Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 Study

Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global... Int J Public Health (2018) 63 (Suppl 1):S187–S198 https://doi.org/10.1007/s00038-017-0987-0 ORIGINAL ARTICLE Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 Study GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators Received: 2 May 2017 / Revised: 23 May 2017 / Accepted: 29 May 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract and the age-standardized disability-adjusted life years Objectives Transport injuries (TI) are ranked as one of the (DALYs) rate decreased by 16%. leading causes of death, disability, and property loss Conclusions Although the burden of TI mortality and mor- worldwide. This paper provides an overview of the burden bidity decreased over the last two decades, there is still a of TI in the Eastern Mediterranean Region (EMR) by age considerable burden that needs to be addressed by increasing and sex from 1990 to 2015. awareness, enforcing laws, and improving road conditions. Methods Transport injuries mortality in the EMR was estimated using the Global Burden of Disease mortality Keywords Transport injuries  Eastern Mediterranean database, with corrections for ill-defined causes of death, Region  Burden of disease using the cause of death ensemble modeling tool. Mor- bidity estimation was based on inpatient and outpatient datasets, 26 cause-of-injury and 47 nature-of-injury Introduction categories. Results In 2015, 152,855 (95% uncertainty interval: Transport injuries (TI) are a major cause of global mor- 137,900–168,100) people died from TI in the EMR coun- tality and morbidity. In 2015, they caused 1.5 million tries. Between 1990 and 2015, the years of life lost (YLL) deaths globally [95% Uncertainty Interval (UI) 1.4–1.5 rate per 100,000 due to TI decreased by 15.5%, while the million] (Wang et al. 2016). In addition to deaths on the years lived with disability (YLD) rate decreased by 10%, roads, up to 50 million people incur nonfatal injuries each year as a result of road traffic crashes and other accidents (GBD 2015 Disease and Injury Incidence and Prevalence This article is part of the supplement ‘‘The state of health in the Collaborators 2016). The significance of this public health Eastern Mediterranean Region, 1990–2015’’. threat is most pronounced in low- and middle-income countries (LMIC), where 90% of the world’s road traffic- The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Transportation Injuries Collaborators are listed related deaths take place. It is projected to be the fifth at the end of the article. Ali H. Mokdad, on behalf of GBD 2015 leading cause of mortality around the world through the Eastern Mediterranean Region Transportation Injuries Collaborators, year 2030 (Naeem 2010). Transport injuries also exert a is the corresponding author. significant impact on the affected families, health care Electronic supplementary material The online version of this services, and national economies (Ainy et al. 2014). article (doi:10.1007/s00038-017-0987-0) contains supplementary Moreover, TI are estimated to cause approximately 3% loss material, which is available to authorized users. of gross domestic product (GDP) in LMIC (WHO 2015). & GBD 2015 Eastern Mediterranean Region Transportation The causes of TI can be attributed to different factors: Injuries Collaborators excessive speed, consumption of drugs and alcohol, failure mokdaa@uw.edu to enforce the use of protective measures such as seatbelts and helmets, poor vehicle impact protection, and poor road Institute for Health Metrics and Evaluation, 2301 5th Avenue, conditions (Keay and Simmonds 2005). The road user, the Suite 600, Seattle, WA 98121, USA 123 S188 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators vehicle, and the built environment are elements of a choices of covariates and mathematical models were run dynamic system that work together to either produce or using the GBD Cause of Death Ensemble modeling prevent injuries. Many factors can also influence the fre- (CODEm) software to derive estimates by age, sex, coun- quency and nature of road crashes, including weather try, year, and cause. Final fatal discontinuity estimations conditions, school holidays, time of the day, and alcohol for these causes were merged with CODEm results post- consumption (Sukhai et al. 2011; Karacasu et al. 2011). Cause of Death Correct (CoD Correct) to produce final The Eastern Mediterranean Region (EMR) contains over cause of death results. CoD Correct is a process that uses a 600 million people and consists of 22 countries with simple algorithm to scale all cause-specific deaths from all varying levels of national income: Afghanistan, Arab causes for each age group, sex, year, and location, and Republic of Egypt, Bahrain, Djibouti, Iraq, Islamic thereby ensures that the sum equals total all-cause mor- Republic of Iran, Jordan, Kingdom of Saudi Arabia (KSA), tality (Wang et al. 2016). Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, The preparation of cause of death data, the redistribution Palestine, Qatar, Republic of Yemen, Somalia, Sudan, of garbage codes, the modeling process, and covariates are Syrian Arab Republic (Syria), Tunisia, and the United Arab explained in more detail elsewhere (Wang et al. 2016). The Emirates (UAE). Although the overall number of registered International Classification of Diseases (ICD) was used to vehicles per 1000 population is comparatively low (96 per classify injuries. In GBD 2015, injury incidence and deaths 1000 population), the case-fatality rate from TI is one of are defined as ICD-9 codes E000-E999 and ICD-10 chap- the highest in the world (WHO Regional Office for the ters V–Y. More details can be found in a full description of Eastern Mediterranean 2017). Despite this, studies sur- GBD 2015 study methodology (Wang et al. 2016). rounding this topic are scarce, and reliable data are limited. We estimated incidence of injury warranting inpatient In addition to their fatality burden, road traffic crashes also admission (‘‘inpatient care’’) and incidence of injury war- increase the burden of nonfatal injuries (Chandran et al. ranting other types of care (‘‘outpatient care’’) for all cause- 2010). According to the World Health Organization of-injury categories. Injuries warranting inpatient care refer (WHO) estimates, TI were ranked as the sixth leading to injury cases of sufficient severity to require inpatient cause of death in the EMR, surpassing tuberculosis, care assuming no restrictions in access to health care. More malaria, and HIV/AIDS, and the region has the second details about data sources and our strategy to assess the highest road traffic fatality rate in the world (Kassebaum nonfatal burden of disease can be found elsewhere et al. 2016). In this manuscript, we assessed the burden of (Kassebaum et al. 2016). TI in the EMR by age and sex from 1990 to 2015, and We calculated years of life lost (YLLs) by multiplying compared the burden to the global TI, from the Global deaths by the residual expected individual life span at the Burden of Diseases, Injuries, and Risk Factors Study 2015. age of death as derived from the GBD 2015 standard model life table (Wang et al. 2016). Years lived with disability (YLDs) were calculated by multiplying the number of Methods prevalent cases of a certain health outcome by the dis- ability weight assigned to this health outcome. A disability Transport injuries estimates included pedestrian, cyclist, weight reflects the magnitude of the health loss associated motorcyclist, and motor vehicle road injuries, in addition to with an outcome and has a value that is anchored between other water and air transport injuries. GBD 2015 estimated 0, equivalent to full health, and 1, equivalent to death. injury mortality from vital registration, verbal autopsy, Disability-adjusted life years (DALYs) were calculated by mortality surveillance, censuses, surveys, and police record adding YLLs and YLDs. data. Police and crime reports were used as data sources We evaluated the associations between TI and socio- only for the estimation of deaths from road traffic injuries demographic status using the Socio-demographic Index (Wang et al. 2016). The police data were collected from (SDI). SDI is a composite measure developed for GBD published studies, national agencies, and institutional sur- 2015 that accounts for fertility rate, lag-dependent income veys such as the United Nations Crime Trends Survey and per capita, and education (Wang et al. 2016). To capture the WHO Global Status Report on Road Safety Survey. For the average relationships for each age–sex group, we countries with vital registration data we did not use police applied a simple least squares spline regression of the TI records, except if the recorded number of road injury deaths mortality rate on SDI. The SDI is scaled from 0 to 1, where from police records exceeded that in the vital registration. 0 represents the lowest possible observed SDI and 1 is the We assessed mortality by mapping all data sources to highest. We reported uncertainty for all our estimates the GBD cause list of diseases and injuries, and then (Kassebaum et al. 2016), which have varying degrees of adjustments were made for ill-defined causes of death, or uncertainty arising from input data, the data adjustments garbage codes. Finally, ensemble models with varying and the statistical models. We have propagated uncertainty 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S189 from all these sources using standard GBD methods of From 1990 to 2015 Libya, Pakistan, and Egypt had 37, 14.8, repeating all calculations 1000 times, each time drawing and 12.4% increases in TI mortality rate, respectively from distributions rather than point estimates for all the (Table 1). Three countries, UAE, Kuwait, and Qatar, have a relevant parameters in our models (Kassebaum et al. high SDI score, with TI mortality rates significantly higher in 2016). For the injury mortality estimates the estimation of UAE (36.8 per 100,000) and Qatar (29.99 per 100,000) than model uncertainty is inherent to the ensemble modeling the global average for high-income countries (12.2 per method (Wang et al. 2016). 100,000). Motor vehicle road injuries and pedestrian road injuries were the leading causes for age-standardized mor- tality rates in the region in 2015 (Fig. 2). Results Males were substantially more affected than females, with an overall mortality rate of 43.6 (UI 38.5–48.5) per Mortality 100,000, compared to a rate of 11.36 (UI 10.1–12.9) per 100,000 for females (Fig. 2). The ratio of age-standardized In 2015, there were 152,855 deaths due to TI in EMR (UI TI mortality between males and females in the EMR was 137,873–168,097), and 1,466,557 deaths globally (UI 3.84 compared to 3.1 globally. Within the EMR, Pakistan 1,394,757–1,536,454). In 2015, TI was the eighth leading had, by far, the highest ratio of mortality in males to cause of death in EMR, but the second leading cause of females at 12.0, with the next being Kuwait at 4.5. death in Qatar, Oman, and UAE. The percentage of deaths Table 2 shows observed-to-expected (based exclusively of TI out of total deaths was the highest in Qatar (20%), on SDI) ratios for sub-causes of TI by country in 2015. The Oman (16%), and UAE (14%), and the lowest in Pakistan observed-to-expected ratio varied substantially across both (1.9%), Lebanon (1.8%), and Somalia (1.5%). TI accoun- country and sub-cause. The rate of pedestrian injuries in ted for 27.8 (UI 25.1–30.5) deaths per 100,000 population, Oman was nearly four times higher than expected. Pedes- higher than the global mortality rate of 20.24 (UI 9.3–21.2) trian injuries in Oman had a ratio of 4.9, an observed 37.9 per 100,000 population (Wang et al. 2016). For the region, (UI 30.7–46.3) deaths per 100,000 compared to an expec- TI accounted for 3% of all deaths. ted 7.66. Only in Oman were pedestrian injuries the largest In 2015, Afghanistan had the highest mortality rate in the sub-cause of TI (Fig. 2). Afghanistan, Iran, and Qatar all region at 66.2 (UI 48.7–87.9) and Lebanon had the lowest at had observed values for multiple sub-causes that greatly 8.5 (UI 5.7–12.7) per 100,000 population (Fig. 1; Table 1). exceeded the expected values (Table 2). Fig. 1 Map of age-standardized mortality rates for transport injuries in the Eastern Mediterranean Region, both sexes, in 