Road Traffic Injuries and Data Systems in Egypt: Addressing the Challenges

Abstract

Objective: Road traffic injuries (RTIs) are a major cause of global mortality and morbidity, killing approximately 1.3 million people and injuring 20 to 50 million each year. The significance of this public health threat is most pronounced in low- and middle-income countries where 90 percent of the world's road traffic–related fatalities take place. Current estimates for Egypt show a road traffic fatality rate of 42 deaths per 100,000 population—one of the highest in the Eastern Mediterranean Region. RTIs are also responsible for 1.8 percent of all deaths and 2.4 percent of all disability-adjusted life years (DALYs) lost in the country. Despite this, studies surrounding this topic are scarce, and reliable data are limited. The overall goal of this article is to define the health impact of RTIs in Egypt and to identify the strengths and weaknesses of each data source for the purpose of improving the current RTI data systems.

Methods: A 2-pronged approach was undertaken to assess the burden of RTIs in Egypt. First, a thorough literature review was performed using PubMed, Embase, ISIS Web of Knowledge, and Scopus databases. Articles pertaining to Egypt and road traffic injuries were selected for screening. With assistance from Egyptian colleagues, a comprehensive exploration of data sources pertaining to RTIs in Egypt was undertaken and secondary data from these sources were procured for analysis.

Results: The literature review yielded a total of 20 studies, of which 6 were multi-country and 5 were hospital-based studies. None examined risk factors such as speeding, alcohol, or seat belt use. Secondary data sources were acquired from national hospital-based injury surveillance; a community-based health survey; pre-hospital injury surveillance; the Ministry of Transport; the General Authority for Roads, Bridges and Land Transport; death certificates; and the central agency for public motorization and statistics. Risk factor data are also limited from these sources.

Conclusion: The results of this article clearly highlight the significant burden that road traffic injuries pose on the health of the Egyptian population. The hospital-based injury surveillance system that has been established in the country and the use of International Classification of Diseases (ICD-10) coding brings the system very closely in line with international guidelines. There is, however, some considerable room for improvement, including the need to extend the coverage of the surveillance system, the inclusion of injury severity scores and disability indicators, and standardization of the sometimes rather disparate sources from various sectors in order to maximally capture the true burden of RTIs.

Keywords:

• Road traffic injuries
• Egypt
• Injury epidemiology

Road traffic injuries (RTIs) pose a major global public health threat that has long been neglected. According to the recently published World Health Organization (WHO) Global Status Report on Road Safety (GSRRS; WHO 2009a), approximately 1.3 million people die each year on the worlds’ roads with between 20 and 50 million people sustaining nonfatal injuries. In 2004, 1.27 million people died as a result of RTIs, a number that is highly comparable to the number of deaths resulting from communicable diseases (Mathers et al. 2004). Though 2004 estimates place road traffic crashes as the ninth leading cause of death (responsible for 2.2% of all deaths globally), modeled projections predict that this will rise to the fifth leading cause by 2030 (3.6% of all deaths) if nothing is done to mitigate this escalating problem. Furthermore, 90 percent of road traffic fatalities occur in low- and middle-income countries (LMICs), which have only 48 percent of the world's registered vehicles (Figure 1). This translates to case-fatality rates of 21.5 and 19.5 per 100,000 population for low- and middle-income countries, respectively, compared to 10.3 per 100,000 for high-income countries (WHO 2009a).

Figure 1 Modeled deaths due to road traffic injuries per 100,000 population in the Eastern Mediterranean region. Source: Global Burden of Disease Update (World Health Organization 2004) (color figure available online).

Table I Characteristics of the WHO Eastern Mediterranean Region.

Countries	High income	Middle income	Low income	All
Population	33.6 million	299 million	213 million	545.6 million
% of global population	3.3	9.6	8.9	8.3
Vehicles	11.5 million	34.4. million	6.8 million	52.7 million
% of global vehicles	1.7	6.7	5.6	4
Source: Global Status Report on Road Safety (WHO 2009a).

Over 50 percent of all deaths resulting from road traffic crashes occurs in the 15- to 44-year-old age group, again with higher rates being seen in LMICs (WHO 2009b). With an overall case-fatality rate of 27.6 per 100,000, RTIs affect males more than females, with the latter having a rate of 10.4 per 100,000. This gender difference is observed in all regions regardless of region or age. In addition to their fatality burden, road traffic crashes also increase the burden of nonfatal injuries (Chandran et al. 2010). In 2004, RTIs were responsible for 41,223,000 disability-adjusted life years (DALYs) lost, equivalent to 2.4 percent of the total number of DALYs lost from disease globally.

