BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Road traffic injury mortality and its mechanisms in India: nationally representative mortality survey of 1.1 million homes
For peer review only Journal: BMJ Open
Manuscript ID: bmjopen-2013-002621
Article Type: Research
Date Submitted by the Author: 21-Jan-2013
Complete List of Authors: Hsiao, Marvin; University of Toronto, Centre for Global Health Research; University of Toronto, Department of Surgery Malhotra, Ajai; VCU Medical Center, Virginia Commonwealth University, Department of Surgery Thakur, JS; Post Graduate Institute of Medical Education and Research, Department of Community Medicine Sheth, Jay; Smt. N.H.L. Municipal Medical College, Nathens, Avery; University of Toronto, Department of Surgery; Sunnybrook Health Sciences Centre, Sunnybrook Research Institute Dhingra, Neeraj; National AIDS Control Organization, Jha, Prabhat; University of Toronto, Centre for Global Health Research
Primary Subject Epidemiology Heading: http://bmjopen.bmj.com/
Secondary Subject Heading: Global health, Public health
Keywords: road traffic injury, verbal autopsy, India, low- and middle-income countries
Note: The following files were submitted by the author for peer review, but cannot be converted to PDF. You must view these files (e.g. movies) online. on October 2, 2021 by guest. Protected copyright. Figure 1 - v7.3 - 2013-01-21 Figure 2 - v2.5 2013-01-21 Figure 3 - Reported Injuries v5.1 2012-11-22 STROBE_checklist_BMJ-Open_cross-sectional-studies.doc
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 Road traffic injury mortality and its mechanisms in India: nationally 5 representative mortality survey of 1.1 million homes 6 7 8 Marvin Hsiao, Ajai Malhotra, JS Thakur, Jay K Sheth, Avery B Nathens, Neeraj Dhingra, 9 10 Prabhat Jha, for the Million Death Study Collaborators. 11 12 13 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 14 15 University of Toronto,For Toronto, peer Canada (M review Hsiao MD, Prof P Jha only DPhil); Division of General 16 17 Surgery, Department of Surgery, University of Toronto, Toronto, Canada (M Hsiao MD, Prof AB 18 Nathens MD); Department of Surgery, VCU Medical Center, Virginia Commonwealth University, 19 20 Richmond, USA (Prof A Malhotra MD); Department of Community Medicine, Post Graduate 21 Institute of Medical Education and Research, Chandigarh, India (JS Thakur MD); Smt. N.H.L. 22 23 Municipal Medical College, Ahmedabad, India (JK Sheth MD); Sunnybrook Research Institute, 24 25 Sunnybrook Health Sciences Centre, Toronto, Canada (Prof AB Nathens MD); National AIDS 26 Control Organization, New Delhi, India (N Dhingra MD) 27 28 29 30 31 Correspondence to: 32 Marvin Hsiao 33 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, and
34 Division of General Surgery, Department of Surgery, University of Toronto http://bmjopen.bmj.com/ 35 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 36 [email protected] 37 +1 416 864 6042 (phone) / +1 416 864 5256 (fax) 38 39 Keywords: Road traffic injury; verbal autopsy; India; low and middle income countries 40
41 42 Word count: Text: 3211 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ABSTRACT: 4 5 6 Objectives: To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. 7 8 Design: We conducted a nationally representative mortality survey where at least two 9 10 physicians coded each non medical field staff’s verbal autopsy reports. RTI mechanism data 11 12 were extracted from the narrative section of these reports. 13 14 Setting: 1.1 million homes in India. 15 For peer review only 16 Participants: Over 122 000 deaths at all ages from 2001 2003. 17 18 19 Primary and secondary outcome measures: Age and sex specific mortality rates, place and 20 21 timing of death, modes of transportation, and injuries sustained. 22 23 Results: The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or 24 25 about 2% of all deaths in 2005 nationally, of which 65% occurred in males between the ages of 26 27 15 59 years. The age adjusted mortality rate was greater in males than in females, in urban 28 29 than in rural areas, and was notably higher than that estimated from national police records. 30 31 32 Pedestrians (68 000), motorcyclists (36 000), and other vulnerable road users (20 000) 33 constituted 68% of RTI deaths (124 000). The majority of all RTI deaths occurred at the scene
34 http://bmjopen.bmj.com/ 35 36 of collision (1005/1733, 58%), within minutes of collision (883/1596, 55%), and/or involved a 37 38 head injury (691/1124, 62%). Compared to non pedestrian RTI deaths, about 55 000 (81%) of 39 40 pedestrian deaths were associated with less education and living in poorer neighbourhoods. 41 42 Conclusions: In India, RTI cause a substantial number of deaths, particularly among on October 2, 2021 by guest. Protected copyright. 43 44 45 pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce 46 47 injuries might address over half of the RTI deaths. Improved pre hospital transport and hospital 48 49 trauma care might address just over a third of the RTI deaths. 50 51 52 53 54 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ARTICLE SUMMARY 4 5 6 Article focus 7 8 • To directly estimate the age and sex specific mortality rates and describe the place and 9 10 timing of death, modes of transportation, and injuries sustained for road traffic injury 11 12 (RTI) deaths in India using a nationally representative mortality survey of 1.1 million 13 14 homes. 15 For peer review only 16 Key messages 17 18 19 • Road traffic injuries cause a substantial number of avertable deaths, particularly in males 20 21 of productive working age and among pedestrians and other vulnerable road users. 22 23 • Preventative interventions should be emphasized as the majority of all RTI deaths 24 25 occurred at the scene of collision, within minutes of collision, and/or involved a head 26 27 injury. 28 29 30 • Properly designed mortality survey with verbal autopsy narratives can provide much 31 32 needed data to assist RTI prevention efforts. 33
34 Strengths and limitations of this study http://bmjopen.bmj.com/ 35 36 • This study is the first nationally representative survey of the causes of death in India and 37 38 overcomes limitations of existing data sources including regional injury surveys, hospital 39 40 41 series, and national police reports. 42 43 • Limitations of the study include potential misclassification of deaths by physician coders, on October 2, 2021 by guest. Protected copyright. 44 45 the use of layperson narratives with a potential for recall bias and inaccuracies, and 46 47 limited ability to forward project study results given the rapid changes in motorization in 48 49 India. 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 INTRODUCTION 4 5 6 Road traffic injuries (RTI) are a large and growing public health burden, especially in low and 7 8 middle income countries (LMIC) where 90% of the world’s RTI deaths are estimated to occur.[1] 9 10 There are few high quality epidemiologic data on RTI to guide the development, 11 12 implementation, and surveillance of evidence based policy and programs in LMICs.[2 4] 13 14 15 For peer review only 16 The number of RTI deaths in India is projected to rise with increasing motorization.[1,5] Aside 17 18 19 from a few regional injury surveys,[6 11] the current data on the numbers and mechanisms of 20 21 RTI deaths in India rely on police or hospital records, both of which can substantially 22 23 underestimate death rates in the poor, rural, and uneducated people who still constitute large 24 25 proportions of the Indian population.[2 4,12,13] 26 27 28 29 The World Health Organization (WHO), using indirect modeling methods, estimated about 202 30 31 32 000 RTI deaths in India in 2004.[14,15] No study has validated this estimate with direct 33 measurement nor documented detailed RTI mechanism for India nationally. Here, we estimate
34 http://bmjopen.bmj.com/ 35 36 the regional, age and sex specific mortality rate and risk of RTI death in India using data from 37 38 the Million Death Study (MDS). We also report the modes of transportation, place and timing of 39 40 death, and injuries sustained in RTI deaths. 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 METHODS 4 5 6 Study Design: The MDS is an on going nationally representative survey designed to determine 7 8 the causes and risk factors of death in India, organized by the Registrar General of India (RGI). 9 10 The design, methodology, and preliminary findings of the MDS have been described 11 12 elsewhere.[16 19] In brief, the MDS used an enhanced version of verbal autopsy (known as the 13 14 routine, reliable, representative, re sampled household investigation of mortality with medical 15 For peer review only 16 evaluation or RHIME) to monitor a nationally representative sample of 1.1 million households in 17 18 19 the Sample Registration System (SRS). Within six months of every death occurring in these 20 21 households from 2001 3, a trained, nonmedical RGI surveyor interviewed a relative or close 22 23 acquaintance of the deceased to obtain the symptoms and events around the death using 24 25 structured questions and a local language narrative guided by a specific symptom list. These 26 27 records were converted into electronic records and emailed to two of 140 trained physicians 28 29 who, independently and anonymously, assigned an underlying cause of death (with allocation 30 31 32 determined randomly based only on the physician’s ability to read the local language), using 33 guidelines for the major causes of death.[20] Records were assigned cause of death in three
34 http://bmjopen.bmj.com/ 35 36 digit International Classification of Diseases and Related Health Problems, 10th revision (ICD 37 38 10).[21] Records where coders disagreed on the cause of death underwent anonymous 39 40 reconciliation. Continuing disagreements were adjudicated by a third senior physician. Five 41 42 percent of households were randomly resurveyed and the results were consistent within families on October 2, 2021 by guest. Protected copyright. 43 44 45 of ICD 10 codes.[16] Participation in the SRS is on a voluntary basis and oral consent was 46 47 obtained under the confidentiality and consent procedures of the Registration of Births and 48 49 Deaths Act, 1969. 50 51 52 53 Road Traffic Injury Deaths: The RTI deaths in this study were of people who died between 54 55 2001 and 2003 with a final assigned ICD 10 code within V01 V89. We translated the open 56 57 58 ended narratives into English from 14 local languages, and systematically extracted the modes 59 60 5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 of transportation, place and timing of death, and injuries sustained from the narratives. For 4 5 6 these four data elements, there were substantial inter rater agreement (kappa statistic > 0.69) 7 8 between two investigators and two research assistants who were trained and independently 9 10 extracted data from the narratives of a random 10% of RTI deaths (data not shown). The two 11 12 research assistants then independently extracted data from all narratives. Adjudication was 13 14 done by an investigator (M.H) for discrepancies in extracted data. 15 For peer review only 16 17 18 19 Analysis: The age and sex specific proportion of RTI deaths within the 2001 2003 survey was 20 21 applied to the 2005 United Nations (UN) estimates of the number of deaths from all causes in 22 23 India, after weighting for sampling probability.[22] The 2005 UN death estimates were used so 24 25 as to correct for the slight undercounts reported in the total death rates in the SRS[23,24] and to 26 27 account for the 12% of enumerated deaths without completed field visits (mostly due to out 28 29 migration of the family or from incomplete field records). The proportion of these missed deaths 30 31 32 was similarly dispersed across sex, age, and states. Use of 2003 or 2004 UN death totals 33 yielded nearly identical results (data not shown). The 99% confidence intervals (99%CI) for
34 http://bmjopen.bmj.com/ 35 36 mortality rate were calculated based on the weighted number of study deaths. State and 37 38 rural/urban specific estimates of the number, mortality rate, and lifetime risk of RTI death were 39 40 calculated by partitioning the UN national death totals according to relative SRS death rates as 41 42 previously described.[18,25,26] Urban and rural status was defined according to the Census of on October 2, 2021 by guest. Protected copyright. 43 44 45 India. Logistic regression was used to compare the socio demographic traits of pedestrian and 46 47 non pedestrian RTI deaths. Household fuel type was used as a measure of community wealth: 48 49 high asset neighbourhoods had >50% of households that used gas, electricity, or kerosene; low 50 51 asset or poor neighbourhoods used primarily coal, firewood, or other. Attributable proportion 52 53 was calculated for traits of pedestrian deaths compared to non pedestrian RTI deaths. 54 55 56 57 58 59 60 6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 The MDS received ethics approval from the review boards of the Post Graduate Institute of 4 5 6 Medical Education and Research in Chandigarh, India; St Michael’s Hospital in Toronto, 7 8 Canada; and the Indian Council of Medical Research’s Health Ministry’s Screening Committee. 9 10 11 12 13 14 RESULTS 15 For peer review only 16 The 2299 RTI deaths in the 2001 2003 survey correspond to an estimated 183 600 (99%CI 173 17 18 19 800 193 400) RTI deaths in India in 2005. The majority of these RTI deaths occurred in males 20 21 (152 100 deaths, 82.8%; table 1). The age standardized RTI mortality rate for males (26.2 per 22 23 100 000, 24.6 27.7) was higher than for females (5.7 per 100 000, 5.0 6.4). While the RTI 24 25 mortality rate increased with age in both genders, the largest number of RTI deaths occurred in 26 27 males between 15 59 years of age (118 900, 64.8%). 28 29 30 31 32 At these death rates and in the theoretical absence of other causes of death, males in India had 33 a 2.1% (2.0 2.3) risk of dying from RTI before age 70, with the highest risks at ages 30 59
34 http://bmjopen.bmj.com/ 35 36 years; females had a 0.5% (0.4 0.5) risk of dying from RTI before age 70. Males in Haryana, 37 38 Punjab, Tamil Nadu, and Uttar Pradesh had significantly higher risks (3.0 4.1%) than the 39 40 national risk (figure 1). In contrast, males in Bihar, Jharkhand, Andhra Pradesh, Orissa, Gujarat, 41 42 and West Bengal had significantly lower risks (1.3 1.6%) than the national risk of RTI deaths. on October 2, 2021 by guest. Protected copyright. 43 44 45 Males living in urban areas had slightly higher age standardized mortality rates and risks of RTI 46 47 deaths (27.6 per 100 000; 2.4%, 2.1 2.6) compared to males living in rural areas (24.9 per 100 48 49 000; 2.0%, 1.8 2.1). By contrast, female RTI mortality rates and risks before age 70 varied much 50 51 less across states and were similar in rural and urban areas (data not shown). 52 53 54 55 56 57 58 59 60 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Page 8 of 26
Period risk for RTI death†
5.7 0.5%† 15.5 1.3%† 26.2 2.1%† 16.2 1.3%† RTI death rateΨ (99% CI)
per 100 000 *Proportion of RTI deaths deaths RTI of *Proportion
9.1 64.5(49.1 80.0) 3.8 3.2 (2.0 4.4) 0.03% 3.5 21.6(13.4 29.9) 8.5 6.6 (4.9 8.3) 0.1% 5.0 8.1 (7.1 9.1)¶ 0.04% 4.9 7.4 (6.5 8.4)¶ 0.04% 4.4 4.1 (2.7 5.5) 0.1% 5.3 3.5 (2.4 4.6) 0.1% 3.7 14.8(9.8 19.9) 0.2% 6.0 8.6 (5.9 11.3) 0.1% 10.6 44.0(34.6 53.4) 0.5% 28.0 38.4(33.2 43.6) 0.6% 43.8 37.9(33.7 42.1) 0.6% 47.1 28.9(25.9 31.9) 0.4% 31.5 171.0 183.6 152.1 All India,All 2005 (27.5 35.6) (5.0 6.4) (0.4 0.5) (173.8 193.4) (15.4 17.1) (1.3 1.4) (161.5 180.4) (14.7 16.4) (1.3 1.4) (143.2 161.0) (24.6 27.7) (2.0 2.3)
Estimated RTI deaths§, thousands
0.9 / 24 0.9 / 73 1.3 / 14 1.3 / 16 1.2 / 61 1.2 / 67 0.6 / 25 0.5 / 69 5.3 / 585 4.5 / 546 0.2 / 118 0.6 / 115 0.2 / 129 0.4 / 163 0.3 / 106 0.3 / 150 7.2 / 1100 9.8 / 1131
All deaths / populationAll (millions, 2005 UN estimates)
8
immediately immediately agree BMJ Open http://bmjopen.bmj.com/ (89.5%) (90.4%)
(88.1%) (89.8%)
Rural (%**)Rural coders Two
tudy deaths, 2001-2003 on October 2, 2021 by guest. Protected copyright. Proportion RTI*
S For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
44 / 1955 2.3% 38 (80.1) 43 97 / 1926 5.2% 86 (84.1) 87 54 / 9016 0.6% 42 (68.6) 52 70 / 6402 1.1% 55 (70.9) 61 59 / 4055 1.4% 39 (59.0) 50 72 / 4394 1.5% 53 (60.5) 63 47 / 17343 0.3% 33 (61.8) 35 529 / 6817 7.7% 385 (67.0) 477 605 / 4727 13.0% 462 (68.9) 558 50 / 11492 0.4% 46 (93.4) 45 44 / 11719 0.4% 37 (76.7) For 44 peer review only 396 / 54657 0.7% 306 (69.8) 349 123 / 18732 0.6% 106 (81.2) 98 149 / 12120 1.2% 117 (71.8) 133 356 / 11731 3.0% 249 (60.9) 312 190367772 / 2.8% 1442(68.9) 1709 212986354 / 2.4% 1609(68.5) 1925 2299122429 / 1.8% 1748(69.0) 2058 deaths / all deaths coded deaths
Number of of Number RTI
compared to all deaths, weighted by state and residence (rural/urban). **Percentage rural is weighted by state and residence (rural/urban). §Obtained by by §Obtained (rural/urban). residence and state by weighted is rural **Percentage (rural/urban). residence and state by weighted deaths, all to compared estimated Nations United the 2005 to standardized ΨAge proportions. the weighted by 2005 in deaths total estimated Nations United the multiplying physician on based those than CI wider in result which deaths, study of number weighted on based calculated are CI shown 99% population; Indian by years 0 69 between calculated is risk which the forlifetime except range, age of the duration by multiplied rate death RTI †Annual agreement. rate. death ¶Crude risks. period specific the age of summation gender. and age by 2005, for totals national estimated and study present the in deaths injury traffic 1: Road Table (% or 99% CI) Total male Total and female, all agesmale (% or 99% CI) Total male Total and female, <70 male years
(% or CI) 99% All ages All >70 60 69 45 59 30 44 15 29 5 14 0 4 Female - Female age yearsin
(% or CI) 99% All ages All >70 60 69 45 59 30 44 15 29 5 14 0 4 Male - age yearsin
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 9 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Vulnerable road users are those without a rigid barrier protecting against traumatic forces and 4 5 6 include pedestrians, motorcyclists, bicyclists, and three wheelers. They constituted a majority 7 8 (68%; n=124 000, 99%CI 115 000 131 000) of RTI deaths, led by pedestrians (37%; n=68 000, 9 10 62 000 73 000) and motorcyclists (20%; n=36 000, 31 000 40 000) (figure 2). Drivers and 11 12 passengers of motorized four wheelers comprised 16% (n=31 000, 27 000 35 000) of RTI 13 14 deaths. By contrast, the 2005 police reports, which use a different but compatible classification 15 For peer review only 16 system to ICD 10, recorded only 33 000 vulnerable road user deaths and only 9000 pedestrian 17 18 19 deaths. The most common types of vehicle to collide into the decedents were heavy transport 20 21 vehicles and buses (37%; n=68 000, 61 000 74 000), followed by cars and vans (15%; n=28 22 23 000, 24 000 32 000). Single vehicle incidents comprised 9% of deaths (n=17 000, 14 000 20 24 25 000). The most frequent combinations, resulting in 23% (n=42 000, 37 000 47 000) of RTI 26 27 deaths, were collisions of heavy transport vehicles or buses with pedestrians and motorcyclists 28 29 (data not shown). 30 31 32 33 The place and timing of death were described in the narratives of 1733 (75%) and 1596 (69%)