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) 123 S190 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators Table 1 Age-standardized death rates, YLLs, YLDs, and DALYs for transport injuries in the Eastern Mediterranean Region by country, in 2015 Country Age standardized death rates (per 100,000) Age-standardized YLL rate 2015 (per Age-standardized YLD rate 2015 Age-standardized YLL/YLD 100,000) (per 100,000) DALY rate 2015 ratio (per 100,000) 1990 2015 % 1990 2015 Change Eastern 29.5 (26.4–32.5) 27.8 (25.1–30.5) -5.8 1187.5 (1072.8–1308.1) 61.4 (43.2–82.8) 1248.9 (1131–1375.1) 20.59 19.34 Mediterranean Region Afghanistan 70.8 (50.9–91.6) 66.2 (48.7–87.9) -6.5 3090.3 (2324.6–4115.3) 61.4 (43.9–81.6) 3151.7 (2378–4188.6) 58.71 50.36 Bahrain 28.5 (24.9–33.1) 14 (11.5–17.2) -50.9 550.5 (449.6–682.7) 68.8 (47.3–94.3) 619.3 (515.8–757.3) 10.48 8.00 Djibouti 27 (16.6–42.6) 25.8 (12.9–48.4) -4.6 976.1 (490.6–1906.3) 42.7 (30.5–57.2) 1018.8 (530.8–1949.4) 24.83 22.86 Egypt 14.3 (13.1–16.6) 16.1 (14.9–17.5) 12.4 693.7 (634.4–755.7) 45.5 (31.9–61.8) 739.1 (678.2–800.6) 12.01 15.26 Iran 53.7 (45–64.3) 46 (36.7–57.3) -14.5 1884.9 (1488.9–2375.3) 96.9 (67.4–132.5) 1981.8 (1588.3–2478.4) 24.23 19.45 Iraq 29.2 (23.2–37.3) 24.1 (18–31.7) -17.5 1068.4 (791.3–1418.2) 65 (46.3–87.6) 1133.4 (856.4–1486.9) 18.56 16.43 Jordan 29.5 (23.3–35.8) 16.3 (14.2–18.7) -44.7 772.6 (667.3–883.6) 54.3 (37.9–74.6) 826.9 (718.9–940.6) 14.64 14.22 Kuwait 23.1 (21.6–24.8) 16.1 (13.7–19.3) -30.4 620.5 (529.2–744.2) 82.7 (57–113.2) 703.1 (602.2–828.2) 8.03 7.50 Lebanon 17.1 (13.6–21.6) 8.5 (5.7–12.7) -50.4 372.1 (248.8–564) 57.7 (40.1–78.9) 429.7 (306.3–620.3) 9.89 6.45 Libya 28.3 (23.2–33.8) 38.8 (28.8–48.6) 37.0 1724.6 (1275.5–2169.5) 75.4 (52–103.1) 1800.1 (1347.9–2247.5) 13.16 22.87 Morocco 29.9 (24.5–35.6) 21.1 (16–28) -29.3 901.3 (682.2–1194.6) 65.8 (47–88.3) 967.1 (745.4–1261.2) 18.10 13.70 Oman 70.9 (51.4–91.7) 46 (37.7–56) -35.0 1851.1 (1537.6–2256.4) 116.2 (80.3–159) 1967.4 (1641.1–2371.3) 22.73 15.93 Pakistan 16.2 (12.8–21.4) 18.6 (13.4–25) 14.8 718.5 (525.4–959.3) 36.1 (25.9–48.1) 754.6 (563–1003.5) 18.48 19.89 Palestine 17.1 (13.4–21.7) 13.7 (10.7–17.5) -19.6 675.8 (521.5–871.5) 44.2 (30.4–60.6) 720 (565.3–917.4) 15.36 15.29 Qatar 53.6 (45.7–62) 33.5 (25.1–42.9) -37.5 1335 (1024.1–1693.9) 120.3 (82.4–164.5) 1455.3 (1136.6–1808.1) 11.54 11.09 Saudi Arabia 40.5 (33.5–46.3) 27.9 (24–31.7) -31.1 1125.1 (987–1269.2) 85.7 (58.9–117.6) 1210.7 (1061.2–1355.5) 15.24 13.13 Somalia 31.1 (10.6–66.1) 29.3 (10.1–66) -5.9 1111.3 (401.5–2630.2) 29.8 (21.5–39.8) 1141 (429.8–2657.2) 40.08 37.31 Sudan 45.6 (31–68.2) 40.2 (27.1–58.6) -11.9 1957.7 (1298.2–2886.1) 84.6 (60.2–113.5) 2042.4 (1384.1–2978.8) 32.74 23.13 Syria 23.5 (18.4–28) 16.3 (13.1–18.8) -30.7 640.6 (529.8–741.2) 50.6 (35.3–68.8) 691.2 (576–791.7) 11.97 12.67 Tunisia 30.5 (26–35.5) 19.8 (15.7 to 24.7) -35.0 756.3 (604.9–956) 61.3 (42.3–84.3) 817.7 (665.2–1021.6) 15.48 12.33 United Arab 61.3 (43.3–78.7) 43.1 (31.5 to 55.4) -29.7 1533 (1114.5–1976.1) 119.4 (82.1–163.2) 1652.4 (1233–2087.7) 12.32 12.84 Emirates Yemen 46.6 (25.2–74.1) 42 (24.4–68.7) -10.0 1945.3 (1166.7–3104.7) 76 (54.7–101.5) 2021.3 (1245.1–3175.3) 33.17 25.59 DALY disability-adjusted life-years, YLD years lived with disability, YLL years of life lost. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 1990–2015) Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S191 Fig. 2 Age-standardized mortality rates for sub-causes of transport injuries in the Eastern Mediterranean Region, by sex and by country, in 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) Years of life lost (YLLs) EMR than globally. YLDs steadily increased with age (Fig. 3). Oman, Qatar, and the UAE had the highest age- The rate of age-adjusted YLLs per 100,000 population was standardized YLD rates at 116.2, 120.3, and 119.4, significantly higher in the EMR than globally, 1187.5 (UI respectively (Table 1). Somalia had the lowest rate, at 29.8 1072.8–1308.1) compared to 881.2 (UI 837.6–923.2) per (UI 21.5–39.8) (Table 1). In all countries, motor vehicle 100,000 population (Table 1). By age, YLLs peaked in the injuries were the leading sub-cause of YLDs (Table 1). 20–24 age group, and then steadily decreased as age The YLL/YLD ratio in the EMR for 2015 was 19.34, increased (Fig. 3). This was consistent with the global trend. almost double the global ratio of 9.77 (Wang et al. 2016). By country, Afghanistan had the highest age-standardized By country, Afghanistan had the highest ratio at 50.36, and YLL rate at 3090.3 (UI 2324.6–4115.3) per 100,000 popu- only Kuwait and Lebanon were below the global ratio at lation, nearly three times the regional average (Table 1). 7.50 and 6.45, respectively (Table 1). For all age groups and countries, YLLs were the primary contributor to Years lived with disability (YLDs) DALYs in terms of TI. Unlike YLLs, the rate of age-adjusted YLDs in the EMR Disability-adjusted life years (DALYs) was lower than the global average, 61.4 (UI 43.2–82.8) compared to 90.2 (UI 63.0–122.2) (Wang et al. 2016). The In 2015, TI were the eleventh leading cause DALYs, percentage of YLDs attributable to TI was also lower in the causing 8,069,712 (95% UI 7,303,759–8,888,094) DALYs. 123 S192 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators Table 2 Ratio of observed mortality rates to expected mortality rates on the basis of SDI alone for sub-causes of transport injuries in the Eastern Mediterranean Region, by country, in 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) Country Observed/expected age-standardized death rates for transport injuries 2015 Pedestrian Cyclist Motorcyclist Motor vehicle Other road injuries Other transport injuries Afghanistan 1.319 1.005 0.918 3.511 2.151 1.678 Bahrain 0.265 0.095 0.150 1.156 0.682 0.985 Djibouti 0.683 1.192 0.499 0.878 0.744 0.561 Egypt 0.403 0.244 0.172 0.721 0.498 0.501 Iran 1.693 0.975 2.088 2.202 1.948 3.107 Iraq 0.524 0.264 0.210 1.073 0.687 0.471 Jordan 0.555 0.195 0.319 0.751 0.611 1.567 Kuwait 1.995 0.562 0.263 2.115 1.651 1.402 Lebanon 0.324 0.126 0.168 0.610 0.433 0.465 Libya 0.561 0.360 0.318 1.340 0.849 10.873 Morocco 0.436 0.237 0.278 0.931 0.598 0.683 Oman 4.955 0.321 0.295 0.483 1.938 0.897 Pakistan 0.502 0.294 0.929 0.453 0.533 0.260 Palestine 0.077 0.154 0.118 0.892 0.387 0.286 Qatar 1.905 0.828 0.333 2.402 1.851 1.539 Saudi Arabia 0.937 0.309 0.319 2.228 1.434 0.510 Somalia 1.040 1.245 0.891 1.060 1.036 1.013 Sudan 0.467 1.129 1.036 1.646 1.197 0.971 Syria 0.309 0.202 0.214 0.604 0.414 1.342 Tunisia 0.584 0.331 0.285 0.977 0.707 0.765 United Arab Emirates 5.292 1.399 0.725 5.881 4.362 1.759 Yemen 0.705 0.543 0.505 2.373 1.278 0.911 decreased in all countries except Pakistan and Libya, which increased 6.64% and 23.9%, respectively (Table 1; (Fig. 4). For all age groups and countries, YLLs were the primary contributor to DALYs (Fig. 4). Discussion Our study is the first to report on the burden of TI in the EMR from 1990 to 2015. Our results show that EMR mortality rates due to TI have not fallen as quickly as the global estimates. Three countries—Libya, Pakistan, and Fig. 3 YLL and YLD rates for transport injuries in the Eastern Egypt—even have had increases in death rates. Our results Mediterranean Region, both sexes, in 2015. YLD years lived with disability, YLL years of life lost. (Global Burden of Disease Study show that TI are still a major health problem in the region 2015, Eastern Mediterranean Countries, 2015) and call for serious efforts to reduce their burden. The YLL to YLD ratio can be used as an indicator for The highest and lowest age-standardized rates of DALYs the severity of TI and the effectiveness of health system were observed in Afghanistan and Sudan. The TI DALY intervention. The higher this ratio is, the more severe and age-standardized rates in 2015, were higher (3.1% of all fatal the crashes are and the less effective interventions the DALYs) compared to 0.3% of the total number of DALYs health system provides are. This ratio may suggest that from disease globally (Wang et al. 2016). Overall, there health care access and interventions are not up to global was a 9.9% increase from 1990 to 2015 for DALYs standards in the region, in spite of the economic growth attributable to TI in EMR. From 1990 to 2015 DALY rates 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S193 development that led to changes in lifestyle and environ- ment and subsequently impacted health and mortality (Razzak et al. 2004; Luoma and Sivak 2012; Hyder and Vecino-Ortiz 2014). Motorization is rapidly increasing in the region (WHO 2015), and our study suggests that many regulations should be implemented. Safer roads, enforced traffic laws, formal driver education with more stringent driver license procedures and policies, and safe vehicle regulations need to be rigorously implemented to cope with the increase in access to vehicles, especially in high-in- come countries in the region. Countries with high numbers for specific causes, like pedestrian injuries in Oman, should implement specific measures to protect those at risk. Similar to global trends (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016; Kassebaum et al. 2016; Wang et al. 2016), TI in the EMR dispropor- tionately affect individuals who are in the economically productive age group of 15–44. This exerts an added Fig. 4 DALY rates per 100,000 population for transport injuries in pressure on the national economies of the EMR countries, the Eastern Mediterranean Region both sexes combined, by country, especially those with limited resources (Mokdad et al. in 1990 and 2015. DALY disability-adjusted life-years, YLD years 2014, 2016 ). The burden of TI is significantly higher in lived with disability, YLL years of life lost. (Global Burden of Disease males than females. This gender ratio is consistent with Study 2015, Eastern Mediterranean Countries, 1990–2015) global trends (Wang et al. 2016). Besides being a public and high SDI of some countries in the EMR. It has been health burden, TI are also associated with an immense shown that improved access to better-quality trauma care economic burden; it is estimated to cost EMR countries a systems has played a role in the decreasing mortality rates total of US$7.5 billion per year, equivalent to 1–1.5% of due to TI in high-income countries (Noland 2003). the GDP of most countries in the region (Bishai et al. Most of the research on the impact of trauma care comes 2006). from high-income countries where systems have been Despite the continuous threat of the burden of injuries implemented with few resource constraints. Assessments in in the EMR, few studies have been conducted to assess LMICs have consistently identified enormous gaps in the the burden of TI in the region, with the available ones resources needed to provide adequate care for the injured being limited to small-scale, city-based, or facility-based (Reynolds et al. 2017). A review describing reports that studies. Coverage of vital registration is low or absent in evaluated the impact of trauma care systems and system large parts of the EMR and issues of incompleteness and components in LMICs, identified reports from 32 countries. differences in death certification systems, definitions of These reports, which describe potentially useful interven- variables, and methods of data collection usually com- tions to strengthen care for the injured in LMICs, were promise the quality of data (Setel et al. 2007; Mahapatra found in only about one-quarter of LMICs. The study et al. 2007; Obermeyer et al. 2010; Joubert et al. 2012). suggests a substantial research gap that spans all regions In our study, it was necessary to predict estimates using (Reynolds et al. 2017). Another study suggested that models, relying on covariates and verbal autopsy data mortality among people with life-threatening but poten- (Noland 2003; Kassebaum et al. 2016). We added police and mortuary data for TI to help predict level and age tially survivable injuries was sixfold lower in high-income countries (6%) than in low-income countries (36%) (Mock patterns in countries with sparse or absent cause of death et al. 1993). data, even though we know from countries with near- Globally, the burden of disease due to TI has decreased complete vital registration data that police records tends significantly since 1990, but this decrease is largely in to underestimate the true level of deaths. The large GBD high-income