The WHO Eastern Mediterranean Region (EMR) consists of 22 countries, covering over 500 million people, with varying country levels of national income (5 are high-income, 12 are middle-income, and 5 are low-income). According to the WHO global burden of disease 2004 estimates, the overall case-fatality rate due to unintentional injuries in the region was 61.7 per 100,000 population, which is very similar to the global case-fatality rate of 61 per 100,000 population (Mathers et al. 2004). Despite its relatively small population and relatively high proportion of higher income countries, the rate of years lived with disability is highest in the EMR (1194 per 100,000 population), indicative of the nonfatal impact of injuries (Chandran et al. 2010). Although the overall number of registered vehicles per 1000 population is comparatively low (96 per 1000 population), the case-fatality rate from RTI is one of the highest in the world (WHO Regional Office for the Eastern Mediterranean 2010). Table I demonstrates some basic vehicle data for the region, demonstrating the proportion of global vehicles that are in the EMR.

In 2002, EMR's 26.4 deaths per 100,000 due to RTI was ranked second, surpassing all but the African region (WHO Regional Office for the Eastern Mediterranean 2009a). In 2004, RTIs caused 146,000 deaths and 2.8 million nonfatal injuries (Mathers et al. 2004). As a result, RTIs were ranked as the sixth leading cause of death in EMR, surpassing tuberculosis, malaria, and HIV/AIDs. Similar to global trends, RTIs in the EMR disproportionately affect individuals who are in the economically productive age group of 15 to 44. It is, for example, the leading cause of death for those between 15 and 29 and the second leading cause of death among those between 5 and 14 and 30 and 44 (WHO Regional Office for the Eastern Mediterranean 2010). Likewise, more men in the EMR die from RTIs than women (WHO Regional Office for the Eastern Mediterranean 2009b). Among children, particularly male children, RTIs are the most common form of injury. In fact, the RTI death rate (34.2 deaths per 100,000 population) among men between 15 and 29 is ranked highest in the world (WHO Regional Office for the Eastern Mediterranean 2010). RTIs also pose a tremendous economic burden; it is estimated to cost EMR a total of US$7.5 billion per year, equivalent to 1 to 1.5 percent of the gross national product of most countries in the region (Razzak 2004).

The high burden of road traffic injuries among vulnerable road users—including pedestrians, children, and bicycle/motorcycle and public transport users—is characteristic of most countries in the region. Pedestrians account for almost half of the deaths due to road traffic crashes in the region (Downing et al. 1993; Mohammadi 2009). Though a number of interventions and road safety efforts have been put into place in the region many challenges are yet to be addressed, the most substantial of which is the poor quality of data (Geziary et al. 2004). It is noted throughout the region that even if a data system is in place, there are often significant discrepancies between the figures issued by the different sectors involved in RTI monitoring.

Egypt is a low-income country located in the northeast corner of Africa. Egypt has the largest, most densely settled population among the Arab countries and has a population of 76,823,000 within a geographic area of approximately 1 million km², only 6 percent of which is inhabited. Basic health information has shown that Egypt has been steadily improving. For example, according to United Nations Children's Fund (UNICEF) data, the under-5 mortality rate in 1990 was 90, whereas it is now 23. Similarly, the infant mortality rate in 1990 was 66, compared with 2008 when it was 20.

Compared to other countries in the EMR, Egypt has one of the highest reported road traffic death rates per 100,000 population (Figure 1). According to the Global Status Report on Road Safety (WHO 2009a), road traffic crashes resulted in 42 deaths per 100,000 population (1.8% of all deaths from all causes in Egypt) and, as per the global burden of disease study 2004 update, 444 DALYs lost per 100,000 population (2.4% of all DALYs lost in Egypt due to all causes).

Despite the alarming increases in the burden of injuries in Egypt, there is a significant scarcity of published scientific articles surrounding the true burden of RTIs in Egypt, with the few that are available being limited to small-scale, city-based, or facility-based studies. Limited public awareness of the issue coupled with diminished emphasis on road safety policies at the national level results in reduced interest in this topic. One of the most significant constraints of policymakers is the limited yet necessary reliable data pertaining to RTIs, and it is therefore imperative that due attention be paid not only to the RTI data systems that already exist in Egypt but also to the necessity to improve these systems.

The overall goal of this article is to define the health impact of RTIs in Egypt using available data in order to gain a clearer picture of the burden of RTIs in Egypt. The primary objective is to review the secondary national data sources available in Egypt, identifying some of the strengths and weaknesses of each data source in order to identify gaps, which, if addressed, could help to improve the RTI data systems in Egypt. A secondary objective of the article is to present a summary of scientifically published studies surrounding RTI in Egypt because currently no such review of the literature is available.

MethodS

In order to assess the burden of RTIs in Egypt, a 2-pronged approach was taken: a comprehensive literature review of published articles and gray literature and an analysis of existing secondary data sources.