34 http://bmjopen.bmj.com/ 35 36 of the RTI deaths respectively (figure 2; see supplementary table 1 for a summary of missing 37 38 data from the narratives with respect to deceased characteristics). For these narratives, only the 39 40 study proportion and not national estimates were made. Most RTI deaths occurred at the scene 41 42 of collision (58%, 1005/1733) or instantly, defined as within 5 minutes (55%, 883/1596). Only 3% on October 2, 2021 by guest. Protected copyright. 43 44 45 (45/1733) were labeled as potentially avertable with better pre hospital transport as they 46 47 occurred on scene but not instantly. Another 35% of deaths occurred en route (7%, 124/1733) or 48 49 in hospital (28%, 481/1733). 50 51 52 53 Injuries sustained by the deceased were reported from 1124 narratives (49%). Head injuries 54 55 were the most commonly reported (62%, 691/1124), of which 76% (524/691) were reported as 56 57 58 isolated head injuries (figure 3). A greater percentage of motorcyclists (78%, 188/241) had head 59 60 9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 injuries reported compared to non motorcyclists (57%, 457/807). After adjusting for age, sex, 4 5 6 rural/urban, neighbourhood asset, and education, bicyclists and motorcyclists were more likely 7 8 to have head injuries reported compared to non vulnerable road users (adjusted OR 1.7, 1.2 9 10 2.5) (supplementary table 2). 11 12 13 14 Compared to non pedestrian RTI deaths, pedestrian deaths occurred to those who had less 15 For peer review only 16 education (or in the case of children age <15 years, have less educated parents) (adjusted OR 17 18 19 2.9, 99%CI 2.0 4.2), lived in poorer neighbourhoods (1.7, 1.1 2.5), were children or elderly 20 21 adults (<15 years: 2.9, 1.8 4.5; >59 years: 1.7, 1.2 2.4), were female (1.5, 1.2 2.2), and lived in 22 23 urban areas (1.5, 1.1 2.2) (table 2). If pedestrian deaths had the same proportion of secondary 24 25 or higher education as non pedestrian RTI deaths, there would be 406/825 (49%) fewer 26 27 pedestrian deaths, corresponding to approximately 33 000 deaths nationally in 2005. The 28 29 corresponding attributable proportion for living in richer versus poorer neighbourhoods would be 30 31 32 265/825 (32%) or approximately 22 000 deaths nationally. Within the narratives we could code, 33 there were no differences between pedestrians and non pedestrian RTI deaths in timing of
34 http://bmjopen.bmj.com/ 35 36 death, place of death, reported injuries, or reported routine use of alcohol or smoking (data not 37 38 shown). 39 40 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 Attributable 7 Pedestrian / Pedestrian Deaths 8 Non Pedestrian Adjusted OR^ (% of all 825 9 Total=825/1280 (99% CI) pedestrian deaths) 10 Education* 11 Secondary or higher 112/382 ref 12 Primary or middle 248/450 1.8 (1.3 2.6) 110 406 (49%) 13 Below primary 451/423 2.9 (2.0 4.2) 296 14 Unknown 14/25 1.6 (0.6 4.2) N/A 15 Neighbourhood AssetFor peer review only 16 High 137/320 ref 17 18 Low 643/895 1.7 (1.1 2.5) 265 (32%) 19 Unknown 45/65 1.5 (0.8 2.8) N/A 20 Age in years 21 15 59 (driving ages) 497/1046 ref 22 <15 (children) 144/74 2.9 (1.8 4.5) 94 170 (21%) 23 >59 (elderly adults) 184/160 1.7 (1.2 2.4) 76 24 Sex 25 Male 621/1121 ref 26 Female 204/159 1.5 (1.1 2.2) 68 (8%) 27 Location 28 Rural 643/962 ref 29 Urban 182/318 1.5 (1.1 2.2) 61 (7%) 30 31 Occupation 32 Salaried / Wage Earner / Professional 229/517 ref 33 Cultivator / Agricultural labour / Other 162/300 0.9 (0.6 1.3) N/A Non worker / Children <15 years 433/463 1.2 (0.9 1.6) N/A
34 http://bmjopen.bmj.com/ 35 Unknown 1/0 N/A N/A 36 Routine Alcohol Use** 37 No 494/877 ref 38 Yes 145/260 1.1 (0.7 1.5) N/A 39 Unknown 42/69 1.0 (0.5 1.9) N/A 40 41 42 Table 2: Characteristics of pedestrian RTI deaths and attributable proportions. *Education on October 2, 2021 by guest. Protected copyright. 43 44 of deceased adults or, in cases of deceased children <15 years, education of respondent. 45 **Excludes 218 children. ^Odds ratios are adjusted for all other variables in this table except for 46 alcohol use; the odds ratios for alcohol use are adjusted for all other variables in this table. 47 48 49 50 51 DISCUSSION 52 53 RTI is an important cause of death in India, causing 183 600 deaths in 2005, or about 2% of all 54 55 56 deaths. Much of the deceased were men between ages 15 59 years. Males had a four fold 57 58 higher cumulative risk of RTI death compared to females before the age of 70. Among the major 59 60 11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 states, there was approximately 3 fold variation in the age standardized RTI death rate and 4 5 6 cumulative risk for males. 7 8 9 10 Our estimated number of RTI deaths is more than 50% greater than the 118 265 deaths 11 12 reported in the official police statistics of the National Crime Records Bureau (NCRB) in 13 14 2005.[27] Compared to our estimates, the extent of under reporting of the crude death rate in 15 For peer review only 16 major states by NCRB ranged from <1% to about 80% (supplementary table 3). Existing 17 18 19 regional population based injury surveys in India support our findings and also report higher 20 21 crude RTI death rates than NCRB statistics.[8,11] Under reporting of RTI deaths in police 22 23 statistics has been reported in India and other LMIC.[28 30] A study in urban India comparing 24 25 both hospital and community based RTI data to police records identified factors contributing to 26 27 under reporting that included the deceased believed to be at fault, collision resulting from hit 28 29 and runs, limited police resources, and the lack of a standard police reporting protocol by 30 31 32 hospitals.[28] The factors contributing to police under reporting, especially in rural India, require 33 further examination. Our estimated number of RTI deaths in 2005 was consistent with the WHO
34 http://bmjopen.bmj.com/ 35 36 estimate for 2004.[14] However, we observed a slightly higher male proportion (83% MDS vs. 37 38 77% WHO, all ages) and a higher proportion of male deaths between 15 59 years (65% MDS 39 40 vs. 61% WHO). 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 Almost three quarters of all RTI deaths in India were of pedestrians and other vulnerable road 46 47 users. In contrast, a much lower proportion (27%) was reported by the NCRB (figure 2). This 48 49 difference equated to 59 000 pedestrian and 32 000 other vulnerable road user deaths that were 50 51 not included in the 2005 NCRB records. Existing RTI studies based on regional surveys and 52 53 hospital series also reported a high proportion (>60%) of vulnerable road user deaths similar to 54 55 our findings.[11,12,30 32] Since the majority of vulnerable road users were pedestrians, our 56 57 58 findings suggested that RTI deaths in individuals who were less educated, poor, female or live in 59 60 12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 urban areas may have been disproportionally excluded from the NCRB records. While poverty 4 5 6 and education are not likely to be in the direct causal pathway of pedestrian deaths, they 7 8 nonetheless point to other associated risk factors. Indeed, 55 000 pedestrian deaths in 2005 9 10 (81%) was associated with lower education or living in poorer neighbourhoods compared to non 11 12 pedestrian RTI deaths. While the less educated and the poor likely travelled more often by foot, 13 14 they might also be exposed to undetermined environmental (neighbourhoods with unsafe 15 For peer review only 16 roads), biological (poor vision or decreased mobility due to poor health), and behavioral (alcohol 17 18 19 or other substance use) risk factors for pedestrian death.[12,33,34] Further studies are needed 20 21 to better understand pedestrian deaths in LMIC. 22 23 24 25 Over half of RTI deaths occurred instantly at the scene of collision and/or had head injury 26 27 reported. Thus, investments in primary and secondary prevention could potentially avert the 28 29 greatest proportion of RTI deaths. To address the high proportion of instant deaths and head 30 31 32 injuries among RTI deaths in India, specific interventions that are effective and based on studies 33 in LMIC should be emphasized; these may include speed bumps, motorcycle helmets, and
34 http://bmjopen.bmj.com/ 35 36 increasing fines and license suspensions for rule infractions.[33] In contrast, improving pre 37 38 hospital transport and hospital trauma care, could only potentially affect the 38% who died on 39 40 scene with delayed hospital transport (3%), en route to hospital (7%), or in hospital (28%). 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 Our study is the first nationally representative survey of the causes of death in India. The simple 46 47 descriptive statistics provide clear evidence on the large and avertable burden from RTI, 48 49 particularly among productive age adults and pedestrians. To the best of our knowledge, only 50 51 one recent study in Vietnam has used similar methods to analyze RTI deaths and policy 52 53 implications on a national scale.[35] 54 55 56 57 58 59 60 13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Our study faced certain limitations. First, we might have misclassified certain causes of death 4 5 6 including suicide as RTI deaths. However, the extent of misclassification should be minimal 7 8 since the RHIME verbal autopsy method was shown to be robust in discerning between types of 9 10 injury deaths[36] and since the immediate two physician agreement was high for RTI deaths 11 12 (89.5%, table 1). Furthermore, suicides cause about 200 000 deaths in India annually but few 13 14 are due to RTI.[19] Second, since the modes of transportation, place and timing of death, and 15 For peer review only 16 injuries sustained were extracted from layperson open ended narratives, the data accuracy may 17 18 19 be in question. For example with the deceased mode of transportation, the extent of 20 21 misclassification (by our study) or misreporting (by NCRB) that contributed to the differences 22 23 between the two sources is uncertain. With reported injuries, our findings from these narratives 24 25 most likely undercounted less visible injuries (chest, abdomen, and spine) compared to highly 26 27 visible injuries such as bleeding and deformity for head and extremity injuries. Nevertheless, our 28 29 findings are consistent with available Indian regional surveys and hospital series on the mode of 30 31 32 transportation[11,12,30 32] place and timing of death,[1,37 39] and injuries sustained.[12,40,41] 33 Third, since the narrative was not designed specifically to capture RTI death characteristics,
34 http://bmjopen.bmj.com/ 35 36 over 25% of deaths had missing data for mode of transportation, place of death, timing of death, 37 38 or reported injuries (supplementary table 1). Thus, our findings for these elements extracted 39 40 from the narratives may be less representative of the decedents who lived in rural or poor areas. 41 42 Finally, reliable forward projection of the number of RTI deaths beyond 2005 was not possible on October 2, 2021 by guest. Protected copyright. 43 44 45 since the increase in the NCRB reported number of RTI deaths of 140% from 2005 to 2011 46 47 appeared to outpace the rate of population growth.[42] As the proportion of vulnerable road user 48 49 deaths remained stable during this period in the NCRB reports, we postulated that this increase 50 51 represented an actual increase in RTI death totals rather than more accurate reporting. 52 53 Furthermore, given the rapid economic expansion and concurrent changes in motorization 54 55 including the types of vehicle sharing the road and road infrastructure,[43,44] our results on 56 57 58 deceased mode of transportation, place and timing of death, and injuries sustained may not 59 60 14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 reflect the current Indian scenario. An analysis of the trend from 2001 2014 is planned pending 4 5 6 ongoing data collection in the MDS. 7 8 9 10 In India, RTI is a significant cause of preventable death, particularly in males of productive 11 12 working age and among pedestrians, bicyclists, and motorcyclist. We have shown that properly 13 14 designed simple verbal autopsy narratives can document the much needed surveillance data on 15 For peer review only 16 the numbers, rates, risks, and basic RTI mechanism such as modes of transportation, timing of 17 18 19 death, place of death, and injuries sustained. Our findings suggested that investment in primary 20 21 and secondary prevention could address a large proportion of avoidable RTI deaths. 22 23 24 25 ACKNOWLEDGEMENTS 26 27 We thank the Office of the RGI for the ongoing productive collaboration on the MDS, C 28 29 Ramasundarahettige for technical assistance, M Puri and S Levitt for data extraction. The 30 31 32 opinions expressed in this article are those of the authors and do not necessarily represent 33 those of the Government of India or the RGI.
34 http://bmjopen.bmj.com/ 35 36 37 38 COMPETING INTERESTS 39 40 We declare that we have no competing interests. 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 FUNDING 46 47 This study is supported by grants from the John E Fogarty International Center of the National 48 49 Institutes of Health (R01 TW05991–01 and TW07939 01) and University of Toronto (to PJ); the 50 51 Canada Research Chair Programme (to PJ and ABN); and the Canadian Institutes of Health 52 53 Research Doctoral Award (to MH). The funding sources had no role in the study design; data 54 55 collection, analysis, interpretation; writing of the manuscript; or decision to submit for publication. 56 57 58 59 60 15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 The senior author had full access to all the data in the study and had final responsibility for the 4 5 6 decision to submit this study for publication. 7 8 9 10 AUTHOR’S CONTRIBUTION 11 12 PJ and the MDS Collaborators (appendix) designed, planned, the executed the MDS in close 13 14 collaboration with the Office of the Registrar General of India (RGI). MH and PJ performed the 15 For peer review only 16 data analysis. All authors contributed to data interpretation, revisions of the manuscript, and 17 18 19 provided final approval. PJ is the guarantor for this report. 20 21 22 23 DATA SHARING STATEMENT 24 25 Data used in this study is the property of the Registrar General of India. Application for data 26 27 access can be made to the Office of the Registrar General of India. 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 REFERENCES 4 5 6 7 1 Peden M, Scurfield R, Sleet D, Mohan D, Hyder A, Jarawan E, et al. World report on road 8 9 traffic injury prevention: World Health Organization. 2004. 10 11 12 2 Chisholm D, Naci H, Hyder AA, Tran NT, Peden M. Cost effectiveness of strategies to 13 14 combat road traffic injuries in sub Saharan Africa and South East Asia: mathematical 15 For peer review only 16 modelling study. BMJ 2012;344:e612. 17 18 19 3 The PLoS Medicine Editors. Preventing Road Deaths—Time for Data. PLoS Med 20 21 22 2010;7:e1000257. 23 24 25 4 Barffour M, Gupta S, Gururaj G, Hyder AA. Evidence based road safety practice in India: 26 27 assessment of the adequacy of publicly available data in meeting requirements for 28 29 comprehensive road safety data systems. Traffic Inj Prev 2012;13 Suppl 1:17–23. 30 31 32 5 Kopits E, Cropper ML. Traffic fatalities and economic growth. World Bank Development 33
34 http://bmjopen.bmj.com/ 35 Research Group Environment and Infrastructure 2003. 36 37 38 6 Sathiyasekaran BW. Population based cohort study of injuries. Injury 1996;27:695–8. 39 40 41 7 Varghese M, Mohan D. Transportation injuries in rural Haryana, North India. In: 42 on October 2, 2021 by guest. Protected copyright. 43 Proceedings of the international conference on traffic safety 2003;:326–9. 44 45 46 8 WHO. Injury Prevention and Control: An epidemiological study of injuries in the area of 47 48 Municipal Corporation of Delhi. Regional Office for South-East Asia 2003;:1–18. 49 50 51 52 9 Gururaj G, Suryanarayana SP. Burden and impact of injuries: Results of population based 53 54 survey. Proceedings of the 7th world conference on injury prevention 2004;:275–6. 55 56 57 10 Dandona R. Patterns of road traffic injuries in a vulnerable population in Hyderabad, India. 58 59 60 17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Injury Prevention 2006;12:183–8. 4 5 6 7 11 Dandona R, Kumar GA, Ameer MA, Ahmed GM, Dandona L. Incidence and burden of road 8 9 traffic injuries in urban India. Inj Prev 2008;14:354–9. 10 11 12 12 Gururaj G. Road traffic deaths, injuries and disabilities in India: current scenario. Natl Med J 13 14 India 2008;21:14–20. 15 For peer review only 16 17 13 Garg N, Hyder A. Road traffic injuries in India: A review of the literature. Scand J of Public 18 19 Health 2006;34:100–9. 20 21 22 23 14 World Health Organization. The Global Burden of Disease: 2004 Update. World Health 24 25 Organization 2008. 26 27 28 15 Mathers CD, Bernard C, Moesgaard Iburg K, Inoue M, Ma Fat D, Shibuya K, et al. Global 29 30 Burden of Disease in 2002: data sources, methods, and results. Global Programme on 31 32 Evidence for Health Policy Discussion Paper No. 54. World Health Organization. 33
34 http://bmjopen.bmj.com/ 35 2003.http://www.who.int/healthinfo/paper54.pdf (accessed Jan2013). 36 37 38 16 Jha P, Gajalakshmi V, Gupta PC, Kumar R, Mony P, Dhingra N, et al. Prospective Study of 39 40 One Million Deaths in India: Rationale, Design, and Validation Results. PLoS Med 41 42 2006;3:e18. 43 on October 2, 2021 by guest. Protected copyright. 44 45 17 Million Death Study Collaborators, Bassani DG, Kumar R, Awasthi S, Morris SK, Paul VK, 46 47 et al. Causes of neonatal and child mortality in India: a nationally representative mortality 48 49 50 survey. Lancet 2010;376:1853–60. 51 52 53 18 Dikshit R, Gupta PC, Ramasundarahettige C, Gajalakshmi V, Aleksandrowicz L, Badwe R, 54 55 et al. Cancer mortality in India: a nationally representative survey. Lancet 2012;379:1807– 56 57 16. 58 59 60 18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 19 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 19 Patel V, Ramasundarahettige C, Vijayakumar L, Thakur JS, Gajalakshmi V, Gururaj G, et 4 5 6 al. Suicide mortality in India: a nationally representative survey. Lancet 2012;379:2343–51. 7 8 9 20 Sinha DN, Dikshit R, Kumar R, Gajalakshmi V, Dhingra N, Shet J, et al. Prospective Study 10 11 of Million Deaths in India: Technical document no VII: Health care professional's manual for 12 13 assigning causes of death based on RHIME household reports. RGI CGHR, University of 14 15 Toronto. http://www.cghr.org/mdsFor peer (accessed review Aug2012). only 16 17 18 21 WHO. International Statistical Classification of Diseases and Related Health Problems, 19 20 21 ICD-10: Three Volume Set. World Health Organization 2010. 22 23 24 22 United Nations Population Division. World population prospects (2008 revision). 25 26 2009.http://www.un.org/esa/population/publications/wpp2008/ 27 28 29 23 Mari Bhat PN. Completeness of India's sample registration system: an assessment using 30 31 the general growth balance method. Popul Stud 2002;56:119–34. 32 33
34 http://bmjopen.bmj.com/ 35 24 Sivanandan V. An assessment of the completeness of death registration in India over the 36 37 periods 1975-1978 and 1996-1999 under the generalized population model: an analysis 38 39 based on SRS data. Mumbai: International Institute for Population Sciences 2004. 40 41 42 25 Jha P, Kumar R, Khera A, Bhattacharya M, Arora P, Gajalakshmi V, et al. HIV mortality and 43 on October 2, 2021 by guest. Protected copyright. 44 infection in India: estimates from nationally representative mortality survey of 1.1 million 45 46 homes. BMJ 2010;340:c621. 47 48 49 50 26 Dhingra N, Jha P, Sharma VP, Cohen AA, Jotkar RM, Rodriguez PS, et al. Adult and child 51 52 malaria mortality in India: a nationally representative mortality survey. Lancet 53 54 2010;376:1768–74. 55 56 57 27 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2005. Ministry of 58 59 60 19 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 20 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Home Affairs, Government of India 2005. 4 5 6 7 28 Dandona R, Kumar GA, Ameer MA, Reddy GB, Dandona L. Under reporting of road traffic 8 9 injuries to the police: results from two data sources in urban India. Inj Prev 2008;14:360–5. 10 11 12 29 Alcorn T. Uncertainty clouds China's road traffic fatality data. Lancet 2011;378:305–6. 13 14 15 30 Naci H, ChisholmFor D, Baker peer TD. Distribution review of road traffic deathsonly by road user group: a 16 17 global comparison. Inj Prev 2009;15:55–9. 18 19 20 31 Mohan D. The road ahead: Traffic injuries and fatalities in India. Transportation research 21 22 23 and injury prevention programme, Indian Institute of Technology, Delhi 2004. 24 25 26 32 Mohan D. Traffic safety and health in Indian cities. Journal of Transport and Infrastructure 27 28 2002;9:79–94. 29 30 31 33 Norton R, Hyder A, Bishai D, Peden M. Unintentional Injuries. In: Disease Control Priorities 32 33 in Developing Countries. Oxford University Press, USA 2006.
