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Reducing Road Traffic Injuries in Low- and Middle-Income Countries

Abdulgafoor M. Bachani, PhD, MHS Johns Hopkins University

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! Understand the public health implications of road traffic injuries

! Describe the global burden of road traffic injuries

! Preventing injuries

! Case study: ! Helmet intervention in Vietnam

Outline

Public Health Implications of Road Traffic Injuries

Section A

! What do we mean by injury? ! “Body damage resulting from acute exposure to excessive amounts of thermal,

mechanical (whether kinetic or potential), electrical, or chemical energy” ! “Or from the absence of such essentials as heat or oxygen”

Defining Injuries

Epidemiology of Injuries

Injury model

Energy

Environment

Host

Vector or

Vehicle

Microorganism

Environment

Vector

Infectious disease model

Host

Typology: Unintentional Injuries

Unintentional Injuries

Burns

Falls

Road traffic

injuries

Drowning

Poisoning

Why Are Injuries Relevant to Public Health?

! The injury pyramid

! Mortality (death)

! Morbidity (nonfatal injuries) ! ED visits ! Hospitalization ! Outpatients visits

! Disability (short-term, mid-term, and long-term sequelae)

! Cost

Why Are Injuries Relevant to Public Health?

Global Burden of Road Traffic Injuries

Section B

Global Mortality, All Injuries (2012)

! > 3,400 people die from road traffic injuries (RTIs) each day (~1.25 million every year)

! > 24% of all injury-related mortality in 2012

! RTI mortality increased by 46% since 1990

! Projected to be 5th leading cause of death by 2030

Health Burden of RTIs: Mortality

Source: WHO. (2014). 3

RTI Mortality Twice as High in LICs Compared to HICs

Source: WHO. (2014).

2000

All unintentional injuries

57.7 74.6 40.4 60.1 76.4 43.3 47.5 66.9 29.0

RTIs 16.7 24.3 8.9 17.0 24.7 9.1 15.4 22.9 8.3

Global LMICs HICs

Total Men Women Total Men Women Total Men Women

Deaths (per 100,000 population)

2012

All unintentional injuries

52.5 67.0 37.8 55.6 70.6 40.1 39.0 50.3 28.0

RTIs 17.7 25.6 9.7 19.6 28.2 10.8 9.2 13.9 4.8

Deaths vs Vehicle Ownership

! Registered vehicles: 1.3 billion vehicles

! Road traffic deaths

HIC= high-income countries, MIC = middle-income countries, LIC = low-income countries

Global Road Traffic Deaths by Road User Category

! For each RTI-related death, an additional 20 to 50 more individuals suffer some disability

! Injury caused 78.7 million disability-adjusted life years lost in 2010 ! 14 million, or 30%, due to disability from injury

! High burden of disability partly because injury disproportionally affect young individuals between age 15 and 44

Health Burden of RTIs: Morbidity

7Source: Peden et al. (2004); WHO. (2014); WHO. (2007).

RTI Morbidity in LMICs

Source: WHO. (2014). 8

Global LMICs HICs Total Men Women Total Men Women Total Men Women

DALY Losses (per 100,000 population)

2012

All unintentional injuries

3,211.4 4,216.2 2,190.2 3,434.0 4,477.8 2,361.6 2,216.5 3,011.7 1,446.4

RTIs 1,112.6 1,603.8 613.5 1,217.3 1,744.2 676.0 644.8 957.3 342.1

2000

All unintentional injuries

3,772.6 4,942.0 2,585.8 4,008.3 5,152.6 2,830.0 2,807.4 4,047.0 1,621.7

RTIs 1,129.0 1,636.1 614.3 1,163.0 1,672.4 638.4 989.9 1,481.8 519.4

Note: DALYs = disability-adjusted life years; HICs = high-income countries; LMICs = low-and-middle-income countries.

! Profound economic burden to individuals, families, and societies ! Total costs range between 0.02% of GDP in New Zealand to 9% in Angola in 2010

! Cost studies on road traffic injuries have been growing over the past decade in LMICs ! Recent studies in Vietnam, Uganda, China, Bangladesh, Belize, etc.

! Improved health information systems in LMICs are needed to understand the full extent and nature of the injury burden ! For example, information on disability resulted from RTIs will help estimate the

long-term economic consequences of road traffic injury

Economic Burden

Source: WHO. (2013); Nguyen et al. (2013); Nguyen et al. (2015); Benmaamar (2012); Zhou et al. (2003); Mashreky et al.( 2010); Perez-Nunes et al. (2010). 9

! It is due to these health consequences that injuries need to be addressed

! The economic implications make a further strong case for investment in prevention and control

! There are moral and ethical concerns especially when injuries afflict the poor and vulnerable around the world

! … So, what do we do about it?