Electronic searches were performed (updated as of November 2010) using PubMed, Embase, ISIS Web of Knowledge, and Scopus databases with the key words: Egypt AND accident, unintentional injury, road safety, traffic accident, traffic injury, traffic death, traffic fatality, seat belt, child seat, child restraint, OR speeding. Neither publication year nor language restrictions were applied. Figure 2 represents a flowchart of how the literature review was carried out. Initial review of titles and abstracts yielded 99 articles, of which 21 were unique citations (Figure 2, Table II; Abbas 2004; Abou-Raya and ElMeguid 2009; Al-Refaie et al. 2009; Day et al. 2010; El Din 2006, 2010; El Islam 1974; El-Zawahary 1967; Hamam and El Sayed 1999; Hammam 1968; Hassan et al. 2010; Hyder 2009; Jacobs and Sayer 1982; Rady 1997; Sakr et al. 2006; Smith and Barss 1991; Wintemute 1984, 1985). Only studies pertaining to Egypt and road traffic injuries were included. Letters, opinion pieces, evaluation of medical interventions, case reports, and case series were excluded from this review. Full texts were then reviewed using the same inclusion criteria. References from the identified studies were scanned and 5 more articles were found. Gray literature acquired from local collaborators was also added.

Figure 2 Flowchart summarizing literature review process for Egypt.

