The burden of child RTI is unacceptable

Globally, 186 300 children (0–17 years) die from RTI each year.16 It should be noted that although the focus of this paper is on children (defined as individuals <18 years), many available datasets present burden estimates by 5-year age groups; hence, in some cases it is difficult to separate children aged 15–17 years from young adults aged 18–19 years. Given our study's focus on children, we will not elaborate on prevention strategies for young adults aged 18–19 years who, as adults, are exposed to different risks on the road.

This paper uses three major sources of RTI data: GBD 2013, Global Status Report on Road Safety 2015 (GSRRS 2015) and Global Health Estimates 2014 (GHE 2014). They are the most widely used comprehensive estimates on the burden of RTI. While the three data sources are produced by different organisations, the underlying approach for generating these data is comparable. GSRRS 2015 and GHE 2014 were produced by WHO that generated country estimates using methods determined by availability and quality of death registration data and population size.17 The difference between GSRRS 2015 and GHE 2014 is that the former is more recent, but only has RTI deaths, while the latter provides multiple measures of mortality and morbidity of all causes of death. GBD 2013 is the most recent version of a comprehensive estimation of disease burden caused by all diseases and injuries around the world.1 The estimates are based on sophisticated statistical models using data from surveys, censuses, official reports, administrative data and systematic reviews.1

An extensive literature search was conducted using keywords of interest including RTI, crashes, fatality and burden of child RTI. We searched through multiple databases including PubMed/MEDLINE, EMBASE, POPLINE, CINAHL and Scopus, as well as search engine Google Scholar. Additionally, we searched for accessible web-based statistics through Google. This paper presents studies that are evidence-based, particularly papers evaluating road safety interventions in LMIC.

Globally, RTI are the fourth leading cause of death among children aged 5–9 years, third among children aged 10–14 years and first among children aged 15–17 years.16 Although the RTI death rate has been declining, particularly for young children, the burden of child RTI is still high, and the rate of decrease varies across age groups (figure 1). Among children and young adults, the RTI death rate is highest for the age group 15–19 years, and this pattern has remained unchanged from 1990 to 2013. However, the number of RTI deaths among people aged 15–19 years increased from 1990 to 2005 (figure 1).

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Figure 1

(A) Global number of deaths due to road traffic injuries by age group: 1990–2013. (B) Global death rates per 100 000 due to road traffic injuries by age group: 1990–2013. (Source: GBD1).

Despite the overall declining trends in rates, there is disparity in the impact of RTI across regions. GBD 2013 categorised 189 countries (for which estimations are made) into seven regions (figure 2). While the RTI death rate has declined in all regions between 1990 and 2013, the rate of reduction was lowest in sub-Saharan Africa (SSA). SSA also had the highest RTI death rate in 2013 (more than three times higher than the lowest rate from high-income countries); the ranking of the other regions has changed somewhat. All regions but SSA experienced a reduction in the number of RTI deaths, while the decrease in Southeast Asia, East Asia and Oceania was the most observable.

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Figure 2

(A) Number of deaths among people aged 0–19 years due to road traffic injuries by region: 1990–2013. (B) Death rates per 100 000 among people aged 0–19 years due to road traffic injuries by region: 1990–2013. (Source: GBD1).

Accordingly, the regional share of global RTI deaths changed from 1990 to 2013. Southeast Asia, East Asia and Oceania accounted for 32.9% of global RTI deaths in 1990, but their share declined to 23.5% in 2013 (figure 3). During the same period, the percentage of global RTI deaths that occurred in SSA almost doubled from 18.8% to 35.2%, making it the number one contributor to global RTI deaths. The number of RTI deaths in SSA will likely increase in the coming decades unless dramatic action is taken for a number of reasons, including rapid urbanisation and motorisation, economic development and population growth due to high fertility.18 Compounding the challenge is the inadequate investment on road safety infrastructure, lack of traffic regulations and laws that meet internationally recognised best practice and weak enforcement in SSA.

