a Departamento de Ortopedia, Santa Casa de São Paulo, São Paulo, SP, Brasil
b Serviço de Ortopedia e Traumatologia, Hospital Israelita Albert Einstein, Universidade Federal de São Paulo (Unifesp), São Paulo, SP,Brasil
c Instituto de Ortopedia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo, SP, Brasil
d Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brasil
Introduction
Terrestrial transport accidents, also known as traffic acci-dents, are an important public health problem because of theirhigh impact relating to morbidity and mortality.
According to Melione and Mello-Jorge,3falls and transportaccidents have been reported to be respectively the first andsecond reasons for hospitalizations due to external causes.Increased rates of accident and violence (external causes)have had a repercussion on the organization of the health-care system, which because of its responsibility for attendingto trauma cases has been faced with higher expenditure onmedical care. External causes account for higher mean expen-diture and cost per day of hospitalization than those of caseswith natural causes.
Among traffic accidents, increasing numbers of motorcycleaccidents have been observed over recent years. These vehi-cles are becoming ever more accepted and approved amongthe population because they are agile, economical and inex-pensive to buy.
In the same way, bicycles are an efficient and popularmeans of transport among many populations around theworld. Because of their low purchase and maintenance costs,they can be considered to be the cheapest form of urban trans-port, accessible to practically all social layers. They do notpollute the environment, they preserve public spaces and theydo not cause the disturbance that characterizes motor vehiclesin urban areas.
For characterizing the epidemiological profile of accidents,hospital morbidity and mortality data present limitations.
In 2008, in the municipality of São Paulo, Brazil, an infor-mation system for monitoring accidents and violence (SIVVA)was implemented within the municipal healthcare system.This has enabled production of information for diagnosing,planning, monitoring and evaluating the actions undertakentoward coping with accidents and violence
Through recognizing accidents as a matter for surveillanceand, at the same time, comprehending the complexity of thephenomenon by means of an interdisciplinary and intersec-toral approach, the system has made it possible to formulateintegrated public policies aimed at prevention.
In the municipality of São Paulo, in 2013, 5624 transportaccidents were notified, among which 51.7% involved motor-cycles and 8.8%, bicycles.
In view of the importance of motorcycle and bicycle acci-dents within the situation of morbidity and mortality, thisstudy describes the characteristics of the victims, accordingto the notifications of suspected and confirmed accidents thatoccurred in the municipality of São Paulo.
Method
A descriptive cross-sectional epidemiological survey wasdeveloped with a view to finding out about and characteriz-ing accidents involving motorcycles and bicycles and outliningthe profile of the victims.
This study covered all of the accidents (12,924) thatinvolved motorcycles (11,366) and bicycles (1558) in the munic-ipality of São Paulo between January 2011 and October 2013.
The data were gathered from SIVVA during September andOctober 2013. This is a public-domain system that can beaccessed through the portal of the municipal authority of thecity of São Paulo, via its health department.
SIVVA is an instrument for all outpatient services (bothprimary care and specialized care), hospitals and emergencyservices, both within the National Health System (SUS) andwithin private hospitals in the city of São Paulo. The noti-fication form for suspected or confirmed cases is filled outby all healthcare professionals when the patient attendedpresents signs or symptoms or reports situations of violenceand/or accidents. Some fields on the form are for physiciansto fill out, such as the diagnosis and characterization of theinjury.
SIVVA makes it possible to gather data on the locationwhere the violence or accident occurred and any associationwith use of alcohol or drugs. It reveals the groups that aremore vulnerable and the consequences that follow from theseevents, so that intervention criteria that take into account thisdiversity can be established. The system also makes it possibleto construct information on the nature and types of violenceand enables characterization of accidents.
The variables used were the type of vehicle, pedes-trian/rider, age (in years), sex (male or female), evolution ofthe case, diagnosis of the injury, whether the riders involvedin the accidents had any type of deficiency (physical, visual,auditory or mental) and any suspicion of alcohol or illicit druguse by the victims (riders or pedestrians).
After the data gathering, data processing and tabulationwere performed and the absolute and relative frequencieswere calculated.
Approval by the university's research ethics committee wasdispensed with for this project, since it involved use of sec-ondary data from a public-domain database, as declared inResolution 196/96 from the National Health Council (CNS).
Results
Over the period studied (2011-2013), 21,795 transport acci-dents were notified in the municipality of São Paulo. Thoseinvolving motorcycles accounted for 52.1% and those involv-ing bicycles, 7.1%
There were 1558 notified bicycle accidents: in 21.4% thevictims were pedestrians, and in 76.8%, the riders themselves.
There were 11,366 notified motorcycle accidents: in 16.2%the victims were pedestrians, and in 79.1%, the riders them-selves.
Male sex predominated in the motorcycle or bicycle acci-dents: 81.6% and 80.6%, respectively (Fig. 2).
Among the motorcycle accidents, the dominant age groupof the victims was between 20 and 29 years (46.2%). Amongthe bicycle accidents, it was between 10 and 19 years (39.3%)(Fig. 3).
Both of these types of accidents occurred during the day,between 07:00 and 18:00 h: 37.4% and 27%, respectively.
Among the cyclists who suffered accidents and had sometype of deficiency (five cases notified), 20% had physical defi-ciency, 40% had auditory deficiency and 40% had unspecifieddeficiency. Among the motorcyclists (eight cases), 62.5% hadphysical deficiency, 12.5% had auditory deficiency and 25% hadunspecified deficiency.
Among the motorcyclists, 3% had made use of alcohol andin 67% of the cases, it was not possible to identify whether thishad occurred. Over the period evaluated, 63 cases of use ofillicit drugs by motorcyclists involved in accidents were noti-fied.