Table II Summary of literature review

Author (date)	Type of study	Location	Study population	Results	Conclusions/ Recommendations
Behavioral/perception/attitude studies
Day et al. (2010)	Cross-sectional	Cairo, Egypt	28 Young Egyptians (14–26 years of age) of medium to high socioeconomic status	The majority of the respondents believed that road traffic crashes are hadthah (accidents/out of one's control) rather than esabah (injuries) Education, enforcement, and engineering were recommended as intervention tactics	Young Egyptians of medium to high socioeconomic status were found to be receptive toward injury prevention programs. However, it is important to understand how these injury concepts are perceived (hadthah or esabah)
Islam et al. (1974)	Cross-sectional	Cairo, Egypt	55 Public transport drivers	Compared to normal drivers, neurotic and accident-prone drivers received a significantly higher score for neuroticism The neuroticism scores of accident-prone drivers were the highest amongst the three groups	Preemployment personality screenings were suggested
Rady (1997)	Cross-sectional	Cairo, Egypt	382 Physicians at Ain Shams University Hospital	11.2% of the participants used a seat belt regularly	Need intervention programs to reduce behavioral risk factors among physicians and laws that mandate seat belt use
Hospital-based studies
Abou-Raya and ElMeguid (2009)	Cross-sectional	Alexandria, Egypt	258 Elderly (65 years and +) road traffic injury patients	Elderly males were at higher risk for RTIs 57% of elderly RTI victims were pedestrians, 26% were car drivers, 14% were car passengers, 2.7% were bicyclists, and 0.7% were motorcyclists	Health and transport professionals must work together to prevent RTIs in vulnerable populations Recommendations include improving motor vehicle and road designs as well as offering frequent medical screenings
Al-Refaie et al. (2009)	Retrospective	Mansoura, Egypt	46 Blunt traumatic diaphragmatic rupture patients	The main cause of blunt traumatic diaphragmatic rupture was road traffic crashes (78.3%) Of the 46 patients, 2 (4.3%) died Blunt traumatic diaphragmatic rupture was more common in men in their 40s	Blunt traumatic diaphragmatic rupture was most common in men who have been involved in road traffic crashes
Hassan et al. (2010)	Cross-sectional	Tanta, Egypt	255 Patients with craniofacial injuries	Road traffic crashes were the most common cause of craniofacial injuries (54.12%) There were a higher percentage of males involved in traffic crashes (45.88%) compared to females (7.06%)	Engineering, enforcement, and education were recommended to decrease the number of craniofacial injuries
Sakr et al. (2006)	Retrospective	Alexandria, Egypt	509 Mandibular fracture patients	The main cause of mandibular fracture was road traffic crashes (39%) Among male patients, road traffic crashes were the leading cause (42%). On the other hand, among female patients, road traffic crashes were the second leading cause (36%) Among all road traffic crash patients, individuals between 21 and 30 years were at the highest risk (39%)	Results agreed with previous research
Modeling
Abbas (2004)	Statistical modeling	Rural roads in Egypt	N/A	The death per million vehicle kilometers in Egypt was 44.1. This was 34 times higher than G-7 countries and 3 times higher than other Middle Eastern countries Over the past 5 years, there has been a decrease in risk-based, causalities, and injury severity indicators but an increase in fatalities severity indicators	Recommendations included increasing the awareness of drivers regarding the importance of inspecting tires and observing speed limits. It is also necessary to implement tougher driver tests and ensure the presence of road signs and road shoulders
Secondary analysis
Hammam (1968)	Secondary data	United Arab Republic	N/A	Of all accident-related deaths in United Arab Republic, 2.8% could be attributed to motor vehicle crashes Urban areas experienced higher rates of motor vehicle related case-fatality compared to rural regions Males were found to be at higher risks of motor vehicle related fatality than females at all ages	Accident prevention program was recommended
Hamam et al. (1999)	Secondary data	Egypt		RTIs were the leading cause of injury-related deaths RTIs were responsible for 56% and 53% of all injury related deaths in rural and urban areas, respectively Victims of RTIs included pedestrians (67%), car occupants (14%), cyclists (7%), and motorcyclists (4%).	Recommendations included improving death registration system; conducting population-based, case-control, and cohort studies; and gaining endorsements from the national committee and safety council to collect injury-related data
Surveillance
El Din (2010)^a	Surveillance	Cairo, Egypt	N/A	Development of a surveillance database system. During the study period, there were 594 traffic crashes, which resulted in 992 injured and 51 dead Road traffic injury rate per 100,000 population in Cairo was 52.9 and road traffic death rate per 100,000 population in Cairo was 2.7 Most victims were male (82.2%) and 40 years or younger (73.6%) 52% of the victims were pedestrians	Recommendations included standardizing data collection system, educating young drivers and child pedestrians, improving road designs, adopting safety laws, creating a national road safety council, increasing the number of ambulances during holidays, and improving EMS performance
El Din (2006)	Surveillance	Egypt	N/A	In 2007, there were 6345 accidents, of which 5403 or 85% were due to road traffic crashes Road traffic crashes contributed to 29,855 injuries and 2416 deaths Giza, Cairo, and Elbehra governorates had the highest percentages of road traffic crashes	Recommendations included increasing the number of ambulances during holidays, forming mobile or static ambulance squads, improving emergency medical service performance, introducing safety laws, and standardizing data collection systems
Saad (2008)	Newspaper surveillance	Egypt	N/A	There were 1221 deaths, of which 48.89% were due to RTIs Among train, trucks, and car users, the latter group experienced the highest percentage of RTI deaths (51.01%) The percentage of RTI deaths compared to assault and drowning-related deaths is highest in the Red Sea governorate (92.86%)	Egypt's mortality registry can be enhanced with the use of public newspapers
Regional/global studies
El-Zawahry (1967)	Secondary data	Multi-country (inclusive of United Arab Republic)	N/A	United Arab Republic (UAR)-specific results: The UAR experienced the highest rates of accidents in general but the lowest rate of road traffic accidents Males were at greater risks for accidents The UAR experienced high risk of accidents but the proportion of case-fatalities was low compared to all other deaths	N/A
Hyder (2009)	Cross-sectional	Multi-country (Bangladesh, Colombia, Egypt, and Pakistan)	1559 Injured children (≤12 years)	Egypt-specific information: About 32% of the 1559 child patients were from Egypt Pooled results showed that: 350 Children suffered road traffic injuries, of which 39% were pedestrians, 19% were passengers of 4-wheelers, and 13% were passengers of 2-wheelers About 5% of the children wore seat belts or helmets 20 Children needed emergency surgery and 2 died	The authors concluded that it is feasible to assess childhood injuries and use standardized injury surveillance in LMICs It was recommended that pedestrian safety be incorporated into interventions
Jacobs and Sayer (1982)	Secondary data Analysis	Multi-country (inclusive of Egypt)	N/A	Pooled results show that: RTI-related fatality rates per vehicles were higher in developing countries compared to developed countries RTIs cost about 1% of the annual gross national product of developing countries RTIs were found to be a growing health and economic problem for developing countries	Recommendations included improving education, training, and enforcement as well as implementing cost-effective interventions
Smith and Barss (1991)	Secondary data analysis	Multi-country (inclusive of Egypt)	N/A	Egypt-specific information: Crude case-fatality rate was 4 per 100,000 population in males and 2 per 100,000 population in females Pooled results showed that: In most of the developing world, motor vehicle crashes were the leading cause of death from unintentional injuries Males were about 5 times more likely than females to experience RTI-related deaths RTI-related fatality rates per population, vehicles, and miles traveled have increased in the developing world	Recommendations included prioritizing causal factors, using epidemiologic surveillance of injuries, ensuring accurate recording, and conducting surveys as well as population-based prospective studies
Wintemute (1984)	Secondary data analysis	Multi-country (inclusive of Egypt)	N/A	Egypt-specific information: In 1978, crude case-fatality rate per 100,000 persons was 2.1. The proportional case-fatality rate for motor vehicle–related fatality to all deaths was 0.2, and the percentage of all RTI-related deaths was 4.4 Pooled results showed that: The relationship between economic development and RTI deaths was found to be weak if not nonexistent Income distribution in low-income countries had a stronger relationship to RTI-related deaths	RTI interventions were recommended to be country-specific because the determinants of RTI-related case-fatality vary across countries
Wintemute (1985)	Secondary data analysis	Multi-country (inclusive of Egypt)	N/A	Pooled results showed that: The relationship between economic development (GNP per capita) and RTI deaths was found to be weak RTI fatality rates were increasing most quickly in low- and middle-income countries. However, this relationship was not straightforward	Future studies that focused on examining noneconomic determinants were recommended
^aPersonal communication, April 10–15, 2010, Cairo, Egypt.