regions, with the reverse trend occurring in mortality database allows us to use statistical models that low-income and middle-income countries. Some studies can borrow strength when data is missing from similar have suggested that this is due to the growth in motoriza- countries, previous years, published literature if no raw tion and traffic density outpacing infrastructural develop- data is available, published reports, police reports, media, ment and levels of law enforcement (Ameratunga et al. etc. Although this ensures an estimate for all causes and 2006; Naghavi et al. 2009; WHO 2013). Countries with all countries, estimates for populations and time periods with sparse or absent data are inherently less precise. fast-growing economies have experienced rapid economic 123 S194 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators While we attempt to capture all sources of uncertainty Conclusion from sampling error, non-sampling error, and model specifications in the 95% uncertainty intervals, additional Our study highlights the significant burden of TI deaths and sources of uncertainty may not have been captured injuries in the EMR countries, and the need for improving trauma centers and implementation of a faster emergency (Mathers et al. 2006; Byass et al. 2013). A study in Saudi Arabia showed that rates of death care in the EMR. Strict monitoring and enforcement of traffic laws, and programs to increase awareness and proper from road traffic accidents based on police reports and on health registration data are different, and that unlike education for drivers should be developed jointly by the Ministries of Health, Interior Affairs, and Education and police-reported data, health registration does not show steadiness or decline in the rates of road traffic deaths provided through their channels. (Barrimah et al. 2012). These inconsistencies may be GBD 2015 Eastern Mediterranean Region Transportation Inju- caused by differences in definitions, or may reflect dif- ries Collaborators: Ali H. Mokdad, PhD (corresponding author), ferences in data collection methods (Loo and Tsui 2007; Institute for Health Metrics and Evaluation, University of Washing- Jeffrey et al. 2009), or road traffic officials may even be ton, Seattle, Washington, United States. Ibrahim Khalil, MD, Institute underreporting TI to avoid criticism from superiors who for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Charbel El Bcheraoui, PhD, Institute for expect to see rates go down, as one study suggested Health Metrics and Evaluation, University of Washington, Seattle, (Dandona et al. 2008). Washington, United States. Raghid Charara, MD, American Univer- The fact that males were substantially more likely to die sity of Beirut, Beirut, Lebanon. Maziar Moradi-Lakeh, MD, Depart- from TI than females may be correlated to the fact that in ment of Community Medicine, Preventive Medicine and Public Health Research Center, Gastrointestinal and Liver Disease Research some of these countries less women drive motorized Center (GILDRC), Iran University of Medical Sciences, Tehran, Iran. vehicles; also in most cases women are accompanied by Ashkan Afshin, MD, Institute for Health Metrics and Evaluation, men outside of their houses. University of Washington, Seattle, Washington, United States. Suboptimal public awareness of the importance of Nicholas J. Kassebaum, MD, Institute for Health Metrics and Eval- uation, University of Washington, Seattle, Washington, United States; the issue has resulted in diminished emphasis on road Department of Anesthesiology & Pain Medicine, Seattle Children’s safety policies at the national level in EMR countries. Hospital, Seattle, Washington, United States. Michael Collison, BS, Lack of solid, reliable data may be a significant barrier Institute for Health Metrics and Evaluation, University of Washing- ton, Seattle, Washington, United States. Farah Daoud, BA/BS, Insti- to policymakers’ prioritizing this major public health tute for Health Metrics and Evaluation, University of Washington. problem. Adrienne Chew, ND, Institute for Health Metrics and Evaluation, There are no definitive data on the number of people University of Washington, Seattle, Washington, United States. who survive with some form of permanent disability for Kristopher J. Krohn, BA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Danny every injury-related death, but estimates run between 10 Colombara, PhD, Institute for Health Metrics and Evaluation, and 50 times more permanent disabilities. As such, these University of Washington, Seattle, Washington, United States. Leslie injuries clearly contribute to the economic and social costs Cornaby, BS, Institute for Health Metrics and Evaluation, University and have a negative impact on individuals, communities, of Washington, Seattle, Washington, United States. Rebecca and societies. Ehrenkranz, MPH, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Many studies have shown that human behavioral factors Nicholas Graetz, MPH, Institute for Health Metrics and Evaluation, collectively represent the main cause of three out of five University of Washington, Seattle, Washington, United States. road traffic crashes, and contribute to the cause in most Michael Kutz, BS, Institute for Health Metrics and Evaluation, remaining cases (Marshall et al. 1996; Evans 1996; Lyz- University of Washington, Seattle, Washington, United States. Christopher Troeger, Institute for Health Metrics and Evaluation, nicki et al. 1998; Sharma et al. 2002). A study in Saudi University of Washington. Haidong Wang, PhD, Institute for Health Arabia showed that more than 43% of unlicensed males Metrics and Evaluation, University of Washington, Seattle, Wash- drove a vehicle (El Bcheraoui et al. 2015). Among those ington, United States. Kalkidan Hassen Abate, MS, Jimma University, male drivers (females are not allowed to drive by law), Jimma, Ethiopia. Foad Abd-Allah, MD, Department of Neurology, Cairo University, Cairo, Egypt. Abdishakur M. Abdulle, PhD, New 86% engaged in at least one risky behavior while driving. York University, Abu Dhabi, United Arab Emirates. Semaw Ferede Up to 95 and 98.5% of respondents reported not wearing a Abera, MSc, School of Public Health, College of Health Sciences, seat belt in the front (enforced by the law), and the back Mekelle University, Mekelle, Ethiopia; Food Security and Institute for Biological Chemistry and Nutrition, University of Hohenheim, seat, respectively. Stuttgart, Germany. Aliasghar Ahmad Kiadaliri, PhD, Department of More attention must also be given to the needs of vul- Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, nerable road users, like pedestrians, children, and bicy- Lund University, Lund, Sweden. Alireza Ahmadi, PhD, Kermanshah cle/motorcycle and public transport users. Making walking University of Medical Sciences, Kermanshah, Iran. Muktar Beshir Ahmed, MPH, College of Health Sciences, Department of Epidemi- and cycling safer is critical to reducing the number of road ology, ICT and e-Learning Coordinator, Jimma University, Jimma, traffic deaths and is important to promote non-motorized Ethiopia. Khurshid Alam, PhD, Murdoch Childrens Research forms of transport. 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S195 Institute, The University of Melbourne, Parkville, Victoria, Australia; Institutes, Taipei, Taiwan. Solomon Weldemariam Gebrehiwot, MS, The University of Melbourne, Melbourne, VIC, Australia. The College of Health Sciences, Mekelle University, Mekelle, Ethiopia; University of Sydney, Sydney, NSW, Australia. Deena Alasfoor, Tsegaye Tewelde Gebrehiwot, MPH, Jimma University, Jimma, MSc, Ministry of Health, Al Khuwair, Muscat, Oman. Suliman Ethiopia. Nima Hafezi-Nejad, MD, Endocrinology and Metabolism Alghnam, PhD King Abdulah International Medical Research Center, Research Center, Tehran University of Medical Sciences, Tehran, Riyadh, Saudi Arabia; Center For Injury Research and Policy, Iran. Hassan Haghparast Bidgoli, PhD, University College London, Bloomberg School of Public Health, Johns Hopkins University, London, United Kingdom. Gessessew Bugssa Hailu, MSc Mekelle Baltimore, MD, United States. Raghib Ali, MSc, University of University, Mekelle, Ethiopia; Kilte Awlaelo Health and Demo- Oxford, Oxford, United Kingdom. Reza Alizadeh-Navaei, PhD, graphic Surveillance System, Mekelle, Ethiopia. Randah Ribhi Gastrointestinal Cancer Research Center, Mazandaran University of Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. Samer Medical Sciences, Sari, Iran. Rajaa Al-Raddadi, PhD, Joint Program Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Dubai, of Family and Community Medicine, Jeddah, Saudi Arabia. Ubai United Arab Emirates. Delia Hendrie, MA, Centre for Population Alsharif, MPH, Charite´ Universita¨tsmedizin, Berlin, Germany. Khalid Health Research, Curtin University, Bentley, WA, Australia. Ileana A. Altirkawi, MD, King Saud University, Riyadh, Saudi Arabia. Beatriz Heredia-Pi, PhD, National Institute of Public Health, Cuer- Nahla Anber, PhD, Mansoura University, Mansoura, Egypt. Hossein navaca, Morelos, Mexico. Kathryn H. Jacobsen, PhD, Department of Ansari, PhD, Health Promotion Research Center, Department of Global and Community Health, George Mason University, Fairfax, Epidemiology and Biostatistics, Zahedan University of Medical Sci- Virginia, United States. Spencer Lewis James, MD, Denver Health/ ences, Zahedan, Iran. Carl Abelardo T. Antonio, MD, Department of University of Colorado, Denver, CO, United States. Achala Upendra Health Policy and Administration, College of Public Health, Jayatilleke, PhD, Postgraduate Institute of Medicine, Colombo, Sri University of the Philippines Manila, Manila, Philippines. Palwasha Lanka; Institute of Violence and Injury Prevention, Colombo, Sri Anwari, MD Self-employed, Kabul, Afghanistan. Hamid Asayesh, Lanka. Guohong Jiang, MD, Tianjin Centers for Disease Control and PhD, Department of Medical Emergency, School of Paramedic, Qom Prevention, Tianjin, China. Jost B. Jonas, MD, Department of Oph- University of Medical Sciences, Qom, Iran. Tesfay Mehari Atey, MS, thalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Mekelle University, Mekelle, Ethiopia. Leticia Avila-Burgos, PhD, Heidelberg, Mannheim, Germany. Amir Kasaeian, PhD, Hematology- National Institute of Public Health, Cuernavaca, Mexico. Suzanne L. Oncology and Stem Cell Transplantation Research Center, Tehran Barker-Collo, PhD, School of Psychology, University of Auckland, University of Medical Sciences, Tehran, Iran; Endocrinology and Auckland, New Zealand. Shahrzad Bazargan-Hejazi, PhD, College of Metabolism Population Sciences Institute, Tehran University of Medicine, Charles R. Drew University of Medicine and Science, Los Medical Sciences, Tehran, Iran. Peter Njenga Keiyoro, PhD, Institute Angeles, CA, United States; David Geffen School of Medicine, of Tropical and Infectious Diseases, Nairobi, Kenya; Kenya School of University of California at Los Angeles, Los Angeles, CA, United Continuing and Distance Education, Nairobi, Kenya. Yousef Saleh States. Neeraj Bedi, MD, College of Public Health and Tropical Khader, ScD, Department of Community Medicine, Public Health Medicine, Jazan, Saudi Arabia. Addisu Shunu Beyene, MPH, College and Family Medicine, Jordan University of Science and Technology, of Health and Medical Science, Haramaya University, Harar, Ethio- Irbid, Jordan. Ejaz Ahmad Khan, MD, Health Services Academy, pia. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Women and Islamabad, Punjab, Pakistan. Abdullah Tawfih Abdullah Khoja, MD, Child Health, Aga Khan University, Karachi, Pakistan; Centre for Mohammed Ibn Saudi University, Riyadh, Saudi Arabia. Ardeshir Global Child Health, The Hospital for Sick Children, Toronto, ON, Khosravi, PhD, Iranian Ministry of Health and Medical Education, Canada. Soufiane Boufous, PhD, Transport and Road Safety (TARS) Tehran, Iran, Non-communicable Diseases Research Center, Tehran Research, University of New South Wales, Sydney, New South University of Medical Sciences, Tehran, Iran. Jagdish Khubchandani, Wales, Australia. Zahid A. Butt, PhD, Al Shifa Trust Eye Hospital, PhD, Department of Nutrition and Health Science, Ball State Rawalpindi, Pakistan. Carlos A. Castan˜eda-Orjuela, MSc, Colombian University, Muncie, Indiana, United States. Yun Jin Kim, PhD, National Health Observatory, Instituto Nacional de Salud, Bogota, Faculty of Chinese Medicine, Southern University College, Skudai, Colombia; Epidemiology and Public Health Evaluation Group, Public Johor, Malaysia. Soewarta Kosen, MD, Center for Community Health Department, Universidad Nacional de Colombia, Bogota, Empowerment, Health Policy and Humanities, National Institute of Colombia. Abdulaal A. Chitheer, MD, Ministry of Health, Baghdad, Health Research & Development, Jakarta, Indonesia. Barthelemy Iraq. Koustuv Dalal, PhD, Centre for Injury Prevention and Safety Kuate Defo, PhD, Department of Social and Preventive Medicine, Promotion, School of Health and Medical Sciences, Orebro Univer- School of Public Health, University of Montreal, Montreal, Quebec, sity, Orebro, Sweden. Hadi Danawi, PhD, Walden University, Min- Canada; Department of Demography and Public Health Research neapolis, Minnesota, United States. Dragos V. Davitoiu, PhD, Institute, University of Montreal, Montreal Canada. Heidi J. Larson, University of Medicine and Pharmacy Bucharest, Bucharest, Roma- PhD, Department of Infectious Disease Epidemiology, London nia. Shirin Djalalinia, PhD, Undersecretary for Research & Tech- School of Hygiene & Tropical Medicine, London, United Kingdom; nology, Ministry of Health & Medical Education, Tehran, Iran. Aman Institute for Health Metrics and Evaluation, University of Washing- Yesuf Endries, MPH, Arba Minch University, Arba Minch, Ethiopia. ton, Seattle, Washington, United States. Shai Linn, MD University of Babak Eshrati, PhD, Ministry of Health and Medical Education, Haifa, Haifa, Israel. Raimundas Lunevicius, PhD, Aintree University Tehran, Iran; Arak University of Medical Sciences, Arak, Iran. Hospital National Health Service Foundation Trust, Liverpool, United Alireza Esteghamati, MD, Endocrinology and Metabolism Research Kingdom; School of Medicine, University of Liverpool, Liverpool, Center, Tehran University of Medical Sciences, Tehran, Iran. Andre´ United Kingdom. Hassan Magdy Abd El Razek, MBBCH, Mansoura Faro, PhD, Federal University of Sergipe, Aracaju, Brazil. Maryam S. Faculty of Medicine, Mansoura, Egypt. Mohammed Magdy Abd El Farvid, PhD, Department of Nutrition, Harvard T. H. Chan School of Razek, MBBCH, Aswan University Hospital, Aswan Faculty of Public Health, Harvard University, Boston, MA, United States; Har- Medicine, Aswan, Egypt. Marek Majdan, PhD, Faculty of Health vard/MGH Center on Genomics, Vulnerable Populations, and Health Sciences and Social Work, Department of Public Health, Trnava Disparities, Mongan Institute for Health Policy, Massachusetts Gen- University, Trnava, Slovakia. Reza Majdzadeh, PhD, Knowledge eral Hospital, Boston, MA, United States. Seyed-Mohammad Utilization Research Center and Community Based Participatory Fereshtehnejad, PhD, Department of Neurobiology, Care Sciences Research Center, Tehran University of Medical Sciences, Tehran, and Society (NVS), Karolinska Institutet, Stockholm, Sweden. Flo- Iran. Azeem Majeed, MD, Department of Primary Care & Public rian Fischer, PhD, School of Public Health, Bielefeld University, Health, Imperial College London, London, United Kingdom. Reza Bielefeld, Germany. Wayne Gao, PhD, National Health Research Malekzadeh, MD, Digestive Diseases Research Institute, Tehran 123 S196 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators University of Medical Sciences, Tehran, Iran. Peter Memiah, PhD, United States. Sadaf G. Sepanlou, PhD, Digestive Diseases Research University of West Florida, Pensacola, FL, United States. Ziad A. Institute, Tehran University of Medical Sciences, Tehran, Iran. Amira Memish, MD, Saudi Ministry of Health, Riyadh, Saudi Arabia; Col- Shaheen, PhD, Department of Public Health, An-Najah University, lege of Medicine, Alfaisal University, Riyadh, Saudi Arabia. Walter Nablus, Palestine. Masood Ali Shaikh, MD, Independent Consultant, Mendoza, MD, United Nations Population Fund, Lima, Peru. Karachi, Pakistan. Mansour Shamsipour, PhD, Institute for Environ- Mubarek Abera Mengistie, MS, Jimma University, Jimma, Ethiopia. mental Research, Tehran University of Medical Sciences, Tehran, Tuomo J. Meretoja, PhD, Comprehensive Cancer Center, Breast Iran. Morteza Shamsizadeh, MPH, Department of Medical Surgical Surgery Unit, Helsinki University Hospital, Helsinki, Finland; Nursing, School of Nursing and Midwifery, Hamadan University of University of Helsinki, Helsinki, Finland. Ted R. Miller, PhD, Pacific Medical Sciences, Hamadan, Iran. Badr H. A. Sobaih, MD, King Institute for Research & Evaluation, Calverton, MD, United States; Saud University, Riyadh, Saudi Arabia. Muawiyyah Babale Sufiyan, Centre for Population Health, Curtin University, Perth, WA, Aus- MBA, Ahmadu Bello University, Zaria, Nigeria. Jacob E. Sunshine, tralia. Shafiu Mohammed, PhD, Health Systems and Policy Research MD, University of Washington, Seattle, Washington, United States. Unit, Ahmadu Bello University, Zaria, Nigeria; Institute of Public Arash Tehrani-Banihashemi, PhD, Preventive Medicine and Public Health, Heidelberg University, Heidelberg, Germany. Ashagre Molla Health Research Center, Iran University of Medical Sciences, Tehran, Assaye, MS, Bahir Dar University, Bahir Dar, Ethiopia. Carla Iran; Community Medicine Department, Iran University of Medical Makhlouf Obermeyer, DSc, Center for Research on Population and Sciences, Tehran, Iran. Mohamad-Hani Temsah, MD, King Saud Health, Faculty of Health Sciences, American University of Beirut, University, Riyadh, Saudi Arabia. Abdullah Sulieman Terkawi, MD, Beirut, Lebanon. Farshad Pourmalek, PhD, University of British Department of Anesthesiology, University of Virginia, Char- Columbia, Vancouver, British Columbia, Canada. Mostafa Qorbani, lottesville, VA, United States; Department of Anesthesiology, King PhD, Non-communicable Diseases Research Center, Alborz Univer- Fahad Medical City, Riyadh, Saudi Arabia; Outcomes Research sity of Medical Sciences, Karaj, Iran. Amir Radfar, MD, A T Still Consortium, Cleveland Clinic, Cleveland, OH, United States. J. S. University, Kirksville, MO, United States. Anwar Rafay, MS, Con- Thakur, MD, School of Public Health, Post Graduate Institute of tech International Health Consultants, Lahore, Pakistan; Contech Medical Education and Research, Chandigarh, Union Territory School of Public Health, Lahore, Pakistan. Vafa Rahimi-Movaghar, Chandigarh, India. Roman Topor-Madry, PhD, Institute of Public MD, Sina Trauma and Surgery Research Center, Tehran University of Health, Faculty of Health Sciences, Jagiellonian University Medical Medical Sciences, Tehran, Iran. Mahfuzar Rahman, PhD, Research College, Krakow, Poland; Faculty of Health Sciences, Wroclaw and Evaluation Division, BRAC, Dhaka, Bangladesh. Rajesh Kumar Medical University, Wroclaw, Poland. Olalekan A. Uthman, PhD, Rai, MPH, Society for Health and Demographic Surveillance, Suri, Warwick Medical School, University of Warwick, Coventry, United India. Kavitha Ranganathan, MD, University of Michigan Health Kingdom. Vasiliy Victorovich Vlassov, MD, National Research Systems, Ann Arbor, Michigan, United States. David Laith Rawaf, University Higher School of Economics, Moscow, Russia. Stein Emil MD, WHO Collaborating Centre, Imperial College London, London, Vollset, DrPH, Center for Disease Burden, Norwegian Institute of United Kingdom, North Hampshire Hospitals, Basingstroke, United Public Health, Bergen, Norway; Department of Global Public Health Kingdom; University College London Hospitals, London, United and Primary Care, University of Bergen, Bergen, Norway; Institute Kingdom. Salman Rawaf, MD, Imperial College London, London, for Health Metrics and Evaluation, University of Washington, Seattle, United Kingdom. Amany H. Refaat, PhD, Walden University, Min- Washington, United States. Tolassa Wakayo, MS, Jimma University, neapolis, MN, United States; Suez Canal University, Ismailia, Egypt. Jimma, Ethiopia. Andrea Werdecker, PhD, Competence Center Andre M. N. Renzaho, PhD, Western Sydney University, Penrith, Mortality-Follow-Up of the German National Cohort, Federal Insti- NSW, Australia. Satar Rezaei, PhD, School of Public Health, Ker- tute for Population Research, Wiesbaden, Germany. Mohsen manshah University of Medical Sciences, Kermanshah, Iran. David Yaghoubi, MSc, School of Public Health, University of Saskatch- Rojas-Rueda, PhD, Campus MAR, Barcelona Biomedical Research ewan, Saskatoon, Saskatchewan, Canada. Mehdi Yaseri, PhD, Tehran Park (PRBB), ISGlobal Instituto de Salud Global de Barcelona, University of Medical Sciences, Tehran, Iran; Ophthalmic Research Catalonia, Spain. Gholamreza Roshandel, PhD, Golestan Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Center of Gastroenterology and Hepatology, Golestan University of Iran. Naohiro Yonemoto, MPH, Department of Biostatistics, School Medical Sciences, Gorgan, Iran; Digestive Diseases Research Insti- of Public Health, Kyoto University, Kyoto, Japan. 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Payman Salamati, MD, Sina Trauma University of Oxford, Oxford, United Kingdom, Institute for Health and Surgery Research Center, Tehran University of Medical Sciences, Metrics and Evaluation, University of Washington, Seattle, Wash- Tehran, Iran. Abdallah M. Samy, PhD, Ain Shams University, Cairo, ington, United States. Mohsen Naghavi, PhD, Institute for Health Egypt. Juan Ramon Sanabria, MD, J Edwards School of Medicine, Metrics and Evaluation, University of Washington, Seattle, Wash- Marshall Univeristy, Huntington, WV, United States; Case Western ington, United States. Christopher J. L. Murray, DPhil, Institute for Reserve University, Cleveland, OH, United States. Milena M. Santric Health Metrics and Evaluation, University of Washington, Seattle, Milicevic, PhD, Institute of Social Medicine, Faculty of Medicine, Washington, United States. University of Belgrade, Belgrade, Serbia, Centre School of Public Health and Health Management, Faculty of Medicine, University of Compliance with ethical standards Belgrade, Belgrade, Serbia. Benn Sartorius, PhD, Public Health Medicine, School of Nursing and Public Health, University of Kwa- This manuscript reflects original work that has not previously been Zulu-Natal, Durban, South Africa; UKZN Gastrointestinal Cancer published in whole or in part and is not under consideration else- Research Centre, South African Medical Research Council where. All authors have read the manuscript and have agreed that the (SAMRC), Durban, South Africa. David C. Schwebel, PhD, work is ready for submission and accept responsibility for its University of Alabama at Birmingham, Birmingham, Alabama, contents. 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S197 Ethical approval The authors of this paper have complied with all Joubert J, Rao C, Bradshaw D et al (2012) Characteristics, availability ethical standards and do not have any conflicts of interest to disclose and uses of vital registration and other mortality data sources in at the time of submission. The funding source played no role in the post-democracy South Africa. Glob Health Action. doi:10.3402/ design of the study, the analysis and interpretation of data, and the gha.v5i0.19263 writing of the paper. 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Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 Study

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Abstract

