 2. A WHO World Bank report has estimated a 65% increase in RTA deaths in low-income and middle-income countries over the 20 years between 2000 and 2020, unless there is new commitment to prevention 7.
A report issued from the injury control unit of the Ministry of health and population (preventive sector) in 2006, stated that more Egyptians die on roads than from tuberculosis, whooping cough, meningitis and measles together. And according to the report issued from the Egyptian Cabinet Information and Decision Support Canter (IDSC) in 2007, road traffic accidents (RTAs) victims represented 35% of victims of all accidents, and the Egyptian roads witness at least an accident every 6 hours and fatality rate due to (RTAs) was estimated to be 16 per 10,000 recorded vehicle, compared to 12 per 10,000 vehicle in other developing countries, and 2–4 per 10,000 vehicle in industrialized countries, (Fatality rate in Egypt was 2–4 times the rate in industrialized countries).
Identification of independent risk and protective factors for injuries is necessary for the development of successful prevention strategies 6.
This study aimed to determine the incidence and describe the patterns of injury-related mortality in Alexandria, Egypt, through 2000–2010, and to identify their association with some demographic characteristics.
Materials and methods
Alexandria, Egypt, is the second-largest city in Egypt (with a population of 3.5–5 million). Alexandria extends about 20 miles (32 km) along the coast of the Mediterranean Sea in north-central Egypt. It is Egypt’s largest seaport, serving ∼80% of Egypt’s imports and exports. Alexandria is also an important tourist resort.
Description of study data
Data on injury-related deaths were obtained from the Information and Decision Support Center in Alexandria, in the form of case records, for the period January 2000 till December 2010. [This center receives all vital event (deaths-births) certificates from health offices and hospitals all over Alexandria, and report the data to the main center in Cairo, where data from all over Egypt are pooled].
Demographic by time strata, were defined by the following factors:
- Year: 2000–2010.
- Seasons defined as quartiles: January–March, April–June, July–September, and October–December.
- Age of the deceased was grouped to identify different risk categories: less than 5 years (preschool), 5 to <10 (elementary school), 10 to <15 (high school), 15 to <25 (university students), 25 to <40 (adults), 40 to <60, 60 to <75, and 75 years and older.
- Districts: the seven districts of Alexandria names.
- Sex of the deceased.
- Estimates of the total size of each demographic stratum in every year were obtained from the Information and Decision Support Center in Alexandria, which used 1996 and 2006 census as bases and projected the population estimates. Then mortality was calculated per 100 000 population.
Effects of the variables – marital status and profession – were not investigated in our statistical models, as there was no estimated population size for every profession stratum or every marital status.
Types of injuries were obtained in the three-digit International Classification of Diseases (ICD)-10 codes and then classified into RTA, accidental burns, accidental falls, unintentional drowning, other unintentional injuries (fractures, unintentional poisoning, asphyxia or choking, collapse, electric shock, surgical complications), and intentional injuries (suicide, interpersonal violence, legal execution).
Statistical analyses were performed using STATA ver. 11 (StataCorp. College Station, TX, US A). Factors were considered significant at the α level 0.05 or less, two sided.
Incidence rates (IRs) of the different injury-related mortalities and temporal trends were calculated from 2000 to 2010. Incidence rate ratios (IRRs) with 95% confidence intervals (CI) were calculated using a zero inflation Poisson regression model, for the related demographic factors, in which the multivariate models controlled for potential confounders such as time (year), age, sex, and geographic region. This was done in separate models for each type of injury. In each model, demographic strata were considered as independent populations that were observed longitudinally at 11 time points (the years of the study time period).
Poisson regression is a method used to model the frequency of event counts or the event rate. In the present study, zero-inflated Poisson regression was used because the count data (number of deaths in each category by time) had excessive zero counts (no event).
Time-series analysis was performed: seasonal indices were calculated. Trend lines were plotted to the deseasonalized data, and equations were computed for significant trends, then the predicted values were computed and multiplied by the seasonal indices to compute predicted values for 2011 and 2012, quarterly.
Approval for this study was granted by the Egyptian Ministry of Health Central Directorate for Research and Health Development in September 2010, upon request from the researcher herself.
Through the period from January 2000 to December 2010, there were a total of 19 731 injury-related deaths. RTA formed 48.9%, drowning 12.2%, burns 12.1%, falls 9.9%, other unintended deaths 15.9%, and intended deaths formed 0.9% of the total injury-related deaths.