34 http://bmjopen.bmj.com/ 35 36 37 34 Grimm M, Treibich C. Determinants of road traffic crash fatalities across Indian states. 38 39 Health Econ Published Online First: 30 August 2012. doi:10.1002/hec.2870 40 41 42 35 Ngo AD, Rao C, Phuong Hoa N, Hoy DG, Thi Quynh Trang K, Hill PS. Road traffic related 43 on October 2, 2021 by guest. Protected copyright. 44 mortality in Vietnam: Evidence for policy from a national sample mortality surveillance 45 46 system. BMC Public Health 2012;12:561. 47 48 49 36 Hsiao M, Morris SK, Bassani DG, Montgomery AL, Thakur JS, Jha P. Factors Associated 50 51 52 with Physician Agreement on Verbal Autopsy of over 11500 Injury Deaths in India. PLoS 53 54 ONE 2012;7:e30336. 55 56 57 37 Dandona R, Mishra A. Deaths due to road traffic crashed in Hyderabad city in India: need 58 59 60 20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 26 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 for strengthening surveillance. Natl Med J India 2004;17:74–9. 4 5 6 7 38 Sahdev P, Lacqua MJ, Singh B, Dogra TD. Road traffic fatalities in Delhi: causes, injury 8 9 patterns, and incidence of preventable deaths. Accident Analysis & Prevention 10 11 1994;26:377–84. 12 13 14 39 Bhattacharjee J, Bora D, Sharma RS, Verghese T. Unnatural deaths in Delhi during 1991. 15 For peer review only 16 Med Sci Law 1996;36:194–8. 17 18 19 40 Gururaj G, Shastry KVR, Chandramouli AB, Subbakrishna DK, Kraus JF. Traumatic brain 20 21 22 injury. Bangalore: : National Institute of Mental Health and Neuro Sciences. 2005. 23 24 25 41 Colohan AR, Alves WM, Gross CR, Torner JC, Mehta VS, Tandon PN, et al. Head injury 26 27 mortality in two centers with different emergency medical services and intensive care. J 28 29 Neurosurg Pediatrics 1989;71:202–7. 30 31 32 42 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2011. Ministry of 33
34 http://bmjopen.bmj.com/ 35 Home Affairs, Government of India 2011. 36 37 38 43 Transport Research Wing, Ministry of Road Transport & Highways. Basic Road Statistics of 39 40 India. Government of India. 2012;:1–109. 41 42 43 44 Transport Research Wing, Ministry of Road Transport & Highways. Road Transport Year on October 2, 2021 by guest. Protected copyright. 44 45 Book (2009 10 & 2010 11). Government of India. 2012;:1–154. 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 FIGURE LEGENDS 4 5 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 6 7 8 0-69 years) across states and regions of India, by gender. 9 10 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol 11 12 size is proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, 13 14 Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 15 For peer review only 16 19 female deaths from Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N 17 18 Islands, Daman & Diu, Lakshadweep, and Goa. CHT=Chhatisgarh. 19 20 21 22 23 Figure 2: Deceased mode of transportation, place of death, and timing of death. 24 25 (A) Deceased mode of transportation in present study compared to National Crime Records 26 27 Bureau 2005 Report. Shaded line represents vulnerable road users (defined as road users 28 29 without a rigid barrier protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, 30 31 and three wheelers). Percentages from present study are weighted by state and rural/urban 32 33 residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death
34 http://bmjopen.bmj.com/ 35 36 and (C) timing of death based on verbal autopsy narratives. Shaded lines represent deaths that 37 38 are reported as occurring at the scene of collision or occurring instantly (defined as within 5 39 40 minutes). 41 42
on October 2, 2021 by guest. Protected copyright. 43 44 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI 45 46 47 deaths). 48 49 Percentages refer to those in each row with given injury (columns). *Values in bold denote two 50 51 by two chi square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were 52 53 also reported but not shown due to small numbers (61 and 25 cases, respectively). 54 55 56 57 58 59 60 22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Injury Reported Injury
Deceased Mode of Transportation Mode Deceased
Place of Death Place BMJ Open http://bmjopen.bmj.com/
There are no missing values for age, sex, and location in the study population. The chi square test was used to to used was test square chi The population. study inthe location and sex, age, for values missing no are There Timing of Death Timing on October 2, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only
Narrative section Narrative
n (%) n (%) n (%) p n (%) n (%) p n (%) n (%) p n (%) n (%) p n (%) n (%) p 4 (8.2) 4 (8.2) 45 (91.8) 18 (36.7) 31 (63.3) 15 (30.6) 34 (69.4) 10 (20.4) 39 (79.6) 25 (51.0) 24 (49.0) 0 (0.0) 0 (0.0) 122 (100.0) 30 (24.6) 92 (75.4) 18 (14.8) 104 (85.3) 12 (9.8) 110 (90.2) 51 (41.8) 71 (58.2) 24 (6.1) 24 (6.1) 372 (93.9) 121 (30.6) 275 (69.4) 105 (26.5) 291 (73.5) 33 (8.3) 363 (91.7) 203 (51.3) 193 (48.7) 12 (2.9) 12 (2.9) 402 (97.1) 0.002 106 (25.6) 308 (74.4) 0.015 90 (21.7) 324 (78.0) 0.133 37 (8.9) 377 (91.1) 0.687 199 (48.1) 215 (51.9) 0.172 16 (3.2) 16 (3.2) 487 (96.8) 121 (24.1) 382 (75.9) 97 (19.3) 406 (80.7) 46 (9.2) 457 (90.9) 241 (47.9) 262 (52.1) 17 (3.1) 17 (3.1) 534 (96.9) 144 (26.1) 407 (73.9) 110 (20.0) 441 (80.0) 51 (9.3) 500 (90.7) 279 (50.6) 272 (49.4) 81 (5.2) 81 (5.2) (94.8) 1478 459 (29.4) (70.6) 1100 360 (23.1) (76.9) 1199 134 (8.6) (91.4) 1425 793 (50.9) 766 (49.1) 60 (8.1) 60 (8.1) 679 (91.9) 0.006 243 (32.9) 496 (67.1) 0.094 205 (27.7) 534 (72.3) 0.016 60 (8.1) 679 (91.9) 0.701 381 (51.6) 358 (48.4) 0.757 Missing Missing missing Not Missing missing Not Missing missing Not Missing missing Not Missing missing Not 118 (6.2) 118 (6.2) (93.8) 1785 0.916 582 (30.6) (69.4) 1321 0.991 461 (24.2) (75.8) 1442 0.336 161 (8.5) (91.5) 1742 0.934 972 (51.1) 931 (48.9) 0.946 125 (7.2) 125 (7.2) (92.9) 1623 0.001 559 (32.0) (68.0) 1189 0.009 456 (26.1) (73.9) 1292 0.004 143 (8.2) (91.8) 1605 0.429 896 (51.3) 852 (48.7) 0.799 130 (6.9) 130 (6.9) (93.1) 1755 597 (31.7) (68.3) 1288 476 (25.3) (75.0) 1409 157 (8.3) (91.7) 1728 976 (51.8) 909 (48.2) 1 (100.0) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 1 (100.0) 1 (100.0) 0 (0.0) 126 (7.5) 126 (7.5) (92.5) 1548 0.001 552 (33.0) (67.0) 1122 0.000 451 (26.9) (73.1) 1223 0.001 136 (8.1) (91.9) 1538 0.468 883 (52.8) 791 (47.3) 0.057
(n=2299) (n=2299) 142 (6.2) (93.8) 2157 703 (30.6) (69.4) 1596 566 (24.6) (75.4) 1733 194 (8.4) (91.6) 2105 (51.1) 1175 (48.9) 1124
data. missing of Summary 1: Table Supplementary missing missing worker worker non worker non worker occupation missing missing primary and above and above primary 100 (7.7) (92.3) 1196 396 (30.6) 900 (69.4) 321 (24.8) 975 (75.2) 104 (8.0) (92.0) 1192 682 (52.6) 614 (47.4) below primary primary below 38 (4.0) 916 (96) 0.000 289 (30.3) 665 (69.7) 0.894 230 (24.1) 724 (75.9) 0.719 80 (8.4) 874 (91.6) 0.757 468 (49.1) 486 (50.9) 0.094 education missing missing high high low low neighbourhood asset neighbourhood urban urban rural rural location female female male male sex ≥20 years years ≥20 <20 years years <20 age all RTI
determine the p values and excluded deaths with missing neighbourhood asset, education, or occupation. occupation. or education, asset, neighbourhood missing with deaths excluded and values p the determine Page 23 of 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Page 24 of 26 Odds ratios Odds
1.2-2.5*
OR 99% CI 1.7* Adjusted Adjusted
Head Injury was Reported
OR 99% CI (%) n Adjusted Adjusted
BMJ Open Place of was PrehospitalDeath http://bmjopen.bmj.com/
OR 99% CI (%) n on October 2, 2021 by guest. Protected copyright. Adjusted Adjusted For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Timing ofwas Death Instant n (%) n 37 (40.2) 0.5 0.3 1.0 55 (51.4) 0.5 0.3 1.0 46 (25.1) 0.8 0.5 1.4 245 (52.0) 0.8 0.5 1.1 306 (59.2) 0.6 0.4 1.0 256 (43.5) 170 (58.6) ref 223 (69.5) ref 125 (31.5) ref 338 (58.5) 1.1 0.7 1.7 425 (69.1) For 1.1 0.7 1.7 peer 192 (24.9) 0.8 review 0.5 1.1 only
reported. injuries head and of death, place death, of timing the and transportation of mode deceased between Association 2: Table Supplementary comparison between difference significant statistically denote bold in *Value education. and asset, neighbourhood sex, rural/urban, age, deceased's for areadjusted unknown three ridersanimal & wheelers 93 (56.4) 0.9 0.5 1.6 117 (67.6) 0.9 0.5 1.7 72 (33.0) 1.2 0.7 1.9 bicyclist bicyclist & motorcyclist pedestrian vulnerable road users: non vulnerable road users Deceased Mode Transportationof
groups. groups. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
5.7 6.4 0.4 53.4 20.7 63.3 26.5 45.0 79.9 15.9 74.0 24.7 60.6 37.4 36.2 70.4 46.4 78.0 55.6 51.1 43.0 Rate Crude RTICrude Death % Under reporting% of *Excludes railroad deaths since NCRB does not doesnot NCRB since deaths railroad *Excludes Rate in 2005 in Rate BMJ Open (per 100,000)* Crude RTICrude Death http://bmjopen.bmj.com/ Number of of Number RTI deaths indeaths 2005* MDS NCRB MDS NCRB on October 2, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 6559 1077 854 16.4 13.0 66154 14808 13961 22.4 21.1 86499 9363 4364 10.8 5.0 11120 2335 857 21.0 7.7 63375 9237 6793 14.6 10.7 13211 3610 724 27.3 5.5 57141 8172 6876 14.3 12.0 14121 4037 1589 28.6 11.3 55926 6987 5264 12.5 9.4 33785 5051 3161 15.0 9.4 16289 2161 2023 13.3 12.4 23688 6128 3282 25.9 13.9 26455 7380 1622 27.9 6.1 81934 10991 10944 13.4 13.4 29150 3277 1456 11.2 5.0 39485 5083 2895 12.9 7.3 122181 13172 3430 10.8 2.8 106386 16638 10613 15.6 10.0 186591 33287 9860 17.8 5.3 1130618 178520 98254 15.8 8.7 2005 UN For peer review only population estimates (inestimates '000)
Himachal PradeshHimachal Maharashtra Gujarat Karnataka Delhi NaduTamil Rajasthan Madhya PradeshMadhya + CDH 90568 15726 7686 17.4 8.5 Kerala Orissa Assam West Bengal Haryana PradeshAndhra Total Other StatesOther Uttar Pradesh Kashmir Jammu & Bihar + Jharkhand Punjab
Northeast StatesNortheast Supplementary Table 3: Comparison between present study (MDS) estimates and National Crime Records Bureau (NCRB) (NCRB) Bureau Records Crime National and estimates (MDS) study present between Comparison 3: Table Supplementary and Meghalaya. Other States include Pondicherry, Chandigarh, Uttaranchal, Dadra & Nagar Haveli, A & N Islands, Daman & Diu, Diu, & Daman Islands, N & A Haveli, Nagar & Dadra Uttaranchal, Chandigarh, Pondicherry, include States Other Meghalaya. and *100%. rate death MDS / death rate) NCRB rate death (MDS = reporting %under Chhatisgarh. = CDH Goa. and Lakshadweep, police reports of the number of RTI deaths and crude death rate, by state. by rate, death crude and deaths of RTI number the of reports police publish state level railroad death figures. Northeast States include Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram, Tripura, Tripura, Mizoram, Manipur, Nagaland, Arunachal Pradesh, Sikkim, include States Northeast figures. death railroad state level publish
Page 25 of 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open Page 26 of 26 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3MILLION DEATH STUDY COLLOBORATORS 4 5Indian Academic Partners (in alphabetical order): 61. Department of Community Medicine Gujarat Medical College, Ahmedabad: DV Bala, P Seth, KN Trivedi 72. Department of Community Medicine Kolkatta Medical College, Kolkatta: SK Roy 83. Department of Community Medicine Regional Institute of Medical Sciences, Imphal: L Usharani 94. Department of Community Medicine S.C.B. Medical College Cuttack, Orissa: Dr. B Mohapatra 105. Department of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R Gupta 116. Epidemiological Research Center, Chennai: V Gajalakshmi, CV Kanimozhi 127. Gandhi Medical College, Bhopal: RP Dikshit, S Sorangi 13 8. Healis Seskarhia Institute of Public Health, Navi Mumbai: PC Gupta, MS Pednekar, S Sreevidya 14 159. Apollo Institute of MedicalFor Sciences & peerResearch, Hyderabad: review P Bhatia only 1610. St. John’s Academy of Health Sciences, Bangalore: A Kurpad, P Mony, M Vaz, S Srinivasan, A Shet, AS Shet, D Xavier, 17 S Rathi, V Habbare 1811. King George Medical College, Lucknow: S Awasthi 1912. Najafgarh Rural Health Training Centre, Ministry of Health Government of India, New Delhi: N Dhingra, J Sudhir, I 20 Rawat (until 2007) 2113. Regional Medical Research Center, ICMR Institute, Bhubaneshwar: AS Karketta, SK Dar 2214. School of Preventative Oncology, Patna: DN Sinha 2315. School of Public Health Post Graduate Institute of Medical Education and Research, Chandigarh: N Kaur, R Kumar, JS 24 Thakur 2516. Tata Memorial Cancer Hospital, Mumbai: RA Badwe, RP Dikshit, M Mallath, K Panse, A Budukh 26 27 28Lead Partners: 291. Office of the Registrar General India, RK Puram, New Delhi India: C Chandramouli (Registrar General of India [RGI]), 30RC Sethi, B Mishra (until 2012), S Jain (until 2008), DK Dey, AK Saxena, MS Thapa, N Kumar; JK Banthia and DK Sikri 31(former RGIs) 32 332. Million Death Study Coordinating Centre for Global Health Research (CGHR) Li Ka Shing Knowledge Institute, St.
34Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto, Canada: P Jha (Principal Investigator), R http://bmjopen.bmj.com/ 35Kamadod, S Rathi, S Rao Seshadri, P Rodriguez, P Sati, J Sudhir, C Ramasundarahettige, W Suraweera 36 37Affiliated Partners: 381. Indian Council of Medical Research, New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly 39 (DG to 2008), L Kant, B Bhattacharya, B Shah, DK Shukla 40 412. World Health Organisation, Geneva and SEARO Office, New Delhi: T Boerma, A Fric, S Habayeb (former WHO 42 Representative India), S Khanum, CD Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director) 433. Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, England: N Bhala, J on October 2, 2021 by guest. Protected copyright. 44 Boreham, R Peto, G Whitlock 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Road traffic injury mortality and its mechanisms in India: nationally representative mortality survey of 1.1 million homes
For peer review only Journal: BMJ Open
Manuscript ID: bmjopen-2013-002621.R1
Article Type: Research
Date Submitted by the Author: 15-May-2013
Complete List of Authors: Hsiao, Marvin; University of Toronto, Centre for Global Health Research; University of Toronto, Department of Surgery Malhotra, Ajai; VCU Medical Center, Virginia Commonwealth University, Department of Surgery Thakur, JS; Post Graduate Institute of Medical Education and Research, Department of Community Medicine Sheth, Jay; Smt. N.H.L. Municipal Medical College, Nathens, Avery; University of Toronto, Department of Surgery; Sunnybrook Health Sciences Centre, Sunnybrook Research Institute Dhingra, Neeraj; National AIDS Control Organization, Jha, Prabhat; University of Toronto, Centre for Global Health Research
Primary Subject Epidemiology Heading: http://bmjopen.bmj.com/
Secondary Subject Heading: Global health, Public health
Keywords: road traffic injury, verbal autopsy, India, low- and middle-income countries
Note: The following files were submitted by the author for peer review, but cannot be converted to PDF. You must view these files (e.g. movies) online. on October 2, 2021 by guest. Protected copyright. STROBE_checklist_BMJ-Open_cross-sectional-studies.doc
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 Road traffic injury mortality and its mechanisms in India: nationally 5 representative mortality survey of 1.1 million homes 6 7 8 Marvin Hsiao, Ajai Malhotra, JS Thakur, Jay K Sheth, Avery B Nathens, Neeraj Dhingra, 9 10 Prabhat Jha, for the Million Death Study Collaborators. 11 12 13 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 14 15 University of Toronto,For Toronto, peer Canada (M review Hsiao MD, Prof P Jha only DPhil); Division of General 16 17 Surgery, Department of Surgery, University of Toronto, Toronto, Canada (M Hsiao MD, Prof AB 18 Nathens MD); Department of Surgery, VCU Medical Center, Virginia Commonwealth University, 19 20 Richmond, USA (Prof A Malhotra MD); Department of Community Medicine, Post Graduate 21 Institute of Medical Education and Research, Chandigarh, India (JS Thakur MD); Smt. N.H.L. 22 23 Municipal Medical College, Ahmedabad, India (JK Sheth MD); Sunnybrook Research Institute, 24 25 Sunnybrook Health Sciences Centre, Toronto, Canada (Prof AB Nathens MD); National AIDS 26 Control Organization, New Delhi, India (N Dhingra MD) 27 28 29 30 31 Correspondence to: 32 Marvin Hsiao 33 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, and
34 Division of General Surgery, Department of Surgery, University of Toronto http://bmjopen.bmj.com/ 35 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 36 [email protected] 37 +1 416 864 6042 (phone) / +1 416 864 5256 (fax) 38 39 Keywords: Road traffic injury; verbal autopsy; India; low and middle income countries 40
41 42 Word count: Text:3440 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ABSTRACT: 4 5 6 Objectives: To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. 7 8 Design: We conducted a nationally representative mortality survey where at least two 9 10 physicians coded each non medical field staff’s verbal autopsy reports.RTI mechanism data 11 12 were extracted from the narrative section of these reports. 13 14 Setting:1.1 million homes in India. 15 For peer review only 16 Participants: Over 122 000 deaths at all ages from 2001 2003. 17 18 19 Primary and secondary outcome measures: Age and sex specific mortality rates, place and 20 21 timing of death, modes of transportation, and injuries sustained. 22 23 Results: The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or 24 25 about 2% of all deaths in 2005 nationally, of which 65% occurred in males between the ages of 26 27 15 59 years. The age adjusted mortality rate was greater in males than in females, in urban 28 29 than in rural areas, and was notably higher than that estimated from national police records. 30 31 32 Pedestrians (68 000), motorcyclists (36 000), and other vulnerable road users (20 000) 33 constituted 68% of RTI deaths (124 000) nationally. Among the study sample, the majority of all
34 http://bmjopen.bmj.com/ 35 36 RTI deaths occurred at the scene of collision (1005/1733, 58%), within minutes of collision 37 38 (883/1596, 55%), and/or involved a head injury (691/1124, 62%). Compared to non pedestrian 39 40 RTI deaths, about 55 000 (81%) of pedestrian deaths were associated with less education and 41 42 living in poorer neighbourhoods. on October 2, 2021 by guest. Protected copyright. 43 44 45 Conclusions: In India, RTI cause a substantial number of deaths, particularly among 46 47 pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce 48 49 injuries might address over half of the RTI deaths. Improved pre hospital transport and hospital 50 51 trauma care might address just over a third of the RTI deaths. 52 53 54 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ARTICLE SUMMARY 4 5 6 Article focus 7 8 • To directly estimate the age and sex specific mortality rates and describe the place and 9 10 timing of death, modes of transportation, and injuries sustained for road traffic injury 11 12 (RTI) deaths in India using a nationally representative mortality survey of 1.1 million 13 14 homes. 15 For peer review only 16 Key messages 17 18 19 • Road traffic injuries cause a substantial number of avertable deaths, particularly in males 20 21 of productive working age and among pedestrians and other vulnerable road users. 22 23 • Preventative interventions should be emphasized as the majority of all RTI deaths 24 25 occurred at the scene of collision, within minutes of collision, and/or involved a head 26 27 injury. 28 29 30 • Properly designed mortality survey with verbal autopsy narratives can provide much 31 32 needed data to assist RTI prevention efforts. 33
34 Strengths and limitations of this study http://bmjopen.bmj.com/ 35 36 • This study is the first nationally representative survey of the causes of death in India and 37 38 overcomes limitations of existing data sources including regional injury surveys, hospital 39 40 41 series, and national police reports. 42 43 • Limitations of the study include potential misclassification of deaths by physician coders, on October 2, 2021 by guest. Protected copyright. 44 45 the use of layperson narratives with a potential for recall bias and inaccuracies, and 46 47 limited ability to forward project study results given the rapid changes in motorization in 48 49 India. 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 INTRODUCTION 4 5 6 Road traffic injuries (RTI) area large and growing public health burden, especially in low and 7 8 middle income countries (LMIC) where 90% of the world’s deaths due to RTI are estimated to 9 10 occur.[1] There are few high quality epidemiologic data on RTI to guide the development, 11 12 implementation, and surveillance of evidence based policy and programs in LMICs.[2 4] 13 14 15 For peer review only 16 The number of deaths due to RTI in India is projected to rise with increasing 17 18 19 motorization.[1,5]Aside from a few regional injury surveys,[6 11] the current data on the 20 21 numbers and mechanisms of RTI deaths in India rely on police or hospital records, both of 22 23 which can substantially underestimate death rates in the poor, rural, and uneducated people 24 25 who still constitute large proportions of the Indian population.[2 4,12,13] 26 27 28 29 The World Health Organization (WHO), using indirect modeling methods, estimated about 202 30 31 32 000 RTI deaths in India in 2004.[14,15] No study has validated this estimate with direct 33 measurement nor documented detailed RTI mechanism for India nationally. Here, we estimate
34 http://bmjopen.bmj.com/ 35 36 the regional, age and sex specific mortality rate and risk of RTI death in India using data from 37 38 the Million Death Study (MDS). We also report the modes of transportation, place and timing of 39 40 death, and injuries sustained in RTI deaths. 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 METHODS 4 5 6 Study Design: The MDS is an on going nationally representative survey designed to determine 7 8 the causes and risk factors of death in India, organized by the Registrar General of India (RGI). 9 10 The design, methodology, and preliminary findings of the MDS have been described 11 12 elsewhere.[16 19]In brief, the MDS used an enhanced version of verbal autopsy (known as the 13 14 routine, reliable, representative, re sampled household investigation of mortality with medical 15 For peer review only 16 evaluation or RHIME) to monitor a nationally representative sample of 1.1 million households in 17 18 19 the Sample Registration System (SRS). Within six months of every death occurring in these 20 21 households from 2001 3, a trained, nonmedical RGI surveyor interviewed a relative or close 22 23 acquaintance of the deceased to obtain the symptoms and events around the death using 24 25 structured questions and a local language narrative guided by a specific symptom list. These 26 27 records were converted into electronic records and emailed to two of 140 trained physicians 28 29 who, independently and anonymously, assigned an underlying cause of death (with allocation 30 31 32 determined randomly based only on the physician’s ability to read the local language), using 33 guidelines for the major causes of death.[20]Records were assigned cause of death in three
34 http://bmjopen.bmj.com/ 35 36 digit International Statistical Classification of Diseases and Related Health Problems, 10th 37 38 revision (ICD 10).[21] Records where coders disagreed on the cause of death underwent 39 40 anonymous reconciliation. Continuing disagreements were adjudicated by a third senior 41 42 physician. Five percent of households were randomly resurveyed and the results were on October 2, 2021 by guest. Protected copyright. 43 44 45 consistent within families of ICD 10 codes.[16] Participation in the SRS is on a voluntary basis 46 47 and oral consent was obtained under the confidentiality and consent procedures of the 48 49 Registration of Births and Deaths Act, 1969. 50 51 52 53 Road Traffic Injury Deaths: The RTI deaths in this study were of people who died between 54 55 2001 and 2003 with a final assigned ICD 10 code within V01 V89. We translated the open 56 57 58 ended narratives into English from 14 local languages, and systematically extracted the modes 59 60 5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 of transportation, place and timing of death, and injuries sustained from 2157 of the 2299 RTI 4 5 6 deaths using a standardized data extraction tool and procedure (the remaining 142 deaths, 6%, 7 8 had missing or illegible narratives). For these four data elements, there were substantial inter 9 10 rater agreement between two investigators and two research assistants who were trained and 11 12 independently extracted data from the narratives of a random 10% of RTI deaths (lowest kappa 13 14 statistic was greater than 0.69 for all pair wise comparisons between the four data extractors; 15 For peer review only 16 data not shown). The two research assistants then independently extracted data from all 17 18 19 narratives. Adjudication was done by an investigator (MH) for discrepancies in extracted data. 20 21 22 23 Analysis: The age and sex specific proportion of RTI deaths within the 2001 2003 survey was 24 25 applied to the 2005 United Nations (UN) estimates of the number of deaths from all causes in 26 27 India, after weighting for sampling probability.[22] The 2005 UN death estimates were used so 28 29 as to correct for the slight undercounts reported in the total death rates in the SRS[23,24] and to 30 31 32 account for the 12% of enumerated deaths without completed field visits (mostly due to out 33 migration of the family or from incomplete field records). The proportion of these missed deaths
34 http://bmjopen.bmj.com/ 35 36 was similarly dispersed across sex, age, and states. Use of 2003 or 2004 UN death totals 37 38 yielded nearly identical results (data not shown). The 99% confidence intervals (99%CI) for 39 40 mortality rate were calculated based on the weighted number of study deaths. State and 41 42 rural/urban specific estimates of the number, mortality rate, and lifetime risk of RTI death were on October 2, 2021 by guest. Protected copyright. 43 44 45 calculated by partitioning the UN national death totals according to relative SRS death rates as 46 47 previously described.[18,25,26]Urban and rural status was defined according to the Census of 48 49 India. Logistic regression was used to compare the socio demographic traits of pedestrian and 50 51 non pedestrian RTI deaths. Household fuel type was used as a measure of community wealth, 52 53 based on earlier principal component analyses [18]: high asset neighbourhoods had >50% of 54 55 households that used gas, electricity, or kerosene; low asset or poor neighbourhoods used 56 57 58 59 60 6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 primarily coal, firewood, or other. Attributable proportion was calculated for traits of pedestrian 4 5 6 deaths compared to non pedestrian RTI deaths. 7 8 9 10 The MDS received ethics approval from the review boards of the Post Graduate Institute of 11 12 Medical Education and Research in Chandigarh, India; St Michael’s Hospital in Toronto, 13 14 Canada; and the Indian Council of Medical Research’s Health Ministry’s Screening Committee. 15 For peer review only 16 17 18 19 20 21 RESULTS 22 23 The 2299 RTI deaths in the 2001 2003 survey correspond to an estimated 183 600 (99%CI 173 24 25 800 193 400) RTI deaths in India in 2005. The majority of these RTI deaths occurred in males 26 27 (152 100 deaths, 82.8%; table 1). The age standardized RTI mortality rate for males (26.2 per 28 29 100 000, 24.6 27.7) was higher than for females (5.7 per 100 000, 5.0 6.4). While the RTI 30 31 32 mortality rate increased with age in both genders, the largest number of RTI deaths occurred in 33 males between 15 59 years of age (118 900, 64.8%).
