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1 UMEÅ INTERNATIONAL SCHOOL OF PUBLIC HEALTH MOTORCYCLE RELATED MAXILLOFACIAL INJURIES IN A SEMI- URBAN TOWN IN NIGERIA: A FOUR YEAR REVIEW OF CASES IN IRRUA SPECIALIST TEACHING HOSPITAL AKHIGBE, OZIEGBE PAUL MASTER THESIS IN PUBLIC HEALTH 2010 EPIDEMIOLOGY AND PUBLIC HEALTH DEPARTMENT OF PUBLIC HEALTH AND CLINICAL MEDICINE UMEÅ UNIVERSITY Supervisor: Prof. Urban Janlert 1

2 ABSTRACT Road traffic injuries are the consequences of road crashes due to the advances in technology of manufacturing motor vehicles for transportation purposes. Motorcycle related injuries are a common feature in developing countries due to the reliance on motorcycle for transporting pillion passengers and good due to poor road networks, economic consideration and absence of effective public transportation system. Maxillofacial injuries are a common feature of motorcycle crashes amongst passengers and riders due to the prominence of facial bones and the predisposition of the face to the injuries. Maxillofacial injuries have aesthetic, functional and psychological components attached to it. Objective This study was carried out to describe the pattern and characteristics of maxillofacial and concomittant injuries, explore potential factors related to the type, severity and scale (FISS) of maxillofacial injuries and describe the mechanism of the crashes amongst commercial motorcyclists and passengers. Methods The medical records of patients treated for motorcycle related maxillofacial injuries on in- and out- basis were obtained retrospectively from from a tertiary hospital in a semi urban area in Nigeria. Information on sex, gender, educational status, mechanism of crash, time and season of occurrence of crashes and type of injuries were obtained from the records. The facial injury severity score (FISS) was used for scoring the injuries, while treatment needs were used to classify injuries into mild, moderate and severe Results A total of 128 patients records were obtained. The predominant age group was year. 55.5% of the patients were riders with no female. Riders sustained a greater proportion of both maxillofacial and concomittant injuries (55.88, 55.32%) respectively compared to passengers. A symmetrical distribution of maxillofacial injuries was observed in the upper, middle and lower thirds of the face. 2

3 14% 0f riders admitted consumption of alcohol. None of the riders or passengers wore helmets. Skidded off/lost control was the predominant crash mechanism (47.7%) and having a statistical association (p-value=0.02) with treatment needs of maxillofacial injuries Conclusion This study has shown that motorcycle related maxillofacial and concomittant injuries are higher amongst the riders than the passengers especially in the years age group. Data from the study could not identify any predictive factor for the occurrence of both maxillofacial and concomitant injuries in the study population. A well designed prospective study at the population level is advocated to evaluate potential risk factors. In addition qualitative study is also suggested to evaluate riders knowledge, attitude and practice of helmet use Key words: Crashes, Maxillofacial injuries, Motorcyclists 3

4 ACKNOWLEDGEMENT My unparalleled thanks go to the Almighty God for giving me the opportunity to undertake this academic journey and seeing me through to the end. To my wife and children, it couldn t have been possible without your love, support, encouragement and your timely visits. I appreciated you being there when needed most. Words cannot express the joy of having you as a family. A million thank you to Dr. Sam Coker, for being so wonderful and so nice. For your moral and financial upliftment, the good Lord will enrich and bless you greatly. I am forever grateful to my parents, in-laws, brothers, sister and friends, your ceaseless prayers, mails, messages, phone calls, kind words and encouragement were a catalyst for my studies. I would like to express my heartfelt appreciation to my Supervisor Prof. Urban Janlert for his constructive criticisms and positive corrections in writing this thesis. To my mentor, Dr. Gold Amuwha thanks for your encouragement, support and prayers My special thanks to Birgitta and Karin for ever willing to help, your kindness and support have been awesome. I enjoyed the time I had together with all the staff of the Department of epidemiology and Public Health Sciences, Umea University which have left an indelible mark in me that will last for a lifetime. Lastly, but definitely not the least, the great cohort in Umea!!!, MPH class of 2008/2010, it has been a wonderful two years together. Been with you has taught me a lot of lessons that will certainly help me in life. I cherish the strong bond of friendship that linked us together despite our different backgrounds. I hope to meet you in the future for more friendship and collaboration. 4