Sources of Road Traffic Injury Data in Egypt

Data systems, where they exist, throughout the whole of the EMR and in particular in Egypt, suffer from various challenges and very rarely do the differing sources of data within a country agree with each other. Though still in their infancy, data systems for addressing the burden of injury in Egypt are in place at a national level across the various sectors. Information on the contents, methods, and quality of each identified data set was collected

Both the WHO and the Ministry of Health, through the injury surveillance and control unit, have implemented pre-hospital and hospital-based injury surveillance systems as well as community-based household surveys. The Ministry of Interior also has an active traffic department with a designated research unit; however, these data are not publicly available at present. In addition, a subsidiary of the Ministry of Transport, the General Authority for Roads, Bridges and Land Transport (GARBLT), also regularly collects crash data; however, their remit is restricted to the federal roads within Egypt.

Table III highlights the main data sources and indicators collected within each data set.

Hospital-based injury surveillance

In 1996, the Ministry of Health responded to a national recommendation for the need to implement a national hospital based injury surveillance system housed within the Injury Control Unit in the Occupational Health Department of the Ministry of Health. The objectives of the system are to

1.	measure the incidence of injuries;
2.	assess the contribution of injuries to the overall disease burden in Egypt; and
3.	measure injury characteristics including populations at risk and areas in need of intervention.

Table III Sources of road traffic injury data, Egypt 2001 to 2009

Data type	Responsible organization	Year(s)	Key indicators available	Comments
National hospital-based injury surveillance	Ministry of Health	1999–2009	For all injury types: Crash location Facility Demographics Place of injury External cause of injury Type of injury Diagnosis Outcome Period of admission Referrals	All national government and teaching/university hospitals.
Community-based health survey	WHO	2009	Proportion of RTI fatalities of all deaths Leading causes of death Demographics Crash location Road user categories Safety intervention use Activity at time of crash Economic data	Nationally representative sampling (PPS)—5 governorates (Alexandria, Cairo, Assuit, Sharkia, Dakhlia) 11,118 households 47,797 individuals
Pre-hospital injury surveillance	Ministry of Health	2008	Fatalities Injuries Crashes Demographics Month/day/time Crash location Vehicle involved External cause of injury Diagnosis Paramedic performance Referrals	Two types of surveillance—one active and one combined active and passive surveillance. Accessible data are from this second form of surveillance and only account for severe, multivehicle crashes
Police	Ministry of Interior		Crash location Date/time Weather/road surface Mode of transport of injured Type of vehicle Vehicle behavior Cause of crash Demographics Driver license Type of injury	Unable to access this data^a
GARBLT			Crash location Date/time Weather/road surface Mode of transport of injured Type of vehicle Vehicle behavior Cause of crash	Looks at 10 national highways, one of which is the Cairo Ring Road. Additional roads to be added as part of RS10 will include the Alexandria roads
Death certificates			Date of death Demographics (name, age, sex, occupation) Place of death Address Cause of death Road user categories Type of vehicle
CAPMAS/Ministry of Interior		2001–2009	Crashes Injuries Deaths Number of vehicles damaged Crash location	Data sourced from Ministry of Interior. Delays in making data publicly available. ^a
^aAs of December 31, 2010.

The injury surveillance questions are administered by trained registry officers to all injury cases when they visit the emergency departments. The system collects injury data from all Ministry of Health facilities, including 234 general and district hospitals, 221 specialized hospitals, 487 health integration hospitals, and 194 rural health centers and units. In 2008, educational hospitals were integrated into the system (9 hospitals) and in 2009, university and teaching hospitals were also included (17 hospitals). The total number of facilities within the system constitutes 46.9 percent of the total number of Egyptian facilities. Currently, the Egyptian health facilities that are still not included in the national surveillance system are in the health insurance sector, police hospitals, prison hospitals, railway hospitals, and private sector hospitals. This equates to 1379 hospitals (53.1% of the Egyptian facilities).

Health information system—mortality data

In Egypt, the major sources of information for injury case-fatality are hospital records, police records, and the mortality information system. In the absence of a centralized agency, data have to be compiled from different sources. All deaths in Egypt are reported to the health system and a death certificate is completed for all deaths. This information is fed into the mortality information system and analyzed at the national information center. Information is available on name, age, sex, cause, place, and time and conditions leading to death. As of December 31, 2010, the most recent mortality data accessible for this article were for 2008, reflecting inconsistencies in coverage and reporting.