Injuries a Public Health Issue

Preventing Injuries: Interventions

Section C

! De Haven (1942): “Survivability of events” ! Stapp (1955): “Energy tolerance”

! Gordon (1949): “Application of epidemiological framework”

! Gibson (1961): “Energy as source of injury”

! Haddon (1970): “Preventability strategies—matrix and principles” ! Nader (1965): “Consumer protection” ! Baker (since late 60s): “Public health leadership in measuring the burden of injury”

History of the Field

Source: Waller. (1996). Am J Pub Health, 84:664-670. 2

! Severity of injuries depends on: ! Energy being dissipated ! Shapes of the colliding objects ! Rigidity of colliding objects ! Tolerance of host

! Impact of injuries depends on: ! Post-event care ! Rehabilitation

Preventing Injuries: Lessons Learned

! Injuries are predictable ! Epidemiology, risk factors

! Accidents vs. injuries ! “Accidents happen” vs. injuries are not accidents

! Injuries are preventable

Preventing Injuries: Lessons Learned

Strategies for Injury Prevention

. 5

! Primary, secondary, and tertiary prevention

! Individual, vector, environment-level interventions

Strategies for Injury Prevention

The Haddon Matrix: 1st Axis

Host (person) Vector/ vehicle

Environment

Physical Socio-

economic

The Haddon Matrix: 2nd Axis

Time frame Host (person) Vector/ vehicle

Environment

Physical Socio-

economic

Pre-event

Event

Post-event

Haddon Matrix (Illustrative)

Pre-crash ! Intervention can

prevent: ! Death ! Injury ! Property damage

Crash ! Intervention can

prevent: ! Death ! Injury

Post-crash ! Intervention can

reduce the chances of: ! Death ! Injury

Haddon Matrix (Illustrative)

! Person ! Alcohol use ! Driving speeds ! Protective equipment

! Vector ! Reflectors ! Lights ! Brakes

! Environment ! Street lighting ! Paved roads ! Road barriers

! Primary prevention or “prevention” ! Avoid something that might happen ! Prevent, reduce, or modify hazards or events that cause injury

What Can We Do? … Prevention

! Secondary prevention or acute care ! Minimize the damage if it happens ! Counter the damage already done by the hazard ! Stabilize and repair the damage

What Can We Do? … Prevention

! Tertiary prevention or rehabilitation ! Reduce the sequelae once it has happened ! Restore the functioning of injured patients to pre-injury levels

What Can We Do? … Prevention

! Scope of the problem

! Trends over time

! Risk factors

! Design of interventions

! Effectiveness and efficiency of strategies

What Do We Need to Know to Prevent Injuries?

! Strategies for injury prevention ! Primary, secondary, and tertiary prevention ! Individual, vector, environment-level interventions ! Systems approach to injury prevention

Strategies for Injury Prevention

Systems Approach to Road Safety

INFRASTRUCTURE

HUMAN RESOURCES

TECHNOLOGY /SCIENCE

Systems Approach

INFRASTRUCTURE

HUMAN RESOURCES

TECHNOLOGY /SCIENCE

PRODUCTION OF SAFETY

Interventions for Road Traffic Injuries: Haddon Matrix

! Systems to prevent road traffic crashes

Person Vector

(Motorcycle) Environment

Pre- Event

Event

Post- Event

Interventions for Road Traffic Injuries: Haddon Matrix

! Systems to ensure road traffic crashes do not cause death or injury and limit impact of disability on quality of life and productivity

Person Vector

(Motorcycle) Environment

Pre- Event

Event

Post- Event

Multi-Sectoral Engagement for Production of Safety

. 20

! Reducing exposure to risk through stabilizing the levels of motorization by providing alternative modes of travel and improving land-use planning practices

! Reducing risk factors directly related to crash causation, such as speeding, drinking and driving, using unsafe vehicles on unsafe roads (with inadequate safety features for the traffic mix), and failing to effectively enforce road safety laws

! Reducing severity of injuries by measures by mandating and enforcing the use of seat belts, child restraints, and helmets, as well as by improving road infrastructure and vehicle design to protect all road users

! Improving post-crash outcomes, from appropriate and life-saving measures at the scene of the crash, health facility, and rehabilitation services

Principles for RTI Interventions

Case Study: Helmet Legislation in Vietnam

Section D

! Publications from which data/graphs are taken: ! Passmore, J.W., Nguyen, L.H., Nguyen, N.P., Olive, J.M. (2010). The formulation

and implementation of a national helmet law: a case study from Viet Nam. Bull World Health Organ, 88: 783-87.