5 TABLE OF CONTENTS TITLE.1 ABSTRACT.2 ACKNOWLEDGEMENT 4 TABLE OF CONTENTS...5 LIST OF ABBREVIATIONS INTRODUCTION Motorcycles As Means of Transport Global burden of Road Traffic Injuries Burden of Road Traffic Injuries in Nigeria Road traffic accidents related maxillofacial injuries Country Profile: Nigeria Geography and Demographic Characteristics Politics and Administration Economy Health Care System Motorcycle Injuries in Nigeria Objectives Study site Geography and demographic characteristics of Irrua Health seeking behavior.22 5

6 2.3 Methods Data Collection and Analysis Ethical clearance Results Demographic Characteristics of Patients Discussion Strengths and limitations Conclusion and General Recommendations 42 References Appendix..49 6

7 LIST OFABBREVIATIONS BAOMS CIA CI DALY DFID FMOH GDP GNP PHC RTA RTI UNDP WHO SD British Association of Oral and Maxillofacial Surgeons Central Intelligence Agency Confidence interval Daily Adjusted Life Years Department for International Development, United Kingdom Federal Ministry of Health Gross Domestic Product Gross National Product Primary Health Care Road Traffic Accident Road Traffic Injuries United Nations Development Programme World Health Organization Standard Deviation 7

8 1.0 INTRODUCTION 1.1 MOTORCYCLES AS MEANS OF TRANSPORT Advances in technological development have led to the production of motorized vehicles for road transportation; this increased motorization obviously has enhanced the mobility of people. A motorcycle which is a motorized vehicle, emergence as a means of transport has become a common feature in Asia (motorcycles registrations comprise 95% (Hung et al.,2006), 67%(MTC, 2007), 63% (Zhang et al.,2004), 60% (Radin-Umar, R.S,1996) in Vietnam, Taiwan, China, Malaysia respectively of all registered vehicles) and Africa unlike in the developed countries, where motorcycling is undertaken as a form of recreation and leisure, for example in the United States of America motorcycles comprise 2% of registered motor vehicles (NHTSA, 2007). The annual production of motorcycles in the world is put at about 45 million with the growth rate in Africa, being between about 12-30%. (Oginni et al., 2009) The growing use of motorcycles in the developing countries for transportation purposes has been attributable to socioeconomic reasons, convenience in negotiating traffic in congested cities and poorly maintained roads, political reasons and the ease of parking in narrow streets. In Nigeria, transportation with motorcycles has evolved over the years, it gained prominence in the commercial city of Lagos, formerly the federal capital in 1992 due to a dearth of other means of public transportation, it has been estimated that about 450,000 motorcycles are in the metropolis alone as at 1995 (Ojekunle, 1996), while registration of motorcycles licence plates in 2004 and 2005 in the country represented 52% of all motor vehicle licence plates (Federal Road Safety Commission, 2006). It is worthy of note to state that the use of motorcycles for commercial transport not only involves the movement of pillion passengers but also of goods. The description of the motorcycle as the most dangerous of all motorized vehicle for transportation can be attributed to its nature and design e.g. absence of airbags to reduce impact in the event of a collision and therefore riders and passengers alike are vulnerable victims of road traffic crashes. In terms of miles covered in comparison, with other motorized vehicles riders are 8

9 prone more to injuries and death by 8 and 34 times respectively (NHTSA, 2007).Factors responsible for this can be classified as host and environmental. Environmental factors include the condition and nature of the roads, traffic flow, poor visibility at night while human factors include amongst other things the attitude and behavior of cyclists on the roads, ignoring safety measures like speed limit, wearing of crash helmets and protective clothing, alcohol and substance abuse prior to riding, carrying more than the stipulated number of pillion passengers (Alvi et al., 2003; McFarland, 1962). In preventing motorcycle related injuries, the most successful measure is to limit the severity of injuries after the crash which is termed a secondary approach. This secondary approach involves the use of crash helmets. Several studies have documented the effectiveness of the crash helmets in saving lives and which ultimately lead to the reduction in the severity of the injuries, but opponents to the crash helmets claims it blocks the peripheral vision of the riders. This approach of risk reduction has been traditionally undertaken because road traffic injuries have been seen as injuries that are unintentional resulting from road accidents but since the term accident has now been replaced with crash this approach is no longer tenable because a crash is suggestive of something that can be preventable and subjective to rational analysis (Peden et al., 2004) 1.2 GLOBAL BURDEN OF ROAD TRAFFIC INJURIES. Injuries arising as a result of road crashes are a major global health and developmental concerns, which require committed efforts at prevention. Globally 1.2 million people die annually on the roads as a result of road traffic crashes averaging 3242 deaths daily, while million people suffer some form of injuries or disabilities by estimation (WHO, 2002), these figures are expected to increase by 65% between 2000 and 2020 with an increase by 80%, in the low and middle-income countries. It is projected that by the year 2020 road traffic injuries will rank third as the leading cause of disability adjusted life years (DALY), in the year 1990 it was ranked ninth in the world(who, 2002). With these seemingly gloomy figures, it is important to note that there are disparities between high-income, middle and low-income countries in terms of mortality; 90% of road traffic mortalities occur in the low and middle-income countries where there are 48% of registered vehicles worldwide, while the remaining 10% occur in the highincome countries (Table 1). These values were arrived at by calculating rates per 100,000 of the 9