Community-based household survey

A community-based survey was carried out over a period of 4 months (March–June) in 2009 with the objectives of identifying the injury burden in Egypt, defining injury patterns and characteristics, and performing a basic assessment of the impact of injuries on affected individuals. Following an initial pilot study in one governorate (Giza), the final survey was undertaken in 5 out of the 27 governorates in Egypt (2 urban: Cairo, Alexandria; and 3 rural: Assuit, Sharkia, Dakhlia), resulting in a final survey population of 11,118 households (47,797 of 77 million individuals in Egypt).

Though this survey looked at all injuries occurring at the community level, there was a specific module for RTIs that disaggregated RTI data by variables such as age, gender, activity at time of RTI, mode of transport, and striking vehicle. Importantly, it is one of the few studies that collected risk factor data such as use of seat belts and helmets. Cross-verification of details with medical records was undertaken where possible as a means of quality control and triangulation of the data with police and hospital records was carried out for additional quality control purposes.

Pre-hospital data

The pre-hospital services in Egypt have 2 types of surveillance systems in place. The first system is passive, giving a monthly count of all of the ambulance fleet missions from the 29 ambulance departments in Egypt with records of on-the-scene deaths and injuries. The second system combines passive and active systems, offering a particular focus on those that involve more than 3 victims and representing 6 percent of the total number of crashes, 23 percent of the injuries, and 48 percent of the total number of deaths resulting from RTIs in Egypt. In addition, only the cases that are reported to the emergency services will be counted under this system. Numerous victims of RTIs in Egypt will be taken to hospitals by other methods of transport, including private ambulance fleets that exist in the country, particularly in the urban cities. There is a large degree of underreporting that accompanies the pre-hospital ambulance data systems.

Central Agency for Public Motorization and Statistics

The Central Agency for Public Motorization and Statistics (CAPMAS) is the official statistical agency of Egypt that collects, processes, analyzes, and disseminates all statistical data and the census. They do not routinely collect traffic crash–related data; however they are sent data by the Ministry of the Interior. Though there is approximately a 1.5-year time lag in receiving these data, they are made available for the public in the CAPMAS Annual Statistics report. The 2008 report was made available for the purposes of this article. CAPMAS is the only source of crash data available that allows disaggregation by governorate, time of day, and vehicular damage and presents injury and case-fatality data.

Results

The aforementioned search methods resulted in 19 studies (Table II): multi-country (inclusive of Egypt; n = 6); hospital-based (n = 4); behavioral, perception, and attitude (n = 3); surveillance methods (n = 3); secondary analysis (n = 2); and modeling (n = 1). The publication years ranged from 1967 to 2010. Multi-country (n = 6), nationwide (n = 4), and Cairo-based studies (n = 4) accounted for the majority of the literature. Similar to global trends, Egypt-specific results revealed that males and individuals from the most economically productive age range (15–44 years) had higher risks of road traffic–related injuries and fatalities compared to their counterparts. Furthermore, 3 studies found pedestrians to be the most vulnerable road users, accounting for the highest percentage of deaths (52%–87%). No studies examined risk factors such as speeding, alcohol, or seat belt use. Lastly, most recommendations included education, engineering, and enforcement:

•	Standardize data collection system (Seif 2006, 2007).
•	Increasing the awareness of drivers regarding the importance of inspecting tires and observing speed limits (Abbas 2004).
•	Health and transport professions must work together to prevent RTIs in vulnerable populations (i.e., the elderly; Abou-Raya and ElMeguid 2009).
•	Improve road design/conditions (Abbas 2004; Abou-Raya and ElMeguid 2009; Hassan et al. 2010; Seif 2006).

Estimates of the burden of RTI in Egypt have been calculated and compiled based on available data sources.

Crashes

Crash data were extracted from the CAPMAS data sets and from pre-hospital data. CAPMAS data support an estimate totaling 22,793 road traffic crashes in Egypt in 2009 and 30,666 damaged vehicles. There is a large discrepancy between the CAPMAS data and the pre-hospital surveillance data, which for the same year reported that there were 73,336 road traffic crashes in Egypt. Pre-hospital data are also subject to underreporting of less serious crashes. Respondents in the community-based survey indicated that only 23 percent of their crashes had been reported to the police.

The number of reported crashes in 2009 represents a crash rate per 1000 registered vehicles of 3.5. Crash rates per 100,000 population from 1990 to 2009 are shown in Figure 3. Disaggregating the available crash data by geographical location shows that the largest number of crashes occur on the national highways. According to these data, the total number of crashes occurring on the national highways in 2008 was 4717, which translates to an average of 12.9 crashes per day.

Figure 3 Rate of crashes per 100,000 population in Egypt, 1990 to 2009. Source: Central Agency for Public Motorization and Statistics (2009).

Figure 4 Rate per 100,000 population of nonfatal road traffic injuries by age and gender in Egypt. Source: hospital-based surveillance system (Ministry of Health 2009).