34 http://bmjopen.bmj.com/ 35 36 37 38 At these death rates and in the theoretical absence of other causes of death, males in India had 39 40 a 2.1% (2.0 2.3) risk of dying from RTI before age 70, with the highest risks at ages 30 59 41 42 years; females had a 0.5% (0.4 0.5) risk of dying from RTI before age 70. Males in Haryana, on October 2, 2021 by guest. Protected copyright. 43 44 45 Punjab, Tamil Nadu, and Uttar Pradesh had significantly higher risks (3.0 4.1%) than the 46 47 national risk (figure 1). In contrast, males in Bihar, Jharkhand, Andhra Pradesh, Orissa, Gujarat, 48 49 and West Bengal had significantly lower risks (1.3 1.6%) than the national risk of RTI deaths. 50 51 Males living in urban areas had slightly higher age standardized mortality rates and risks of RTI 52 53 deaths (27.6 per 100 000; 2.4%, 2.1 2.6) compared to males living in rural areas (24.9 per 100 54 55 000; 2.0%, 1.8 2.1). By contrast, female RTI mortality rates and risks before age 70 varied much 56 57 58 less across states and were similar in rural and urban areas (data not shown). 59 60 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 8 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Period risk for RTI death†
5.7 0.5%† 15.5 1.3%† 26.2 2.1%† 16.2 1.3%† RTI death rateΨ (99% CI)
per 100 000 *Proportion of RTI deaths deaths RTI of *Proportion
3.8 3.2 (2.0 4.4) 0.03% 8.5 6.6 (4.9 8.3) 0.1% 9.1 64.5(49.1 80.0) 5.0 8.1 (7.1 9.1)¶ 0.04% 4.9 7.4 (6.5 8.4)¶ 0.04% 3.5 21.6(13.4 29.9) 4.4 4.1 (2.7 5.5) 0.1% 5.3 3.5 (2.4 4.6) 0.1% 3.7 14.8(9.8 19.9) 0.2% 6.0 8.6 (5.9 11.3) 0.1% 10.6 44.0(34.6 53.4) 0.5% 28.0 38.4(33.2 43.6) 0.6% 43.8 37.9(33.7 42.1) 0.6% 47.1 28.9(25.9 31.9) 0.4% 31.5 171.0 183.6 152.1 All India,All 2005 (27.5 35.6) (5.0 6.4) (0.4 0.5) (173.8 193.4) (15.4 17.1) (1.3 1.4) (161.5 180.4) (14.7 16.4) (1.3 1.4) (143.2 161.0) (24.6 27.7) (2.0 2.3)
Estimated RTI deaths§, thousands
0.9 / 24 0.9 / 73 1.3 / 14 1.2 / 61 1.2 / 67 1.3 / 16 0.6 / 25 0.5 / 69 5.3 / 585 4.5 / 546 0.2 / 118 0.6 / 115 0.2 / 129 0.4 / 163 0.3 / 106 0.3 / 150 7.2 / 1100 9.8 / 1131
All deaths / populationAll (millions, 2005 UN estimates)
9
immediately immediately agree BMJ Open http://bmjopen.bmj.com/ (89.5%) (90.4%)
(88.1%) (89.8%)
Rural (%**)Rural coders Two
tudy deaths, 2001-2003 on October 2, 2021 by guest. Protected copyright. Proportion RTI*
S For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
44 / 1955 2.3% 38 (80.1) 43 97 / 1926 5.2% 86 (84.1) 87 54 / 9016 0.6% 42 (68.6) 52 70 / 6402 1.1% 55 (70.9) 61 59 / 4055 1.4% 39 (59.0) 50 72 / 4394 1.5% 53 (60.5) 63 529 / 6817 7.7% 385 (67.0) 477 605 / 4727 13.0% 462 (68.9) 558 50 / 11492 0.4% 46 (93.4) 45 44 / 11719 0.4% 37 (76.7) 44 For peer47 / 17343 review 0.3% 33 (61.8) 35 only 396 / 54657 0.7% 306 (69.8) 349 149 / 12120 1.2% 117 (71.8) 133 356 / 11731 3.0% 249 (60.9) 312 123 / 18732 0.6% 106 (81.2) 98 190367772 / 2.8% 1442(68.9) 1709 212986354 / 2.4% 1609(68.5) 1925 2299122429 / 1.8% 1748(69.0) 2058 deaths / all deaths coded deaths
Number of of Number RTI
compared to all deaths, weighted by state and residence (rural/urban). **Percentage rural is weighted by state and residence (rural/urban). §Obtained by by §Obtained (rural/urban). residence and state by weighted is rural **Percentage (rural/urban). residence and state by weighted deaths, all to compared estimated Nations United the 2005 to standardized ΨAge proportions. the weighted by 2005 in deaths total estimated Nations United the multiplying physician on based those than CI wider in result which deaths, study of number weighted on based calculated are CI shown 99% population; Indian by years 0 69 between calculated is risk which the forlifetime except range, age of the duration by multiplied rate death RTI †Annual agreement. rate. death ¶Crude risks. period specific the age of summation gender. and age by 2005, for totals national estimated and study present the in deaths injury traffic 1: Road Table (% or 99% CI) Total male Total and female, all agesmale (% or 99% CI) Total male Total and female, <70 male years
(% or CI) 99% All ages All >70 >70 60 69 45 59 30 44 15 29 5 14 0 4 Female - Female age yearsin
(% or CI) 99% All ages All >70 >70 60 69 45 59 30 44 15 29 5 14 0 4 Male - age yearsin
Page 9 of 55 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open Page 10 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 The deceased mode of transportation was described in the narratives of 2105 (92%) of the RTI 4 5 6 deaths. National estimates for the deceased mode of transportation were calculated, as those 7 8 with unknown and known modes of transportation did not appear to differ with respect to the 9 10 major socio demographic traits (Supplementary Table 1).Vulnerable road users are those 11 12 without a rigid barrier protecting against traumatic forces and include pedestrians, motorcyclists, 13 14 bicyclists, and three wheelers. They constituted a majority (68%; n=124 000, 99%CI 115 000 15 For peer review only 16 131 000) of RTI deaths, led by pedestrians (37%; n=68 000, 62 000 73 000) and motorcyclists 17 18 19 (20%; n=36 000, 31 000 40 000) (figure 2). Drivers and passengers of motorized four wheelers 20 21 comprised 16% (n=31 000, 27 000 35 000) of RTI deaths. By contrast, the 2005 police reports, 22 23 which use a different but compatible classification system to ICD 10, recorded only 33000 24 25 vulnerable road user deaths and only9000 pedestrian deaths.[27] The most common types of 26 27 vehicle to collide into the decedents were heavy transport vehicles and buses (37%; n=68 000, 28 29 61 000 74 000), followed by cars and vans (15%; n=28 000, 24 000 32 000). Single vehicle 30 31 32 incidents comprised 9% of deaths (n=17 000, 14 000 20 000). The most frequent combinations, 33 resulting in 23% (n=42 000, 37 000 47 000) of RTI deaths, were collisions of heavy transport
34 http://bmjopen.bmj.com/ 35 36 vehicles or buses with pedestrians and motorcyclists (data not shown). 37 38 39 40 The place and timing of death were described in the narratives of 1733 (75%) and 1596 (69%) 41 42 of the RTI deaths respectively (figure 2; see supplementary table 1 for a summary of missing on October 2, 2021 by guest. Protected copyright. 43 44 45 data from the narratives with respect to deceased characteristics).For these narratives, only the 46 47 study proportion and not national estimates were made. Most RTI deaths occurred at the scene 48 49 of collision (58%, 1005/1733) or instantly, defined as within 5 minutes (55%, 883/1596). Only 3% 50 51 (45/1733) were labeled as potentially avertable with better pre hospital transport as they 52 53 occurred on scene but not instantly. Another 35% of deaths occurred en route (7%, 124/1733) or 54 55 in hospital (28%, 481/1733). 56 57 58 59 60 10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Injuries sustained by the deceased were reported from1124 narratives (49%). Head injuries 4 5 6 were the most commonly reported (62%, 691/1124), of which 76% (524/691) were reported as 7 8 isolated head injuries (figure 3). A greater percentage of motorcyclists (78%, 188/241) had head 9 10 injuries reported compared to non motorcyclists (57%, 457/807). After adjusting for age, sex, 11 12 rural/urban, neighbourhood asset, and education, bicyclists and motorcyclists were more likely 13 14 to have head injuries reported compared to non vulnerable road users (adjusted OR 1.7, 1.2 15 For peer review only 16 2.5) (supplementary table 2). 17 18 19 20 21 Compared to non pedestrian RTI deaths, pedestrian deaths occurred to those who had less 22 23 education (or in the case of children age <15 years, have less educated parents) (adjusted OR 24 25 2.9, 99%CI 2.0 4.2), lived in poorer neighbourhoods (1.7, 1.1 2.5),were children or elderly adults 26 27 (<15 years: 2.9, 1.8 4.5; >59 years: 1.7, 1.2 2.4), were female (1.5, 1.2 2.2), and lived in urban 28 29 areas (1.5, 1.1 2.2) (table 2). If pedestrian deaths had the same proportion of secondary or 30 31 32 higher education as non pedestrian RTI deaths, there would be 406/825 (49%) fewer pedestrian 33 deaths, corresponding to approximately 33 000 deaths nationally in 2005. The corresponding
34 http://bmjopen.bmj.com/ 35 36 attributable proportion for living in richer versus poorer neighbourhoods would be 265/825 (32%) 37 38 or approximately 22 000 deaths nationally. Within the narratives we could code, there were no 39 40 differences between pedestrians and non pedestrian RTI deaths in timing of death, place of 41 42 death, reported injuries, or reported routine use of alcohol or smoking (data not shown). on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 Attributable 7 Pedestrian / Pedestrian Deaths 8 Non Pedestrian Adjusted OR^ (% of all 825 9 Total=825/1280 (99% CI) pedestrian deaths) 10 Education* 11 Secondary or higher 112/382 ref 12 Primary or middle 248/450 1.8 (1.3 2.6) 110 406 (49%) 13 Below primary 451/423 2.9 (2.0 4.2) 296 14 Unknown 14/25 1.6 (0.6 4.2) N/A 15 Neighbourhood AssetFor peer review only 16 High 137/320 ref 17 18 Low 643/895 1.7 (1.1 2.5) 265 (32%) 19 Unknown 45/65 1.5 (0.8 2.8) N/A 20 Age in years 21 15 59 (driving ages) 497/1046 ref 22 <15 (children) 144/74 2.9 (1.8 4.5) 94 170 (21%) 23 >59 (elderly adults) 184/160 1.7 (1.2 2.4) 76 24 Sex 25 Male 621/1121 ref 26 Female 204/159 1.5 (1.1 2.2) 68 (8%) 27 Location 28 Rural 643/962 ref 29 Urban 182/318 1.5 (1.1 2.2) 61 (7%) 30 31 Occupation 32 Salaried / Wage Earner / Professional 229/517 ref 33 Cultivator / Agricultural labour / Other 162/300 0.9 (0.6 1.3) N/A Non worker / Children <15 years 433/463 1.2 (0.9 1.6) N/A
34 http://bmjopen.bmj.com/ 35 Unknown 1/0 N/A N/A 36 Routine Alcohol Use** 37 No 494/877 ref 38 Yes 145/260 1.1 (0.7 1.5) N/A 39 Unknown 42/69 1.0 (0.5 1.9) N/A 40 41 42 Table 2: Characteristics of pedestrian RTI deaths and attributable proportions. *Education on October 2, 2021 by guest. Protected copyright. 43 44 of deceased adults or, in cases of deceased children <15 years, education of respondent. 45 **Excludes 218 children. ^Odds ratios are adjusted for all other variables in this table except for 46 alcohol use; the odds ratios for alcohol use are adjusted for all other variables in this table. 47 48 49 50 51 DISCUSSION 52 53 RTI is an important cause of death in India, causing 183 600 deaths in 2005, or about 2% of all 54 55 56 deaths.[22] Much of the deceased were men between ages 15 59 years. Males had a four fold 57 58 higher cumulative risk of RTI death compared to females before the age of 70. Among the major 59 60 12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 states, there was approximately 3 fold variation in the age standardized RTI death rate and 4 5 6 cumulative risk for males. 7 8 9 10 Our estimated number of RTI deaths is more than 50% greater than the 118 265 deaths 11 12 reported in the official police statistics of the National Crime Records Bureau (NCRB) in 13 14 2005.[27] Compared to our estimates, the extent of under reporting of the crude death rate in 15 For peer review only 16 major states by NCRB ranged from <1% to about 80% (supplementary table 3). Existing 17 18 19 regional population based injury surveys in India support our findings and also report higher 20 21 crude RTI death rates than NCRB statistics.[8,11]Under reporting of RTI deaths in police 22 23 statistics has been reported in India and other LMIC.[28 30]A study in urban India comparing 24 25 both hospital and community based RTI data to police records identified factors contributing to 26 27 under reporting that included the deceased believed to be at fault, collision resulting from hit 28 29 and runs, limited police resources, and the lack of a standard police reporting protocol by 30 31 32 hospitals.[28] The factors contributing to police under reporting, especially in rural India, require 33 further examination. Our estimated number of RTI deaths in 2005 was consistent with the WHO
34 http://bmjopen.bmj.com/ 35 36 estimate for 2004.[14] However, we observed a slightly higher male proportion (83% MDS vs. 37 38 77% WHO, all ages) and a higher proportion of male deaths between 15 59 years (65% MDS 39 40 vs. 61% WHO). 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 Almost three quarters of all RTI deaths in India were of pedestrians and other vulnerable road 46 47 users. In contrast, a much lower proportion (27%) was reported by the NCRB (figure 2).This 48 49 difference equated to 59 000 pedestrian and 32 000 other vulnerable road user deaths that were 50 51 not included in the 2005 NCRB records. Existing RTI studies based on regional surveys and 52 53 hospital series also reported a high proportion (>60%) of vulnerable road user deaths similar to 54 55 our findings.[11,12,30 32]Since the majority of vulnerable road users were pedestrians, our 56 57 58 findings suggested that RTI deaths in individuals who were less educated, poor, female or live in 59 60 13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 urban areas may have been disproportionally excluded from the NCRB records. While poverty 4 5 6 and education are not likely to be in the direct causal pathway of pedestrian deaths, they 7 8 nonetheless point to other associated risk factors. Indeed, 55 000 pedestrian deaths in 2005 9 10 (81%) was associated with lower education or living in poorer neighbourhoods compared to non 11 12 pedestrian RTI deaths. While the less educated and the poor likely travelled more often by foot, 13 14 they might also be exposed to undetermined environmental (neighbourhoods with unsafe 15 For peer review only 16 roads), biological (poor vision or decreased mobility due to poor health), and behavioral (alcohol 17 18 19 or other substance use) risk factors for pedestrian death.[12, 33, 34]Further studies are needed 20 21 to better understand pedestrian deaths in LMIC. 22 23 24 25 Over half of RTI deaths occurred instantly at the scene of collision and/or had head injury 26 27 reported. These findings, together with existing RTI hospital series and regional surveys in India, 28 29 make a strong argument that investments in primary and secondary prevention could potentially 30 31 32 avert the greatest proportion of RTI deaths. To address the high proportion of instant deaths and 33 head injuries among RTI deaths in India, specific interventions that are effective and based on
34 http://bmjopen.bmj.com/ 35 36 studies in LMIC should be emphasized; these may include speed bumps, motorcycle helmets, 37 38 and increasing fines and license suspensions for rule infractions.[33]In contrast, improving pre 39 40 hospital transport and hospital trauma care, could only potentially affect the 38%who died on 41 42 scene with delayed hospital transport (3%), en route to hospital (7%), or in hospital (28%). on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 Our study is the first nationally representative survey of the causes of death in India. The simple 48 49 descriptive statistics provide clear evidence on the large and avertable burden from RTI, 50 51 particularly among productive age adults and pedestrians. To the best of our knowledge, only 52 53 one recent study in Vietnam has used similar methods to analyze RTI deaths and policy 54 55 implications on a national scale.[35] 56 57 58 59 60 14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Our study faced certain limitations. First, we might have misclassified certain causes of death 4 5 6 including suicide as RTI deaths. However, the extent of misclassification should be minimal 7 8 since the RHIME verbal autopsy method was shown to be robust in discerning between types of 9 10 injury deaths[36]and since the immediate two physician agreement was high for RTI 11 12 deaths(89.5%, table 1). Furthermore, suicides cause about 200 000 deaths in India annually but 13 14 few are due to RTI.[19] Second, since the modes of transportation, place and timing of death, 15 For peer review only 16 and injuries sustained were extracted from layperson open ended narratives, the data accuracy 17 18 19 may be in question. For example with the deceased mode of transportation, the extent of 20 21 misclassification (by our study) or misreporting (by NCRB) that contributed to the differences 22 23 between the two sources is uncertain. With reported injuries, our findings from these narratives 24 25 most likely undercounted less visible injuries (chest, abdomen, and spine) compared to highly 26 27 visible injuries such as bleeding and deformity for head and extremity injuries. Nevertheless, our 28 29 findings are consistent with available Indian regional surveys and hospital series on the mode of 30 31 32 transportation[11,12,30 32,37] place and timing of death,[1,37 41] and injuries 33 sustained.[12,37,42,43]Third, since the narrative was not designed specifically to capture RTI
34 http://bmjopen.bmj.com/ 35 36 death characteristics, over 25% of deaths had missing data for mode of transportation, place of 37 38 death, timing of death, or reported injuries(supplementary table 1).Thus, our findings for these 39 40 elements extracted from the narratives may be less representative of the decedents who lived in 41 42 rural or poor areas. Finally, reliable forward projection of the number of RTI deaths beyond 2005 on October 2, 2021 by guest. Protected copyright. 43 44 45 was not possible since the increase in the NCRB reported number of RTI deaths of140% from 46 47 2005 to 2011 appeared to outpace the rate of population growth.[44] As the proportion of 48 49 vulnerable road user deaths remained stable during this period in the NCRB reports, we 50 51 postulated that this increase represented an actual increase in RTI death totals rather than more 52 53 accurate reporting. Furthermore, given the rapid economic expansion and concurrent changes 54 55 in motorization including the types of vehicle sharing the road and road infrastructure,[45,46]our 56 57 58 results on deceased mode of transportation, place and timing of death, and injuries sustained 59 60 15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 may not reflect the current Indian scenario. An analysis of the trend from 2001 2014 is planned 4 5 6 pending ongoing data collection in the MDS. 7 8 9 10 In India, RTI is a significant cause of preventable death, particularly in males of productive 11 12 working age and among pedestrians, bicyclists, and motorcyclist. We have shown that properly 13 14 designed simple verbal autopsy narratives can document the much needed surveillance data on 15 For peer review only 16 the numbers, rates, risks, and basic RTI mechanism such as modes of transportation, timing of 17 18 19 death, place of death, and injuries sustained. Our findings suggested that investment in primary 20 21 and secondary prevention could address a large proportion of avoidable RTI deaths. 22 23 24 25 ACKNOWLEDGEMENTS 26 27 We thank the Office of the RGI for the ongoing productive collaboration on the MDS, C 28 29 Ramasundarahettige for technical assistance, M Puri and S Levitt for data extraction. The 30 31 32 opinions expressed in this article are those of the authors and do not necessarily represent 33 those of the Government of India or the RGI.
34 http://bmjopen.bmj.com/ 35 36 37 38 COMPETING INTERESTS 39 40 We declare that we have no competing interests. 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 FUNDING 46 47 This study is supported by grants from the John E Fogarty International Center of the National 48 49 Institutes of Health (R01 TW05991–01 and TW07939 01), the Bill & Melinda Gates Foundation 50 51 through the Disease Control Priorities Network Project, and the University of Toronto (to PJ); the 52 53 Canada Research Chair Programme (to PJ and ABN); and the Canadian Institutes of Health 54 55 Research Doctoral Award (to MH). The funding sources had no role in the study design; data 56 57 58 collection, analysis, interpretation; writing of the manuscript; or decision to submit for publication. 59 60 16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 The senior author had full access to all the data in the study and had final responsibility for the 4 5 6 decision to submit this study for publication. 7 8 9 10 AUTHOR’S CONTRIBUTION 11 12 PJ and the MDS Collaborators (appendix) designed, planned, the executed the MDS in close 13 14 collaboration with the Office of the Registrar General of India (RGI). MH and PJ performed the 15 For peer review only 16 data analysis. All authors contributed to data interpretation, revisions of the manuscript, and 17 18 19 provided final approval. PJ is the guarantor for this report. 20 21 22 23 DATA SHARING STATEMENT 24 25 Data used in this study are the property of the Registrar General of India and the overall 26 27 mortality results have been published in 2009.[47] This specific analyses is produced under an 28 29 agreement with CGHR. 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 18 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 REFERENCES 4 5 6 7 1 Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention: World 8 9 Health Organization 2004;1–244. 10 11 12 2 Chisholm D, Naci H, Hyder AA, et al. Cost effectiveness of strategies to combat road traffic 13 14 injuries in sub Saharan Africa and South East Asia: mathematical modelling study. BMJ 15 For peer review only 16 2012;344:e612. 17 18 19 3 The PLoS Medicine Editors. Preventing Road Deaths—Time for Data. PLoS Med 20 21 22 2010;7:e1000257. 23 24 25 4 Barffour M, Gupta S, Gururaj G, et al. Evidence based road safety practice in India: 26 27 assessment of the adequacy of publicly available data in meeting requirements for 28 29 comprehensive road safety data systems. Traffic Inj Prev 2012;13 Suppl 1:17–23. 30 31 32 5 Kopits E, Cropper ML. Traffic fatalities and economic growth. World Bank Development 33
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34 http://bmjopen.bmj.com/ 35 2012;12:561. 36 37 38 36 Hsiao M, Morris SK, Bassani DG, et al. Factors Associated with Physician Agreement on 39 40 Verbal Autopsy of over 11500 Injury Deaths in India. PLoS ONE 2012;7:e30336. 41 42 43 37 Singh H, Dhattarwal SK. Pattern and distribution of injuries in fatal road traffic accidents in on October 2, 2021 by guest. Protected copyright. 44 45 Rohtak (Haryana). Journal of Indian Academy of Forensic Medicine 2004;26:20–3. 46 47 48 38 Dandona R, Mishra A. Deaths due to road traffic crashed in Hyderabad city in India: need 49 50 51 for strengthening surveillance. Natl Med J India 2004;17:74–9. 52 53 54 39 Sahdev P, Lacqua MJ, Singh B, et al. Road traffic fatalities in Delhi: causes, injury patterns, 55 56 and incidence of preventable deaths. Accident Analysis & Prevention 1994;26:377–84. 57 58 59 60 21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 40 Bhattacharjee J, Bora D, Sharma RS, et al. Unnatural deaths in Delhi during 1991. Med Sci 4 5 6 Law 1996;36:194–8. 7 8 9 41 Jain A, Menezes RG, Kanchan T, et al. Two wheeler accidents on Indian roads a study 10 11 from Mangalore, India. J Forensic Leg Med 2009;16:130–3. 12 13 14 42 Gururaj G, Shastry KVR, Chandramouli AB, et al.Traumatic brain injury. Bangalore: 15 For peer review only 16 National Institute of Mental Health and Neuro Sciences, 2005. 17 18 19 43 Colohan AR, Alves WM, Gross CR, et al. Head injury mortality in two centers with different 20 21 22 emergency medical services and intensive care. J Neurosurg Pediatrics 1989;71:202–7. 23 24 25 44 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2011. Ministry of 26 27 Home Affairs, Government of India2011. 28 29 30 45 Transport Research Wing, Ministry of Road Transport & Highways. Basic Road Statistics of 31 32 India. Government of India 2012. 33
34 http://bmjopen.bmj.com/ 35 36 46 Transport Research Wing, Ministry of Road Transport & Highways. Road Transport Year 37 38 Book (2009 10 & 2010 11). Government of India 2012. 39 40 41 47 Registrar General of India and Centre for Global Health Research. Causes of Death in 42 43 India, 2001-2003: Sample Registration System. Government of India 2009. on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49
50 51 52 53 54 55 56 57 58 59 60 22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 FIGURE LEGENDS 4 5 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 6 7 8 0-69 years) across states and regions of India, by gender. 9 10 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol 11 12 size is proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, 13 14 Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 15 For peer review only 16 19 female deaths from Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N 17 18 Islands, Daman & Diu, Lakshadweep, and Goa. CHT=Chhatisgarh. 19 20 21 22 23 Figure 2: Deceased mode of transportation, place of death, and timing of death. 24 25 (A) Deceased mode of transportation in present study compared to National Crime Records 26 27 Bureau 2005 Report. Shaded line represents vulnerable road users (defined as road users 28 29 without a rigid barrier protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, 30 31 and three wheelers). Percentages from present study are weighted by state and rural/urban 32 33 residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death
34 http://bmjopen.bmj.com/ 35 36 and (C) timing of death based on verbal autopsy narratives. Shaded lines represent deaths that 37 38 are reported as occurring at the scene of collision or occurring instantly (defined as within 5 39 40 minutes). 41 42
on October 2, 2021 by guest. Protected copyright. 43 44 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI 45 46 47 deaths). 48 49 Percentages refer to those in each row with given injury (columns). *Values in bold denote two 50 51 by two chi square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were 52 53 also reported but not shown due to small numbers (61 and 25 cases, respectively). 54 55 56 57 58 59 60 23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 LIST OF ACRONYMS 4 5 6 7 8 CI Confidence interval 9 th 10 ICD 10 International Statistical Classification of Diseases and Related Health Problems, 10 11 12 Revision 13 14 LMIC Low and middle income countries 15 For peer review only 16 MDS Million Death Study 17 18 19 NCRB National Crime Records Bureau 20 21 RGI Registrar General of India 22 23 RTI Road traffic injury 24 25 SRS Sample registration system 26 27 UN United Nations 28 29 WHO World Health Organization 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 24 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 0-69 years) 31 across states and regions of India, by gender. 32 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol size is 33 proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 19 female deaths from
34 http://bmjopen.bmj.com/ 35 Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N Islands, Daman & Diu, Lakshadweep, 36 and Goa. CHT=Chhatisgarh.