Int J Public Health (2018) 63 (Suppl 1):S187–S198 https://doi.org/10.1007/s00038-017-0987-0 ORIGINAL ARTICLE Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 Study GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators Received: 2 May 2017 / Revised: 23 May 2017 / Accepted: 29 May 2017 / Published online: 3 August 2017 The Author(s) 2017. This article is an open access publication Abstract and the age-standardized disability-adjusted life years Objectives Transport injuries (TI) are ranked as one of the (DALYs) rate decreased by 16%. leading causes of death, disability, and property loss Conclusions Although the burden of TI mortality and mor- worldwide. This paper provides an overview of the burden bidity decreased over the last two decades, there is still a of TI in the Eastern Mediterranean Region (EMR) by age considerable burden that needs to be addressed by increasing and sex from 1990 to 2015. awareness, enforcing laws, and improving road conditions. Methods Transport injuries mortality in the EMR was estimated using the Global Burden of Disease mortality Keywords Transport injuries  Eastern Mediterranean database, with corrections for ill-defined causes of death, Region  Burden of disease using the cause of death ensemble modeling tool. Mor- bidity estimation was based on inpatient and outpatient datasets, 26 cause-of-injury and 47 nature-of-injury Introduction categories. Results In 2015, 152,855 (95% uncertainty interval: Transport injuries (TI) are a major cause of global mor- 137,900–168,100) people died from TI in the EMR coun- tality and morbidity. In 2015, they caused 1.5 million tries. Between 1990 and 2015, the years of life lost (YLL) deaths globally [95% Uncertainty Interval (UI) 1.4–1.5 rate per 100,000 due to TI decreased by 15.5%, while the million] (Wang et al. 2016). In addition to deaths on the years lived with disability (YLD) rate decreased by 10%, roads, up to 50 million people incur nonfatal injuries each year as a result of road traffic crashes and other accidents (GBD 2015 Disease and Injury Incidence and Prevalence This article is part of the supplement ‘‘The state of health in the Collaborators 2016). The significance of this public health Eastern Mediterranean Region, 1990–2015’’. threat is most pronounced in low- and middle-income countries (LMIC), where 90% of the world’s road traffic- The members of GBD (Global Burden of Disease) 2015 Eastern Mediterranean Region Transportation Injuries Collaborators are listed related deaths take place. It is projected to be the fifth at the end of the article. Ali H. Mokdad, on behalf of GBD 2015 leading cause of mortality around the world through the Eastern Mediterranean Region Transportation Injuries Collaborators, year 2030 (Naeem 2010). Transport injuries also exert a is the corresponding author. significant impact on the affected families, health care Electronic supplementary material The online version of this services, and national economies (Ainy et al. 2014). article (doi:10.1007/s00038-017-0987-0) contains supplementary Moreover, TI are estimated to cause approximately 3% loss material, which is available to authorized users. of gross domestic product (GDP) in LMIC (WHO 2015). & GBD 2015 Eastern Mediterranean Region Transportation The causes of TI can be attributed to different factors: Injuries Collaborators excessive speed, consumption of drugs and alcohol, failure mokdaa@uw.edu to enforce the use of protective measures such as seatbelts and helmets, poor vehicle impact protection, and poor road Institute for Health Metrics and Evaluation, 2301 5th Avenue, conditions (Keay and Simmonds 2005). The road user, the Suite 600, Seattle, WA 98121, USA 123 S188 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators vehicle, and the built environment are elements of a choices of covariates and mathematical models were run dynamic system that work together to either produce or using the GBD Cause of Death Ensemble modeling prevent injuries. Many factors can also influence the fre- (CODEm) software to derive estimates by age, sex, coun- quency and nature of road crashes, including weather try, year, and cause. Final fatal discontinuity estimations conditions, school holidays, time of the day, and alcohol for these causes were merged with CODEm results post- consumption (Sukhai et al. 2011; Karacasu et al. 2011). Cause of Death Correct (CoD Correct) to produce final The Eastern Mediterranean Region (EMR) contains over cause of death results. CoD Correct is a process that uses a 600 million people and consists of 22 countries with simple algorithm to scale all cause-specific deaths from all varying levels of national income: Afghanistan, Arab causes for each age group, sex, year, and location, and Republic of Egypt, Bahrain, Djibouti, Iraq, Islamic thereby ensures that the sum equals total all-cause mor- Republic of Iran, Jordan, Kingdom of Saudi Arabia (KSA), tality (Wang et al. 2016). Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, The preparation of cause of death data, the redistribution Palestine, Qatar, Republic of Yemen, Somalia, Sudan, of garbage codes, the modeling process, and covariates are Syrian Arab Republic (Syria), Tunisia, and the United Arab explained in more detail elsewhere (Wang et al. 2016). The Emirates (UAE). Although the overall number of registered International Classification of Diseases (ICD) was used to vehicles per 1000 population is comparatively low (96 per classify injuries. In GBD 2015, injury incidence and deaths 1000 population), the case-fatality rate from TI is one of are defined as ICD-9 codes E000-E999 and ICD-10 chap- the highest in the world (WHO Regional Office for the ters V–Y. More details can be found in a full description of Eastern Mediterranean 2017). Despite this, studies sur- GBD 2015 study methodology (Wang et al. 2016). rounding this topic are scarce, and reliable data are limited. We estimated incidence of injury warranting inpatient In addition to their fatality burden, road traffic crashes also admission (‘‘inpatient care’’) and incidence of injury war- increase the burden of nonfatal injuries (Chandran et al. ranting other types of care (‘‘outpatient care’’) for all cause- 2010). According to the World Health Organization of-injury categories. Injuries warranting inpatient care refer (WHO) estimates, TI were ranked as the sixth leading to injury cases of sufficient severity to require inpatient cause of death in the EMR, surpassing tuberculosis, care assuming no restrictions in access to health care. More malaria, and HIV/AIDS, and the region has the second details about data sources and our strategy to assess the highest road traffic fatality rate in the world (Kassebaum nonfatal burden of disease can be found elsewhere et al. 2016). In this manuscript, we assessed the burden of (Kassebaum et al. 2016). TI in the EMR by age and sex from 1990 to 2015, and We calculated years of life lost (YLLs) by multiplying compared the burden to the global TI, from the Global deaths by the residual expected individual life span at the Burden of Diseases, Injuries, and Risk Factors Study 2015. age of death as derived from the GBD 2015 standard model life table (Wang et al. 2016). Years lived with disability (YLDs) were calculated by multiplying the number of Methods prevalent cases of a certain health outcome by the dis- ability weight assigned to this health outcome. A disability Transport injuries estimates included pedestrian, cyclist, weight reflects the magnitude of the health loss associated motorcyclist, and motor vehicle road injuries, in addition to with an outcome and has a value that is anchored between other water and air transport injuries. GBD 2015 estimated 0, equivalent to full health, and 1, equivalent to death. injury mortality from vital registration, verbal autopsy, Disability-adjusted life years (DALYs) were calculated by mortality surveillance, censuses, surveys, and police record adding YLLs and YLDs. data. Police and crime reports were used as data sources We evaluated the associations between TI and socio- only for the estimation of deaths from road traffic injuries demographic status using the Socio-demographic Index (Wang et al. 2016). The police data were collected from (SDI). SDI is a composite measure developed for GBD published studies, national agencies, and institutional sur- 2015 that accounts for fertility rate, lag-dependent income veys such as the United Nations Crime Trends Survey and per capita, and education (Wang et al. 2016). To capture the WHO Global Status Report on Road Safety Survey. For the average relationships for each age–sex group, we countries with vital registration data we did not use police applied a simple least squares spline regression of the TI records, except if the recorded number of road injury deaths mortality rate on SDI. The SDI is scaled from 0 to 1, where from police records exceeded that in the vital registration. 0 represents the lowest possible observed SDI and 1 is the We assessed mortality by mapping all data sources to highest. We reported uncertainty for all our estimates the GBD cause list of diseases and injuries, and then (Kassebaum et al. 2016), which have varying degrees of adjustments were made for ill-defined causes of death, or uncertainty arising from input data, the data adjustments garbage codes. Finally, ensemble models with varying and the statistical models. We have propagated uncertainty 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S189 from all these sources using standard GBD methods of From 1990 to 2015 Libya, Pakistan, and Egypt had 37, 14.8, repeating all calculations 1000 times, each time drawing and 12.4% increases in TI mortality rate, respectively from distributions rather than point estimates for all the (Table 1). Three countries, UAE, Kuwait, and Qatar, have a relevant parameters in our models (Kassebaum et al. high SDI score, with TI mortality rates significantly higher in 2016). For the injury mortality estimates the estimation of UAE (36.8 per 100,000) and Qatar (29.99 per 100,000) than model uncertainty is inherent to the ensemble modeling the global average for high-income countries (12.2 per method (Wang et al. 2016). 100,000). Motor vehicle road injuries and pedestrian road injuries were the leading causes for age-standardized mor- tality rates in the region in 2015 (Fig. 2). Results Males were substantially more affected than females, with an overall mortality rate of 43.6 (UI 38.5–48.5) per Mortality 100,000, compared to a rate of 11.36 (UI 10.1–12.9) per 100,000 for females (Fig. 2). The ratio of age-standardized In 2015, there were 152,855 deaths due to TI in EMR (UI TI mortality between males and females in the EMR was 137,873–168,097), and 1,466,557 deaths globally (UI 3.84 compared to 3.1 globally. Within the EMR, Pakistan 1,394,757–1,536,454). In 2015, TI was the eighth leading had, by far, the highest ratio of mortality in males to cause of death in EMR, but the second leading cause of females at 12.0, with the next being Kuwait at 4.5. death in Qatar, Oman, and UAE. The percentage of deaths Table 2 shows observed-to-expected (based exclusively of TI out of total deaths was the highest in Qatar (20%), on SDI) ratios for sub-causes of TI by country in 2015. The Oman (16%), and UAE (14%), and the lowest in Pakistan observed-to-expected ratio varied substantially across both (1.9%), Lebanon (1.8%), and Somalia (1.5%). TI accoun- country and sub-cause. The rate of pedestrian injuries in ted for 27.8 (UI 25.1–30.5) deaths per 100,000 population, Oman was nearly four times higher than expected. Pedes- higher than the global mortality rate of 20.24 (UI 9.3–21.2) trian injuries in Oman had a ratio of 4.9, an observed 37.9 per 100,000 population (Wang et al. 2016). For the region, (UI 30.7–46.3) deaths per 100,000 compared to an expec- TI accounted for 3% of all deaths. ted 7.66. Only in Oman were pedestrian injuries the largest In 2015, Afghanistan had the highest mortality rate in the sub-cause of TI (Fig. 2). Afghanistan, Iran, and Qatar all region at 66.2 (UI 48.7–87.9) and Lebanon had the lowest at had observed values for multiple sub-causes that greatly 8.5 (UI 5.7–12.7) per 100,000 population (Fig. 1; Table 1). exceeded the expected values (Table 2). Fig. 1 Map of age-standardized mortality rates for transport injuries in the Eastern Mediterranean Region, both sexes, in 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) 123 S190 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators Table 1 Age-standardized death rates, YLLs, YLDs, and DALYs for transport injuries in the Eastern Mediterranean Region by country, in 2015 Country Age standardized death rates (per 100,000) Age-standardized YLL rate 2015 (per Age-standardized YLD rate 2015 Age-standardized YLL/YLD 100,000) (per 100,000) DALY rate 2015 ratio (per 100,000) 1990 2015 % 1990 2015 Change Eastern 29.5 (26.4–32.5) 27.8 (25.1–30.5) -5.8 1187.5 (1072.8–1308.1) 61.4 (43.2–82.8) 1248.9 (1131–1375.1) 20.59 19.34 Mediterranean Region Afghanistan 70.8 (50.9–91.6) 66.2 (48.7–87.9) -6.5 3090.3 (2324.6–4115.3) 61.4 (43.9–81.6) 3151.7 (2378–4188.6) 58.71 50.36 Bahrain 28.5 (24.9–33.1) 14 (11.5–17.2) -50.9 550.5 (449.6–682.7) 68.8 (47.3–94.3) 619.3 (515.8–757.3) 10.48 8.00 Djibouti 27 (16.6–42.6) 25.8 (12.9–48.4) -4.6 976.1 (490.6–1906.3) 42.7 (30.5–57.2) 1018.8 (530.8–1949.4) 24.83 22.86 Egypt 14.3 (13.1–16.6) 16.1 (14.9–17.5) 12.4 693.7 (634.4–755.7) 45.5 (31.9–61.8) 739.1 (678.2–800.6) 12.01 15.26 Iran 53.7 (45–64.3) 46 (36.7–57.3) -14.5 1884.9 (1488.9–2375.3) 96.9 (67.4–132.5) 1981.8 (1588.3–2478.4) 24.23 19.45 Iraq 29.2 (23.2–37.3) 24.1 (18–31.7) -17.5 1068.4 (791.3–1418.2) 65 (46.3–87.6) 1133.4 (856.4–1486.9) 18.56 16.43 Jordan 29.5 (23.3–35.8) 16.3 (14.2–18.7) -44.7 772.6 (667.3–883.6) 54.3 (37.9–74.6) 826.9 (718.9–940.6) 14.64 14.22 Kuwait 23.1 (21.6–24.8) 16.1 (13.7–19.3) -30.4 620.5 (529.2–744.2) 82.7 (57–113.2) 703.1 (602.2–828.2) 8.03 7.50 Lebanon 17.1 (13.6–21.6) 8.5 (5.7–12.7) -50.4 372.1 (248.8–564) 57.7 (40.1–78.9) 429.7 (306.3–620.3) 9.89 6.45 Libya 28.3 (23.2–33.8) 38.8 (28.8–48.6) 37.0 1724.6 (1275.5–2169.5) 75.4 (52–103.1) 1800.1 (1347.9–2247.5) 13.16 22.87 Morocco 29.9 (24.5–35.6) 21.1 (16–28) -29.3 901.3 (682.2–1194.6) 65.8 (47–88.3) 967.1 (745.4–1261.2) 18.10 13.70 Oman 70.9 (51.4–91.7) 46 (37.7–56) -35.0 1851.1 (1537.6–2256.4) 116.2 (80.3–159) 1967.4 (1641.1–2371.3) 22.73 15.93 Pakistan 16.2 (12.8–21.4) 18.6 (13.4–25) 14.8 718.5 (525.4–959.3) 36.1 (25.9–48.1) 754.6 (563–1003.5) 18.48 19.89 Palestine 17.1 (13.4–21.7) 13.7 (10.7–17.5) -19.6 675.8 (521.5–871.5) 44.2 (30.4–60.6) 720 (565.3–917.4) 15.36 15.29 Qatar 53.6 (45.7–62) 33.5 (25.1–42.9) -37.5 1335 (1024.1–1693.9) 120.3 (82.4–164.5) 1455.3 (1136.6–1808.1) 11.54 11.09 Saudi Arabia 40.5 (33.5–46.3) 27.9 (24–31.7) -31.1 1125.1 (987–1269.2) 85.7 (58.9–117.6) 1210.7 (1061.2–1355.5) 15.24 13.13 Somalia 31.1 (10.6–66.1) 29.3 (10.1–66) -5.9 1111.3 (401.5–2630.2) 29.8 (21.5–39.8) 1141 (429.8–2657.2) 40.08 37.31 Sudan 45.6 (31–68.2) 40.2 (27.1–58.6) -11.9 1957.7 (1298.2–2886.1) 84.6 (60.2–113.5) 2042.4 (1384.1–2978.8) 32.74 23.13 Syria 23.5 (18.4–28) 16.3 (13.1–18.8) -30.7 640.6 (529.8–741.2) 50.6 (35.3–68.8) 691.2 (576–791.7) 11.97 12.67 Tunisia 30.5 (26–35.5) 19.8 (15.7 to 24.7) -35.0 756.3 (604.9–956) 61.3 (42.3–84.3) 817.7 (665.2–1021.6) 15.48 12.33 United Arab 61.3 (43.3–78.7) 43.1 (31.5 to 55.4) -29.7 1533 (1114.5–1976.1) 119.4 (82.1–163.2) 1652.4 (1233–2087.7) 12.32 12.84 Emirates Yemen 46.6 (25.2–74.1) 42 (24.4–68.7) -10.0 1945.3 (1166.7–3104.7) 76 (54.7–101.5) 2021.3 (1245.1–3175.3) 33.17 25.59 DALY disability-adjusted life-years, YLD years lived with disability, YLL years of life lost. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 1990–2015) Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S191 Fig. 2 Age-standardized mortality rates for sub-causes of transport injuries in the Eastern Mediterranean Region, by sex and by country, in 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) Years of life lost (YLLs) EMR than globally. YLDs steadily increased with age (Fig. 3). Oman, Qatar, and the UAE had the highest age- The rate of age-adjusted YLLs per 100,000 population was standardized YLD rates at 116.2, 120.3, and 119.4, significantly higher in the EMR than globally, 1187.5 (UI respectively (Table 1). Somalia had the lowest rate, at 29.8 1072.8–1308.1) compared to 881.2 (UI 837.6–923.2) per (UI 21.5–39.8) (Table 1). In all countries, motor vehicle 100,000 population (Table 1). By age, YLLs peaked in the injuries were the leading sub-cause of YLDs (Table 1). 20–24 age group, and then steadily decreased as age The YLL/YLD ratio in the EMR for 2015 was 19.34, increased (Fig. 3). This was consistent with the global trend. almost double the global ratio of 9.77 (Wang et al. 2016). By country, Afghanistan had the highest age-standardized By country, Afghanistan had the highest ratio at 50.36, and YLL rate at 3090.3 (UI 2324.6–4115.3) per 100,000 popu- only Kuwait and Lebanon were below the global ratio at lation, nearly three times the regional average (Table 1). 7.50 and 6.45, respectively (Table 1). For all age groups and countries, YLLs were the primary contributor to Years lived with disability (YLDs) DALYs in terms of TI. Unlike YLLs, the rate of age-adjusted YLDs in the EMR Disability-adjusted life years (DALYs) was lower than the global average, 61.4 (UI 43.2–82.8) compared to 90.2 (UI 63.0–122.2) (Wang et al. 2016). The In 2015, TI were the eleventh leading cause DALYs, percentage of YLDs attributable to TI was also lower in the causing 8,069,712 (95% UI 7,303,759–8,888,094) DALYs. 123 S192 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators Table 2 Ratio of observed mortality rates to expected mortality rates on the basis of SDI alone for sub-causes of transport injuries in the Eastern Mediterranean Region, by country, in 2015. (Global Burden of Disease Study 2015, Eastern Mediterranean Countries, 2015) Country Observed/expected age-standardized death rates for transport injuries 2015 Pedestrian Cyclist Motorcyclist Motor vehicle Other road injuries Other transport injuries Afghanistan 1.319 1.005 0.918 3.511 2.151 1.678 Bahrain 0.265 0.095 0.150 1.156 0.682 0.985 Djibouti 0.683 1.192 0.499 0.878 0.744 0.561 Egypt 0.403 0.244 0.172 0.721 0.498 0.501 Iran 1.693 0.975 2.088 2.202 1.948 3.107 Iraq 0.524 0.264 0.210 1.073 0.687 0.471 Jordan 0.555 0.195 0.319 0.751 0.611 1.567 Kuwait 1.995 0.562 0.263 2.115 1.651 1.402 Lebanon 0.324 0.126 0.168 0.610 0.433 0.465 Libya 0.561 0.360 0.318 1.340 0.849 10.873 Morocco 0.436 0.237 0.278 0.931 0.598 0.683 Oman 4.955 0.321 0.295 0.483 1.938 0.897 Pakistan 0.502 0.294 0.929 0.453 0.533 0.260 Palestine 0.077 0.154 0.118 0.892 0.387 0.286 Qatar 1.905 0.828 0.333 2.402 1.851 1.539 Saudi Arabia 0.937 0.309 0.319 2.228 1.434 0.510 Somalia 1.040 1.245 0.891 1.060 1.036 1.013 Sudan 0.467 1.129 1.036 1.646 1.197 0.971 Syria 0.309 0.202 0.214 0.604 0.414 1.342 Tunisia 0.584 0.331 0.285 0.977 0.707 0.765 United Arab Emirates 5.292 1.399 0.725 5.881 4.362 1.759 Yemen 0.705 0.543 0.505 2.373 1.278 0.911 decreased in all countries except Pakistan and Libya, which increased 6.64% and 23.9%, respectively (Table 1; (Fig. 4). For all age groups and countries, YLLs were the primary contributor to DALYs (Fig. 4). Discussion Our study is the first to report on the burden of TI in the EMR from 1990 to 2015. Our results show that EMR mortality rates due to TI have not fallen as quickly as the global estimates. Three countries—Libya, Pakistan, and Fig. 3 YLL and YLD rates for transport injuries in the Eastern Egypt—even have had increases in death rates. Our results Mediterranean Region, both sexes, in 2015. YLD years lived with disability, YLL years of life lost. (Global Burden of Disease Study show that TI are still a major health problem in the region 2015, Eastern Mediterranean Countries, 2015) and call for serious efforts to reduce their burden. The YLL to YLD ratio can be used as an indicator for The highest and lowest age-standardized rates of DALYs the severity of TI and the effectiveness of health system were observed in Afghanistan and Sudan. The TI DALY intervention. The higher this ratio is, the more severe and age-standardized rates in 2015, were higher (3.1% of all fatal the crashes are and the less effective interventions the DALYs) compared to 0.3% of the total number of DALYs health system provides are. This ratio may suggest that from disease globally (Wang et al. 2016). Overall, there health care access and interventions are not up to global was a 9.9% increase from 1990 to 2015 for DALYs standards in the region, in spite of the economic growth attributable to TI in EMR. From 1990 to 2015 DALY rates 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S193 development that led to changes in lifestyle and environ- ment and subsequently impacted health and mortality (Razzak et al. 2004; Luoma and Sivak 2012; Hyder and Vecino-Ortiz 2014). Motorization is rapidly increasing in the region (WHO 2015), and our study suggests that many regulations should be implemented. Safer roads, enforced traffic laws, formal driver education with more stringent driver license procedures and policies, and safe vehicle regulations need to be rigorously implemented to cope with the increase in access to vehicles, especially in high-in- come countries in the region. Countries with high numbers for specific causes, like pedestrian injuries in Oman, should implement specific measures to protect those at risk. Similar to global trends (GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016; Kassebaum et al. 2016; Wang et al. 2016), TI in the EMR dispropor- tionately affect individuals who are in the economically productive age group of 15–44. This exerts an added Fig. 4 DALY rates per 100,000 population for transport injuries in pressure on the national economies of the EMR countries, the Eastern Mediterranean Region both sexes combined, by country, especially those with limited resources (Mokdad et al. in 1990 and 2015. DALY disability-adjusted life-years, YLD years 2014, 2016 ). The burden of TI is significantly higher in lived with disability, YLL years of life lost. (Global Burden of Disease males than females. This gender ratio is consistent with Study 2015, Eastern Mediterranean Countries, 1990–2015) global trends (Wang et al. 2016). Besides being a public and high SDI of some countries in the EMR. It has been health burden, TI are also associated with an immense shown that improved access to better-quality trauma care economic burden; it is estimated to cost EMR countries a systems has played a role in the decreasing mortality rates total of US$7.5 billion per year, equivalent to 1–1.5% of due to TI in high-income countries (Noland 2003). the GDP of most countries in the region (Bishai et al. Most of the research on the impact of trauma care comes 2006). from high-income countries where systems have been Despite the continuous threat of the burden of injuries implemented with few resource constraints. Assessments in in the EMR, few studies have been conducted to assess LMICs have consistently identified enormous gaps in the the burden of TI in the region, with the available ones resources needed to provide adequate care for the injured being limited to small-scale, city-based, or facility-based (Reynolds et al. 2017). A review describing reports that studies. Coverage of vital registration is low or absent in evaluated the impact of trauma care systems and system large parts of the EMR and issues of incompleteness and components in LMICs, identified reports from 32 countries. differences in death certification systems, definitions of These reports, which describe potentially useful interven- variables, and methods of data collection usually com- tions to strengthen care for the injured in LMICs, were promise the quality of data (Setel et al. 2007; Mahapatra found in only about one-quarter of LMICs. The study et al. 2007; Obermeyer et al. 2010; Joubert et al. 2012). suggests a substantial research gap that spans all regions In our study, it was necessary to predict estimates using (Reynolds et al. 2017). Another study suggested that models, relying on covariates and verbal autopsy data mortality among people with life-threatening but poten- (Noland 2003; Kassebaum et al. 2016). We added police and mortuary data for TI to help predict level and age tially survivable injuries was sixfold lower in high-income countries (6%) than in low-income countries (36%) (Mock patterns in countries with sparse or absent cause of death et al. 1993). data, even though we know from countries with near- Globally, the burden of disease due to TI has decreased complete vital registration data that police records tends significantly since 1990, but this decrease is largely in to underestimate the true level of deaths. The large GBD high-income regions, with the reverse trend occurring in mortality database allows us to use statistical models that low-income and middle-income countries. Some studies can borrow strength when data is missing from similar have suggested that this is due to the growth in motoriza- countries, previous years, published literature if no raw tion and traffic density outpacing infrastructural develop- data is available, published reports, police reports, media, ment and levels of law enforcement (Ameratunga et al. etc. Although this ensures an estimate for all causes and 2006; Naghavi et al. 2009; WHO 2013). Countries with all countries, estimates for populations and time periods with sparse or absent data are inherently less precise. fast-growing economies have experienced rapid economic 123 S194 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators While we attempt to capture all sources of uncertainty Conclusion from sampling error, non-sampling error, and model specifications in the 95% uncertainty intervals, additional Our study highlights the significant burden of TI deaths and sources of uncertainty may not have been captured injuries in the