The Lancet, Volume 381, Issue 9873, Pages 1171 - 1172, 6 April 2013
USA reviews motorcycle safety laws as crash deaths increase
Against
a backdrop of falling traffic collision fatalities in America,
motorcycle crash deaths continue to increase, prompting a national
review. Tony Kirby reports.
Unlike many high-income nations
such as the UK, the USA has no universal law relating to use of
motorcycle helmets. As of January, 2013, 19 states and the District of
Columbia had universal helmet laws, 28 states had partial helmet laws
(generally requiring only young riders to wear helmets), and three
states (Illinois, Iowa, and New Hampshire) had no helmet law. The
situation continues to change, with many states having a history of
repeatedly enacting and repealing motorcycle helmet legislation. This
has been, in part, related to whether or not the US Federal Government
provides incentives to states that have compulsory helmet laws.
Rebecca
Ivers is one of the world's leading injury experts, based at the George
Institute for Global Health, Sydney, NSW, Australia. Ivers and her team
are working with the US Centers for Disease Control and Prevention
(CDC) on a systematic review on motorcycle safety to guide America's
policy in this controversial area. The results, due in the first half of
2013, will guide the US Community Preventive Services Task Force in
recommendations they make. The Task Force reviews the evidence and uses
it to make decisions and recommendations when enough good quality
evidence is available. CDC and other partners then work to ensure the
wide dissemination of the results.
"Our review will
systematically examine epidemiological studies of helmet legislation
from all over the world. The results are important not just for the US
but also for low-income countries where motorcycle use is common", says
Ivers. Her task should be an easy one, since most published data clearly
point to far better outcomes in states (and nations) that have
compulsory helmet laws. Between 2008 and 2010, more than 14 000
motorcyclists (including passengers) were fatally injured on the USA's
roads. Motorcycle-related crash deaths have risen by 55% since 2000,
while motor vehicle-related deaths in all road users excluding
motorcyclists decreased by 23%. There are many reasons behind the
increasing motorcycle fatalities, including increasing numbers of
motorcycles on the road, more larger engine motorcycles, speeding,
inconsistent helmet use, drink driving, and increasing numbers of riders
older than 40 years with increasing numbers of fatalities in that age
group. Ivers also points to issues such as road design, maintenance, and
roadside objects.
"According to a CDC analysis of fatal crash
data from 2008 to 2010, 12% of motorcyclists in states with universal
helmet laws were not wearing helmets. In comparison, 64% of riders were
not wearing helmets in states with partial helmet laws, and 79% of
riders were not wearing helmets in states with no helmet laws", says
Rebecca Naumann, Division of Unintentional Injury Prevention, CDC, who,
in 2012, completed a study on motorcycle safety with colleague Ruth
Shults for the CDC's Morbidity and Mortality Weekly Report (MMWR).
"In 2010, the 4502 motorcyclists (riders and passengers) killed in
motorcycle crashes made up 14% of all road traffic deaths, yet
motorcycles accounted for less than 1% of all vehicle miles travelled",
she adds. The MMWR study by Naumann and Shults concludes,
"helmets are proven to save lives and universal helmet laws are the most
effective way to increase helmet use". They also point out that partial
laws do not seem to protect the young riders they are meant for: 60% of
fatally injured minors were unhelmeted in states with this type of law
compared with 22% in states with universal helmet laws from 2008 to
2010. "Of course, it's not only lives helmet use saves, it's also huge
costs", adds Naumann, pointing out that, while helmet use saved the USA
around US$3 billion in costs in 2010, another $1·4 billion could have
been saved if all motorcyclists had worn helmets, according to 2012 data
as yet unpublished by the National Highway Traffic Safety
Administration.
Research has shown that states that repeal
compulsory helmet laws completely or partially experience sharp drops in
helmet use and increases in motorcycle-related deaths, injuries, and
costs. In 2000, Florida changed its universal helmet law to a partial
helmet law that covered only riders aged 21 years and younger. In the
subsequent 2 years, helmet use fell from 99% to 53%, the motorcyclist
death rate increased by 21%, deaths among motorcycle riders aged younger
than 21 years nearly tripled, and hospital admissions of motorcyclists
with injuries to the head, brain, and skull almost doubled. Conversely,
helmet use increases and deaths fall in states that strengthen their
laws, such as Louisiana (2004), which saw helmet use increase from 60%
to 99%. Naumann and Shults highlight other research in the MMWR that
shows "Riders who do not wear helmets are more likely to suffer
traumatic brain injuries, and riders who do not wear helmets also are
less likely to have health insurance, and therefore require publicly
funded health care."
