Reported by: Nicoletta Bertozzi, Barbara Bondi, Francesca Righi, Patrizia Vitali (Dipartimento di Sanità Pubblica, AUSL Cesena), Pierluigi Cesari (Dipartimento di Sanità Pubblica, AUSL Rimini),  Aldo De Togni (Dipartimento di Sanità Pubblica, AUSL Ferrara), Aligi Giardini, Oscar Mingozzi (Dipartimento di Sanità Pubblica, AUSL Forli) Giuliano Silvi (Dipartimento di Sanità Pubblica, AUSL Ravenna). Morena Cantarelli, Marinella Franceschini, Gianalberta Savelli, Carlo Turatti.

Among the objectives of the Italian National Health Plan 1998-2000 is a 20% reduction in deaths caused by traffic accidents. In the Emilia-Romagna region (northeastern Italy), where traffic-related mortality is higher than the national average, the Regional Health Plan has assigned highest priority to the prevention of traffic accidents.

Information on the number and characteristics of traffic-related deaths in the coastal provinces of Emilia-Romagna (Forlì-Cesena, Ravenna, Rimini e Ferrara)  for the period 1994-1998 were obtained from the death register of the Local Health Agencies and from a surveillance on traffic accidents maintained by  the National Statistics Institute and the Automobile Association of Italy (ISTAT-ACI).  In the case of the former data set, the cause of death was considered traffic-related when the ICD-9 cause of death was listed as E810-819, E826 and E829; in the second system, deaths were considered traffic-related if they occurred within 7 days of the accident.

The overall number of accidents reported in the study area increased from 5.6 per 1000 residents in 1994 to 6.2 per 1000 in 1998. The median number of persons injured in each accident remained consistent over time at 1.4.   Nonetheless the number of deaths per 1000 accidents decreased from 39 to 34 per 1000 during 1994 to 1998.

Overall, the mortality rate was three times higher among males than females; 37 per 100,000 versus 12 per 100,000. The rates were higher for males than females in all age groups. The highest rates were found in the age groups 18-29 years and in those 65 years of age and older (both 38 per 100,000), followed by the 14-17 year age group (25/100,000); the lowest value was observed in those 0-13 years of age (3/100,000). Overall, 27% of the traffic-related fatalities occurred among non-residents, with a wide variation from 11% in Forli to 55% in Rimini, a major tourist destination. A total of 42% of the deaths occurred in hospital, with a range from 33% in Ferrara to 52% in Rimini.

Data on type of accident were available for 74% of the 1581 deaths among residents of the study area. The mortality rate for car accidents was 9.3 per 100,000 residents, while deaths from motorcycle or moped accidents was 4.3 per 100,000. The corresponding figures for bicycle and pedestrian accidents were 2.9 and 2.3 per 100,000 residents, respectively. Figure 1 shows the distribution by type of accident and age group.

The priorities for prevention for the involved Local Health Agencies include educational efforts designed to increase the use of motorcycle helmets and seatbelts among adolescents and young adults and to publicize the risks associated with driving under the influence of alcohol and drugs. Among the elderly, it will be important to consider urban design interventions to provide bicycle paths and protected routes.

Commentary by Franco Taggi and Marco Giustini Laboratorio di Epidemiologia e Biostatistica Istituto Superiore di Sanità.

Traffic accidents are an important public health problem from both a health and economic point of view. They account for a million victims annually throughout the world and are the main cause of death in persons 15-44 years in the developed world (1). It is therefore not surprising that the National Health Plan 1998-2000 as well as the European community have proposed as a priority objective the reduction of traffic-related facilities.

The social and public health impact of traffic accidents in the coastal areas of Emilia-Romagna is high. In the study area, the mortality rate was much higher than the national average (24.0 per 100,000 versus 13.5 per 100,000), although the age and sex distribution of deaths parallels that observed nationally.

The data reported by the Departments of Prevention of the Local Health Agencies of the coastal provinces of Emilia-Romagna was conducted using two data sources, and the information contained in the two sources not always coincide. Mortality data was examined using information provided by the death registers of the Local Health Agencies, while other data  of a more general nature on the circumstances of the accident were obtained from ISTAT-ACI. The statistical unit is different in the two systems: in the first, the unit is the individual, while in the second, it is the accident. These two sources of data are in fact complementary, in that the data from ISTAT-ACI contain detailed information on the dynamics of accidents (number of accidents, type of vehicles involved, circumstances of the accident), while the data from the Local Health Agencies provide more complete data on the number of deaths. It should be recalled, in fact, that the statistics of ISTAT-ACI include only those accidents notified to law enforcement authorities and that until recently reported only those deaths occurring within 7 days the accident. Such a case definition results in an estimated under-notification of the “true” mortality of 20-25%.

A comparison of the differences in mortality rates by age and type of accident between the study area and Italy as a whole permits a partial explanation of the higher mortality rate in the coastal provinces of Emilia-Romagna. Most of the difference is explained by the higher mortality from car accidents in the 14-17 and 18-29 year age groups observed in the study area. In the 14-17 year age group, the motor-vehicle-related mortality rate was 3.8/100,000 nationally vs 8.9/100,000 in the study area, while in the 18-29 year age group, the corresponding values were 13.4/100,000 and 20.4/100,000.

In relative terms, bicyclists have a considerably higher mortality rate, which in this study was four times higher than the national figures. This may be a consequence of the long tradition in this area of using bicycles as a mode of transportation. In addition, mortality among pedestrians is one-and-one-half times higher than the national average.

The mortality rate associated with the use of motorcycles and mopeds was similar to the national average in spite of the presence of risk factors in the area such as driving at speeds in excess of established limits and a high concentration of vehicles on the road.  Although data on the use of helmets are not available for the study period 1994-1998, data obtained from a national study on safety measures known as ULISSE have shown that in early 2001, helmet use in the study areas was nearly 100%.

Considering the efficacy of available preventive measures and their feasibility in the study area, the priority should be the evaluation and enforcement of seat belt use, which is currently estimated at 30-40%. A second priority should be to intensify efforts to identify drunk drivers and enforcement of speed limits.

1  OMS. Annuaire de statistiques sanitaires mondiales 1995. Geneve, 1996.

2  Commissione Europea, “Promuovere la sicurezza stradale nell’Unione Europea: programma 1997-2001”, Com. (97) 131 def.

3  ISTAT, Statistiche Sanitarie, pubblicazione annuale. 1997.

4 M. Giustini, G. Fondi, F. Taggi I ciclisti e gli incidenti stradali: considerazioni statistico-epidemiologiche sulla mortalità osservata in Italia nel periodo 1969-1994 in atti della 55° Conferenza del Traffico e della Circolazione, pp. 249-255, Riva del Garda, 27-30 ottobre 1999.