37 160x111mm (300 x 300 DPI) 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 Figure 2: Deceased mode of transportation, place of death, and timing of death. 42 (A) Deceased mode of transportation in present study compared to National Crime Records Bureau 2005 43 Report. Shaded line represents vulnerable road users (defined as road users without a rigid barrier on October 2, 2021 by guest. Protected copyright. 44 protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, and three wheelers). Percentages 45 from present study are weighted by state and rural/urban residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death and (C) timing of death based on verbal autopsy 46 narratives. Shaded lines represent deaths that are reported as occurring at the scene of collision or 47 occurring instantly (defined as within 5 minutes). 48 49 178x182mm (300 x 300 DPI) 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 27 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI deaths). Percentages refer to those in each row with given injury (columns). *Values in bold denote two by two chi 48 square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were also reported but not 49 shown due to small numbers (61 and 25 cases, respectively). 50 141x191mm (300 x 300 DPI) 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Page 28 of 55
Injury Reported Injury
Deceased Mode of Transportation Mode Deceased
Place of Death Place BMJ Open http://bmjopen.bmj.com/
There are no missing values for age, sex, and location in the study population. The chi square test was used to to used was test square chi The population. study inthe location and sex, age, for values missing no are There Timing of Death Timing on October 2, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only
Narrative section Narrative
n (%) n (%) n (%) p n (%) n (%) p n (%) n (%) p n (%) n (%) p n (%) n (%) p 4 (8.2) 4 (8.2) 45 (91.8) 18 (36.7) 31 (63.3) 15 (30.6) 34 (69.4) 10 (20.4) 39 (79.6) 25 (51.0) 24 (49.0) 0 (0.0) 0 (0.0) 122 (100.0) 30 (24.6) 92 (75.4) 18 (14.8) 104 (85.3) 12 (9.8) 110 (90.2) 51 (41.8) 71 (58.2) 24 (6.1) 24 (6.1) 372 (93.9) 121 (30.6) 275 (69.4) 105 (26.5) 291 (73.5) 33 (8.3) 363 (91.7) 203 (51.3) 193 (48.7) 12 (2.9) 12 (2.9) 402 (97.1) 0.002 106 (25.6) 308 (74.4) 0.015 90 (21.7) 324 (78.0) 0.133 37 (8.9) 377 (91.1) 0.687 199 (48.1) 215 (51.9) 0.172 16 (3.2) 16 (3.2) 487 (96.8) 121 (24.1) 382 (75.9) 97 (19.3) 406 (80.7) 46 (9.2) 457 (90.9) 241 (47.9) 262 (52.1) 17 (3.1) 17 (3.1) 534 (96.9) 144 (26.1) 407 (73.9) 110 (20.0) 441 (80.0) 51 (9.3) 500 (90.7) 279 (50.6) 272 (49.4) 81 (5.2) 81 (5.2) (94.8) 1478 459 (29.4) (70.6) 1100 360 (23.1) (76.9) 1199 134 (8.6) (91.4) 1425 793 (50.9) 766 (49.1) 60 (8.1) 60 (8.1) 679 (91.9) 0.006 243 (32.9) 496 (67.1) 0.094 205 (27.7) 534 (72.3) 0.016 60 (8.1) 679 (91.9) 0.701 381 (51.6) 358 (48.4) 0.757 Missing Missing missing Not Missing missing Not Missing missing Not Missing missing Not Missing missing Not 118 (6.2) 118 (6.2) (93.8) 1785 0.916 582 (30.6) (69.4) 1321 0.991 461 (24.2) (75.8) 1442 0.336 161 (8.5) (91.5) 1742 0.934 972 (51.1) 931 (48.9) 0.946 125 (7.2) 125 (7.2) (92.9) 1623 0.001 559 (32.0) (68.0) 1189 0.009 456 (26.1) (73.9) 1292 0.004 143 (8.2) (91.8) 1605 0.429 896 (51.3) 852 (48.7) 0.799 130 (6.9) 130 (6.9) (93.1) 1755 597 (31.7) (68.3) 1288 476 (25.3) (75.0) 1409 157 (8.3) (91.7) 1728 976 (51.8) 909 (48.2) 1 (100.0) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 1 (100.0) 1 (100.0) 0 (0.0) 126 (7.5) 126 (7.5) (92.5) 1548 0.001 552 (33.0) (67.0) 1122 0.000 451 (26.9) (73.1) 1223 0.001 136 (8.1) (91.9) 1538 0.468 883 (52.8) 791 (47.3) 0.057
(n=2299) (n=2299) 142 (6.2) (93.8) 2157 703 (30.6) (69.4) 1596 566 (24.6) (75.4) 1733 194 (8.4) (91.6) 2105 (51.1) 1175 (48.9) 1124
data. missing of Summary 1: Table Supplementary missing missing worker worker non worker non worker occupation missing missing primary and above and above primary 100 (7.7) (92.3) 1196 396 (30.6) 900 (69.4) 321 (24.8) 975 (75.2) 104 (8.0) (92.0) 1192 682 (52.6) 614 (47.4) below primary primary below 38 (4.0) 916 (96) 0.000 289 (30.3) 665 (69.7) 0.894 230 (24.1) 724 (75.9) 0.719 80 (8.4) 874 (91.6) 0.757 468 (49.1) 486 (50.9) 0.094 education missing missing high high low low neighbourhood asset neighbourhood urban urban rural rural location female female male male sex ≥20 years years ≥20 <20 years years <20 age all RTI
determine the p values and excluded deaths with missing neighbourhood asset, education, or occupation. occupation. or education, asset, neighbourhood missing with deaths excluded and values p the determine 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Odds ratios Odds
1.2-2.5*
OR 99% CI 1.7* Adjusted Adjusted
Head Injury was Reported
OR 99% CI (%) n Adjusted Adjusted
BMJ Open Place of was PrehospitalDeath http://bmjopen.bmj.com/
OR 99% CI (%) n on October 2, 2021 by guest. Protected copyright. Adjusted Adjusted For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Timing ofwas Death Instant n (%) n 37 (40.2) 0.5 0.3 1.0 55 (51.4) 0.5 0.3 1.0 46 (25.1) 0.8 0.5 1.4 245 (52.0) 0.8 0.5 1.1 306 (59.2) 0.6 0.4 1.0 256 (43.5) 170 (58.6) ref 223 (69.5) ref 125 (31.5) ref 338 (58.5) 1.1 0.7 1.7 425 (69.1) For 1.1 0.7 1.7 peer 192 (24.9) 0.8 review 0.5 1.1 only
reported. injuries head and of death, place death, of timing the and transportation of mode deceased between Association 2: Table Supplementary comparison between difference significant statistically denote bold in *Value education. and asset, neighbourhood sex, rural/urban, age, deceased's for areadjusted unknown three ridersanimal & wheelers 93 (56.4) 0.9 0.5 1.6 117 (67.6) 0.9 0.5 1.7 72 (33.0) 1.2 0.7 1.9 bicyclist bicyclist & motorcyclist pedestrian vulnerable road users: non vulnerable road users Deceased Mode Transportationof
groups. groups. Page 29 of 55 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Page 30 of 55
5.7 6.4 0.4 53.4 20.7 63.3 26.5 45.0 79.9 15.9 74.0 24.7 60.6 37.4 36.2 70.4 46.4 78.0 55.6 51.1 43.0 Rate Crude RTICrude Death % Under reporting% of *Excludes railroad deaths since NCRB does not doesnot NCRB since deaths railroad *Excludes Rate in 2005 in Rate BMJ Open (per 100,000)* Crude RTICrude Death http://bmjopen.bmj.com/ Number of of Number RTI deaths indeaths 2005* MDS NCRB MDS NCRB on October 2, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 6559 1077 854 16.4 13.0 66154 14808 13961 22.4 21.1 86499 9363 4364 10.8 5.0 11120 2335 857 21.0 7.7 63375 9237 6793 14.6 10.7 13211 3610 724 27.3 5.5 57141 8172 6876 14.3 12.0 14121 4037 1589 28.6 11.3 55926 6987 5264 12.5 9.4 33785 5051 3161 15.0 9.4 16289 2161 2023 13.3 12.4 23688 6128 3282 25.9 13.9 26455 7380 1622 27.9 6.1 81934 10991 10944 13.4 13.4 29150 3277 1456 11.2 5.0 39485 5083 2895 12.9 7.3 122181 13172 3430 10.8 2.8 106386 16638 10613 15.6 10.0 186591 33287 9860 17.8 5.3 1130618 178520 98254 15.8 8.7 2005 UN For peer review only population estimates (inestimates '000)
Himachal PradeshHimachal Maharashtra Gujarat Karnataka Delhi NaduTamil Rajasthan Madhya PradeshMadhya + CDH 90568 15726 7686 17.4 8.5 Kerala Orissa Assam West Bengal Haryana PradeshAndhra Total Other StatesOther Uttar Pradesh Kashmir Jammu & Bihar + Jharkhand Punjab
Northeast StatesNortheast Supplementary Table 3: Comparison between present study (MDS) estimates and National Crime Records Bureau (NCRB) (NCRB) Bureau Records Crime National and estimates (MDS) study present between Comparison 3: Table Supplementary and Meghalaya. Other States include Pondicherry, Chandigarh, Uttaranchal, Dadra & Nagar Haveli, A & N Islands, Daman & Diu, Diu, & Daman Islands, N & A Haveli, Nagar & Dadra Uttaranchal, Chandigarh, Pondicherry, include States Other Meghalaya. and *100%. rate death MDS / death rate) NCRB rate death (MDS = reporting %under Chhatisgarh. = CDH Goa. and Lakshadweep, police reports of the number of RTI deaths and crude death rate, by state. by rate, death crude and deaths of RTI number the of reports police publish state level railroad death figures. Northeast States include Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram, Tripura, Tripura, Mizoram, Manipur, Nagaland, Arunachal Pradesh, Sikkim, include States Northeast figures. death railroad state level publish
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 31 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3MILLION DEATH STUDY COLLOBORATORS 4 5Indian Academic Partners (in alphabetical order): 61. Department of Community Medicine Gujarat Medical College, Ahmedabad: DV Bala, P Seth, KN Trivedi 72. Department of Community Medicine Kolkatta Medical College, Kolkatta: SK Roy 83. Department of Community Medicine Regional Institute of Medical Sciences, Imphal: L Usharani 94. Department of Community Medicine S.C.B. Medical College Cuttack, Orissa: Dr. B Mohapatra 105. Department of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R Gupta 116. Epidemiological Research Center, Chennai: V Gajalakshmi, CV Kanimozhi 127. Gandhi Medical College, Bhopal: RP Dikshit, S Sorangi 13 8. Healis Seskarhia Institute of Public Health, Navi Mumbai: PC Gupta, MS Pednekar, S Sreevidya 14 159. Apollo Institute of MedicalFor Sciences & peerResearch, Hyderabad: review P Bhatia only 1610. St. John’s Academy of Health Sciences, Bangalore: A Kurpad, P Mony, M Vaz, S Srinivasan, A Shet, AS Shet, D Xavier, 17 S Rathi, V Habbare 1811. King George Medical College, Lucknow: S Awasthi 1912. Najafgarh Rural Health Training Centre, Ministry of Health Government of India, New Delhi: N Dhingra, J Sudhir, I 20 Rawat (until 2007) 2113. Regional Medical Research Center, ICMR Institute, Bhubaneshwar: AS Karketta, SK Dar 2214. School of Preventative Oncology, Patna: DN Sinha 2315. School of Public Health Post Graduate Institute of Medical Education and Research, Chandigarh: N Kaur, R Kumar, JS 24 Thakur 2516. Tata Memorial Cancer Hospital, Mumbai: RA Badwe, RP Dikshit, M Mallath, K Panse, A Budukh 26 27 28Lead Partners: 291. Office of the Registrar General India, RK Puram, New Delhi India: C Chandramouli (Registrar General of India [RGI]), 30RC Sethi, B Mishra (until 2012), S Jain (until 2008), DK Dey, AK Saxena, MS Thapa, N Kumar; JK Banthia and DK Sikri 31(former RGIs) 32 332. Million Death Study Coordinating Centre for Global Health Research (CGHR) Li Ka Shing Knowledge Institute, St.
34Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto, Canada: P Jha (Principal Investigator), R http://bmjopen.bmj.com/ 35Kamadod, S Rathi, S Rao Seshadri, P Rodriguez, P Sati, J Sudhir, C Ramasundarahettige, W Suraweera 36 37Affiliated Partners: 381. Indian Council of Medical Research, New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly 39 (DG to 2008), L Kant, B Bhattacharya, B Shah, DK Shukla 40 412. World Health Organisation, Geneva and SEARO Office, New Delhi: T Boerma, A Fric, S Habayeb (former WHO 42 Representative India), S Khanum, CD Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director) 433. Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, England: N Bhala, J on October 2, 2021 by guest. Protected copyright. 44 Boreham, R Peto, G Whitlock 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 Road traffic injury mortality and its mechanisms in India: nationally 10 representative mortality survey of 1.1 million homes 11 12 13 Marvin Hsiao, Ajai Malhotra, JS Thakur, Jay K Sheth, Avery B Nathens, Neeraj Dhingra, 14 Prabhat Jha, for the Million Death Study Collaborators. 15 For peer review only 16 17 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 18 University of Toronto, Toronto, Canada (M Hsiao MD, Prof P Jha DPhil); Division of General 19 Surgery, Department of Surgery, University of Toronto, Toronto, Canada (M Hsiao MD, Prof AB 20 21 Nathens MD); Department of Surgery, VCU Medical Center, Virginia Commonwealth University, 22 Richmond, USA (Prof A Malhotra MD); Department of Community Medicine, Post Graduate 23 Institute of Medical Education and Research, Chandigarh, India (JS Thakur MD); Smt. N.H.L. 24 25 Municipal Medical College, Ahmedabad, India (JK Sheth MD); Sunnybrook Research Institute, 26 Sunnybrook Health Sciences Centre, Toronto, Canada (Prof AB Nathens MD); National AIDS 27 Control Organization, New Delhi, India (N Dhingra MD) 28
29 30 31 Correspondence to: 32 Marvin Hsiao Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, and 33 Division of General Surgery, Department of Surgery, University of Toronto
34 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 http://bmjopen.bmj.com/ 35 [email protected] 36 +1 416 864 6042 (phone) / +1 416 864 5256 (fax) 37 38 Keywords: Road traffic injury; verbal autopsy; India; low and middle income countries
39 Word count: Text:32113440 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 1 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 ABSTRACT: 10 11 Objectives: To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. 12 Design: We conducted a nationally representative mortality survey where at least two 13 14 physicians coded each non medical field staff’s verbal autopsy reports.RTI mechanism data 15 For peer review only 16 were extracted from the narrative section of these reports. 17 Setting:1.1 million homes in India. 18 19 Participants: Over 122 000 deaths at all ages from 2001 2003. 20 21 Primary and secondary outcome measures: Age and sex specific mortality rates, place and 22 23 timing of death, modes of transportation, and injuries sustained. 24 Results: The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or 25 26 about 2% of all deaths in 2005 nationally, of which 65% occurred in males between the ages of 27 28 15 59 years. The age adjusted mortality rate was greater in males than in females, in urban 29 30 than in rural areas, and was notably higher than that estimated from national police records. 31 Pedestrians (68 000), motorcyclists (36 000), and other vulnerable road users (20 000) 32 33 constituted 68% of RTI deaths (124 000) nationally. Among the study sample, tThe majority of
34 http://bmjopen.bmj.com/ 35 all RTI deaths occurred at the scene of collision (1005/1733, 58%), within minutes of collision 36 37 (883/1596, 55%), and/or involved a head injury (691/1124, 62%). Compared to non pedestrian 38 RTI deaths, about 55 000 (81%) of pedestrian deaths were associated with less education and 39 40 living in poorer neighbourhoods. 41 42 Conclusions: In India, RTI cause a substantial number of deaths, particularly among 43 on October 2, 2021 by guest. Protected copyright. pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce 44 45 injuries might address over half of the RTI deaths. Improved pre hospital transport and hospital 46 47 trauma care might address just over a third of the RTI deaths. 48 49 50 51 52 53 54 55 2 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 ARTICLE SUMMARY 10 11 Article focus 12 • To directly estimate the age and sex specific mortality rates and describe the place and 13 14 timing of death, modes of transportation, and injuries sustained for road traffic injury 15 For peer review only 16 (RTI) deaths in India using a nationally representative mortality survey of 1.1 million 17 18 homes. 19 Key messages 20 21 • Road traffic injuries cause a substantial number of avertable deaths, particularly in males 22 23 of productive working age and among pedestrians and other vulnerable road users. 24 25 • Preventative interventions should be emphasized as the majority of all RTI deaths 26 occurred at the scene of collision, within minutes of collision, and/or involved a head 27 28 injury. 29 30 • Properly designed mortality survey with verbal autopsy narratives can provide much 31 32 needed data to assist RTI prevention efforts. 33 Strengths and limitations of this study
34 http://bmjopen.bmj.com/ 35 • This study is the first nationally representative survey of the causes of death in India and 36 37 overcomes limitations of existing data sources including regional injury surveys, hospital 38 series, and national police reports. 39 40 • Limitations of the study include potential misclassification of deaths by physician coders, 41 42 the use of layperson narratives with a potential for recall bias and inaccuracies, and 43 on October 2, 2021 by guest. Protected copyright. 44 limited ability to forward project study results given the rapid changes in motorization in 45 India. 46 47 48 49 50 51 52 53 54 55 3 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 INTRODUCTION 10 11 Road traffic injuries (RTI) area large and growing public health burden, especially in low and 12 middle income countries (LMIC) where 90% of the world’s RTI deaths due to RTI are estimated 13 14 to occur.[1] There are few high quality epidemiologic data on RTI to guide the development, 15 For peer review only 16 implementation, and surveillance of evidence based policy and programs in LMICs.[2 4] 17
18 19 The number of RTI deaths due to RTI in India is projected to rise with increasing 20 21 motorization.[1,5]Aside from a few regional injury surveys,[6 11] the current data on the 22 23 numbers and mechanisms of RTI deaths in India rely on police or hospital records, both of 24 which can substantially underestimate death rates in the poor, rural, and uneducated people 25 26 who still constitute large proportions of the Indian population.[2 4,12,13] 27 28 29 30 The World Health Organization (WHO), using indirect modeling methods, estimated about 202 31 000 RTI deaths in India in 2004.[14,15] No study has validated this estimate with direct 32 33 measurement nor documented detailed RTI mechanism for India nationally. Here, we estimate
34 http://bmjopen.bmj.com/ 35 the regional, age and sex specific mortality rate and risk of RTI death in India using data from 36 37 the Million Death Study (MDS). We also report the modes of transportation, place and timing of 38 death, and injuries sustained in RTI deaths. 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 4 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 METHODS 10 11 Study Design: The MDS is an on going nationally representative survey designed to determine 12 the causes and risk factors of death in India, organized by the Registrar General of India (RGI). 13 14 The design, methodology, and preliminary findings of the MDS have been described 15 For peer review only 16 elsewhere.[16 19]In brief, the MDS used an enhanced version of verbal autopsy (known as the 17 routine, reliable, representative, re sampled household investigation of mortality with medical 18 19 evaluation or RHIME) to monitor a nationally representative sample of 1.1 million households in 20 21 the Sample Registration System (SRS). Within six months of every death occurring in these 22 23 households from 2001 3, a trained, nonmedical RGI surveyor interviewed a relative or close 24 acquaintance of the deceased to obtain the symptoms and events around the death using 25 26 structured questions and a local language narrative guided by a specific symptom list. These 27 28 records were converted into electronic records and emailed to two of 140 trained physicians 29 30 who, independently and anonymously, assigned an underlying cause of death (with allocation 31 determined randomly based only on the physician’s ability to read the local language), using 32 33 guidelines for the major causes of death.[20]Records were assigned cause of death in three
34 http://bmjopen.bmj.com/ 35 digit International Statistical Classification of Diseases and Related Health Problems, 10th 36 37 revision (ICD 10).[21] Records where coders disagreed on the cause of death underwent 38 anonymous reconciliation. Continuing disagreements were adjudicated by a third senior 39 40 physician. Five percent of households were randomly resurveyed and the results were 41 42 consistent within families of ICD 10 codes.[16] Participation in the SRS is on a voluntary basis 43 on October 2, 2021 by guest. Protected copyright. and oral consent was obtained under the confidentiality and consent procedures of the 44 45 Registration of Births and Deaths Act, 1969. 46 47 48 49 Road Traffic Injury Deaths: The RTI deaths in this study were of people who died between 50 2001 and 2003 with a final assigned ICD 10 code within V01 V89. We translated the open 51 52 ended narratives into English from 14 local languages, and systematically extracted the modes 53 54 55 5 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 of transportation, place and timing of death, and injuries sustained from the 2157 of the 2299 10 11 RTI narrativesdeaths using a standardized data extraction tool and procedure (the remaining 12 142 deaths, 6%, had missing or illegible narratives). For these four data elements, there were 13 14 substantial inter rater agreement (kappa statistic > 0.69) between two investigators and two 15 For peer review only 16 research assistants who were trained and independentlyextractedindependently extracted data 17 from the narratives of a random 10% of RTI deaths (lowest kappa statistic was greater than 0.69 18 19 for all pair wise comparisons between the fourdatafour data extractors; data not shown). The 20 21 two research assistants then independently extracted data from all narratives. Adjudication was 22 23 done by an investigator (M.H) for discrepancies in extracted data. 24
25 26 Analysis: The age and sex specific proportion of RTI deaths within the 2001 2003 survey was 27 28 applied to the 2005 United Nations (UN) estimates of the number of deaths from all causes in 29 30 India, after weighting for sampling probability.[22] The 2005 UN death estimates were used so 31 as to correct for the slight undercounts reported in the total death rates in the SRS[23,24] and to 32 33 account for the 12% of enumerated deaths without completed field visits (mostly due to out
34 http://bmjopen.bmj.com/ 35 migration of the family or from incomplete field records). The proportion of these missed deaths 36 37 was similarly dispersed across sex, age, and states. Use of 2003 or 2004 UN death totals 38 yielded nearly identical results (data not shown). The 99% confidence intervals (99%CI) for 39 40 mortality rate were calculated based on the weighted number of study deaths. State and 41 42 rural/urban specific estimates of the number, mortality rate, and lifetime risk of RTI death were 43 on October 2, 2021 by guest. Protected copyright. calculated by partitioning the UN national death totals according to relative SRS death rates as 44 45 previously described.[18,25,26]Urban and rural status was defined according to the Census of 46 47 India. Logistic regression was used to compare the socio demographic traits of pedestrian and 48 49 non pedestrian RTI deaths. Household fuel type was used as a measure of community wealth, 50 based on earlier principal component analyses [18]: high asset neighbourhoods had >50% of 51 52 households that used gas, electricity, or kerosene; low asset or poor neighbourhoods used 53 54 55 6 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 38 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 primarily coal, firewood, or other. Attributable proportion was calculated for traits of pedestrian 10 11 deaths compared to non pedestrian RTI deaths. 12 13 14 The MDS received ethics approval from the review boards of the Post Graduate Institute of 15 For peer review only 16 Medical Education and Research in Chandigarh, India; St Michael’s Hospital in Toronto, 17 Canada; and the Indian Council of Medical Research’s Health Ministry’s Screening Committee. 18 19 20 21 22 23 RESULTS 24 The 2299 RTI deaths in the 2001 2003 survey correspond to an estimated 183 600 (99%CI 173 25 26 800 193 400) RTI deaths in India in 2005. The majority of these RTI deaths occurred in males 27 28 (152 100 deaths, 82.8%; table 1). The age standardized RTI mortality rate for males (26.2 per 29 30 100 000, 24.6 27.7) was higher than for females (5.7 per 100 000, 5.0 6.4). While the RTI 31 mortality rate increased with age in both genders, the largest number of RTI deaths occurred in 32 33 males between 15 59 years of age (118 900, 64.8%).