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Figure 3

 Percentage distribution of road traffic fatalities among people aged 0–19 years by region: 1990 and 2013. (Source: GBD1).

Other LMIC regions, including South Asia, North Africa/Middle East and Latin America/Caribbean, are also experiencing high burden of child RTI over the last two decades. The global share of high-income countries has however reduced almost by half over the same period, from 9.6% in 1990 to 5.4% in 2013.

There is an even larger disparity of the RTI burden among countries based on income level. About 90% of the global RTI deaths and DALYs occur in LMIC that only have 54% of the registered motorised vehicles in the world (table 1). However, middle-income countries bear the largest share of global RTI deaths (about 75%). It is also important to note in these comparisons that deaths reported to WHO by low-income countries are estimated to be severely undercounted (table 1).

Globally, medically certified vital registration system data were available for only 2.7% of the under-five deaths in 2010.19 The problem is more serious in LMIC where a large fraction of RTI deaths are under-reported in existing surveillance systems. The ratio of modelled over reported number of RTI deaths is 1.05 in 52 high-income countries, indicating a nearly complete coverage of data-reporting system (table 1). However, the ratio is 1.90 in middle-income countries/areas and 4.82 in low-income countries/areas, which means that about 80% of RTI deaths are missed by the reporting system. Through a comprehensive search of multiple databases and a review of over 2000 articles, Hyder et al20 found very limited information available for estimating child mortality and morbidity due to RTI in LMIC in South Asia. The type of poor data quality can compromise policy action in LMIC.

Fortunately, progress has been made in many LMIC in establishing injury surveillance programmes, illustrating the feasibility of obtaining quality data with limited resources.

For example, Egypt implemented an injury surveillance system in 1999 to assess the burden of injuries in the country and determine the incidence and characteristics of the different types of injuries.21 The system collected information on 20 000 deaths and over 746 000 injuries in 2007.22 A locally customised, electronic pilot trauma registry was implemented at a tertiary care hospital of Karachi, Pakistan, in 2010.23 In 2006, the National Injury Surveillance System was launched in China, based on 126 hospitals from 43 sample points (23 rural, 20 urban).24 It has become an important data source for injuries in China and enabled analyses of level, trend and pattern of injury morbidity and mortality.25

Risk factors for child road injuries are clear

The commonly used Haddon Matrix has been used to indicate that a variety of human, vehicle and equipment, and environmental factors before, during and after crashes determine the risk and outcome of RTI.26 While risk factors such as speeding and drink driving are associated with RTI in the general population, there are other factors that particularly affect children as captured in the literature including the World Report on Child Injury Prevention.27 Age is an important risk factor; RTI death rate increases with age, and children aged 15–19 years are at the greatest risk (figure 1). This results from increased exposure and tendency for risk-taking behaviour and changes in the way children use the road as they grow older; the prevalence of drinking and driving, speeding, distraction while driving and fatigue is also higher among teenage drivers than adult drivers.

Male children have a higher mortality rate than female children (figure 4). Globally, the ratio of male over female RTI death rate increases from 1.90 in 1990 to 2.05 in 2013. Among the seven GBD-categorised regions, SSA has the lowest ratio, stabilising at 1.6. Four regions, South Asia, North Africa/Middle East, Southeast/East Asia and Oceania and Latin America/Caribbean, witnessed an increase in the ratio, from around 2 in 1990 to about 2.5 in 2013. Among children killed or injured in traffic crashes in LMIC, a third or more are often pedestrians, making them the most vulnerable type of road users.16 Child occupants of vehicles are another common type of vulnerable population; front seating and the lack or improper use of a child restraint (which ought to be determined by age, weight and height) are factors.28

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Figure 4

 (A) The ratio of male over female death rates among people aged 0–19 years due to road traffic injuries by region: 1990–2013. (B) The ratio of male over female death rates due to road traffic injuries in the world by age: 1990–2013. (Source: GBD1).

