Fatalities to occupants of cargo areas of pickup trucks

Effectiveness of road safety interventions: An evidence and gap map

Background

Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge.

Objectives

The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels.

Search Methods

The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019.

Selection Criteria

The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes.

Data Collection and Analysis

The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2.

Main Results

The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality.

Authors' Conclusions

The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Identification of Factors Affecting Road Traffic Injuries Incidence and Severity in Southern Thailand Based on Accident Investigation Reports

Thailand has the second-highest rates of road traffic mortality globally. Detailed information on the combination of human, vehicle, and environmental risks giving rise to each incident is important for addressing risk factors holistically. This paper presents the result of forensic road traffic investigation reports in Thailand and determines risk factor patterns for road traffic injuries. Detailed forensic reports were extracted for 25 serious traffic accident events. The Haddon matrix was used to analyze risk factors in three phases stratified by four agents. The 25 events analyzed involved 407 victims and 47 vehicles. A total of 65.8% of victims were injured, including 14.5% who died. The majority (66.1%) of deaths occurred at the scene. Human-error-related factors included speeding and drowsiness. Passenger risks included not using the seat belt, sitting in the cargo area and the cab of pickups. Overloaded vehicles, unsafe car modifications, no occupant safety equipment and having unfixed seats were vehicular risks. Environmental risks included fixed objects on the roadside, no traffic lights, no guard rails, no traffic signs, and road accident black spots. At present, traffic accidents cause much avoidable severe injury and death. The outcome of this paper identifies a number of preventable risk factors for traffic injury, and importantly examines them in conjunction. Road traffic safety measures need to consider how human, vehicle, and environmental risks intersect to influence injury likelihood and severity. The Haddon matrix is useful in identifying these pre- and post-accident risk factors. Furthermore, the sustainable preventions of road traffic injury need to address these risks together with active law enforcement.

Child passenger safety

Despite significant reductions in the number of children killed in motor vehicle crashes over the past decade, crashes continue to be the leading cause of death for children 4 years and older. Therefore, the American Academy of Pediatrics continues to recommend inclusion of child passenger safety anticipatory guidance at every health-supervision visit. This technical report provides a summary of the evidence in support of 5 recommendations for best practices to optimize safety in passenger vehicles for children from birth through adolescence that all pediatricians should know and promote in their routine practice. These recommendations are presented in the revised policy statement on child passenger safety in the form of an algorithm that is intended to facilitate their implementation by pediatricians with their patients and families. The algorithm is designed to cover the majority of situations that pediatricians will encounter in practice. In addition, a summary of evidence on a number of additional issues that affect the safety of children in motor vehicles, including the proper use and installation of child restraints, exposure to air bags, travel in pickup trucks, children left in or around vehicles, and the importance of restraint laws, is provided. Finally, this technical report provides pediatricians with a number of resources for additional information to use when providing anticipatory guidance to families.

Injuries to cargo area passengers of heavy goods vehicles

Transporting manual labourers in the cargo area of heavy goods vehicles is a common practice in Singapore. Earlier studies have reported higher fatalities and more serious injuries in such unrestrained cargo area passengers compared with those sitting in the cabin of the vehicle. We conducted a case series of injured cargo area passengers presenting to the Emergency Department from 1 January 2006 to 31 December 2007. A total of 34 male casualties (mean age 29.7 years) were treated. They were injured in four separate heavy goods vehicle crashes during the study period. Patients who were nonresident manual labourers comprised 94.1%; 44.1% (15 patients) were ejected from the vehicle but despite this, the mean Injury Severity Score was 2.2 (SD 3.5). Three of the patients were admitted to hospital, with one patient (Injury Severity Score 22) requiring surgery and intensive care stay. The remaining patients were discharged from the Emergency Department, and there were no deaths. Six patients reattended the Emergency Department for unresolved pain from their injuries. A total of 173 absent-days were incurred. This report highlights the fact that cargo area passengers are at high risk of ejection, and they incur significant morbidity from their injuries with subsequent loss of productivity. In addition, heavy goods vehicle crashes are usually mass casualty events, severely taxing the receiving Emergency Department. Safer alternatives for mass transport of manual labourers are required.

The effectiveness of child restraint systems for children aged 3 years or younger during motor vehicle collisions: 1996 to 2005

OBJECTIVES

We estimated the effectiveness of child restraints in preventing death during motor vehicle collisions among children 3 years or younger.