34 http://bmjopen.bmj.com/ 35 36 37 At these death rates and in the theoretical absence of other causes of death, males in India had 38 a 2.1% (2.0 2.3) risk of dying from RTI before age 70, with the highest risks at ages 30 59 39 40 years; females had a 0.5% (0.4 0.5) risk of dying from RTI before age 70. Males in Haryana, 41 42 Punjab, Tamil Nadu, and Uttar Pradesh had significantly higher risks (3.0 4.1%) than the 43 on October 2, 2021 by guest. Protected copyright. national risk (figure 1). In contrast, males in Bihar, Jharkhand, Andhra Pradesh, Orissa, Gujarat, 44 45 and West Bengal had significantly lower risks (1.3 1.6%) than the national risk of RTI deaths. 46 47 Males living in urban areas had slightly higher age standardized mortality rates and risks of RTI 48 49 deaths (27.6 per 100 000; 2.4%, 2.1 2.6) compared to males living in rural areas (24.9 per 100 50 000; 2.0%, 1.8 2.1). By contrast, female RTI mortality rates and risks before age 70 varied much 51 52 less across states and were similar in rural and urban areas (data not shown). 53 54 55 7 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 39 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 8 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Page 40 of 55
3) . 2
0 . (2
Period risk risk Period RTI for death†
7) . 27
5.7 5.7 0.5%† 6 15.5 1.3%† 26.2 2.1%† 16.2 1.3%† . (24
RTI death RTI rateΨ (99% CI) per 000 100 *Proportion of RTI deaths deaths of RTI *Proportion
0) . 161
5.0 8.1 (7.1 9.1)¶ 0.04% 4.9 7.4 (6.5 8.4)¶ 0.04% 9.1 64.5 (49.1 80.0) 3.5 21.6 (13.4 29.9) 3.8 3.2 (2.0 4.4) 0.03% 8.5 6.6 (4.9 8.3) 0.1% 3.7 14.8(9.8 19.9) 0.2% 6.0 8.6(5.9 11.3) 0.1% 4.4 4.1 (2.7 5.5) 0.1% 5.3 3.5 (2.4 4.6) 0.1% 2 10.6 10.6 44.0 (34.6 53.4) 0.5% 28.0 28.0 38.4 (33.2 43.6) 0.6% 47.1 47.1 28.9 (25.9 31.9) 0.4% 43.8 43.8 37.9 (33.7 42.1) 0.6% 31.5 31.5 . 171.0 183.6 152.1 All India,2005 (27.5 35.6) (5.0 6.4) (0.4 0.5) (143 (173.8 193.4) (15.4 17.1) (1.3 1.4) (161.5 180.4) (14.7 16.4) (1.3 1.4)
Estimated RTI deaths§, thousands
1.2 / 61 1.2 / 67 1.3 / 14 0.9 / 24 0.9 / 73 1.3 / 16 0.6 / 25 0.5 / 69 4.5 / 546 4.5/546 5.3 / 585 5.3/585 0.4 / 163 0.4/163 0.2 / 118 0.2/118 0.6 / 115 0.6/115 0.2 / 129 0.2/129 0.3 / 106 0.3/106 0.3 / 150 0.3/150 BMJ Open 7.2 / 1100 9.8 / 1131 http://bmjopen.bmj.com/
All deathsAll / population (millions, UN 2005 estimates)
8%) . 9 (89
immediately immediately agree
(89.5%) (90.4%)
(88.1%) on October 2, 2021 by guest. Protected copyright.
Rural Rural (%**) coders Two For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Proportion RTI* Study deaths,2001-2003 For peer review only
44 / 1955 2.3% 38(80.1) 43 97 / 1926 5.2% 86(84.1) 87 54 / 9016 0.6% 42(68.6) 52 70 / 6402 1.1% 55(70.9) 61 59 / 4055 1.4% 39(59.0) 50 72 / 4394 1.5% 53(60.5) 63 50/11492 0.4% 46(93.4) 45 44/11719 0.4% 37(76.7) 44 47/17343 0.3% 33(61.8) 35 5296817 / 7.7% 385 (67.0) 477 6054727 / 13.0% 462 (68.9) 558 396 / 54657 0.7% 306 (69.8) 349 123 / 18732 0.6% 106 (81.2) 98 149 / 12120 1.2% 117 (71.8) 133 356 / 11731 3.0% 249 (60.9) 312 190367772 / 2.8% 1442 (68.9) 1709 212986354 / 2.4% 1609 (68.5) 1925 2299122429 / 1.8% 1748 (69.0) 2058
deaths / all deaths / all codeddeaths Number RTI of
(% 99% (% CI) or compared to all deaths, weighted by state and residence (rural/urban). **Percentage rural is weighted by state and residence (rural/urban). §Obtained by by §Obtained (rural/urban). residence and state by isweighted rural **Percentage (rural/urban). residence and state by weighted deaths, all to compared estimated Nations United 2005 the to standardized ΨAge proportions. the weighted by 2005 indeaths total estimated Nations United the multiplying physician on based those than CI wider in result which deaths, study of number weighted on based calculated are shown CI 99% population; Indian by years 0 69 between calculated is which risk lifetime for the except range, ageof by duration the multiplied rate death RTI †Annual agreement. deathrate. ¶Crude risks. period specific age of the summation gender. ageand by 2005, for totals national andestimated study present the deaths in injury traffic Road 1: Table (% or(% CI) 99% Total and male all ages female, (% or(% CI) 99% Total and years male <70female,
(% 99% (% CI) or All ages All >70 60 69 60 69 45 59 45 59 30 44 30 44 15 29 15 29 5 14 0 4 0 4 Female ageyears- in
All ages All >70 60 69 60 69 45 59 45 59 30 44 30 44 15 29 15 29 5 14 0 4 0 4 Male years- in age
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 41 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 The deceased mode of transportation was described in the narratives of 2105 (92%) of the RTI 10 11 deaths. National estimates for the deceased mode of transportation were calculated, as those 12 with unknown and known modes of transportation did not appear to differ with respect to the 13 14 major socio demographic traits (Supplementary Table 1).Vulnerable road users are those 15 For peer review only 16 without a rigid barrier protecting against traumatic forces and include pedestrians, motorcyclists, 17 bicyclists, and three wheelers. They constituted a majority (68%; n=124 000, 99%CI 115 000 18 19 131 000) of RTI deaths, led by pedestrians (37%; n=68 000, 62 000 73 000) and motorcyclists 20 21 (20%; n=36 000, 31 000 40 000) (figure 2). Drivers and passengers of motorized four wheelers 22 23 comprised 16% (n=31 000, 27 000 35 000) of RTI deaths. By contrast, the 2005 police reports, 24 which use a different but compatible classification system to ICD 10, recorded only 33000 25 26 vulnerable road user deaths and only9000 pedestrian deaths.[27] The most common types of 27 28 vehicle to collide into the decedents were heavy transport vehicles and buses (37%; n=68 000, 29 30 61 000 74 000), followed by cars and vans (15%; n=28 000, 24 000 32 000). Single vehicle 31 incidents comprised 9% of deaths (n=17 000, 14 000 20 000). The most frequent combinations, 32 33 resulting in 23% (n=42 000, 37 000 47 000) of RTI deaths, were collisions of heavy transport
34 http://bmjopen.bmj.com/ 35 vehicles or buses with pedestrians and motorcyclists (data not shown). 36 37 38 The place and timing of death were described in the narratives of 1733 (75%) and 1596 (69%) 39 40 of the RTI deaths respectively (figure 2; see supplementary table 1 for a summary of missing 41 42 data from the narratives with respect to deceased characteristics).For these narratives, only the 43 on October 2, 2021 by guest. Protected copyright. study proportion and not national estimates were made. Most RTI deaths occurred at the scene 44 45 of collision (58%, 1005/1733) or instantly, defined as within 5 minutes (55%, 883/1596). Only 3% 46 47 (45/1733) were labeled as potentially avertable with better pre hospital transport as they 48 49 occurred on scene but not instantly. Another 35% of deaths occurred en route (7%, 124/1733) or 50 in hospital (28%, 481/1733). 51 52 53 54 55 10 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 42 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 Injuries sustained by the deceased were reported from1124 narratives (49%). Head injuries 10 11 were the most commonly reported (62%, 691/1124), of which 76% (524/691) were reported as 12 isolated head injuries (figure 3). A greater percentage of motorcyclists (78%, 188/241) had head 13 14 injuries reported compared to non motorcyclists (57%, 457/807). After adjusting for age, sex, 15 For peer review only 16 rural/urban, neighbourhood asset, and education, bicyclists and motorcyclists were more likely 17 to have head injuries reported compared to non vulnerable road users (adjusted OR 1.7, 1.2 18 19 2.5) (supplementary table 2). 20 21 22 23 Compared to non pedestrian RTI deaths, pedestrian deaths occurred to those who had less 24 education (or in the case of children age <15 years, have less educated parents) (adjusted OR 25 26 2.9, 99%CI 2.0 4.2), lived in poorer neighbourhoods (1.7, 1.1 2.5),were children or elderly adults 27 28 (<15 years: 2.9, 1.8 4.5; >59 years: 1.7, 1.2 2.4), were female (1.5, 1.2 2.2), and lived in urban 29 30 areas (1.5, 1.1 2.2) (table 2). If pedestrian deaths had the same proportion of secondary or 31 higher education as non pedestrian RTI deaths, there would be 406/825 (49%) fewer pedestrian 32 33 deaths, corresponding to approximately 33 000 deaths nationally in 2005. The corresponding
34 http://bmjopen.bmj.com/ 35 attributable proportion for living in richer versus poorer neighbourhoods would be 265/825 (32%) 36 37 or approximately 22 000 deaths nationally. Within the narratives we could code, there were no 38 differences between pedestrians and non pedestrian RTI deaths in timing of death, place of 39 40 death, reported injuries, or reported routine use of alcohol or smoking (data not shown). 41 42 43 on October 2, 2021 by guest. Protected copyright.
44 45 46 47 48 49 50 51 52 53 54 55 11 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 43 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 Attributable Pedestrian / Pedestrian Deaths 12 Non Pedestrian Adjusted OR^ (% of all 825 13 Total=825/1280 (99% CI) pedestrian deaths) 14 Education* 15 Secondary or higher For peer112/382 reviewref only 16 Primary or middle 248/450 1.8 (1.3 2.6) 110 406 (49%) 17 Below primary 451/423 2.9 (2.0 4.2) 296 18 Unknown 14/25 1.6 (0.6 4.2) N/A Neighbourhood Asset 19 High 137/320 ref 20 Low 643/895 1.7 (1.1 2.5) 265 (32%) 21 Unknown 45/65 1.5 (0.8 2.8) N/A 22 Age in years 23 15 59 (driving ages) 497/1046 ref 24 <15 (children) 144/74 2.9 (1.8 4.5) 94 170 (21%) >59 (elderly adults) 184/160 1.7 (1.2 2.4) 76 25 Sex 26 Male 621/1121 ref 27 Female 204/159 1.5 (1.1 2.2) 68 (8%) 28 Location 29 Rural 643/962 ref 30 Urban 182/318 1.5 (1.1 2.2) 61 (7%)
31 Occupation Salaried / Wage Earner / Professional 229/517 ref 32 Cultivator / Agricultural labour / Other 162/300 0.9 (0.6 1.3) N/A 33 Non worker / Children <15 years 433/463 1.2 (0.9 1.6) N/A Unknown 1/0 N/A N/A 34 http://bmjopen.bmj.com/ 35 Routine Alcohol Use** 36 No 494/877 ref 37 Yes 145/260 1.1 (0.7 1.5) N/A Unknown 42/69 1.0 (0.5 1.9) N/A 38 39 40 Table 2: Characteristics of pedestrian RTI deaths and attributable proportions. *Education 41 of deceased adults or, in cases of deceased children <15 years, education of respondent. 42 **Excludes 218 children. ^Odds ratios are adjusted for all other variables in this table except for 43 alcohol use; the odds ratios for alcohol use are adjusted for all other variables in this table. on October 2, 2021 by guest. Protected copyright. 44 45 46 47 DISCUSSION 48 49 RTI is an important cause of death in India, causing 183 600 deaths in 2005, or about 2% of all 50 deaths.[22] Much of the deceased were men between ages 15 59 years. Males had a four fold 51 52 higher cumulative risk of RTI death compared to females before the age of 70. Among the major 53 54 55 12 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 states, there was approximately 3 fold variation in the age standardized RTI death rate and 10 11 cumulative risk for males. 12 13 14 Our estimated number of RTI deaths is more than 50% greater than the 118 265 deaths 15 For peer review only 16 reported in the official police statistics of the National Crime Records Bureau (NCRB) in 17 2005.[27] Compared to our estimates, the extent of under reporting of the crude death rate in 18 19 major states by NCRB ranged from <1% to about 80% (supplementary table 3). Existing 20 21 regional population based injury surveys in India support our findings and also report higher 22 23 crude RTI death rates than NCRB statistics.[8,11]Under reporting of RTI deaths in police 24 statistics has been reported in India and other LMIC.[28 30]A study in urban India comparing 25 26 both hospital and community based RTI data to police records identified factors contributing to 27 28 under reporting that included the deceased believed to be at fault, collision resulting from hit 29 30 and runs, limited police resources, and the lack of a standard police reporting protocol by 31 hospitals.[28]] The factors contributing to police under reporting, especially in rural India, require 32 33 further examination. Our estimated number of RTI deaths in 2005 was consistent with the WHO
34 http://bmjopen.bmj.com/ 35 estimate for 2004.[14] However, we observed a slightly higher male proportion (83% MDS vs. 36 37 77% WHO, all ages) and a higher proportion of male deaths between 15 59 years (65% MDS 38 vs. 61% WHO). 39 40 41 42 Almost three quarters of all RTI deaths in India were of pedestrians and other vulnerable road 43 on October 2, 2021 by guest. Protected copyright. users. In contrast, a much lower proportion (27%) was reported by the NCRB (figure 2).This 44 45 difference equated to 59 000 pedestrian and 32 000 other vulnerable road user deaths that were 46 47 not included in the 2005 NCRB records. Existing RTI studies based on regional surveys and 48 49 hospital series also reported a high proportion (>60%) of vulnerable road user deaths similar to 50 our findings.[11,12,30 32]Since the majority of vulnerable road users were pedestrians, our 51 52 findings suggested that RTI deaths in individuals who were less educated, poor, female or live in 53 54 55 13 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 45 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 urban areas may have been disproportionally excluded from the NCRB records. While poverty 10 11 and education are not likely to be in the direct causal pathway of pedestrian deaths, they 12 nonetheless point to other associated risk factors. Indeed, 55 000 pedestrian deaths in 2005 13 14 (81%) was associated with lower education or living in poorer neighbourhoods compared to non 15 For peer review only 16 pedestrian RTI deaths. While the less educated and the poor likely travelled more often by foot, 17 they might also be exposed to undetermined environmental (neighbourhoods with unsafe 18 19 roads), biological (poor vision or decreased mobility due to poor health), and behavioral (alcohol 20 21 or other substance use) risk factors for pedestrian death.[12, 33, 34]Further studies are needed 22 23 to better understand pedestrian deaths in LMIC. 24
25 26 Over half of RTI deaths occurred instantly at the scene of collision and/or had head injury 27 28 reported. ThusThese findings, together with existing RTI hospital series and regional surveys in 29 30 India, make a strong argument that , investments in primary and secondary prevention could 31 potentially avert the greatest proportion of RTI deaths. To address the high proportion of instant 32 33 deaths and head injuries among RTI deaths in India, specific interventions that are effective and
34 http://bmjopen.bmj.com/ 35 based on studies in LMIC should be emphasized; these may include speed bumps, motorcycle 36 37 helmets, and increasing fines and license suspensions for rule infractions.[33]In contrast, 38 improving pre hospital transport and hospital trauma care, could only potentially affect the 39 40 38%who died on scene with delayed hospital transport (3%), en route to hospital (7%), or in 41 42 hospital (28%). 43 on October 2, 2021 by guest. Protected copyright.
44 45 Our study is the first nationally representative survey of the causes of death in India. The simple 46 47 descriptive statistics provide clear evidence on the large and avertable burden from RTI, 48 49 particularly among productive age adults and pedestrians. To the best of our knowledge, only 50 one recent study in Vietnam has used similar methods to analyze RTI deaths and policy 51 52 implications on a national scale.[35] 53 54 55 14 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 46 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 Our study faced certain limitations. First, we might have misclassified certain causes of death 12 including suicide as RTI deaths. However, the extent of misclassification should be minimal 13 14 since the RHIME verbal autopsy method was shown to be robust in discerning between types of 15 For peer review only 16 injury deaths[36]and since the immediate two physician agreement was high for RTI 17 deaths(89.5%, table 1). Furthermore, suicides cause about 200 000 deaths in India annually but 18 19 few are due to RTI.[19] Second, since the modes of transportation, place and timing of death, 20 21 and injuries sustained were extracted from layperson open ended narratives, the data accuracy 22 23 may be in question. For example with the deceased mode of transportation, the extent of 24 misclassification (by our study) or misreporting (by NCRB) that contributed to the differences 25 26 between the two sources is uncertain. With reported injuries, our findings from these narratives 27 28 most likely undercounted less visible injuries (chest, abdomen, and spine) compared to highly 29 30 visible injuries such as bleeding and deformity for head and extremity injuries. Nevertheless, our 31 findings are consistent with available Indian regional surveys and hospital series on the mode of 32 33 transportation[11,12,30 32,37][11,12,30 32] place and timing of death,[1,37 41][1,37 39] and
34 http://bmjopen.bmj.com/ 35 injuries sustained.[12,37,42,43][12,40,41]Third, since the narrative was not designed specifically 36 37 to capture RTI death characteristics, over 25% of deaths had missing data for mode of 38 transportation, place of death, timing of death, or reported injuries(supplementary table 1).Thus, 39 40 our findings for these elements extracted from the narratives may be less representative of the 41 42 decedents who lived in rural or poor areas. Finally, reliable forward projection of the number of 43 on October 2, 2021 by guest. Protected copyright. RTI deaths beyond 2005 was not possible since the increase in the NCRB reported number of 44 45 RTI deaths of140% from 2005 to 2011 appeared to outpace the rate of population growth.[44] 46 47 As the proportion of vulnerable road user deaths remained stable during this period in the NCRB 48 49 reports, we postulated that this increase represented an actual increase in RTI death totals 50 rather than more accurate reporting. Furthermore, given the rapid economic expansion and 51 52 concurrent changes in motorization including the types of vehicle sharing the road and road 53 54 55 15 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 47 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 infrastructure,[45,46]our results on deceased mode of transportation, place and timing of death, 10 11 and injuries sustained may not reflect the current Indian scenario. An analysis of the trend from 12 2001 2014 is planned pending ongoing data collection in the MDS. 13 14 15 For peer review only 16 In India, RTI is a significant cause of preventable death, particularly in males of productive 17 working age and among pedestrians, bicyclists, and motorcyclist. We have shown that properly 18 19 designed simple verbal autopsy narratives can document the much needed surveillance data on 20 21 the numbers, rates, risks, and basic RTI mechanism such as modes of transportation, timing of 22 23 death, place of death, and injuries sustained. Our findings suggested that investment in primary 24 and secondary prevention could address a large proportion of avoidable RTI deaths. 25 26 27 28 ACKNOWLEDGEMENTS 29 30 We thank the Office of the RGI for the ongoing productive collaboration on the MDS, C 31 Ramasundarahettige for technical assistance, M Puri and S Levitt for data extraction. The 32 33 opinions expressed in this article are those of the authors and do not necessarily represent
34 http://bmjopen.bmj.com/ 35 those of the Government of India or the RGI. 36
37 38 COMPETING INTERESTS 39 40 We declare that we have no competing interests. 41 42 43 on October 2, 2021 by guest. Protected copyright. FUNDING 44 45 This study is supported by grants from the John E Fogarty International Center of the National 46 47 Institutes of Health (R01 TW05991–01 and TW07939 01), the Bill & Melinda Gates Foundation 48 49 through the Disease Control Priorities Network Project, and the University of Toronto (to PJ); the 50 Canada Research Chair Programme (to PJ and ABN); and the Canadian Institutes of Health 51 52 Research Doctoral Award (to MH). The funding sources had no role in the study design; data 53 54 55 16 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 48 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 collection, analysis, interpretation; writing of the manuscript; or decision to submit for publication. 10 11 The senior author had full access to all the data in the study and had final responsibility for the 12 decision to submit this study for publication. 13 14 15 For peer review only 16 AUTHOR’S CONTRIBUTION 17 PJ and the MDS Collaborators (appendix) designed, planned, the executed the MDS in close 18 19 collaboration with the Office of the Registrar General of India (RGI). MH and PJ performed the 20 21 data analysis. All authors contributed to data interpretation, revisions of the manuscript, and 22 23 provided final approval. PJ is the guarantor for this report. 24
25 26 DATA SHARING STATEMENT 27 28 Data used in this study is are the property of the Registrar General of India and the overall 29 30 mortality results have been published in 2009.[47] This specific analyses is produced under an 31 agreement with CGHR. Application for data access can be made to the Office of the Registrar 32 33 General of India.