Poverty and low socioeconomic status have been identified to be associated with elevated RTI risk. Excessive mortality due to RTI disproportionately affects children and young adults living in LMIC, where roads are the commonly shared places for playing, working, walking, cycling and driving.29 ,30 Even in high-income countries, it has been found that children from poorer families and ethnic minority groups are more likely to fall victims to unintentional injuries.31

Global policy actions are needed

Interventions to prevent RTI among children have been successfully implemented in high-income countries, indicating that confronting this challenge is possible. For example, through a comprehensive intervention package, Australia reduced the RTI death rate by 60% between 1970 and 1995.32 Other success stories include the Vision Zero policy adopted by the Swedish Parliament in October 1997 which contributed to the reduction in RTI deaths per 100 000 people from seven to fewer than three in that country, making Sweden an international leader in the area of RTI prevention.1 ,33

In an effort to extend best practices around RTI prevention globally, the United Nations General Assembly proclaimed the Decade of Action for Road Safety 2011–2020 in March 2010. The goal is to stabilise and reduce RTI deaths around the world; the achievement of the goal means potentially averting millions of RTI deaths and serious injuries between 2011 and 2020.34 The Decade of Action encourages countries to implement activities organised around five pillars of RTI prevention. The first pillar is to build road safety management capacity, such as adherence to and full implementation of the relevant United Nations legal instruments, as well as encouraging the creation of regional road safety instruments.35 Another component is a network of multisectoral partnerships led by an agency with the capacity to develop and implement national road safety strategies, plans and targets. The vulnerability of children needs to be taken into special consideration in road safety management; for example, the Norwegian Public Roads Administration set particular targets for the use of bicycle helmets among children when developing a comprehensive system of road safety management.36

The second pillar focuses on infrastructure, emphasising the importance of raising the inherent safety and protective quality of road networks for the benefit of all road users, particularly the most vulnerable such as children, pedestrians, bicyclists and motorcyclists. Specific approaches under this pillar include road designs that separate pedestrians from other road users, road bumps (speed control) around schools and play areas, as well as facilitating safe walking and cycling for children.16 This pillar also promotes safe operation, maintenance and improvement of existing and future road infrastructure by requiring road authorities to identify hazardous road location and conditions. For example, poor road surface has been associated with elevated risk of traffic crashes.37 The third pillar is enhancing the safety of vehicles, such as improving passive and active vehicle safety technologies through a combination of harmonisation of relevant global standards, consumer information schemes and incentives to accelerate the update of new technologies. This pillar also covers safety for children as passengers and other types of road users. For example, the Global New Car Assessment Programme, a non-governmental organisation that conducts testing programmes to assess the safety of motor vehicles, has influenced vehicle safety standards in many countries around the world.38

The fourth pillar deals with road user behaviour that significantly affects the risk of crashes involving children (table 2). This pillar encourages the development of comprehensive programmes to improve road user behaviour;35 for example, wearing a seat belt has reduced child RTI death rates in North America and Europe.39 ,40 It can cut the risk of death by 40%–65% for front-seat passengers and by 25%–75% for rear-seat passengers. However, only 105 countries, representing 67% of the world's population, have legislation on seat belts (table 2).2 Seat belts are not designed for younger children and do not effectively protect them from injuries in traffic crashes. Child seats, appropriate for age, height and weight, and booster seats lower the risk of death by 54%–80% for younger children.40 ,41 While 96 countries have some type of child restraint law, only 85 countries base this law on age, weight and height, and even fewer countries (53 countries) meet best practice for child restraint (table 2). The child restraint use rate is low in many countries; for example, the rate of use among children under 5 years of age ranged from 7.9% to 17.4% in two Mexican cities.42 Even in countries with high use rate, correct and appropriate restraint use can still be a problem. Observational data show that children and young adults are less likely to use seat belts than adults.43 A reason for the low compliance with child restraint and seat belts is the lack of or weak enforcement of existing child restraint laws.3 On a scale of 0–10 measuring the strength of enforcement, only 22 countries have a self-reported rating of ‘good’ (8 or above) on the enforcement of child restraint rules and laws.2 Other barriers for increasing child restraint use in LMIC include cost of child restraint, knowledge and awareness of parents and caregivers and relatively low safety standard for vehicles44 ,45 ( box 1).