Full-size image (50K) Corbis
Three US states have no compulsory helmet laws and 28 have only partial laws
Motorcyclists
comprise between 5% and 18% of road traffic injury deaths in
high-income countries; however, in many low-income and middle-income
countries, they comprise a substantially higher proportion. In Thailand
and Indonesia, for instance, motorcycle fatalities account for 70% and
55% of total road fatalities, respectively. In most other countries in
the WHO Western Pacific Region, there is an over-representation of
fatalities among motorcyclists relative to the size of their motorcycle
fleets. Data are showing that the risk to motorcyclists is also
increasing in Africa and Latin America.
Ivers is equally
active in the drive to bring down motorcycle injury in low-income and
middle-income countries, through collaborations the George Institute has
in locations such as Vietnam, which has recently enacted a law
requiring all riders and passengers to wear helmets. Along with Ha
Nguyen from the Center for Injury Policy and Prevention Research, Hanoi
School of Public Health, Vietnam, and colleagues, Ivers has concluded
that "the costs of dealing with head injuries in motorcycle collisions
in Vietnam are 40% higher in cases where the injured persons are not
wearing a helmet, and hospital costs can be equivalent to 6 months or
more of the average annual wage in Vietnam…thus the country's new helmet
law needs to be closely monitored and enforced."
A new area
of research for high-income and developing countries alike is the
effectiveness of motorcycle protective clothing, and Ivers and colleague
Liz de Rome have studied this in their home nation of Australia. The
research, published in Accident Analysis and Prevention, involved
212 motorcyclists and found they were less likely to be admitted to
hospital if they crashed wearing protective clothing or body armour. But
de Rome adds that: "Around a quarter of motorcycle designed gloves,
jackets, and pants were assessed to have failed due to material damage
in the crash, indicating a need for improved quality control." Ivers
concludes that "While at the moment, making protective clothing
compulsory is not recommended, there could instead be incentives for
using it, such as tax exemptions and health insurance premium reductions
and rebates."
Motorcycle safety is a growing issue around the
world. WHO's Decade of Action for Road Safety Global Plan encourages
countries to take action on a number of levels, including improving the
safety of road networks in general. "We are working with a number of
countries, including China, Vietnam, Cambodia, Kenya, Brazil to improve
rates and monitoring of helmet use in motorcyclists", says Margie Peden,
Coordinator of Unintentional Injury Prevention in the Department of
Violence and Injury Prevention and Disability at WHO. "Cambodia is about
to pass a new helmet law, and WHO has helped the country run a mass
media campaign showing the potential tragic consequences of failing to
wear a helmet", says Peden. She adds it is vital to ensure that helmets
meet minimum safety standards, since a substandard helmet can be as
ineffective as no helmet at all. The Global status report on road safety 2013 published on March 14 showed that 155 countries around the world had comprehensive helmet laws in 2011, up from 131 in 2008.
Peden
is also a coauthor of a recent review of helmet quality in low-income
and middle-income countries, along with Robyn Norton, principal director
of the George Institute for Global Health in Sydney and professor of
global health at the University of Oxford, UK, who was the founding
chair of the Road Traffic Injuries Research Network that undertook the
review. Their team analysed some 5500 helmets from motorcycle riders
across nine low-income and middle-income countries: China, Ghana, India,
Malaysia, Mexico, Nigeria, Pakistan, Thailand, and Vietnam, and found
that around half were likely to be substandard. "The lower costs of
these substandard helmets—$10 or less—are the most significant factor
associated with their use", says Norton, with the study finding standard
helmets were generally two to three times more expensive than
non-standard helmets. These findings suggest that the widespread use of
non-standard helmets could negate the gains of compulsory helmet-wearing
legislation in these poorer countries. "Consequently, we strongly
recommend that as mandatory helmet laws are introduced, they are
introduced in conjunction with relevant legislation and enforcement
pertaining to helmet standards", she says.
Back in the USA,
the average age of motorcyclists killed in accidents is rising, with
half now aged 40 years or older, up from 25% in 1995. High-income
countries have had access to motorcycle safety data for some time,
showing that helmets on motorcyclists reduce the risk of death by 37%
and the risk of head injury by 69%, while not reducing visibility or
impairing hearing. In a country such as the USA, it seems staggering
that any debate at all should be required, and it will be surprising if
the US Community Preventive Services Task Force review stops anywhere
short of recommending compulsory helmet laws across all states that do
not currently have them.
For the CDC's motorcycle safety pages see http://www.cdc.gov/
For WHO's booklet encouraging helmet use on motorcycles seehttp://www.who.
For more on the Road Traffic Injuries Research Network see http://rtirn.net