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 17 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 49 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 REFERENCES 10 11 1 Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention: World 12 13 Health Organization 2004;1–244. 14 15 For peer review only 16 2 Chisholm D, Naci H, Hyder AA, et al. Cost effectiveness of strategies to combat road traffic Formatted: French (France) 17 injuries in sub Saharan Africa and South East Asia: mathematical modelling study. BMJ 18 19 2012;344:e612. 20 21 22 3 The PLoS Medicine Editors. Preventing Road Deaths—Time for Data. PLoS Med 23 2010;7:e1000257. 24 25 26 4 Barffour M, Gupta S, Gururaj G, et al. Evidence based road safety practice in India: 27 28 assessment of the adequacy of publicly available data in meeting requirements for 29 comprehensive road safety data systems. Traffic Inj Prev 2012;13 Suppl 1:17–23. 30 31 32 5 Kopits E, Cropper ML. Traffic fatalities and economic growth. World Bank Development 33 Research Group Environment and Infrastructure, 2003.
34 http://bmjopen.bmj.com/ 35 36 6 Sathiyasekaran BW. Population based cohort study of injuries. Injury 1996;27:695–8. 37 38 39 7 Varghese M, Mohan D. Transportation injuries in rural Haryana, North India. In: 40 41 Proceedings of the international conference on traffic safety 2003;326–9. 42 on October 2, 2021 by guest. Protected copyright. 43 8 WHO. Injury Prevention and Control: An epidemiological study of injuries in the area of 44 45 Municipal Corporation of Delhi. Regional Office for South-East Asia 2003;1–18. 46 47 9 Gururaj G, Suryanarayana SP. Burden and impact of injuries: Results of population based 48 49 survey. Proceedings of the 7th world conference on injury prevention 2004;275–6. 50 51 52 10 Dandona R. Patterns of road traffic injuries in a vulnerable population in Hyderabad, India. 53 54 55 18 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 50 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 Injury Prevention 2006;12:183–8. 10 11 11 Dandona R, Kumar GA, Ameer MA, et al. Incidence and burden of road traffic injuries in 12 13 urban India. Inj Prev 2008;14:354–9. 14 15 For peer review only 16 12 Gururaj G. Road traffic deaths, injuries and disabilities in India: current scenario. Natl Med J 17 India 2008;21:14–20. 18 19 20 13 Garg N, Hyder A. Road traffic injuries in India: A review of the literature. Scand J of Public 21 22 Health 2006;34:100–9. 23 24 14 World Health Organization. The Global Burden of Disease: 2004 Update. World Health 25 26 Organization 2008. 27 28 15 Mathers CD, Bernard C, Moesgaard Iburg K, et al. Global Burden of Disease in 2002: data 29 30 sources, methods, and results. Global Programme on Evidence for Health Policy 31 32 Discussion Paper No. 54. World Health Organization 2003. 33
34 http://bmjopen.bmj.com/ 16 Jha P, Gajalakshmi V, Gupta PC, et al. Prospective Study of One Million Deaths in India: 35 36 Rationale, Design, and Validation Results. PLoS Med 2006;3:e18. 37 38 39 17 Million Death Study Collaborators,. Causes of neonatal and child mortality in India: a 40 41 nationally representative mortality survey. Lancet 2010;376:1853–60. 42 on October 2, 2021 by guest. Protected copyright. 43 18 Dikshit R, Gupta PC, Ramasundarahettige C, et al. Cancer mortality in India: a nationally 44 45 representative survey. Lancet 2012;379:1807–16. 46 47 19 Patel V, Ramasundarahettige C, Vijayakumar L, et al. Suicide mortality in India: a nationally 48 49 representative survey. Lancet 2012;379:2343–51. 50 51 52 20 Sinha DN, Dikshit R, Kumar R, et al. Prospective Study of Million Deaths in India: Technical 53 54 55 19 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 51 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 document no VIII: Health care professional's manual for assigning causes of death based 10 11 on RHIME household reports. RGI CGHR, University of Toronto. 12 2011.http://www.cghr.org/mds (accessed 1 Aug2012). 13 14 15 21 WHO. InternationalFor Statistical Classification peer of Diseases review and Related Health Problems,only 16 17 ICD-10: Three Volume Set. World Health Organization 2010. 18 19 22 United Nations Populations Division. World population prospects (2008 revision). 20 21 2009.http://www.un.org/esa/population/publications/wpp2008/ (accessed 2 July 2011). 22 23 23 Mari Bhat PN. Completeness of India's sample registration system: an assessment using 24 25 the general growth balance method. Popul Stud 2002;56:119–34. 26 27 28 24 Sivanandan V. An assessment of the completeness of death registration in India over the 29 periods 1975-1978 and 1996-1999 under the generalized population model: an analysis 30 31 based on SRS data. Mumbai: International Institute for Population Sciences2004. Formatted: French (France) 32 33 25 Jha P, Kumar R, Khera A, et al. HIV mortality and infection in India: estimates from
34 http://bmjopen.bmj.com/ 35 nationally representative mortality survey of 1.1 million homes. BMJ 2010;340:c621. French (France) 36 Formatted: 37 38 26 Dhingra N, Jha P, Sharma VP, et al. Adult and child malaria mortality in India: a nationally 39 40 representative mortality survey. Lancet 2010;376:1768–74. 41 42
27 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2005. Ministry of on October 2, 2021 by guest. Protected copyright. 43 44 Home Affairs, Government of India2005. 45 46 47 28 Dandona R, Kumar GA, Ameer MA, et al. Under reporting of road traffic injuries to the Formatted: French (France) 48 police: results from two data sources in urban India. Inj Prev 2008;14:360–5. 49 50 51 29 Alcorn T. Uncertainty clouds China's road traffic fatality data. Lancet 2011;378:305–6. 52 53 54 55 20 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 52 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 30 Naci H, Chisholm D, Baker TD. Distribution of road traffic deaths by road user group: a 10 11 global comparison. Inj Prev 2009;15:55–9. 12 13 31 Mohan D. The road ahead: Traffic injuries and fatalities in India. Transportation research 14 15 and injury preventionFor programme, peer Indian Institute of reviewTechnology, Delhi2004. only 16 17 32 Mohan D. Traffic safety and health in Indian cities. Journal of Transport and Infrastructure 18 19 2002;9:79–94. 20 21 22 33 Norton R, Hyder A, Bishai D, et al. Unintentional Injuries. In: Disease Control Priorities in 23 Developing Countries. Oxford University Press, USA2006. 24 25 26 34 Grimm M, Treibich C. Determinants of road traffic crash fatalities across Indian states. 27 28 Health Econ Published Online First: 30 August 2012. doi:10.1002/hec.2870 29 30 35 Ngo AD, Rao C, Phuong Hoa N, et al. Road traffic related mortality in Vietnam: Evidence 31 32 for policy from a national sample mortality surveillance system. BMC Public Health 33 2012;12:561.
34 http://bmjopen.bmj.com/ 35 36 36 Hsiao M, Morris SK, Bassani DG, et al. Factors Associated with Physician Agreement on 37 38 Verbal Autopsy of over 11500 Injury Deaths in India. PLoS ONE 2012;7:e30336. 39 40 41 37 Singh H, Dhattarwal SK. Pattern and distribution of injuries in fatal road traffic accidents in 42
Rohtak (Haryana). Journal of Indian Academy of Forensic Medicine 2004;26:20–3. on October 2, 2021 by guest. Protected copyright. 43 44 45 38 Dandona R, Mishra A. Deaths due to road traffic crashed in Hyderabad city in India: need 46 47 for strengthening surveillance. Natl Med J India 2004;17:74–9. 48 49 39 Sahdev P, Lacqua MJ, Singh B, et al. Road traffic fatalities in Delhi: causes, injury patterns, 50 51 and incidence of preventable deaths. Accident Analysis & Prevention 1994;26:377–84. 52 53 54 55 21 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 53 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 40 Bhattacharjee J, Bora D, Sharma RS, et al. Unnatural deaths in Delhi during 1991. Med Sci 10 11 Law 1996;36:194–8. 12 13 41 Jain A, Menezes RG, Kanchan T, et al. Two wheeler accidents on Indian roads a study Formatted: French (France) 14 15 from Mangalore, India.For J Forensic peer Leg Med 2009;16 review:130–3. only 16 17 42 Gururaj G, Shastry KVR, Chandramouli AB, et al.Traumatic brain injury. Bangalore: 18 19 National Institute of Mental Health and Neuro Sciences, 2005. 20 21 22 43 Colohan AR, Alves WM, Gross CR, et al. Head injury mortality in two centers with different 23 emergency medical services and intensive care. J Neurosurg Pediatrics 1989;71:202–7. 24 25 26 44 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2011. Ministry of 27 28 Home Affairs, Government of India2011. 29 30 45 Transport Research Wing, Ministry of Road Transport & Highways. Basic Road Statistics of 31 32 India. Government of India 2012. 33
34 http://bmjopen.bmj.com/ 35 46 Transport Research Wing, Ministry of Road Transport & Highways. Road Transport Year 36 Book (2009 10 & 2010 11). Government of India 2012. 37 38 39 47 Registrar General of India and Centre for Global Health Research. Causes of Death in 40 41 India, 2001-2003: Sample Registration System. Government of India 2009. 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 22 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 54 of 55 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 FIGURE LEGENDS 10 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 11 12 0-69 years) across states and regions of India, by gender. 13 14 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol 15 For peer review only 16 size is proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, 17 Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 18 19 19 female deaths from Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N 20 21 Islands, Daman & Diu, Lakshadweep, and Goa. CHT=Chhatisgarh. 22 23 24 Figure 2: Deceased mode of transportation, place of death, and timing of death. 25 26 (A) Deceased mode of transportation in present study compared to National Crime Records 27 28 Bureau 2005 Report. Shaded line represents vulnerable road users (defined as road users 29 30 without a rigid barrier protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, 31 and three wheelers). Percentages from present study are weighted by state and rural/urban 32 33 residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death
34 http://bmjopen.bmj.com/ 35 and (C) timing of death based on verbal autopsy narratives. Shaded lines represent deaths that 36 are reported as occurring at the scene of collision or occurring instantly (defined as within 5 37 38 minutes). 39 40 41 42 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI 43 on October 2, 2021 by guest. Protected copyright. deaths). 44 45 Percentages refer to those in each row with given injury (columns). *Values in bold denote two 46 47 by two chi square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were 48 49 also reported but not shown due to small numbers (61 and 25 cases, respectively). 50 51 52 53 54 55 23 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 55 of 55 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 LIST OF ACRONYMS 10 11 12 CI Confidence interval 13 14 ICD 10 International Statistical Classification of Diseases and Related Health Problems, 10th 15 For peer review only 16 Revision 17 LMIC Low and middle income countries 18 19 MDS Million Death Study 20 21 NCRB National Crime Records Bureau 22 23 RGI Registrar General of India 24 RTI Road traffic injury 25 26 SRS Sample registration system 27 28 UN United Nations 29 30 WHO World Health Organization 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 24 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Road traffic injury mortality and its mechanisms in India: nationally representative mortality survey of 1.1 million homes
For peer review only Journal: BMJ Open
Manuscript ID: bmjopen-2013-002621.R2
Article Type: Research
Date Submitted by the Author: 17-Jul-2013
Complete List of Authors: Hsiao, Marvin; University of Toronto, Centre for Global Health Research; University of Toronto, Department of Surgery Malhotra, Ajai; VCU Medical Center, Virginia Commonwealth University, Department of Surgery Thakur, JS; Post Graduate Institute of Medical Education and Research, Department of Community Medicine Sheth, Jay; Smt. N.H.L. Municipal Medical College, Nathens, Avery; University of Toronto, Department of Surgery; Sunnybrook Health Sciences Centre, Sunnybrook Research Institute Dhingra, Neeraj; National AIDS Control Organization, Jha, Prabhat; University of Toronto, Centre for Global Health Research
Primary Subject Epidemiology Heading: http://bmjopen.bmj.com/
Secondary Subject Heading: Global health, Public health
Keywords: road traffic injury, verbal autopsy, India, low- and middle-income countries
Note: The following files were submitted by the author for peer review, but cannot be converted to PDF. You must view these files (e.g. movies) online. on October 2, 2021 by guest. Protected copyright. STROBE_checklist_BMJ-Open_cross-sectional-studies.doc
For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 1 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 Road traffic injury mortality and its mechanisms in India: nationally 5 representative mortality survey of 1.1 million homes 6 7 8 Marvin Hsiao, Ajai Malhotra, JS Thakur, Jay K Sheth, Avery B Nathens, Neeraj Dhingra, 9 10 Prabhat Jha, for the Million Death Study Collaborators. 11 12 13 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 14 15 University of Toronto,For Toronto, peer Canada (M review Hsiao MD, Prof P Jha only DPhil); Division of General 16 17 Surgery, Department of Surgery, University of Toronto, Toronto, Canada (M Hsiao MD, Prof AB 18 Nathens MD); Department of Surgery, VCU Medical Center, Virginia Commonwealth University, 19 20 Richmond, USA (Prof A Malhotra MD); Department of Community Medicine, Post Graduate 21 Institute of Medical Education and Research, Chandigarh, India (JS Thakur MD); Smt. N.H.L. 22 23 Municipal Medical College, Ahmedabad, India (JK Sheth MD); Sunnybrook Research Institute, 24 25 Sunnybrook Health Sciences Centre, Toronto, Canada (Prof AB Nathens MD); National AIDS 26 Control Organization, New Delhi, India (N Dhingra MD) 27 28 29 30 31 Correspondence to: 32 Marvin Hsiao 33 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, and
34 Division of General Surgery, Department of Surgery, University of Toronto http://bmjopen.bmj.com/ 35 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 36 [email protected] 37 +1 416 864 6042 (phone) / +1 416 864 5256 (fax) 38 39 Keywords: Road traffic injury; verbal autopsy; India; low and middle income countries 40
41 42 Word count: Text: 3361 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 2 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ABSTRACT: 4 5 6 Objectives: To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. 7 8 Design: We conducted a nationally representative mortality survey where at least two 9 10 physicians coded each non medical field staff’s verbal autopsy reports. RTI mechanism data 11 12 were extracted from the narrative section of these reports. 13 14 Setting: 1.1 million homes in India. 15 For peer review only 16 Participants: Over 122 000 deaths at all ages from 2001 2003. 17 18 19 Primary and secondary outcome measures: Age and sex specific mortality rates, place and 20 21 timing of death, modes of transportation, and injuries sustained. 22 23 Results: The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or 24 25 about 2% of all deaths in 2005 nationally, of which 65% occurred in males between the ages of 26 27 15 59 years. The age adjusted mortality rate was greater in males than in females, in urban 28 29 than in rural areas, and was notably higher than that estimated from national police records. 30 31 32 Pedestrians (68 000), motorcyclists (36 000), and other vulnerable road users (20 000) 33 constituted 68% of RTI deaths (124 000) nationally. Among the study sample, the majority of all
34 http://bmjopen.bmj.com/ 35 36 RTI deaths occurred at the scene of collision (1005/1733, 58%), within minutes of collision 37 38 (883/1596, 55%), and/or involved a head injury (691/1124, 62%). Compared to non pedestrian 39 40 RTI deaths, about 55 000 (81%) of pedestrian deaths were associated with less education and 41 42 living in poorer neighbourhoods. on October 2, 2021 by guest. Protected copyright. 43 44 45 Conclusions: In India, RTI cause a substantial number of deaths, particularly among 46 47 pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce 48 49 injuries might address over half of the RTI deaths. Improved pre hospital transport and hospital 50 51 trauma care might address just over a third of the RTI deaths. 52 53 54 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 3 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ARTICLE SUMMARY 4 5 6 Article focus 7 8 • To directly estimate the age and sex specific mortality rates and describe the place and 9 10 timing of death, modes of transportation, and injuries sustained for road traffic injury 11 12 (RTI) deaths in India using a nationally representative mortality survey of 1.1 million 13 14 homes. 15 For peer review only 16 Key messages 17 18 19 • Road traffic injuries cause a substantial number of avertable deaths, particularly in males 20 21 of productive working age and among pedestrians and other vulnerable road users. 22 23 • Preventative interventions should be emphasized as the majority of all RTI deaths 24 25 occurred at the scene of collision, within minutes of collision, and/or involved a head 26 27 injury. 28 29 30 • Properly designed mortality survey with verbal autopsy narratives can provide much 31 32 needed data to assist RTI prevention efforts. 33
34 Strengths and limitations of this study http://bmjopen.bmj.com/ 35 36 • This study is the first nationally representative survey of the causes of death in India and 37 38 overcomes limitations of existing data sources including regional injury surveys, hospital 39 40 41 series, and national police reports. 42 43 • Limitations of the study include potential misclassification of deaths by physician coders, on October 2, 2021 by guest. Protected copyright. 44 45 the use of layperson narratives with a potential for recall bias and inaccuracies, and 46 47 limited ability to forward project study results given the rapid changes in motorization in 48 49 India. 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 4 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 INTRODUCTION 4 5 6 Road traffic injuries (RTI) area large and growing public health burden, especially in low and 7 8 middle income countries (LMIC) where 90% of the world’s deaths due to RTI are estimated to 9 10 occur.[1] There are few high quality epidemiologic data on RTI to guide the development, 11 12 implementation, and surveillance of evidence based policy and programs in LMICs.[2 4] 13 14 15 For peer review only 16 The number of deaths due to RTI in India is projected to rise with increasing motorization.[1,5] 17 18 19 Aside from a few regional injury surveys,[6 11] the current data on the numbers and 20 21 mechanisms of RTI deaths in India rely on police or hospital records, both of which can 22 23 substantially underestimate death rates in the poor, rural, and uneducated people who still 24 25 constitute large proportions of the Indian population.[2 4,12,13] 26 27 28 29 The World Health Organization (WHO), using indirect modeling methods, estimated about 202 30 31 32 000 RTI deaths in India in 2004.[14,15] No study has validated this estimate with direct 33 measurement nor documented detailed RTI mechanism for India nationally. Here, we estimate
34 http://bmjopen.bmj.com/ 35 36 the regional, age and sex specific mortality rate and risk of RTI death in India using data from 37 38 the Million Death Study (MDS). We also report the modes of transportation, place and timing of 39 40 death, and injuries sustained in RTI deaths. 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 5 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 METHODS 4 5 6 Study Design: The MDS is an on going nationally representative survey designed to determine 7 8 the causes and risk factors of death in India, organized by the Registrar General of India (RGI). 9 10 The design, methodology, and preliminary findings of the MDS have been described 11 12 elsewhere.[16 19] In brief, the MDS used an enhanced version of verbal autopsy (known as the 13 14 routine, reliable, representative, re sampled household investigation of mortality with medical 15 For peer review only 16 evaluation or RHIME) to monitor a nationally representative sample of 1.1 million households in 17 18 19 the Sample Registration System (SRS). Within six months of every death occurring in these 20 21 households from 2001 3, a trained, nonmedical RGI surveyor interviewed a relative or close 22 23 acquaintance of the deceased to obtain the symptoms and events around the death using 24 25 structured questions and a local language narrative guided by a specific symptom list. These 26 27 records were converted into electronic records and emailed to two of 140 trained physicians 28 29 who, independently and anonymously, assigned an underlying cause of death (with allocation 30 31 32 determined randomly based only on the physician’s ability to read the local language), using 33 guidelines for the major causes of death.[20] Records were assigned cause of death in three
34 http://bmjopen.bmj.com/ 35 36 digit International Statistical Classification of Diseases and Related Health Problems, 10th 37 38 revision (ICD 10).[21] Records where coders disagreed on the cause of death underwent 39 40 anonymous reconciliation. Continuing disagreements were adjudicated by a third senior 41 42 physician. Five percent of households were randomly resurveyed and the results were on October 2, 2021 by guest. Protected copyright. 43 44 45 consistent within families of ICD 10 codes.[16] Participation in the SRS is on a voluntary basis 46 47 and oral consent was obtained under the confidentiality and consent procedures of the 48 49 Registration of Births and Deaths Act, 1969. 50 51 52 53 Road Traffic Injury Deaths: The RTI deaths in this study were of people who died between 54 55 2001 and 2003 with a final assigned ICD 10 code within V01 V89. We translated the open 56 57 58 ended narratives into English from 14 local languages, and systematically extracted the modes 59 60 5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 6 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 of transportation, place and timing of death, and injuries sustained from 2157 of the 2299 RTI 4 5 6 deaths using a standardized data extraction tool and procedure (the remaining 142 deaths, 6%, 7 8 had missing or illegible narratives). For these four data elements, there were substantial inter 9 10 rater agreement between two investigators and two research assistants who were trained and 11 12 independently extracted data from the narratives of a random 10% of RTI deaths (lowest kappa 13 14 statistic was greater than 0.69 for all pair wise comparisons between the four data extractors; 15 For peer review only 16 data not shown). The two research assistants then independently extracted data from all 17 18 19 narratives. Adjudication was done by an investigator (MH) for discrepancies in extracted data. 20 21 22 23 Analysis: The age and sex specific proportion of RTI deaths within the 2001 2003 survey was 24 25 applied to the 2005 United Nations (UN) estimates of the number of deaths from all causes in 26 27 India, after weighting for sampling probability for each rural or urban stratum per state (although 28 29 such weighting made little difference because the study was nationally representative).[18,22] 30 31 32 The 2005 UN death estimates were used so as to correct for the slight undercounts reported in 33 the total death rates in the SRS [23,24] and to account for the 12% of enumerated deaths
34 http://bmjopen.bmj.com/ 35 36 without completed field visits (mostly due to out migration of the family or from incomplete field 37 38 records). The proportion of these missed deaths was similarly dispersed across sex, age, and 39 40 states. Use of 2003 or 2004 UN death totals yielded nearly identical results (data not shown). 41 42 The 99% confidence intervals (99%CI) for mortality rate were calculated based on the weighted on October 2, 2021 by guest. Protected copyright. 43 44 45 number of study deaths. State and rural/urban specific estimates of the number, mortality rate, 46 47 and lifetime risk of RTI death were calculated by partitioning the UN national death totals 48 49 according to relative SRS death rates as previously described.[18,25,26] Urban and rural status 50 51 was defined according to the Census of India. Logistic regression was used to compare the 52 53 socio demographic traits of pedestrian and non pedestrian RTI deaths. Household fuel type was 54 55 used as a measure of community wealth, based on earlier principal component analyses [18]: 56 57 58 high asset neighbourhoods had >50% of households that used gas, electricity, or kerosene; low 59 60 6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 7 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 asset or poor neighbourhoods used primarily coal, firewood, or other. Attributable proportion 4 5 6 was calculated for traits of pedestrian deaths compared to non pedestrian RTI deaths. 7 8 9 10 The MDS received ethics approval from the review boards of the Post Graduate Institute of 11 12 Medical Education and Research in Chandigarh, India; St Michael’s Hospital in Toronto, 13 14 Canada; and the Indian Council of Medical Research’s Health Ministry’s Screening Committee. 15 For peer review only 16 17 18 19 20 21 RESULTS 22 23 The 2299 RTI deaths in the 2001 2003 survey correspond to an estimated 183 600 (99%CI 173 24 25 800 193 400) RTI deaths in India in 2005. The majority of these RTI deaths occurred in males 26 27 (152 100 deaths, 82.8%; table 1). The age standardized RTI mortality rate for males (26.2 per 28 29 100 000, 24.6 27.7) was higher than for females (5.7 per 100 000, 5.0 6.4). While the RTI 30 31 32 mortality rate increased with age in both genders, the largest number of RTI deaths occurred in 33 males between 15 59 years of age (118 900, 64.8%).