From the injury-related deaths (2000–2010), the age groups 15 to <60 formed 69.2%, men were almost three quarters, and the highest percent were married (42.5%) or single (33.2%; Table 1).
Study of the male to female distribution for different age groups revealed a high men to women ratio in the age groups 10 to <40 years. This was more evident in intentional deaths and deaths due to drowning, and was also clear for other injury-related mortalities, except for burning, which revealed an opposite ratio for those age groups (Fig. 1).
All injury-related mortalities combined showed a quadratic trend: starting with the highest incidence in 2000 (51.1/100 000), then reducing to an incidence of 38.3/100 000 in 2006 and then increasing again, till reaching 48.7/100 000 in 2008. Expected deaths for 2011 were 1987 (367 in Q1, 454 Q2, 704 Q3, 462 Q4) and 2068 deaths for 2012 (380 Q1, 472 Q2, 733 Q3, 482 Q4). (Fig. 2a and b).
RTA-related mortality followed a significant increasing trend (quadratic model): starting with a high incidence of 22.7/100 000 in 2000, then reducing to 17/100 000 in 2004, and then increasing again to reach the highest IR in 2008 (28.5/100 000) and 2009 (26.2/100 000). Expected RTA deaths were calculated to be 1133 deaths in 2011 (225 in Q1, 250 Q2, 345 Q3, 313 Q4) and 1246 deaths in 2012 (246 Q1, 275 Q2, 380 Q3, 345 Q4).
As regards drowning, mortality ranged from 4.7/100 000 in 2003 and 2010 to 6.7/100 000 in 2000.
Concerning burns, mortality followed a significant decreasing trend (linear model), with the highest IR in 2003 (7.7/100 000) and 2002 (7.4/100 000), and the lowest IR in 2009 (3.6/100 000). Expected to be 159 deaths in 2011 and 144 in 2012).
As regards falls, the highest IR (5.4/100 000) was detected in 2002 and 2003 and the lowest IR in 2009 (3.7/100 000) and 2010 (4.1/100 000). No significant trend was found.
As regards intended injury-related mortalities, deaths were the highest in 2000 (1/100 000), and then it decreased and remained uniform between 0.3/100 000 and 0.5/100 000.
Seasonal decomposition revealed that all types of injury-related mortalities combined were the highest in summer, with a seasonal index (SI) of 1.4. The seasonal effect was manifested most in deaths due to drowning, where SI were the highest in summer (SI of 2.68) and the lowest in winter (SI of 0.19) Fig. 3.
RTA-related deaths were the highest in summer (SI of 1.2) and autumn (SI of 1.06) and the lowest in winter (SI of 0.83). Deaths due to burns were the highest in summer (SI of 1.3) and the lowest in winter (SI of 0.75). Deaths due to falls were the highest in summer (SI of 1.23) and the lowest in winter (SI of 0.83).
As regards intentional injury relayed deaths, a seasonal effect was not obvious.
Some demographic characteristics associated with injury-related mortality
Males had a significantly higher estimated risk than females in all types of injury-related deaths, except for burns. IRR were 3.34, 95% CI [3.17, 3.51] in RTA; 4.01, 95% CI [3.47, 4.65] in drowning; 1.95, 95% CI [1.76, 2.17] in falls; and 1.15, 95% CI [0.64, 2.05] in intended deaths (in intended deaths, the risk value was not statistically significant), whereas in case of mortality related to burns, IRR was 0.71, 95% CI [0.65, 0.77] in males in relation to females (Table 2).
In all types of injury, those above 75 years of age had at least a five times higher estimated injury-related mortality rate than other age groups (P<0.05) (Table 2).
In reference to children below 5 years of age, estimated RTA-related mortalities were at least two times higher for all the other age groups.
As regards drowning, in reference to those 5 to <10 years of age, estimated mortality rates were 4.26, 95% CI [3.57, 5.09] times higher for those aged 15 to <25 years and 1.69, 95% CI [1.39, 2.05] higher for adults 25 to <40 years in age. Other age groups had almost the same risk.
Also, in reference to those 5 to <10 years of age, estimated mortality rates due to burns were 4.56, 95% CI [3.45, 6.04] times higher in the age group 60 to <75 years and at least three times higher for the age group 15 to <60 years. Those 0 to <5 years or 10 to <15 years had almost the same risk.
