Overview
Road traffic injuries are a leading cause of death and disability and present a public health and economic threat to Europe (Racioppi, et al., 2004). There is much variation in traffic deaths and injuries in the WHO European Region, both between countries and within countries. A growing evidence base suggests that many road traffic injuries can be prevented and their severity ameliorated through preventive action.
Definitions
The World report on road traffic injury prevention defines a road traffic injury as fatal or non-fatal injuries incurred as a result of a road traffic crash. A road traffic crash is defined as a collision or incident that may or may not lead to injury, occurring on a public road and involving at least one moving vehicle (Peden, et al., 2004).
What’s the problem? Key facts
Road traffic injuries (RTIs) are a leading cause of death and kill 127 000 people per year in the 53 countries of the WHO European Region (Sethi, et al., 2006a). There are at least 2.4 million people recorded to be injured each year, although this figure is an underestimation because of under recording of non-fatal injuries by police. The true figure is more likely to be around 6 million (Gill, et al., 2006, Sethi, et al., 2007a).
Overall mortality rates for RTIs have declined, especially in western Europe. In the countries of the Commonwealth of Independent States (CIS)[1], an increase is observed though. The average mortality rates from RTIs are higher than the EU-27 (UNECE, 2008).
About 55% of deaths occur in younger people aged 15-44 and 75% occur in males as opposed to females. RTIs are the leading cause of death in young people under the age of 29 years. Children are particularly vulnerable because they can cope less well with traffic dangers (Sethi 2007, UNECE, 2008).
People over 80 years of age have the highest death rates even though they only make up 3% of all RTI deaths (Fig. 1). Older people have a higher risk of fatality once injured because they are frailer. As pedestrians they are more vulnerable road users because they may be more severely injured. The second highest death rate is in young people aged 15-29 years, who make up 30% of RTI deaths. The highest disease burden is also in the younger age group. Altogether the RTI-related disease burden amounts to about 3.6 million healthy life-years lost (expressed in disability-adjusted life-years or DALYs[2]) and 45% of these are in the age group 15-29 years. 77% of the DALYs lost from RTIs are in males.
Figure 1: Age and sex-specific mortality rates from road traffic injury per 100,000 people in the European Region 2002. Source: GBD 2002 version 3.
What influences death rates on the roads?
The burden of RTIs is unequally distributed across the WHO European Region. People living in low- and middle-income countries in the Region are 50% more likely to die from RTIs as compared to a high-income country (Sethi, et al., 2006b). When standardized death rates are considered, the difference between countries with the highest and lowest rates can vary by a factor of 5 (Fig. 2). In addition, children in lower social classes are 3–4 times more likely to die from traffic injuries than those in higher classes (Roberts, et al., 1996).
Death rates on the roads are influenced by population and vehicle density, transport mode used, legislation, enforcement, road design and infrastructure, vehicle design, road user behaviour, use of safety equipment and access to high-quality emergency trauma services. The World report on road traffic injury prevention identified the following as key areas for preventive intervention (Peden, et al., 2004):
· controlling speed
· stopping driving when under the influence of alcohol
· enforcing use of safety equipment such as seat-belts
· child safety seats and motorcycle helmets
· increasing conspicuity and making infrastructural changes to road design to ensure that vulnerable road users are not exposed to unnecessary risk by mixing them with motorized traffic.
Excess speed is the main road safety problem in many countries (UNECE, 2008). In some CIS countries urban speed limits are 60 km/hour whereas good practice advocates 50 km/h in urban areas and 30 in residential areas (Racioppi 2004, UNECE, 2008). Speeding vehicles are particularly dangerous for pedestrians. There is an eight-fold increase in probability of a pedestrian being killed as the speed of impact with a car increases from 30km/h to 50km/h. Alcohol is an important risk factor in all road users, and young drivers and riders aged 18-25 years are particularly at risk of crashing (Sethi et al., 2007a). As blood alcohol concentrations (BAC) increase, so does the likelihood of crashing, particularly after a BAC of 0.04g/dl. At a BAC of 0.08g/dl the risk is twice that at 0.05g/dl.
Countries undergoing transition with intense economic activity, such Latvia, Lithuania, Kazakhstan and the Russian Federation, have undergone rapid motorization, but without adequate infrastructure development and regulatory controls such as speed, alcohol and driving-licensing systems. This explains the high mortality rates from transport injuries in these countries (see Fig. 2). Those on the cusp of motorization may want to take heed, and apply lessons learnt elsewhere (Sethi, et al., 2007b).
Figure 2: Age standardized death rates from transport injury per 100,000 people in the European Region by country for 2003*. Source: HFA Mortality dataset (WHO, 2007a).
* Transport crash deaths rather than RTIs have been used for greater completeness. 95% of transport injury deaths are due to RTIs.
** The International Organization for Standardization acronym for the former Yugoslav Republic of Macedonia
Road users
There are different types of road users and they are affected differently by traffic exposure. Amongst those most vulnerable to RTIs are pedestrians, cyclists and motorized two-wheelers. Unfortunately relatively little research on prevention has been conducted for these groups. Two thirds of crashes occur in towns, where there is a greater mix between these vulnerable road users and motor vehicles. Fatalities for cyclists and pedestrians are 7-9 times higher than for those involved in car crashes (Racioppi, et al., 2004, Sethi, et al., 2007a). The mortality and proportion of deaths on the roads among pedestrians varies from country to country. This reflects differences in exposure as well as safety. It is lowest in the Nordic countries, such as Iceland and Sweden and highest in the CIS and Baltic countries, such as the Russian Federation and Latvia. It is important to pay extra attention to pedestrian safety because (a) pedestrians are more vulnerable to sustaining a severe injury when struck (b) more children and older people are affected and more vulnerable and (c) most safety interventions historically were geared to protecting vehicle occupants rather than pedestrians. Walking and cycling are healthier transport modes, but these will only be chosen as an option if safety is assured.
[1] EECCA (CIS): Eastern Europe, Caucasus and Central Asia (12 countries)
[2] One DALY is one year of healthy life lost, either due to premature death or life lived with disability.