10 population for comparison purposes instead of absolute values; to estimate the magnitude of the problem, to assess the risk and evaluation of performance of any intervention geared towards reduction of road traffic crashes. There is gross underestimation of the global burden of road traffic injuries because of under reporting and outright absence of quality data especially in developing countries. Furthermore deaths and injuries from motorcycle crashes also vary from high-income, middle-income and low-income countries, for instance in Malaysia, a middleincome country the fatalities amongst road users was found to be 60% and attributed to motorcycle crashes with motorcycles being 47% of the total registered vehicles. In Austria, a high income country, deaths from motorcycle crashes was 17% amongst road users with motorcycle registrations being 11% of the total vehicles. (WHO, 2009) The economic costs of road traffic injuries estimated in terms of the gross national product (GNP) has also shown some disparities when comparing high, middle and low-income countries. In the high-income countries, it is estimated that 2% of the GNP is spent on road traffic injuries while it is 1.5% and 1% in the middle and low-income countries respectively (Jacobs, G et al. 2000). Globally, estimates of the economic cost of road traffic crashes is put at US $518 billion while the cost is US$65 billion in low-income countries (Jacobs, G et al., 2000), an amount that far exceeds development aids annually. In the United States of America as at 2000, the human capital cost of road traffic crashes was estimated to be US$ 230 billion. (Blincoe, L.J et al., 2002) In many developing countries majority of injuries from road traffic crashes involve cyclists, motorcyclists, pedestrians, elderly and children who are the vulnerable users of the roads, while the case is different in the developed countries where occupants of cars are more likely to be injured in the event of a crash. The group of people mostly injured or who die as a result of road traffic crashes are in the age group who are the productive people in the economy (Peden, M. et al. 2000) this has an obvious disadvantage especially in the developing countries where fatalities from road traffic crashes is high; with the resultant effect of a diminish contribution to the economy, in Kenya 75% of road traffic casualties are in the productive workforce group (Odero et al, 2003). In addition hospitalization due to traffic related injuries in middle and lowincome countries represent between 30% and 86% of all trauma admissions (Odero et al., 1997; Bars et al., 1998). This further worsens the economic situation of the injured as they are often poor and accessing health care is expensive when in existence, as user fees are usually charged in 10

11 order to get the required medical attention. Road traffic injuries also place a social burden not only on the survivors of crashes but also on their dependents and relatives. Table 1 Summary of road traffic deaths in high, middle and low- income countries. Source: WHO Global Burden of Disease project, 2002, Version 1 Figure 1 Road traffic injury mortality rates (per population) in WHO regions, Source: WHO Global Burden of Disease project, 2002, Version 1 11