Figure 5 Rate of road traffic fatality per 100,000 population by age and gender. Source: mortality information systems (Ministry of Health 2009).

The community-based household survey also looked at crash location for nonfatal injuries. The results of the survey mirror the data from CAPMAS demonstrating that over half (53%) of all crashes resulting in nonfatal injuries occurred on national highways. Further disaggregation by governorate revealed that the majority of crashes occurring on the national highways occurred in Cairo (33%).

Injuries

The majority of the nonfatal road traffic injury data for this article stem from national hospital-based surveillance. Surveillance data from 2009 report an overall RTI rate of 131.91 per 100,000 population and rates of 207.36 and 52.98 per 100,000 population among males and females, respectively. Disaggregating these rates by age shows that the highest rate of RTI is among the productive age range in males with an age-specific rate of 275.12 per 100,000 for the 15- to 44-year-old group (Figure 4).

The community-based survey looked at nonfatal injuries among the survey population. The reported nonfatal injury rates due to RTIs are, for each age category, significantly lower than the reported rates from the national hospital-based surveillance. However, the age pattern observed is mirrored in the survey findings with the highest nonfatal injury rates observed in the 15- to 44-year male age group (51.4 per 100,000 population) followed by females aged 15 to 44 years (45.1 per 100,000 population).

Table IV Overview of the strengths and weaknesses of select data sources for road traffic injury in Egypt, 2010

Data source	Strengths	Weaknesses
Mortality information systems	Well-established reporting system in place (CAPMAS) that all health and other injury-related authorities such as the Ministry of Interior, Ministry of Transport, and traffic police, are mandated to report deaths to	Definition of road traffic death does not include 30-day follow-up Underreporting of injury deaths due to inaccurate coding practices No formal evaluation of the data system has been carried out
Hospital-based injury surveillance	System collects all injured victims who present to emergency departments in select facilities Revised surveillance forms in keeping with international guidelines using ICD-10 coding Started including university hospitals in the national injury surveillance system in 2009	Until 2008, the coverage represented 53% of the reporting facilities (Ministry of Health faculties) Follow-up of patients for 30 days not carried out routinely No reporting for injury severity scores or degree of caused disabilities
Pre-hospital injury surveillance	Two surveillance systems in place—a passive one and a combined active/passive system The passive system accounts for all 29 ambulance fleets and gives details of all missions	Passive system not routinely used for monitoring and assessment of RTI burden The combined active/passive approach only represents 6%, 23%, and 48% of crashes, injuries, and deaths, respectively, in Egypt Looks at multivehicle crashes only
Police	Traffic police have a strong research department in place and are continuously improving their reporting systems Report some data to CAPMAS, which publish them in special report	Not all crashes and injuries are reported to police; therefore, underreporting exists
Community-based injury survey, 2009	Covered 5 governorates and used strong statistical sampling techniques Covered all injuries and included modules on risk factors and socio-economic costs	Small sample sizes of RTIs mean that survey results may not be generalizable to a national level Recall bias 21 Governorates excluded

Figure 6 Road traffic fatality rate by year, 2004 to 2008. Source: CAPMAS (2009).

Table V Comparison of data key data sources for road traffic deaths and injuries, 2007

	Data source
Indicator	Ministry of Interior (from GSRRS)	Mortality information systems	Pre-hospital surveillance	Hospital-based surveillance
Number of road traffic fatalities, 2007	12,295	7145	4205	1657
Number of road traffic injuries, 2007	154,000	n/a	n/a	86,244

Case Fatalities

For Ministry of Interior and CAPMAS case-fatality data, the definition of a road traffic fatality is one in which the victim dies at the scene of the crash. The follow-up of a victim to hospital or other facility to assess whether a death occurs within the standard 30 days following a crash is yet to be achieved in Egypt. Region-specific data stemming from the GSRRS for the Eastern Mediterranean region (which is based on Ministry of Interior data) stated that the rate of reported deaths per 10,000 vehicles was 28.6, with a modeled death rate of 73.1 when underreporting was taken into consideration. These rates are similar to those experienced in other EMR countries such as Pakistan and Yemen (78.5 and 84.3 per 10,000 vehicles, respectively). In addition, reported vehicle occupant deaths per 10,000 vehicles was 17, and when underreporting was factored in, this resulted in a modeled rate of 43.5 per 10,000 vehicles.

As mentioned previously, the predominant source of case-fatality data for road traffic crashes is the mortality information system in Egypt, which is fed into the WHO mortality database. These data are available at a national level disaggregated by age and gender (Figure 5). The national case-fatality rate for all ages as reported by the mortality information systems in 2008 was 10.58 per 100,000 population. The overall case-fatality rate for males for all ages is 16.41 per 100,000 population. This is compared to an overall female rate of 4.48 per 100,000 population. The trends show that case-fatality rates generally increase as age increases, reflecting the greater severity of RTI on the elderly populations.