! Pervin, A., Passmore, J., Sidik, M. et al. (2009). Viet Nam’s mandatory motorcycle helmet law and its impact on children. Bull World Health Organ, 87, 369-73.

! Passmore, Nguyen, and Luong et al. (2010). Impact of Mandatory Motorcycle Helmet Wearing Legislation on Head Injuries in Viet Nam: Results of a Preliminary Analysis.� Traffic Injury Prevention, 11: 202-6.

! Personal communications, Jonathon W. Passmore

Acknowledgments

! January 2009: 27 million registered vehicles ! 95% motorcycles

! Number of motorcycles increased by 7,680 per day in 2008

! Represents ~ three-fold increase in fleet size over the past decade

Description of Fleet in Viet Nam

! 2007: 12,800 road traffic deaths ! 15 deaths per 100,000 population ! Potential of 30% underestimate of deaths and 90%

underestimate of injuries (Pervin et al., 2009)

! 1995 to 2002: 135% increase in road traffic deaths

! 60% of road traffic fatalities occur in motorcycle occupants (Pervin et al., 2009)

Burden of Road Traffic Injuries

! Cochrane Review: ! Reduce risk of death by 42% (OR 0.58, 95% CI: 0.50, 0.68) ! Reduce risk of head injury by 69% (OR 0.31, 95% CI: 0.25, 0.38)

! WHO recommends laws/implementation

Evidence of Helmet Efficacy

! 80% of helmets in use did not meet standards (April 2008 Viet Nam Standard & Consumer Association survey)

Wide Range of “Helmets” in Use

! 1998–2006: confusing legislation ! Helmets mandated on certain roads ! Unclear if passengers needed to wear them ! No coverage of children

! 2007: Resolution 32 (December 15th) ! Mandatory helmets: locally appropriate ! All occupants, all roads, all times

Helmet Legislation

! ECE 22: ! Approved worldwide ! Safe, effective ! Is it practical?

! QCVN 2: ! “Tropical helmet” ! Approved for motorcycle heavy roads

Helmet Standards

Implementation Details

! Political support ! Buy-in from high levels

• Prime minister, all parties • Full government approach

! Demonstrated effectiveness ! Used data to convince public of benefits

! Enforcement ! Penalties increased by ten-fold ! High perception of being caught

! Social marketing/education ! Eliminated confusion in messaging

Enforcement ! Increased penalties ! From 20-40,000 VND to 200-400,000 VND (US $10-20) per

offense

! Traffic tickets in 2008: ! Total: 5,431,191 ! 682,789 (13%) for helmets ! No reliable prior data

! Ongoing challenges ! Human resources for enforcement ! Maintaining perception of “getting caught”

! Campaigns commenced prior to the law

! Targeted ! TV ! Cinema ! Posters ! Billboards ! Bus stops

! Focused on the law, benefits, and penalties

Social Marketing

Social Marketing: Focused and Graphic

! Intermediate: ! Helmet wearing prevalence ! Tickets issued for inappropriate/lack of wearing

! Outcome: ! Decrease in motorcycle-associated road traffic mortality ! Decrease in motorcycle-associated road traffic injuries

• All injuries • Severe injuries • Head injuries

Indicators

! MoH surveillance, three months ! 16% reduction in head injuries (RR 0.84, 95% CI:

0.81, 0.87) ! 18% reduction in traffic deaths (RR 0.82, 95% CI:

0.73, 0.93)

! Police data ! 2008 vs 2007: 1,557 less deaths, 2,495 less injuries ! 2009 vs 2008: 149 less deaths, 212 less injuries

Immediate Visible and Reported Impact

Sustained Success: Helmet Wearing in Yen Bai Province

. 17

Is It Working in Everyone? Helmet Wearing in Urban vs Rural Drivers

. 18

Vulnerable Group: Helmet Wearing in Primary School Children

. 19

! Perceptions: ! Thought to be dangerous for kids

! Enforcement ! No way to punish a parent

! Wearing rate (<16) ! 39% in 2008

Loophole: Children

! Low quality helmets ! Is something better than nothing?

! Incorrect wearing ! Lack of fastening straps

Loophole: Incorrect Use

! Must be fastened! ! Defined unfastened as equivalent to unworn

! Parent penalties ! Able to penalize parents if children not wearing a helmet

Legal Modifications: 2009

Thank You ! [email protected]

! A link to the Johns Hopkins International Injury Research Unit Web site is available on the lecture home page