12 1.3 BURDEN OF ROAD TRAFFIC INJURIES IN NIGERIA Nigeria with a population of 144.7million people (WHO, 2009) is considered to be the most populous country in Africa. Road traffic injuries have been reported to be one of the leading causes of deaths; specifically WHO in 2002 ranked road traffic injuries (RTIs) as the 11 th major cause of death and 6 th major cause of DALYs lost in the country. Nigeria is ranked number two in terms of the number of road crashes in the African continent. Road traffic accidents kill an average of 12 persons daily. 80% 0f road traffic accidents occur in the highways. According to reports published in 2006 and 2007 by the Federal Road Safety Commission in Nigeria, an agency shouldered with the responsibility of ensuring safety on the roads indicated that 4673 people died as a result of road crashes while 17,794 people sustained some form of non fatal injuries. A greater proportion of these injuries and deaths were attributable to motorcycle crashes which is known to be the second most common source of road traffic accidents(oluwadiya et al., 2009). As at 2007 the number of registered vehicles was 7.6 million (Motorized 4-wheeler (60%), Motorized 2- wheeler (40%) and trucks (<1%) depicting a huge difference in comparison to figures in the 1980s when they were above 200,000 units. (WHO, 2009) In terms of economic costs it was estimated that >US$25 million was spent on road traffic injuries for hospitalization and treatment in the 1990s which represent about 2% of the GNP, but current estimates seem to have greatly increased over the two decade period (WHO, 2002). It is important to note that injuries from road crashes mainly occur in the adolescents and young adults who constitute the productive work force of the nation s economy. 12

13 1.4 ROAD TRAFFIC ACCIDENTS RELATED MAXILLOFACIAL INJURIES Road traffic accidents have been implicated as the commonest cause of maxillofacial injuries especially in the developing countries and countries like Japan, India and Saudi Arabia. Maxillofacial injuries defined as injuries to the face, facial skeleton and associated specialized soft tissues within the head and neck, account for 80% of all severe injuries sustained in road traffic accidents, and also occur in approximately 80% of all fatal cases of road traffic accidents (Sherry, E (ed), 2010). It is also important to note that maxillofacial injuries occur concomitantly with other injuries to the body during road traffic crashes. In the United States of America the annual incidence of road traffic accidents associated maxillofacial injuries requiring hospitalization and eventual treatment is estimated to be 139 per 100,000 population (Sherry, E (ed), 2010). In a survey conducted in the United Kingdom by the British Association of Oral and Maxillofacial Surgeons (BAOMS) identified 6114 patients in 163 accident and emergency departments with facial injuries. Three hundred and six patients had facial injuries as a result of road traffic accidents, with 40% resulting in serious facial injuries. Incidences of maxillofacial injuries have been decreasing in the developed countries due to better road safety measures and compulsory legislation for the usage of protective gadgets like seatbelts and crash helmets for cyclists e.g. in Sweden when the compulsory usage of seatbelts legislation was enacted in 1975 there was a reduction of maxillofacial injuries by 28%, similarly in the United Kingdom in 1983 there was a reduction of maxillofacial injuries by 25-75% when a similar law was enacted (Sherry, E (ed), 2010). In a study carried by Malara et al., 2006 road traffic accidents were responsible for 19.93% cases of maxillofacial injuries, while Hussaini et al., reported that motorcycle accidents were responsible for 40% of facial soft tissue injuries. Lelels Rodrigues et al., 2010 carried out a cross sectional study in Brazil and reported that road traffic accidents accounted for 45.7% of maxillofacial trauma with motorcycle crashes 13

14 (18.9%) mainly responsible for the accidents. Cheema and Amin, 2006 studied 702 patients with facial injuries in Mayo Hospital in Lahore, Pakistan and reported that 382 patients had injuries secondary to road traffic accidents representing 54% of the total patient population. In Nigeria, various studies which are mainly hospital based have documented that road traffic accidents are mainly implicated for maxillofacial injuries in all the zones of the country except in the north eastern zone where assault was the major cause (Adebayo et al., 2003; Fasola et al., 2000; Fasola et al., 2003; Ogunlewe et al., 2006; Oji, 1996) 1.5 COUNTRY PROFILE: NIGERIA Geography and Demographic Characteristics Nigeria is located on the west coast of Africa with a landmass of 923,768 square kilometers is bounded on the west by the republic of Benin, on the east by the republic of Cameroon, on the northeast by the republic of Chad, on the northwest by the republic of Niger and finally on the south by the Atlantic Ocean. There is variation in the vegetation cover in various parts of the country with the Sahel savannah found in the far north, while changing to the Sudan savannah when moving downwards and merging into Guinea savannah in the middle belt. The rain forest is mainly found in the southern part of the country, while the mangrove forest is in the coastal areas. There are also variations in the climate conditions in the various parts of the country resulting in four broadly divided climatic regions namely: (i) the humid sub- equatorial, in the southern lowlands (ii) the hot tropical continental, in the far north (iii) the moderated sub-temperate in the high plateaus and mountains and (iv) the hot, wet tropical, in the hinterland (the middle-belt).based on the 1991 national population census, the population of the country was 89 million but with a growth rate of 2.8% it is estimated that by the year 2025 the population will be 256 million people. Furthermore the percentage of the population in the age brackets was 45.6%. Presently the census conducted by the National Population Commission in July, 2006 estimates the population to be 146 million 14