METHODS

We conducted a matched cohort study using Fatality Analysis Reporting System data from 1996 to 2005. We estimated death risk ratios using conditional Poisson regression, bootstrapping, multiple imputation, and a sensitivity analysis of misclassification bias. We examined possible effect modification by selected factors.

RESULTS

The estimated death risk ratios comparing child safety seats with no restraint were 0.27 (95% confidence interval [CI] = 0.21, 0.34) for infants, 0.24 (95% CI = 0.19, 0.30) for children aged 1 year, 0.40 (95% CI = 0.32, 0.51) for those aged 2 years, and 0.41 (95% CI = 0.33, 0.52) for those aged 3 years. Estimated safety seat effectiveness was greater during rollover collisions, in rural environments, and in light trucks. We estimated seat belts to be as effective as safety seats in preventing death for children aged 2 and 3 years.

CONCLUSIONS

Child safety seats are highly effective in reducing the risk of death during severe traffic collisions and generally outperform seat belts. Parents should be encouraged to use child safety seats in favor of seat belts.

Analysis of Non Enemy Action Deaths in Counter Insurgency Operations through Mortuary Services

BACKGROUND

Regional Trauma Centre in the northern India receives the mortal remains of all fallen soldiers for embalming. Non enemy action deaths during counter insurgency operations (CI Ops) were analysed for planning preventive measures.

METHODS

Mortal remains received for embalming from Jan 1999 to Dec 2006 were analysed with respect to mode of injury, causation, body parts involved, fatality, seasonal variation and changing trends.

RESULT

Accidents accounted for 3.02 deaths per thousand troops and environmental factors were responsible for 1.14 deaths per thousand troops deployed. Accidental deaths peaked in 2000, declined in 2001 and then remained more or less static. Of the accidental deaths, 88% were brought in dead and 12% died after reaching hospital. Road traffic accidents were the major killers accounting for 48.2%, followed by accidental discharge of weapon 35.5%. The latter is showing a rising trend from 8% of total accidents in 2001 to 65% in 2005 and 51% in 2006 (p<.01). Most (49.7%) of the deaths were below 25 years of age. Proportion of persons below 25 years was more in fatalities due to accidental gunshot wound. Amongst the road traffic accidents, 40% died of head injury and 51.2% due to multiple injuries. When deaths occurred due to accidental discharge of own weapon, 36.4% had brain injury and 22% heart injury. Of the environmental fatalities all but one were brought in dead. Majority were due to avalanches and landslides (51.2%), followed by earthquake (22.4%), lightning (12.8%), high altitude pulmonary oedema (10.4%) and hypothermia (3.2%). Most of the deaths due to avalanches occurred in February while all deaths due to earthquake were in October 2005. Of the deaths due to lightning, 75% occurred in April and May.

CONCLUSION

Prevention of death caused by road traffic accidents, accidental discharge of weapon, avalanches and lightning will conserve manpower and add to operational preparedness.

Cargo areas of pickup trucks: an avoidable mechanism for neurological injuries in children

OBJECT

Falls from pickup truck cargo areas represent a unique mode of injury in children and adolescents. The goal of this study was to identify the neurological spectrum of injuries resulting from children riding in the back of pickup trucks.

METHODS

The authors undertook a retrospective review of the University of New Mexico Hospital trauma registry of data compiled over a 7-year period. Their goal was to identify instances in which a fall or ejection from a pickup truck cargo area was the mechanism of injury. The charts of pediatric patients (< or = 16 years of age) with neurological injuries were reviewed and analyzed. Seventy-three pediatric patients with injuries related to riding in the cargo areas of trucks were identified, of which 53 children (73%) had sustained neurological injuries. Among these 53 children, 64% sustained isolated head injuries, 15% isolated spine injuries, 9.4% combined spine and head injuries, 2% combined peripheral nerve, spine, and head injuries, 4% isolated peripheral nerve injuries, and 5.6% concussive events. In 53.4% of patients with neurological injuries the results of computed tomography (CT) examination were abnormal. In 36% of patients with Glasgow Coma Scale (GCS) scores of 14 to 15 there was evidence of intracranial hemorrhage on head CT scans. Injury Severity Scores were similar in the patients who were ejected and those who fell from cargo areas, but patients who were ejected had a lower mean GCS score than those who suffered falls (GCS score 12.5 and 14.3, respectively).