Among the cyclists, five cases of use of illicit drugs and 2.4%with use of alcoholic drinks were notified.
According to the instructions from the Ministry of Healthin 2006, the notification should be filled out when there is asuspicion or evidence that the patient had made use of alcoholor illicit drugs before the accident that gave rise to the injury.This should be done by the professional who attends to thepatient, at any healthcare establishment.
The main diagnosis for the injuries, according to the Inter-national Classification of Diseases, 10th edition (ICD-10), wastrauma to the knee in motorcycle accidents and to the leg, inbicycle accidents.
In relation to the evolution of cases, 14% of the bicycleaccident cases were transferred to specialized services and72.5% were discharged from hospital immediately. Among themotorcycle cases, 3.7% were kept in hospital at the servicewhere they were attended, 1% were dead on arrival, 6.9%were transferred to specialized services and the others werereleased from hospital immediately (Fig. 4).
The bicycle accidents occurred mainly in the southern zoneof the city (15.2%) and the eastern zone (6.1%). The motorcycleaccidents occurred in the same zones: 11.2% and 3.5%, respec-tively.
Discussion
Prevention of accidents and violence is the most importantmeans for avoiding morbidity and mortality due to externalcauses.
The victims of motorcycle and bicycle accidents observedhere were mostly young males, as has already been indicatedin very many studies conducted in other Brazilian cities.
In the present study, the bicycle accidents occurred pre-dominantly during adolescence (10-19 years) and amongmales. The great participation of bicycles in accidents is due toa variety of factors, such as their relatively low cost and theiruse among children and adolescents as recreational equip-ment (Figs. 2 and 3).
Today, bicycles are considered in many countries to be aviable solution for traffic problems, because of the high num-bers of automotive vehicles in large and medium-sized cities.Health benefits for users and non-degradation of the environ-ment are some of the advantages of this vehicle.13However, inthis study, it was not possible to assess whether those involvedin accidents were using bicycles for recreation or as a meansof transport. It was also not possible to ascertain whether theyhad been using helmets, knee pads and elbow pads.
According to Malta et al.,14the importance of events withintraffic that involve motorcyclists also has to be highlighted.Motorcycle riders and pillion passengers are now in first placeamong traffic accident victims. This trend has now been regis-tered for some years in the mortality information system andthe hospitalization information system. The present study hasdemonstrated, through data from SIVVA, that the number ofaccidents caused by motorcycles is greater than the numberscaused by other means of transport and that the victims ofthese accidents are young males.
In the present study, the majority of the accidents occurredduring the daytime; some authors have suggested that thegreater traffic flows during the day and the excessively longworking days of up to 15 h without breaks among professionalmotorcyclists may be factors associated with greater occur-rence of accidents during this period.
Although in the present study no relationship was shownbetween the presence of deficiencies and the accidents thatoccurred, social inclusion practices are now under discussion at national level, starting from the principle that for all indi-viduals to be integrated into society, it needs to be capable ofmeeting the demands of all its members.
In several countries, studies have indicated that consump-tion of alcoholic drinks and illicit drugs is one of the mainfactors responsible for the high incidence of accidents withvictims. In Brazil, this consumption has also been pointed outas one of the main causal factors of accidents. In comparingthe relevance of the impact of alcohol on traffic accidents,there is significant underestimation and undernotification ofalcohol consumption and illicit drug abuse in relation to trafficaccidents in Brazil.
Transport accidents have been described in the litera-ture as the second biggest cause of hospitalization. Lignaniand Vilella18observed that in Brazil, hospitalizations due toinjuries resulting from transport accidents increased by 8.7%between 2000 and 2010, while the risk of hospitalization dueto motorcycle accidents tripled. In the present study, it wasseen that most of the cases of bicycle and motorcycle acci-dents were released from hospital immediately. However, thiscould be a limitation of the present study, given that we wereunable to affirm whether the notification form was filled outat the time of release or whether the cases really evolved tohospital discharge.
As shown in Fig. 4, it was seen that the main injury diag-noses, according to the ICD-10, were knee and leg traumaand hand and wrist trauma. For motorcyclists and cyclists,the limbs are precisely the regions that are most unprotected,given that the safety equipment used provides protection onlyfor the head. According to Oliveira and Sousa,4authors inJapan concluded from a study conducted on the necropsyrecords of motorcyclists that effective use of a helmet signifi-cantly reduced the severity of their head and neck injuries butdid not have any effect on the overall severity of injuries inother parts of the body.
The effectiveness of using helmets to reduce head injuriesis incontestable. Most authors not only suggest that theyshould be used but also affirm the importance of multiple,synergic and contextualized strategies for injury prevention.Such strategies involve: use of bicycle lights; regulation andlegislation for the transit of vehicles and bicycles; educationalprograms; and support and modifications of the environmentin order to make practices safer, which includes cycle pathsand exclusive lanes for motorcyclists and cyclists.
One important point that is worth taking into considerationis the difficulty and limitations of working with secondarydata, because of deficiencies in filling out the notificationforms and delays in data entry into the databases and inupdating the information system.
The alarming growth in the number of motorcycles andbicycles, in relation to automobiles, because these are cheaperand more agile means of transport and, moreover, less pollut-ing, constitutes a new public health problem because of theaccidents that occur.
Conclusion
Actions toward minimizing traffic accidents should prioritizedrivers' and riders' hours of work activity. It is necessary to adopt public policies that give priority to application of finan-cial resources to strategies for reducing these accidents.
Traffic education is essential for accident prevention, for alltypes of transport vehicles used by the population.
Conflicts of interest
The authors declare no conflicts of interest.
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