15 Figure 1.1 territory, Abuja Map of Nigeria showing some state capitals and the federal capital Source:http://www.cia.gov/library/publications/the-worldfactbook/geos/ni.html (CIA world fact book) Politics and Administration Nigeria has diverse ethnic groups comprising about 250 in number. The country gained her independence in 1960 from Great Britain, and became a republic in She operates a federal system of governance similar to USA and its former colonial masters, with three levels of government namely: federal, state and local government but power mostly lies with the federal government. Nigeria is divided into 36 states located in the six geopolitical zones with a federal capital territory as the seat of the federal government. There 774 local government areas which is further subdivided into districts, in addition there are 9572 political wards which serve as the basic units for grass root development. 15

16 For a greater part of her 40 years of independence, Nigeria has been under several military dictatorship regimens and 1999 marked the beginning of a long stretch of civilian rule with the successful transition of power from a democratically elected government to another in 2007 in the entire history of governance in the nation Economy The main stay of the nation s economy is oil which account for about 20% of the gross domestic product (GDP). She occupies the 16 th position by 2008 estimates in terms of oil production in the world (CIA World fact book, 2010). It is estimated to provide 95% of the country s foreign exchange earnings and 80% of budgetary revenues (CIA World fact book, 2010). Agriculture which is mainly at the subsistence level contributes about 33.4% to the GDP. The industrial and service sectors of the economy contribute 34.1% and 32.5% respectively to the GDP (CIA World fact book, 2010). The nation has witnessed increased revenues from petroleum oil in 2007 and 2008 due to increases in exports because of excessive demand. During these two periods there were increases in the GDP. The gross domestic product per capita according to 2009 estimates stood at US$2,300 with a growth rate of 3.8%, but despite this 70% of the population lives below the poverty line i.e. less than 1US$ per day. (CIA World fact book, 2010).According to the United Nations Development Programme (UNDP) report of 2008, Nigeria occupies the 154 th position out of 179 countries in the world with complete data in terms of the Human Development Index with a value of Health care system The health care system in Nigeria is basically a three tier structure involving the three levels of government. The health care system entails the following: Primary health care (PHC) 16

17 Health care at this level represents the foundational level of health care delivery. The responsibility of the provision of health care at this level is the exclusive privy of the local governments with support of the state governments through the various state ministries of health. Health facilities at this level are located in suburbs and villages in the form of health centres, maternity centres or health post. Private medical practitioners can also be involved with the provision of health care at this level. Secondary health care Health care at this level is structured to provide specialized services to referred patients from the primary health care facilities on an in-patient and out-patients basis. The location of hospitals at the secondary health care is at the various districts, divisions and zones of the state. Apart from providing services for in-patients and out-patients in terms of surgical and medical needs, they also undertake community health services for the general populace. The secondary health care is also designed to provide adequate support services such as blood bank, diagnostics and laboratory. In addition physiotherapy and rehabilitation services are also provided when the need arises. Tertiary Health Care This level of health care is primarily concerned with the provision of highly specialized services. This level is the highest level of health care, and highly trained medical personnel are responsible for the provision of health services in teaching and other specialist hospitals such as the federal medical centres. Due to political reasons, the siting of hospitals with this type of specialized care is done to ensure adequate and equal representation in the various geographical regions of the country. It provides services for specific diseases such as maternity, eye, orthopaedics, psychiatric and paediatric cases. The responsibility of providing health care for the populace rest on the three organs of government namely: the Federal, State and Local Government Areas (LGAS). Furthermore the financial expenditures of the Secondary health Care (SHC) and Primary 17