The risk of severe injury and death increase with speed, particularly for child pedestrians, cyclists and motorcyclists.49 Reducing speed limit around schools and play areas is a proven intervention to prevent child RTI.50 The adoption of speed detection devices to enhance enforcement of speed limits has also been effective and, if properly implemented, could save thousands (44 000+) of children every year;51 for example, the ‘20 is plenty’ speed zones in London and Portsmouth, UK, significantly reduced child fatality and injury rates.16 ,52

The danger of driving after drinking alcohol has been widely documented especially for teen drivers and pedestrians. WHO recommends a blood-alcohol concentration (BAC) of ≤0.05 g/dL, and a reduced limit of 0.02 g/dL for young and novice drivers. A few countries set a lower alcohol limit for young and new drivers than for adult and experienced drivers. For example, the alcohol limit is 0 g/dL for drivers who have held a driver licence for <2 years in Australia and Germany. It is estimated that introducing legal BAC limits could potentially save thousands (16 000+) of children annually.53 The most common non-fatal RTI sustained by children are head injuries and fractured limbs. Appropriately wearing a helmet that meets standards can reduce the risk of severe injury by over 70%.54 It has been estimated that over 50 000 children could be saved if the bicycle helmet use rate increases to 80%, a goal set by Sweden, in all countries.55–57 Graduated Driver Licensing has also been proven to be effective to prevent traffic crashes among young drivers in a variety of settings such as New Zealand and USA.57–59 Other proven interventions include encouraging all child and teenager pedestrians and bicyclists to wear white or bright colour or reflective clothing to improve their visibility to other road users.27

The fifth pillar aims to increase the responsiveness of postcrash emergency systems and improve the ability of the health systems to provide appropriate acute treatment and long-term rehabilitation for crash victims.35 Such interventions, while often not designed specifically for children, allow child victims to benefit from appropriate emergency medical care.

Most of the interventions above save lives and reduce the severity of injuries.40 ,60–62 These benefits measured with indicators such as DALYs and healthy life years are all well documented in the literature.63–66

Call for action

Since the adoption of Decade of Action in 2010, much progress has been made with many countries implementing road safety interventions. However, there are several challenges to intervention implementation and legislation for child RTI. Although it has been widely established that most child RTI are preventable, poor collaboration between agencies and lack of political commitment and understanding may be barriers to making roads safe for children.50 Concerted action is needed to create a strong policy context for child RTI prevention, enable a common vision for all stakeholders and implement evidence-based interventions. Often, one of these components is missing, leading to either lack of action or investments that may not be effective.

Non-governmental organisations (NGOs) can play an increasingly important role in road safety by supporting the development of national capacity and international cooperation for child RTI. WHO began engaging with NGOs that are advocating for road safety and the reduction of RTI.67 They can integrate child RTI prevention advocacy in both child health and RTI work and promote specific interventions. NGOs can also call for greater protection of children from non-health sectors and allow RTI to be a part of many agendas for child survival.

Improved data collection is also urgently needed for evidence-based policy-making and programme evaluation. Efforts should be devoted to harmonise information from a variety of sources, such as sample surveys and injury surveillance systems, to obtain a complete estimate of the burden of child RTI.

A successful response to the gap between the high burden and inadequate response for child RTI depends on several domains: strong political will, capacity building, implementation of evidence-based interventions, rigorous evaluation, adequate global funding, multisectoral action and sustainability.68 It is time to take immediate action and stop losing children from RTI—often the same children the world has saved from infectious diseases. The world can do better in saving the children from RTI by implementing a comprehensive package across the five pillars of road safety as a key component of child health and welfare.