However, as regards estimated mortality rates due to falls, in reference to the age group 10 to <15 years, it was 4.33, 95% CI [3.38, 5.56] times higher in children less than 5 years and 4.23, 95% CI [3.22, 5.55] times higher in those 60 to <75 years of age.
Estimated mortality rate due to intended injuries was 3.15, 95% CI [1.14, 8.73] times higher in the age group 60 to <75 years in reference to the age group 15 to <25 years.
Estimated mortality rates related to the different types of injuries varied among people from the seven districts of Alexandria, but all were the highest in district 7, which has a less privileged socioeconomic status.
The results of this study showed a high incidence of injury related mortalities in Alexandria which ranged from 39.5 to 51.1/100 000 population (19 731 deaths), expected to increase by 4055 deaths by 2013, if no interventions are implemented. Of all injury-related deaths, 69.3% occurred in the age group 15 to <60 years, which is the most productive age. Almost 75% of the deceased were married, widowed, or divorced and expected to have been a source of income to their families. Besides, there may be social problems and emotional trauma due to the death of young family members, especially considering that almost 18% of deaths are of children less than 15 years of age. One very important factor in injury-related deaths is that they are preventable to a very large extent, which makes their patterns an important subject for investigation.
An important limitation noticed in the studied data is the lack of a uniform definition of the causes of deaths, which were instead sometimes encoded by the organ injured, which the researcher believes might have caused under-recording in some causes of deaths under the category of other unintentional injuries. This particularly applies for RTA, as the deaths included were only the immediate ones found at the site of the accident and did not include deaths occurring within 30 days of road traffic crashes, the definition stated by WHO 7. Also, deaths recorded as unintentional burns might, to some extent, include self-inflicted burns, reported as accidental to avoid legal issues.
A previous study performed on the validity of death certificates for injury-related causes of death reported at least 90% sensitivity and specificity on using three-digit ICD-9 coding and ICD-10 9,10.
In the present study, RTA mortality rates in 2000 through 2010 ranged between a minimum of 17/100 000 and a maximum of 28.5/100 000 population. This was similar to the rates reported by WHO in 2008 as an update of the 2004 report for the Eastern Mediterranean region (28/100 000), higher than the Americas (22/100 000) and Europe (18/100 000), and yet less than that reported for western Pacific (41/100 000), Africa (47/100 000), and south-east Asia (86/100 000).
The male to female ratio calculated for the distribution of different types of injury, except burns, reveals that the high incidence in youths and adulthood was mostly due to higher incidence in men, which can be attributed to their impulsiveness at that age (Fig. 1).
In the present study, RTA formed 48.9%, drowning 12.2%, burns 12.1%, falls 9.9%, other unintended deaths 15.9%, and intended deaths formed 0.9% of the total injury-related deaths.
Another study showed that all Canadian provinces and territories 1979–2002 showed a decreasing trend in the mortality rates of total injuries. Motor vehicle-related injuries were the most common cause of injury deaths (accounting for an average of 36.4% of total injury deaths), followed by suffocation (14.3%), drowning (13.5%), and burning (11.1%) 11.
The current study shows that 68.4% of RTA deaths occurred in the age groups 15 to <60 years, the productive earning years, and 80% were men. Similar results were obtained in WHO report, in which 15–44 year olds accounted for more than half of all road traffic deaths in 2002. They also accounted for about 60% of all disability adjusted life years lost because of road traffic injury 12 another WHO report 2004 and 73% of the people killed were men 7. A recent study in Bangladesh found that 21% of road traffic deaths occurred to household heads among nonpoor people versus 32% among poor people. Three quarters of all poor families who had lost a member to road traffic death reported a decrease in their standard of living, and 61% reported that they had had to borrow money to cover expenses following their loss 7.
The current study shows that RTA-related deaths were highest in the summer, the time when around two million people travel to Alexandria for summer vacations and recreation, causing high rates of traffic flow and groups of pedestrians crossing the streets, especially the Korneesh road, which is a main road along the beach about 23 km long. Also the increasing incidence starting 2008–2009 can be attributed to the widening of the Korneesh, where cars move faster and people are unable to cross the roads fast enough.
Estimated risk ratio showed that children below 5 years of age were at the least risk and this can be explained by the fact that they do not go to streets alone and are always under their parents’ protection while crossing the streets. Estimated RTA-related mortalities were four times higher for those 60 to <75 years of age due to deterioration of their visual acuity and color identification, which is not insisted upon during renewal of driving licenses, and also because of the deterioration of their locomotor ability, which does not allow them to cross the road rapidly, especially after widening the roads. Estimated IRR was seven times higher for those above 75 years of age, which is a vulnerable age group that cannot survive fractures or internal injuries.