18 Health Care (PHC) departments are the responsibility of the 36 states and 774 LGA s. In addition the states and the LGAs also provide funds for personnel costs, consumables, running costs and capital investments. The federal government dictates the rules by setting policy statement and goals, benchmark for quality of health care service provision, training and implementation of sector programmes such as immunization (DFID, 2000). An important organ of the health care structure worth mentioning is the National Primary Health Care Development Agency (NPHCDA), this agency on behalf of the Federal Ministry of Health (FMOH) serve as a vital source of technical knowledge and expertise on the provision and monitoring of PHC. The ward health system serving as a functional unit of the PHC service delivery was introduced in the country due to studies conducted by the NPHCDA. The function of the ward health system is to align the provision of health care delivery with the political wards, thereby demonstrating in strong terms the desire of the national government to establish a PHC system that is focused and people oriented which is community driven and co-managed by the community members and the health staff. This ward arrangement of provision of primary health care has actually led to the development of a homogenous and robust grass root commitment to service delivery than the previous District Health system created by the LGA health departments based on vague boundaries, and has also be known to be more beneficial. It is important to state that public PHC services are administered and funded by the State Ministry of Health (MoH), while the SHC come under the authority of the State Hospital Management Board (HMB). (DFID, 2000) 1.6 MOTORCYCLE RELATED MAXILLOFACIAL INJURIES IN NIGERIA Motorcycles popularly called okada are primarily used for commercial purposes moving pillion passengers and goods, with only few motorcyclists employed by the courier companies to deliver their services to clients, in addition few individuals own motorcycles solely for private use. The emergence of motorcycles as an informal mode of transportation in the country has been rising steadily at a pace that has made it generally acceptable to the 18

19 populace, making it the most common source of transport in a weak transit system. The popularity of the motorcycles for transport has been enhanced by its ability to negotiate through congested traffic, bad roads, low cost of maintenance and purchase in comparison with other motorized vehicle. Of importance to public health is the spate of injuries which might lead to long term disabilities and even death that occur as a result of traffic accidents involving the cyclists, passengers and pedestrians. There is no known national registry for motorcycle related injuries data in the country, so data on the burden of motorcycle related injuries are obtained from anecdotal sources e.g. police reports. Several studies which are mainly hospital based have tried to explore this lack of data to try and estimate the incidence of motorcycle related injuries. Solagberu et al., 2006 in a study carried out in a Nigerian teaching hospital estimated the incidence of motorcycle injuries to be 27% of all road traffic injuries. Obuekwe et al.,2003 reported motorcycle crashes as the second commonest cause (22.7%) of maxillofacial injuries of the 312 patients studied. Oginni et al., 2009 reported that injuries to the soft tissues were the most prevalent (47%) followed bony and dental injuries (38%, 15%) respectively in 221 studied patients. Similarly Oginni et al., 2006 reported soft tissue injuries as the most prevalent injuries in their study. Motorcycle related maxillofacial injuries occur in association with injuries to the other parts of the body with head and lower limb injuries being predominant as shown in studies (Obuekwe et al., 2003; Oginni et al., 2009; Oluwadiya et al., 2004; Oluwadiya et al., 2009). Various mechanisms have been implicated as the reasons for the crashes; Oginni et al., 2006 attributed head-on collision as the predominant mechanism of the crashes in 107 patients studied, while Obuekwe et al., 2003 reported blow out tyres as the main mechanism responsible for the crashes. Solagberu et al., 2006 reported 40.6% as the rate of motorcycle other vehicle collisions as the mechanism for the crashes; Oginni et al., 2009 reported the predominant crash to be head-on collision (58%); Oluwadiya et al., 2009 reported collision with other vehicles accounting for 50% of all crashes. Most studies reported injuries were more in the riders than the passengers. 19

20 2.1 Objectives The main objective of this study is: To describe the pattern and characteristics of maxillofacial injuries and other concomitant injuries amongst commercial motorcyclists and passengers. The specific objectives include the following: To explore potential factors related to the type, severity and scale (FISS) of maxillofacial injuries To describe the mechanism leading to the crashes. 2.2 Study site Geography and demographic characteristics of Irrua Irrua is the local government headquarters of Esan central local government area, is situated at latitude 6.79 degrees north of the equator and longitude east of the prime meridian. It is one of the eighteen local government areas of Edo state. The state is located in the south central part of the country, and bounded in the east and north by Kogi state, south by delta state and in the west by Ondo state. Edo state is ranked 22 th in the country in terms of area (17,802km 2 ) with a population of 3,218,332 people according to the 2006 national census figures making it the 24 th most populated state of Nigeria. Irrua which is located about 300km to the north of the state capital, Benin City has an area of 253km 2 and a population of 105,310 people according to the latest census performed in the country in The population density is 416 people per km 2.The 20

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