EMR countries, and the need for improving trauma centers and implementation of a faster emergency (Mathers et al. 2006; Byass et al. 2013). A study in Saudi Arabia showed that rates of death care in the EMR. Strict monitoring and enforcement of traffic laws, and programs to increase awareness and proper from road traffic accidents based on police reports and on health registration data are different, and that unlike education for drivers should be developed jointly by the Ministries of Health, Interior Affairs, and Education and police-reported data, health registration does not show steadiness or decline in the rates of road traffic deaths provided through their channels. (Barrimah et al. 2012). These inconsistencies may be GBD 2015 Eastern Mediterranean Region Transportation Inju- caused by differences in definitions, or may reflect dif- ries Collaborators: Ali H. Mokdad, PhD (corresponding author), ferences in data collection methods (Loo and Tsui 2007; Institute for Health Metrics and Evaluation, University of Washing- Jeffrey et al. 2009), or road traffic officials may even be ton, Seattle, Washington, United States. Ibrahim Khalil, MD, Institute underreporting TI to avoid criticism from superiors who for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Charbel El Bcheraoui, PhD, Institute for expect to see rates go down, as one study suggested Health Metrics and Evaluation, University of Washington, Seattle, (Dandona et al. 2008). Washington, United States. Raghid Charara, MD, American Univer- The fact that males were substantially more likely to die sity of Beirut, Beirut, Lebanon. Maziar Moradi-Lakeh, MD, Depart- from TI than females may be correlated to the fact that in ment of Community Medicine, Preventive Medicine and Public Health Research Center, Gastrointestinal and Liver Disease Research some of these countries less women drive motorized Center (GILDRC), Iran University of Medical Sciences, Tehran, Iran. vehicles; also in most cases women are accompanied by Ashkan Afshin, MD, Institute for Health Metrics and Evaluation, men outside of their houses. University of Washington, Seattle, Washington, United States. Suboptimal public awareness of the importance of Nicholas J. Kassebaum, MD, Institute for Health Metrics and Eval- uation, University of Washington, Seattle, Washington, United States; the issue has resulted in diminished emphasis on road Department of Anesthesiology & Pain Medicine, Seattle Children’s safety policies at the national level in EMR countries. Hospital, Seattle, Washington, United States. Michael Collison, BS, Lack of solid, reliable data may be a significant barrier Institute for Health Metrics and Evaluation, University of Washing- ton, Seattle, Washington, United States. Farah Daoud, BA/BS, Insti- to policymakers’ prioritizing this major public health tute for Health Metrics and Evaluation, University of Washington. problem. Adrienne Chew, ND, Institute for Health Metrics and Evaluation, There are no definitive data on the number of people University of Washington, Seattle, Washington, United States. who survive with some form of permanent disability for Kristopher J. Krohn, BA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Danny every injury-related death, but estimates run between 10 Colombara, PhD, Institute for Health Metrics and Evaluation, and 50 times more permanent disabilities. As such, these University of Washington, Seattle, Washington, United States. Leslie injuries clearly contribute to the economic and social costs Cornaby, BS, Institute for Health Metrics and Evaluation, University and have a negative impact on individuals, communities, of Washington, Seattle, Washington, United States. Rebecca and societies. Ehrenkranz, MPH, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States. Many studies have shown that human behavioral factors Nicholas Graetz, MPH, Institute for Health Metrics and Evaluation, collectively represent the main cause of three out of five University of Washington, Seattle, Washington, United States. road traffic crashes, and contribute to the cause in most Michael Kutz, BS, Institute for Health Metrics and Evaluation, remaining cases (Marshall et al. 1996; Evans 1996; Lyz- University of Washington, Seattle, Washington, United States. Christopher Troeger, Institute for Health Metrics and Evaluation, nicki et al. 1998; Sharma et al. 2002). A study in Saudi University of Washington. Haidong Wang, PhD, Institute for Health Arabia showed that more than 43% of unlicensed males Metrics and Evaluation, University of Washington, Seattle, Wash- drove a vehicle (El Bcheraoui et al. 2015). Among those ington, United States. Kalkidan Hassen Abate, MS, Jimma University, male drivers (females are not allowed to drive by law), Jimma, Ethiopia. Foad Abd-Allah, MD, Department of Neurology, Cairo University, Cairo, Egypt. Abdishakur M. Abdulle, PhD, New 86% engaged in at least one risky behavior while driving. York University, Abu Dhabi, United Arab Emirates. Semaw Ferede Up to 95 and 98.5% of respondents reported not wearing a Abera, MSc, School of Public Health, College of Health Sciences, seat belt in the front (enforced by the law), and the back Mekelle University, Mekelle, Ethiopia; Food Security and Institute for Biological Chemistry and Nutrition, University of Hohenheim, seat, respectively. Stuttgart, Germany. Aliasghar Ahmad Kiadaliri, PhD, Department of More attention must also be given to the needs of vul- Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, nerable road users, like pedestrians, children, and bicy- Lund University, Lund, Sweden. Alireza Ahmadi, PhD, Kermanshah cle/motorcycle and public transport users. Making walking University of Medical Sciences, Kermanshah, Iran. Muktar Beshir Ahmed, MPH, College of Health Sciences, Department of Epidemi- and cycling safer is critical to reducing the number of road ology, ICT and e-Learning Coordinator, Jimma University, Jimma, traffic deaths and is important to promote non-motorized Ethiopia. Khurshid Alam, PhD, Murdoch Childrens Research forms of transport. 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S195 Institute, The University of Melbourne, Parkville, Victoria, Australia; Institutes, Taipei, Taiwan. Solomon Weldemariam Gebrehiwot, MS, The University of Melbourne, Melbourne, VIC, Australia. The College of Health Sciences, Mekelle University, Mekelle, Ethiopia; University of Sydney, Sydney, NSW, Australia. Deena Alasfoor, Tsegaye Tewelde Gebrehiwot, MPH, Jimma University, Jimma, MSc, Ministry of Health, Al Khuwair, Muscat, Oman. Suliman Ethiopia. Nima Hafezi-Nejad, MD, Endocrinology and Metabolism Alghnam, PhD King Abdulah International Medical Research Center, Research Center, Tehran University of Medical Sciences, Tehran, Riyadh, Saudi Arabia; Center For Injury Research and Policy, Iran. Hassan Haghparast Bidgoli, PhD, University College London, Bloomberg School of Public Health, Johns Hopkins University, London, United Kingdom. Gessessew Bugssa Hailu, MSc Mekelle Baltimore, MD, United States. Raghib Ali, MSc, University of University, Mekelle, Ethiopia; Kilte Awlaelo Health and Demo- Oxford, Oxford, United Kingdom. Reza Alizadeh-Navaei, PhD, graphic Surveillance System, Mekelle, Ethiopia. Randah Ribhi Gastrointestinal Cancer Research Center, Mazandaran University of Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. Samer Medical Sciences, Sari, Iran. Rajaa Al-Raddadi, PhD, Joint Program Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Dubai, of Family and Community Medicine, Jeddah, Saudi Arabia. Ubai United Arab Emirates. Delia Hendrie, MA, Centre for Population Alsharif, MPH, Charite´ Universita¨tsmedizin, Berlin, Germany. Khalid Health Research, Curtin University, Bentley, WA, Australia. Ileana A. Altirkawi, MD, King Saud University, Riyadh, Saudi Arabia. Beatriz Heredia-Pi, PhD, National Institute of Public Health, Cuer- Nahla Anber, PhD, Mansoura University, Mansoura, Egypt. Hossein navaca, Morelos, Mexico. Kathryn H. Jacobsen, PhD, Department of Ansari, PhD, Health Promotion Research Center, Department of Global and Community Health, George Mason University, Fairfax, Epidemiology and Biostatistics, Zahedan University of Medical Sci- Virginia, United States. Spencer Lewis James, MD, Denver Health/ ences, Zahedan, Iran. Carl Abelardo T. Antonio, MD, Department of University of Colorado, Denver, CO, United States. Achala Upendra Health Policy and Administration, College of Public Health, Jayatilleke, PhD, Postgraduate Institute of Medicine, Colombo, Sri University of the Philippines Manila, Manila, Philippines. Palwasha Lanka; Institute of Violence and Injury Prevention, Colombo, Sri Anwari, MD Self-employed, Kabul, Afghanistan. Hamid Asayesh, Lanka. Guohong Jiang, MD, Tianjin Centers for Disease Control and PhD, Department of Medical Emergency, School of Paramedic, Qom Prevention, Tianjin, China. Jost B. Jonas, MD, Department of Oph- University of Medical Sciences, Qom, Iran. Tesfay Mehari Atey, MS, thalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Mekelle University, Mekelle, Ethiopia. Leticia Avila-Burgos, PhD, Heidelberg, Mannheim, Germany. Amir Kasaeian, PhD, Hematology- National Institute of Public Health, Cuernavaca, Mexico. Suzanne L. Oncology and Stem Cell Transplantation Research Center, Tehran Barker-Collo, PhD, School of Psychology, University of Auckland, University of Medical Sciences, Tehran, Iran; Endocrinology and Auckland, New Zealand. Shahrzad Bazargan-Hejazi, PhD, College of Metabolism Population Sciences Institute, Tehran University of Medicine, Charles R. Drew University of Medicine and Science, Los Medical Sciences, Tehran, Iran. Peter Njenga Keiyoro, PhD, Institute Angeles, CA, United States; David Geffen School of Medicine, of Tropical and Infectious Diseases, Nairobi, Kenya; Kenya School of University of California at Los Angeles, Los Angeles, CA, United Continuing and Distance Education, Nairobi, Kenya. Yousef Saleh States. Neeraj Bedi, MD, College of Public Health and Tropical Khader, ScD, Department of Community Medicine, Public Health Medicine, Jazan, Saudi Arabia. Addisu Shunu Beyene, MPH, College and Family Medicine, Jordan University of Science and Technology, of Health and Medical Science, Haramaya University, Harar, Ethio- Irbid, Jordan. Ejaz Ahmad Khan, MD, Health Services Academy, pia. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Women and Islamabad, Punjab, Pakistan. Abdullah Tawfih Abdullah Khoja, MD, Child Health, Aga Khan University, Karachi, Pakistan; Centre for Mohammed Ibn Saudi University, Riyadh, Saudi Arabia. Ardeshir Global Child Health, The Hospital for Sick Children, Toronto, ON, Khosravi, PhD, Iranian Ministry of Health and Medical Education, Canada. Soufiane Boufous, PhD, Transport and Road Safety (TARS) Tehran, Iran, Non-communicable Diseases Research Center, Tehran Research, University of New South Wales, Sydney, New South University of Medical Sciences, Tehran, Iran. Jagdish Khubchandani, Wales, Australia. Zahid A. Butt, PhD, Al Shifa Trust Eye Hospital, PhD, Department of Nutrition and Health Science, Ball State Rawalpindi, Pakistan. Carlos A. Castan˜eda-Orjuela, MSc, Colombian University, Muncie, Indiana, United States. Yun Jin Kim, PhD, National Health Observatory, Instituto Nacional de Salud, Bogota, Faculty of Chinese Medicine, Southern University College, Skudai, Colombia; Epidemiology and Public Health Evaluation Group, Public Johor, Malaysia. Soewarta Kosen, MD, Center for Community Health Department, Universidad Nacional de Colombia, Bogota, Empowerment, Health Policy and Humanities, National Institute of Colombia. Abdulaal A. Chitheer, MD, Ministry of Health, Baghdad, Health Research & Development, Jakarta, Indonesia. Barthelemy Iraq. Koustuv Dalal, PhD, Centre for Injury Prevention and Safety Kuate Defo, PhD, Department of Social and Preventive Medicine, Promotion, School of Health and Medical Sciences, Orebro Univer- School of Public Health, University of Montreal, Montreal, Quebec, sity, Orebro, Sweden. Hadi Danawi, PhD, Walden University, Min- Canada; Department of Demography and Public Health Research neapolis, Minnesota, United States. Dragos V. Davitoiu, PhD, Institute, University of Montreal, Montreal Canada. Heidi J. Larson, University of Medicine and Pharmacy Bucharest, Bucharest, Roma- PhD, Department of Infectious Disease Epidemiology, London nia. Shirin Djalalinia, PhD, Undersecretary for Research & Tech- School of Hygiene & Tropical