Also, men were at a higher risk, which could be explained by the higher risk exposure. This was in agreement with the United Nations population projections, which indicated that people 60 years and older will account for ever-greater proportions of all countries’ populations at risk of RTA deaths over the next 30 years, and that the vulnerability of elderly people to road traffic deaths and serious injury will be of increasing concern globally 7.
Also, a higher risk was estimated for remote areas, which are usually on a high way, where cars move at a very high speed, and people are from a lower socioeconomic strata and have to walk long distances on the road to access public transportation.
This study showed that drowning-related deaths were the second leading cause (12%) of injury-related deaths. WHO reported drowning to be the third leading cause of unintentional injury death worldwide, accounting for 7% of all injury-related deaths, and that 96% of unintentional drowning deaths occur in low-income and middle-income countries. Deaths due to drowning were the highest in summer, the season of water-related recreation in Alexandria. Also, men were at a four times higher risk, which could be explained by higher exposure to water through activities such as swimming and boating. Also higher risk estimated for people from remote less privileged economic level areas may be due to nontraining on swimming and lack of flotation devices, or that many of them work at simple jobs by the sea example fishing and repairing boats.
The third leading cause of unintentional injury death was burns (12.1%). It showed a decreasing trend from a highest of 7.7/100 000 in 2003 to a lowest of 3.6/100 000 in 2009. These rates were lower than those reported by the WHO for Africa (17/100 000), Americas (33/100 000), Europe (53/100 000), and south-east Asia (59/100 000).
It was reported that about 75% of house fire deaths are caused by a victim’s inhalation of smoke and subsequent lack of oxygen, rather than extensive burns 6.
Overall, residential fire-related deaths have decreased by almost 50% during the past 20 years. This trend may be attributable to both prevention efforts and marked improvements in burn care and burn survival during the past two decades 13,14.
Higher rates of burn-related deaths were estimated for women and for those above 15 years of age, which might indicate causes related to kitchen accidents or self-immolation. This age–sex pattern was consistent across multiple studies, and the average ratio of fire-related deaths of young women to young men was 3 : 1 15.
As regards deaths related to falls, it was the fourth leading cause (9.9%) of injury-related deaths, with a highest IR of 5.4 in 2003 (206 deaths) and a lowest IR of 3.7 in 2009 (161 deaths).
The WHO reported that an estimated 424 000 fatal falls occur each year, with an IR of 3.73/100 000 population, making it the second leading cause of unintentional injury death, after road traffic injuries. Over 80% of fall-related fatalities occur in low-income and middle-income countries 15. It is higher in summer, the season of holidays.
Estimated mortality rates due to falls were 4.33 times higher in children less than 5 years of age, in reference to the age group 10 to <15 years; infants left unsupervised or alone with another child (with their high curiosity to explore things) are so prone to fall, where strong falls in this vulnerable age groups, together with those 60 years old and above, are usually fatal.
Men were 1.95 times more prone to fall-related deaths. Possible explanations of the greater burden seen among men may include higher levels of risk-taking behaviors and hazards within occupations 16.
The higher seasonal factors for falls in summer may be attributed to the fact that it is the season for vacations and students are more outgoing and also it is a dry season in Egypt (no rain) and so building constructions increase in summer and workers may be more prone to falls from heights.
Intended injury-related mortalities have remained stable between 0.3/100 000 and 0.5/100 000. This can be either due to under-recording or the fact that violence-related injuries are usually not fatal.
Conclusion and recommendations
Injury-related mortalities were of high incidence between the years 2000 and 2010. RTA was the first leading cause of injury related deaths. More than two thirds of injury-related deaths occurred in the most productive age group. Deaths related to falls had high estimates in children less than 5 years. Men were more at risk than women in all types except for mortality related to burns. Higher rates were calculated for remote districts and during summer. Policy makers need to recognize injury problem as a public health crisis, design appropriate policy responses, and implement urgent interventions for safety (incidence prevention and timely appropriate management) applicable to the demography of Egyptian population, focusing efforts on most affected population. Also, there should be more accurate recording of data and conforming to operational definitions (standardization of registration).
The authors thank the technician at the information and decision support center in Alexandria, for her help in providing the needed data.
Conflicts of interest
There are no conflicts of interest.