Figure 6 is sourced from the mortality information systems report and shows a gradual increase in the road traffic fatality rate per 100,000 between 2004 and 2008.

CONCLUSION

The results of this article clearly highlight the significant burden that road traffic injuries pose on the health of the Egyptian population. There are, however, inherent gaps in the data presented due to the lack of data and limited coverage of the existing, accessible data systems. Inevitably each data source used here has its own inherent strengths and weaknesses (Table IV).

Many countries in the region, especially among the LMICs, do not have a hospital-based injury surveillance in place and therefore such an initiative is of great significance to Egypt. The use of International Classification of Diseases (ICD-10) coding in the hospital surveillance with several of the WHO-recommended core and optional data elements included brings the system very closely into line with international guidelines (Holder et al. 2001). There is still room for improvement, however; for example, the inclusion of injury severity scores and disability indicators that would serve to dramatically improve the quality and future applicability of the collected data. Increasing the coverage of the already existing hospital injury surveillance would be a large benefit to assessing the burden of injuries in Egypt. Many victims of road traffic crashes will go to private hospitals, which are currently not formerly included in the surveillance system.

Many of the data sources that report fatalities due to RTI do not follow the internationally recommended definition of a road traffic fatality, which includes a 30-day follow-up. This therefore results in a significant underrepresentation of the number of deaths that result from RTIs. Such data would be invaluable in obtaining a more accurate estimate of the years of potential life lost, which would, in turn, add strength to the argument that RTIs in Egypt are a significant public health problem that requires urgent attention.

The community-based household survey was one of the first surveys of its kind to be formally carried out in Egypt and therefore provides valuable and unique community-level data on RTIs in Egypt. Despite covering all causes of injury, the RTI module was comprehensive and included data that were not being collected elsewhere—specifically risk factor data on the use of safety devices. However, a more focused survey on RTIs would enable more detailed information to be drawn from the community level that would provide valuable information on disability, loss of earnings, attitudes toward road safety, etc. No such survey has been carried out in Egypt and, therefore, there is a good opportunity to involve local governmental agencies such as CAPMAS and incorporate injury modules into their regular household surveys.

As can be seen from the data in this article on Egypt, though systems are in place, there are considerable gaps that need to be addressed, and the sometimes rather disparate sources from various sectors need to come into line with each other in order to maximally capture the true burden of RTIs. However, unlike many countries in the Eastern Mediterranean region, there are existing systems in Egypt that are becoming well established as standard practice and are continuously evolving. It is clear that there is a strong awareness of the increasing burden of RTIs in Egypt and, more important, that this awareness is being acted upon through the development of the national road safety board, the establishment of the injury surveillance system, and the continuous improvements to existing data sources in the country.

The nonstandardization between data sets, particularly that between the health and transport sectors, is highlighted when road traffic fatalities and injuries are considered. For example, for the year 2007, it was reported in the Global Status Report on Road Safety (WHO 2009a) that there were 12,295 deaths due to RTIs. For the purposes of the GSRRS, the Ministry of Interior supplied the data. For the same year, the mortality information systems data reported that there were 7145 deaths as a result of RTIs (Table V). Similar discrepancies can be seen when road traffic injuries are considered.

Needless to say, however, it is clear from the data presented that road traffic crashes result in a considerable loss of lives in Egypt. With a modeled road traffic fatality rate of 41.6 deaths per 100,000 population, Egypt has the unfortunate distinction of suffering from the highest case-fatality rates than any other country in the EMR (Mathers et al. 2004). There is a rapid rise in the case-fatality rates in both men and women as age increases, with the highest rates seen in the 60+ age group.

Although deaths due to RTI are tragic and entirely preventable, another great impact of RTI is the morbidity and disability that accompanies nonfatal injuries. High RTI rates among men between the age of 15 to 44years demonstrate a significant burden in the most economically productive age and gender group in Egypt that needs to be addressed. The inclusion of cost data modules in the proposed data systems work will undoubtedly demonstrate the enormous economic burden that such a trend can have on a country and therefore may play an important part in convincing decision makers in Egypt to focus on this issue.

It is clear that there needs to be a strong push in Egypt to bring the various data systems in line with international guidelines and to bring them together in a standardized manner. Plans are in place to improve the existing systems, such as the vital registration database as well as injury surveillance, police, and mortuary data, and it is envisaged that gaps in the data that are being identified will be incorporated into the improved standardized data systems; for example, risk factor data, cost information, and disabilities. Such initiatives will only serve to further improve the ability of national stakeholders to accurately examine the burden of RTIs (and injuries as a whole) in Egypt and thereby effectively target programs toward alleviating this issue.

ACKNOWLEDGMENTS

This work was conducted as part of the Road Safety in 10 Countries project funded by the Bloomberg Philanthropies.