Medicine, London, United Kingdom; nology, Ministry of Health & Medical Education, Tehran, Iran. Aman Institute for Health Metrics and Evaluation, University of Washing- Yesuf Endries, MPH, Arba Minch University, Arba Minch, Ethiopia. ton, Seattle, Washington, United States. Shai Linn, MD University of Babak Eshrati, PhD, Ministry of Health and Medical Education, Haifa, Haifa, Israel. Raimundas Lunevicius, PhD, Aintree University Tehran, Iran; Arak University of Medical Sciences, Arak, Iran. Hospital National Health Service Foundation Trust, Liverpool, United Alireza Esteghamati, MD, Endocrinology and Metabolism Research Kingdom; School of Medicine, University of Liverpool, Liverpool, Center, Tehran University of Medical Sciences, Tehran, Iran. Andre´ United Kingdom. Hassan Magdy Abd El Razek, MBBCH, Mansoura Faro, PhD, Federal University of Sergipe, Aracaju, Brazil. Maryam S. Faculty of Medicine, Mansoura, Egypt. Mohammed Magdy Abd El Farvid, PhD, Department of Nutrition, Harvard T. H. Chan School of Razek, MBBCH, Aswan University Hospital, Aswan Faculty of Public Health, Harvard University, Boston, MA, United States; Har- Medicine, Aswan, Egypt. Marek Majdan, PhD, Faculty of Health vard/MGH Center on Genomics, Vulnerable Populations, and Health Sciences and Social Work, Department of Public Health, Trnava Disparities, Mongan Institute for Health Policy, Massachusetts Gen- University, Trnava, Slovakia. Reza Majdzadeh, PhD, Knowledge eral Hospital, Boston, MA, United States. Seyed-Mohammad Utilization Research Center and Community Based Participatory Fereshtehnejad, PhD, Department of Neurobiology, Care Sciences Research Center, Tehran University of Medical Sciences, Tehran, and Society (NVS), Karolinska Institutet, Stockholm, Sweden. Flo- Iran. Azeem Majeed, MD, Department of Primary Care & Public rian Fischer, PhD, School of Public Health, Bielefeld University, Health, Imperial College London, London, United Kingdom. Reza Bielefeld, Germany. Wayne Gao, PhD, National Health Research Malekzadeh, MD, Digestive Diseases Research Institute, Tehran 123 S196 GBD 2015 Eastern Mediterranean Region Transportation Injuries Collaborators University of Medical Sciences, Tehran, Iran. Peter Memiah, PhD, United States. Sadaf G. Sepanlou, PhD, Digestive Diseases Research University of West Florida, Pensacola, FL, United States. Ziad A. Institute, Tehran University of Medical Sciences, Tehran, Iran. Amira Memish, MD, Saudi Ministry of Health, Riyadh, Saudi Arabia; Col- Shaheen, PhD, Department of Public Health, An-Najah University, lege of Medicine, Alfaisal University, Riyadh, Saudi Arabia. Walter Nablus, Palestine. Masood Ali Shaikh, MD, Independent Consultant, Mendoza, MD, United Nations Population Fund, Lima, Peru. Karachi, Pakistan. Mansour Shamsipour, PhD, Institute for Environ- Mubarek Abera Mengistie, MS, Jimma University, Jimma, Ethiopia. mental Research, Tehran University of Medical Sciences, Tehran, Tuomo J. Meretoja, PhD, Comprehensive Cancer Center, Breast Iran. Morteza Shamsizadeh, MPH, Department of Medical Surgical Surgery Unit, Helsinki University Hospital, Helsinki, Finland; Nursing, School of Nursing and Midwifery, Hamadan University of University of Helsinki, Helsinki, Finland. Ted R. Miller, PhD, Pacific Medical Sciences, Hamadan, Iran. Badr H. A. Sobaih, MD, King Institute for Research & Evaluation, Calverton, MD, United States; Saud University, Riyadh, Saudi Arabia. Muawiyyah Babale Sufiyan, Centre for Population Health, Curtin University, Perth, WA, Aus- MBA, Ahmadu Bello University, Zaria, Nigeria. Jacob E. Sunshine, tralia. Shafiu Mohammed, PhD, Health Systems and Policy Research MD, University of Washington, Seattle, Washington, United States. Unit, Ahmadu Bello University, Zaria, Nigeria; Institute of Public Arash Tehrani-Banihashemi, PhD, Preventive Medicine and Public Health, Heidelberg University, Heidelberg, Germany. Ashagre Molla Health Research Center, Iran University of Medical Sciences, Tehran, Assaye, MS, Bahir Dar University, Bahir Dar, Ethiopia. Carla Iran; Community Medicine Department, Iran University of Medical Makhlouf Obermeyer, DSc, Center for Research on Population and Sciences, Tehran, Iran. Mohamad-Hani Temsah, MD, King Saud Health, Faculty of Health Sciences, American University of Beirut, University, Riyadh, Saudi Arabia. Abdullah Sulieman Terkawi, MD, Beirut, Lebanon. Farshad Pourmalek, PhD, University of British Department of Anesthesiology, University of Virginia, Char- Columbia, Vancouver, British Columbia, Canada. Mostafa Qorbani, lottesville, VA, United States; Department of Anesthesiology, King PhD, Non-communicable Diseases Research Center, Alborz Univer- Fahad Medical City, Riyadh, Saudi Arabia; Outcomes Research sity of Medical Sciences, Karaj, Iran. Amir Radfar, MD, A T Still Consortium, Cleveland Clinic, Cleveland, OH, United States. J. S. University, Kirksville, MO, United States. Anwar Rafay, MS, Con- Thakur, MD, School of Public Health, Post Graduate Institute of tech International Health Consultants, Lahore, Pakistan; Contech Medical Education and Research, Chandigarh, Union Territory School of Public Health, Lahore, Pakistan. Vafa Rahimi-Movaghar, Chandigarh, India. Roman Topor-Madry, PhD, Institute of Public MD, Sina Trauma and Surgery Research Center, Tehran University of Health, Faculty of Health Sciences, Jagiellonian University Medical Medical Sciences, Tehran, Iran. Mahfuzar Rahman, PhD, Research College, Krakow, Poland; Faculty of Health Sciences, Wroclaw and Evaluation Division, BRAC, Dhaka, Bangladesh. Rajesh Kumar Medical University, Wroclaw, Poland. Olalekan A. Uthman, PhD, Rai, MPH, Society for Health and Demographic Surveillance, Suri, Warwick Medical School, University of Warwick, Coventry, United India. Kavitha Ranganathan, MD, University of Michigan Health Kingdom. Vasiliy Victorovich Vlassov, MD, National Research Systems, Ann Arbor, Michigan, United States. David Laith Rawaf, University Higher School of Economics, Moscow, Russia. Stein Emil MD, WHO Collaborating Centre, Imperial College London, London, Vollset, DrPH, Center for Disease Burden, Norwegian Institute of United Kingdom, North Hampshire Hospitals, Basingstroke, United Public Health, Bergen, Norway; Department of Global Public Health Kingdom; University College London Hospitals, London, United and Primary Care, University of Bergen, Bergen, Norway; Institute Kingdom. Salman Rawaf, MD, Imperial College London, London, for Health Metrics and Evaluation, University of Washington, Seattle, United Kingdom. Amany H. Refaat, PhD, Walden University, Min- Washington, United States. Tolassa Wakayo, MS, Jimma University, neapolis, MN, United States; Suez Canal University, Ismailia, Egypt. Jimma, Ethiopia. Andrea Werdecker, PhD, Competence Center Andre M. N. Renzaho, PhD, Western Sydney University, Penrith, Mortality-Follow-Up of the German National Cohort, Federal Insti- NSW, Australia. Satar Rezaei, PhD, School of Public Health, Ker- tute for Population Research, Wiesbaden, Germany. Mohsen manshah University of Medical Sciences, Kermanshah, Iran. David Yaghoubi, MSc, School of Public Health, University of Saskatch- Rojas-Rueda, PhD, Campus MAR, Barcelona Biomedical Research ewan, Saskatoon, Saskatchewan, Canada. Mehdi Yaseri, PhD, Tehran Park (PRBB), ISGlobal Instituto de Salud Global de Barcelona, University of Medical Sciences, Tehran, Iran; Ophthalmic Research Catalonia, Spain. Gholamreza Roshandel, PhD, Golestan Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Center of Gastroenterology and Hepatology, Golestan University of Iran. Naohiro Yonemoto, MPH, Department of Biostatistics, School Medical Sciences, Gorgan, Iran; Digestive Diseases Research Insti- of Public Health, Kyoto University, Kyoto, Japan. Mustafa Z. Younis, tute, Tehran University of Medical Sciences, Tehran, Iran. Mahdi DrPH, Jackson State University, Jackson, MS, United States. Maysaa Safdarian, MD, Sina Trauma & Surgery Research Center, Tehran El Sayed Zaki, PhD, Faculty of Medicine, Mansoura University, University of Medical Sciences, Tehran, Iran. Saeid Safiri, PhD, Mansoura, Egypt. Aisha O. Jumaan, PhD, Independent Consultant, Managerial Epidemiology Research Center, Department of Public Seattle, Washington, United States. Theo Vos, PhD, Institute for Health, School of Nursing and Midwifery, Maragheh University of Health Metrics and Evaluation, University of Washington, Seattle, Medical Sciences, Maragheh, Iran. Mohammad Ali Sahraian, MD, Washington, United States. Simon I. Hay, DSc, Oxford Big Data MS Research Center, Neuroscience Institute, Tehran University of Institute, Li Ka Shing Centre for Health Information and Discovery, Medical Sciences, Tehran, Iran. Payman Salamati, MD, Sina Trauma University of Oxford, Oxford, United Kingdom, Institute for Health and Surgery Research Center, Tehran University of Medical Sciences, Metrics and Evaluation, University of Washington, Seattle, Wash- Tehran, Iran. Abdallah M. Samy, PhD, Ain Shams University, Cairo, ington, United States. Mohsen Naghavi, PhD, Institute for Health Egypt. Juan Ramon Sanabria, MD, J Edwards School of Medicine, Metrics and Evaluation, University of Washington, Seattle, Wash- Marshall Univeristy, Huntington, WV, United States; Case Western ington, United States. Christopher J. L. Murray, DPhil, Institute for Reserve University, Cleveland, OH, United States. Milena M. Santric Health Metrics and Evaluation, University of Washington, Seattle, Milicevic, PhD, Institute of Social Medicine, Faculty of Medicine, Washington, United States. University of Belgrade, Belgrade, Serbia, Centre School of Public Health and Health Management, Faculty of Medicine, University of Compliance with ethical standards Belgrade, Belgrade, Serbia. Benn Sartorius, PhD, Public Health Medicine, School of Nursing and Public Health, University of Kwa- This manuscript reflects original work that has not previously been Zulu-Natal, Durban, South Africa; UKZN Gastrointestinal Cancer published in whole or in part and is not under consideration else- Research Centre, South African Medical Research Council where. All authors have read the manuscript and have agreed that the (SAMRC), Durban, South Africa. David C. Schwebel, PhD, work is ready for submission and accept responsibility for its University of Alabama at Birmingham, Birmingham, Alabama, contents. 123 Transport injuries and deaths in the Eastern Mediterranean Region: findings from the Global… S197 Ethical approval The authors of this paper have complied with all Joubert J, Rao C, Bradshaw D et al (2012) Characteristics, availability ethical standards and do not have any conflicts of interest to disclose and uses of vital registration and other mortality data sources in at the time of submission. The funding source played no role in the post-democracy South Africa. Glob Health Action. doi:10.3402/ design of the study, the analysis and interpretation of data, and the gha.v5i0.19263 writing of the paper. The study did not involve human participants Karacasu M, Er A, Bilgic¸ S, Barut HB (2011) Variations in traffic and/or animals; therefore, no informed consent was needed. accidents on seasonal, monthly, daily and hourly basis: Eskisehir case. Proc Soc Behav Sci 20:767–775. doi:10.1016/j.sbspro. 2011.08.085 Funding This research was funded by the Bill & Melinda Gates Kassebaum NJ, Arora M, Barber RM et al (2016) Global, regional, Foundation. and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), Conflict of interest The authors declare that they have no conflicts of 1990–2015: a systematic analysis for the Global Burden of interest at this time. Disease Study 2015. The Lancet 388:1603–1658. doi:10.1016/ S0140-6736(16)31460-X Open Access This article is distributed under the terms of the Keay K, Simmonds I (2005) The association of rainfall and other Creative Commons Attribution 4.0 International License (http://crea weather variables with road traffic volume in Melbourne, tivecommons.org/licenses/by/4.0/), which permits unrestricted use, Australia. Accid Anal Prev 37:109–124. doi:10.1016/j.aap. distribution, and reproduction in any medium, provided you give 2004.07.005 appropriate credit to the original author(s) and the source, provide a Loo BPY, Tsui KL (2007) Factors affecting the likelihood of link to the Creative Commons license, and indicate if changes were reporting road crashes resulting in medical treatment to the made. police. 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