CONCLUSIONS

Falls or ejections from pickup truck cargo areas result in a relatively high incidence of traumatic head, spine, and peripheral nerve injury. Head CT scanning should therefore be considered in pediatric patients with this mechanism of injury. Cargo area occupancy poses an unacceptable risk of injury and should be avoided.

Pediatric motor vehicle related injuries in the Navajo Nation: the impact of the 1988 child occupant restraint laws

BACKGROUND

Navajo motor vehicle mortality is the highest among the 12 Indian Health Service (IHS) administrative areas. In July 1988, the Navajo Nation enacted a primary enforcement safety belt use and a child restraint law.

OBJECTIVE

Assess the impact of the laws on the rate and severity of pediatric (0-19 years) motor vehicle injury resulting in hospitalizations in the Navajo Nation.

METHODS

Hospitalizations associated with motor vehicle related injury discharges were identified by International Classification of Diseases, 9th revision, CM E codes, 810-825 (.0,.1) from the Navajo IHS hospital discharge database. Age specific rates for the period before the law, 1983-88, were compared with those after enactment and enforcement, 1991-95. Severity of injury, measured by the abbreviated injury scale (AIS) score and new injury severity score (NISS), was determined with ICDMAP-90 software. Wilcoxon rank sum and chi(2) tests were used for analysis.

RESULTS

Discharge rates (SE) for motor vehicle injury (per 100 000) decreased significantly in all age groups: 0-4 years (62 (7) to 28 (4)), 5-11 years (55.3 (6) to 26 (4)), and 15-19 years (139 (14) to 68 (7)); p=0.0001. In children 0-4 years, the median AIS score decreased from 1.5 (1,3) (25th, 75th centile) to 1 (1,2), p=0.06, and the median NISS decreased from 3.5 (1,9) to 2 (1,5), p=0.07. The proportion of children with NISS scores >4 decreased significantly for the 0-4 year age group (p=0.03).

CONCLUSIONS

Concurrent with enactment of the Navajo Nation occupant and child restraint laws there was a reduction in the rate of motor vehicle related hospital discharges for children. Severity of injury declined in very young Navajo children. The effect of enactment and enforcement of this Native American child occupant restraint law may serve as an example of an effective injury control effort directed at Native American children.

Pickup truck use in the National Personal Transportation Survey

To guide interventions to prevent injuries to pickup-truck occupants, we characterized pickup truck ownership, drivers and use in the 1995 National Personal Transportation Survey, which collects travel data from the civilian noninstitutionalized population of the US. SUDAAN software was used to account for the complex nature of the sample. Pickup truck ownership was more common in households with more vehicles, in rural households, in households living in single family homes and mobile homes, and in middle-income households. Among US regions, pickup truck ownership was highest among households in the mountain west. Pickup truck ownership was greater in households with two adults, whether or not children or youths were present, but this was largely due to the number of vehicles in these households. Driving a pickup on the sample day was more frequent among men, among drivers with less education and among full-time workers. A higher proportion of trips to work, work-related trips, longer trips and trips with fewer people were by pickup truck. Seat belt use was lower among pickup truck drivers than drivers of other vehicles. For only 0.5% of households (those with three or more members and a pickup truck as their only vehicle), restrictions on travel in cargo areas might be burdensome. Restrictions on cargo area travel, strengthening existing seat belt laws and social marketing strategies might increase the safety of pickup truck occupants.

Children in pickup trucks. American Academy of Pediatrics. Committee on Injury and Poison Prevention

Pickup trucks have become increasingly popular in the United States. A recent study found that in crashes involving fatalities, cargo area passengers were 3 times more likely to die than were occupants in the cab. Compared with restrained cab occupants, the risk of death for those in the cargo area was 8 times higher. Furthermore, the increased use of extended-cab pickup trucks and air bag-equipped front passenger compartments creates concerns about the safe transport of children. The most effective preventive strategies are the legislative prohibition of travel in the cargo area and requirements for age-appropriate restraint use and seat selection in the cab. Parents should select vehicles that are appropriate for the safe transportation needs of the family. Physicians have an important role in counseling families and advocating public policy measures to reduce the number of deaths and injuries to occupants of pickup trucks.