34 http://bmjopen.bmj.com/ 35 36 37 38 At these death rates and in the theoretical absence of other causes of death, males in India had 39 40 a 2.1% (2.0 2.3) risk of dying from RTI before age 70, with the highest risks at ages 30 59 41 42 years; females had a 0.5% (0.4 0.5) risk of dying from RTI before age 70. Males in Haryana, on October 2, 2021 by guest. Protected copyright. 43 44 45 Punjab, Tamil Nadu, and Uttar Pradesh had significantly higher risks (3.0 4.1%) than the 46 47 national risk (figure 1). In contrast, males in Bihar, Jharkhand, Andhra Pradesh, Orissa, Gujarat, 48 49 and West Bengal had significantly lower risks (1.3 1.6%) than the national risk of RTI deaths. 50 51 Males living in urban areas had slightly higher age standardized mortality rates and risks of RTI 52 53 deaths (27.6 per 100 000; 2.4%, 2.1 2.6) compared to males living in rural areas (24.9 per 100 54 55 000; 2.0%, 1.8 2.1). By contrast, female RTI mortality rates and risks before age 70 varied much 56 57 58 less across states and were similar in rural and urban areas (data not shown). 59 60 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Page 8 of 53
Period risk for RTI death†
5.7 0.5%† 15.5 1.3%† 26.2 2.1%† 16.2 1.3%† RTI death rateΨ (99% CI)
per 100 000 *Proportion of RTI deaths deaths RTI of *Proportion
3.8 3.2 (2.0 4.4) 0.03% 8.5 6.6 (4.9 8.3) 0.1% 9.1 64.5(49.1 80.0) 5.0 8.1 (7.1 9.1)¶ 0.04% 4.9 7.4 (6.5 8.4)¶ 0.04% 3.5 21.6(13.4 29.9) 4.4 4.1 (2.7 5.5) 0.1% 5.3 3.5 (2.4 4.6) 0.1% 3.7 14.8(9.8 19.9) 0.2% 6.0 8.6 (5.9 11.3) 0.1% 10.6 44.0(34.6 53.4) 0.5% 28.0 38.4(33.2 43.6) 0.6% 43.8 37.9(33.7 42.1) 0.6% 47.1 28.9(25.9 31.9) 0.4% 31.5 171.0 183.6 152.1 All India,All 2005 (27.5 35.6) (5.0 6.4) (0.4 0.5) (173.8 193.4) (15.4 17.1) (1.3 1.4) (161.5 180.4) (14.7 16.4) (1.3 1.4) (143.2 161.0) (24.6 27.7) (2.0 2.3)
Estimated RTI deaths§, thousands
0.9 / 24 0.9 / 73 1.3 / 14 1.2 / 61 1.2 / 67 1.3 / 16 0.6 / 25 0.5 / 69 5.3 / 585 4.5 / 546 0.2 / 118 0.6 / 115 0.2 / 129 0.4 / 163 0.3 / 106 0.3 / 150 7.2 / 1100 9.8 / 1131
All deaths / populationAll (millions, 2005 UN estimates)
8
immediately immediately agree BMJ Open http://bmjopen.bmj.com/ (89.5%) (90.4%)
(88.1%) (89.8%)
Rural (%**)Rural coders Two
tudy deaths, 2001-2003 on October 2, 2021 by guest. Protected copyright. Proportion RTI*
S For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
44 / 1955 2.3% 38 (80.1) 43 97 / 1926 5.2% 86 (84.1) 87 54 / 9016 0.6% 42 (68.6) 52 70 / 6402 1.1% 55 (70.9) 61 59 / 4055 1.4% 39 (59.0) 50 72 / 4394 1.5% 53 (60.5) 63 529 / 6817 7.7% 385 (67.0) 477 605 / 4727 13.0% 462 (68.9) 558 50 / 11492 0.4% 46 (93.4) 45 44 / 11719 0.4% 37 (76.7) 44 For peer47 / 17343 review 0.3% 33 (61.8) 35 only 396 / 54657 0.7% 306 (69.8) 349 149 / 12120 1.2% 117 (71.8) 133 356 / 11731 3.0% 249 (60.9) 312 123 / 18732 0.6% 106 (81.2) 98 190367772 / 2.8% 1442(68.9) 1709 212986354 / 2.4% 1609(68.5) 1925 2299122429 / 1.8% 1748(69.0) 2058 deaths / all deaths coded deaths
Number of of Number RTI
compared to all deaths, weighted by state and residence (rural/urban). **Percentage rural is weighted by state and residence (rural/urban). §Obtained by by §Obtained (rural/urban). residence and state by weighted is rural **Percentage (rural/urban). residence and state by weighted deaths, all to compared estimated Nations United the 2005 to standardized ΨAge proportions. the weighted by 2005 in deaths total estimated Nations United the multiplying physician on based those than CI wider in result which deaths, study of number weighted on based calculated are CI shown 99% population; Indian by years 0 69 between calculated is risk which the forlifetime except range, age of the duration by multiplied rate death RTI †Annual agreement. rate. death ¶Crude risks. period specific the age of summation gender. and age by 2005, for totals national estimated and study present the in deaths injury traffic 1: Road Table (% or 99% CI) Total male Total and female, all agesmale (% or 99% CI) Total male Total and female, <70 male years
(% or CI) 99% All ages All >70 >70 60 69 45 59 30 44 15 29 5 14 0 4 Female - Female age yearsin
(% or CI) 99% All ages All >70 >70 60 69 45 59 30 44 15 29 5 14 0 4 Male - age yearsin
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 9 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 The deceased mode of transportation was described in the narratives of 2105 (92%) of the RTI 4 5 6 deaths. National estimates for the deceased mode of transportation were calculated, as those 7 8 with unknown and known modes of transportation did not appear to differ with respect to the 9 10 major socio demographic traits (Supplementary Table 1). Vulnerable road users are those 11 12 without a rigid barrier protecting against traumatic forces and include pedestrians, motorcyclists, 13 14 bicyclists, and three wheelers. They constituted a majority (68%; n=124 000, 99%CI 115 000 15 For peer review only 16 131 000) of RTI deaths, led by pedestrians (37%; n=68 000, 62 000 73 000) and motorcyclists 17 18 19 (20%; n=36 000, 31 000 40 000) (figure 2). Drivers and passengers of motorized four wheelers 20 21 comprised 16% (n=31 000, 27 000 35 000) of RTI deaths. By contrast, the 2005 police reports, 22 23 which use a different but compatible classification system to ICD 10, recorded only 33000 24 25 vulnerable road user deaths and only 9000 pedestrian deaths.[27] The most common types of 26 27 vehicle to collide into the decedents were heavy transport vehicles and buses (37%; n=68 000, 28 29 61 000 74 000), followed by cars and vans (15%; n=28 000, 24 000 32 000). Single vehicle 30 31 32 incidents comprised 9% of deaths (n=17 000, 14 000 20 000). The most frequent combinations, 33 resulting in 23% (n=42 000, 37 000 47 000) of RTI deaths, were collisions of heavy transport
34 http://bmjopen.bmj.com/ 35 36 vehicles or buses with pedestrians and motorcyclists (data not shown). 37 38 39 40 The place and timing of death were described in the narratives of 1733 (75%) and 1596 (69%) 41 42 of the RTI deaths respectively (figure 2; see supplementary table 1 for a summary of missing on October 2, 2021 by guest. Protected copyright. 43 44 45 data from the narratives with respect to deceased characteristics). For these narratives, only the 46 47 study proportion and not national estimates were made. Most RTI deaths occurred at the scene 48 49 of collision (58%, 1005/1733) or instantly, defined as within 5 minutes (55%, 883/1596). Only 3% 50 51 (45/1733) were labeled as potentially avertable with better pre hospital transport as they 52 53 occurred on scene but not instantly. Another 35% of deaths occurred en route (7%, 124/1733) or 54 55 in hospital (28%, 481/1733). 56 57 58 59 60 9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 10 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Injuries sustained by the deceased were reported from1124 narratives (49%). Head injuries 4 5 6 were the most commonly reported (62%, 691/1124), of which 76% (524/691) were reported as 7 8 isolated head injuries (figure 3). A greater percentage of motorcyclists (78%, 188/241) had head 9 10 injuries reported compared to non motorcyclists (57%, 457/807). After adjusting for age, sex, 11 12 rural/urban, neighbourhood asset, and education, bicyclists and motorcyclists were more likely 13 14 to have head injuries reported compared to non vulnerable road users (adjusted OR 1.7, 1.2 15 For peer review only 16 2.5) (supplementary table 2). 17 18 19 20 21 Compared to non pedestrian RTI deaths, pedestrian deaths occurred to those who had less 22 23 education (or in the case of children age <15 years, have less educated parents) (adjusted OR 24 25 2.9, 99%CI 2.0 4.2), lived in poorer neighbourhoods (1.7, 1.1 2.5), were children or elderly 26 27 adults (<15 years: 2.9, 1.8 4.5; >59 years: 1.7, 1.2 2.4), were female (1.5, 1.2 2.2), and lived in 28 29 urban areas (1.5, 1.1 2.2) (table 2). If pedestrian deaths had the same proportion of secondary 30 31 32 or higher education as non pedestrian RTI deaths, there would be 406/825 (49%) fewer 33 pedestrian deaths, corresponding to approximately 33 000 deaths nationally in 2005. The
34 http://bmjopen.bmj.com/ 35 36 corresponding attributable proportion for living in richer versus poorer neighbourhoods would be 37 38 265/825 (32%) or approximately 22 000 deaths nationally. Within the narratives we could code, 39 40 there were no differences between pedestrians and non pedestrian RTI deaths in timing of 41 42 death, place of death, reported injuries, or reported routine use of alcohol or smoking (data not on October 2, 2021 by guest. Protected copyright. 43 44 45 shown). 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 11 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 Attributable 9 Pedestrian / Pedestrian Deaths 10 Non Pedestrian Adjusted OR^ (% of all 825 11 Total=825/1280 (99% CI) pedestrian deaths) 12 Education* 13 Secondary or higher 112/382 ref 14 Primary or middle 248/450 1.8 (1.3 2.6) 110 406 (49%) 15 Below primary For peer451/423 review 2.9 (2.0 4.2) only 296 16 Unknown 14/25 1.6 (0.6 4.2) N/A 17 18 Neighbourhood Asset 19 High 137/320 ref 20 Low 643/895 1.7 (1.1 2.5) 265 (32%) 21 Unknown 45/65 1.5 (0.8 2.8) N/A 22 Age in years 23 15 59 (driving ages) 497/1046 ref 24 <15 (children) 144/74 2.9 (1.8 4.5) 94 170 (21%) 25 >59 (elderly adults) 184/160 1.7 (1.2 2.4) 76 26 Sex 27 Male 621/1121 ref 28 Female 204/159 1.5 (1.1 2.2) 68 (8%) 29 Location 30 31 Rural 643/962 ref 32 Urban 182/318 1.5 (1.1 2.2) 61 (7%) 33 Occupation Salaried / Wage Earner / Professional 229/517 ref
34 http://bmjopen.bmj.com/ 35 Cultivator / Agricultural labour / Other 162/300 0.9 (0.6 1.3) N/A 36 Non worker / Children <15 years 433/463 1.2 (0.9 1.6) N/A 37 Unknown 1/0 N/A N/A 38 Routine Alcohol Use** 39 No 494/877 ref 40 Yes 145/260 1.1 (0.7 1.5) N/A 41 Unknown 42/69 1.0 (0.5 1.9) N/A 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 Table 2: Characteristics of pedestrian RTI deaths and attributable proportions. *Education 46 of deceased adults or, in cases of deceased children <15 years, education of respondent. 47 **Excludes 218 children. ^Odds ratios are adjusted for all other variables in this table except for 48 alcohol use; the odds ratios for alcohol use are adjusted for all other variables in this table. 49 50 51 52 53 DISCUSSION 54 55 56 RTI is an important cause of death in India, causing 183 600 deaths in 2005, or about 2% of all 57 58 deaths.[22] Much of the deceased were men between ages 15 59 years. Males had a four fold 59 60 11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 12 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 higher cumulative risk of RTI death compared to females before the age of 70. Among the major 4 5 6 states, there was approximately 3 fold variation in the age standardized RTI death rate and 7 8 cumulative risk for males. 9 10 11 12 Our estimated number of RTI deaths is more than 50% greater than the 118 265 deaths 13 14 reported in the official police statistics of the National Crime Records Bureau (NCRB) in 15 For peer review only 16 2005.[27] Compared to our estimates, the extent of under reporting of the crude death rate in 17 18 19 major states by NCRB ranged from <1% to about 80% (supplementary table 3). Existing 20 21 regional population based injury surveys in India support our findings and also report higher 22 23 crude RTI death rates than NCRB statistics.[8,11] Under reporting of RTI deaths in police 24 25 statistics has been reported in India and other LMIC.[28 30] A study in urban India comparing 26 27 both hospital and community based RTI data to police records identified factors contributing to 28 29 under reporting that included the deceased believed to be at fault, collision resulting from hit 30 31 32 and runs, limited police resources, and the lack of a standard police reporting protocol by 33 hospitals.[28] The factors contributing to police under reporting, especially in rural India, require
34 http://bmjopen.bmj.com/ 35 36 further examination. Our estimated number of RTI deaths in 2005 was consistent with the WHO 37 38 estimate for 2004.[14] However, we observed a slightly higher male proportion (83% MDS vs. 39 40 77% WHO, all ages) and a higher proportion of male deaths between 15 59 years (65% MDS 41 42 vs. 61% WHO). on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 Almost three quarters of all RTI deaths in India were of pedestrians and other vulnerable road 48 49 users. In contrast, a much lower proportion (27%) was reported by the NCRB (figure 2). This 50 51 difference equated to 59 000 pedestrian and 32 000 other vulnerable road user deaths that were 52 53 not included in the 2005 NCRB records. Existing RTI studies based on regional surveys and 54 55 hospital series also reported a high proportion (>60%) of vulnerable road user deaths similar to 56 57 58 our findings.[11,12,30 32] Since the majority of vulnerable road users were pedestrians, our 59 60 12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 13 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 findings suggested that RTI deaths in individuals who were less educated, poor, female or live in 4 5 6 urban areas may have been disproportionally excluded from the NCRB records. While poverty 7 8 and education are not likely to be in the direct causal pathway of pedestrian deaths, they 9 10 nonetheless point to other associated risk factors. Indeed, 55 000 pedestrian deaths in 2005 11 12 (81%) was associated with lower education or living in poorer neighbourhoods compared to non 13 14 pedestrian RTI deaths. While the less educated and the poor likely travelled more often by foot, 15 For peer review only 16 they might also be exposed to undetermined environmental (neighbourhoods with unsafe 17 18 19 roads), biological (poor vision or decreased mobility due to poor health), and behavioral (alcohol 20 21 or other substance use) risk factors for pedestrian death.[12, 33, 34] Further studies are needed 22 23 to better understand pedestrian deaths in LMIC. 24 25 26 27 Over half of RTI deaths occurred instantly at the scene of collision and/or had head injury 28 29 reported. These findings, together with existing RTI hospital series and regional surveys in India, 30 31 32 make a strong argument that investments in primary and secondary prevention could potentially 33 avert the greatest proportion of RTI deaths. To address the high proportion of instant deaths and
34 http://bmjopen.bmj.com/ 35 36 head injuries among RTI deaths in India, specific interventions that are effective and based on 37 38 studies in LMIC should be emphasized; these may include speed bumps, motorcycle helmets, 39 40 and increasing fines and license suspensions for rule infractions.[33] In contrast, improving pre 41 42 hospital transport and hospital trauma care, could only potentially affect the 38%who died on on October 2, 2021 by guest. Protected copyright. 43 44 45 scene with delayed hospital transport (3%), en route to hospital (7%), or in hospital (28%). 46 47 48 49 Our study is the first nationally representative survey of the causes of death in India. The simple 50 51 descriptive statistics provide clear evidence on the large and avertable burden from RTI, 52 53 particularly among productive age adults and pedestrians. To the best of our knowledge, only 54 55 one recent study in Vietnam has used similar methods to analyze RTI deaths and policy 56 57 58 implications on a national scale.[35] 59 60 13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 14 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 Our study faced certain limitations. First, we might have misclassified certain causes of death 7 8 including suicide as RTI deaths. However, the extent of misclassification should be minimal 9 10 since the RHIME verbal autopsy method was shown to be robust in discerning between types of 11 12 injury deaths[36] and since the immediate two physician agreement was high for RTI 13 14 deaths(89.5%, table 1). Furthermore, suicides cause about 200 000 deaths in India annually but 15 For peer review only 16 few are due to RTI.[19] Second, since the modes of transportation, place and timing of death, 17 18 19 and injuries sustained were extracted from layperson open ended narratives, the data accuracy 20 21 may be in question. For example with the deceased mode of transportation, the extent of 22 23 misclassification (by our study) or misreporting (by NCRB) that contributed to the differences 24 25 between the two sources is uncertain. With reported injuries, our findings from these narratives 26 27 most likely undercounted less visible injuries (chest, abdomen, and spine) compared to highly 28 29 visible injuries such as bleeding and deformity for head and extremity injuries. Nevertheless, our 30 31 32 findings are consistent with available Indian regional surveys and hospital series on the mode of 33 transportation[11,12,30 32,37] place and timing of death,[1,37 41] and injuries
34 http://bmjopen.bmj.com/ 35 36 sustained.[12,37,42,43] Third, since the narrative was not designed specifically to capture RTI 37 38 death characteristics, over 25% of deaths had missing data for mode of transportation, place of 39 40 death, timing of death, or reported injuries (supplementary table 1). Thus, our findings for these 41 42 elements extracted from the narratives may be less representative of the decedents who lived in on October 2, 2021 by guest. Protected copyright. 43 44 45 rural or poor areas. Finally, reliable forward projection of the number of RTI deaths beyond 2005 46 47 was not possible since the increase in the NCRB reported number of RTI deaths of 140% from 48 49 2005 to 2011 appeared to outpace the rate of population growth.[44] As the proportion of 50 51 vulnerable road user deaths remained stable during this period in the NCRB reports, we 52 53 postulated that this increase represented an actual increase in RTI death totals rather than more 54 55 accurate reporting. Furthermore, given the rapid economic expansion and concurrent changes 56 57 58 in motorization including the types of vehicle sharing the road and road infrastructure,[45,46] our 59 60 14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 15 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 results on deceased mode of transportation, place and timing of death, and injuries sustained 4 5 6 may not reflect the current Indian scenario. An analysis of the trend from 2001 2014 is planned 7 8 pending ongoing data collection in the MDS. 9 10 11 12 In India, RTI is a significant cause of preventable death, particularly in males of productive 13 14 working age and among pedestrians, bicyclists, and motorcyclist. We have shown that properly 15 For peer review only 16 designed simple verbal autopsy narratives can document the much needed surveillance data on 17 18 19 the numbers, rates, risks, and basic RTI mechanism such as modes of transportation, timing of 20 21 death, place of death, and injuries sustained. Our findings suggested that investment in primary 22 23 and secondary prevention could address a large proportion of avoidable RTI deaths. 24 25 26 27 ACKNOWLEDGEMENTS 28 29 We thank the Office of the RGI for the ongoing productive collaboration on the MDS, C 30 31 32 Ramasundarahettige for technical assistance, M Puri and S Levitt for data extraction. The 33 opinions expressed in this article are those of the authors and do not necessarily represent
34 http://bmjopen.bmj.com/ 35 36 those of the Government of India or the RGI. 37 38 39 40 COMPETING INTERESTS 41 42 We declare that we have no competing interests. on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 FUNDING 48 49 This study is supported by grants from the John E Fogarty International Center of the National 50 51 Institutes of Health (R01 TW05991–01 and TW07939 01), the Bill & Melinda Gates Foundation 52 53 through the Disease Control Priorities Network Project, and the University of Toronto (to PJ); the 54 55 Canada Research Chair Programme (to PJ and ABN); and the Canadian Institutes of Health 56 57 58 Research Doctoral Award (to MH). The funding sources had no role in the study design; data 59 60 15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 16 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 collection, analysis, interpretation; writing of the manuscript; or decision to submit for publication. 4 5 6 The senior author had full access to all the data in the study and had final responsibility for the 7 8 decision to submit this study for publication. 9 10 11 12 AUTHOR’S CONTRIBUTION 13 14 PJ and the MDS Collaborators (appendix) designed, planned, the executed the MDS in close 15 For peer review only 16 collaboration with the Office of the Registrar General of India (RGI). MH and PJ performed the 17 18 19 data analysis. All authors contributed to data interpretation, revisions of the manuscript, and 20 21 provided final approval. PJ is the guarantor for this report. 22 23 24 25 DATA SHARING STATEMENT 26 27 Data used in this study are the property of the Registrar General of India and the overall 28 29 mortality results have been published in 2009.[47] This specific analyses is produced under an 30 31 32 agreement with CGHR. 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 17 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 REFERENCES 4 5 6 7 1 Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention: World 8 9 Health Organization 2004;1–244. 10 11 12 2 Chisholm D, Naci H, Hyder AA, et al. Cost effectiveness of strategies to combat road traffic 13 14 injuries in sub Saharan Africa and South East Asia: mathematical modelling study. BMJ 15 For peer review only 16 2012;344:e612. 17 18 19 3 The PLoS Medicine Editors. Preventing Road Deaths—Time for Data. PLoS Med 20 21 22 2010;7:e1000257. 23 24 25 4 Barffour M, Gupta S, Gururaj G, et al. Evidence based road safety practice in India: 26 27 assessment of the adequacy of publicly available data in meeting requirements for 28 29 comprehensive road safety data systems. Traffic Inj Prev 2012;13 Suppl 1:17–23. 30 31 32 5 Kopits E, Cropper ML. Traffic fatalities and economic growth. World Bank Development 33
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34 http://bmjopen.bmj.com/ 35 2012;12:561. 36 37 38 36 Hsiao M, Morris SK, Bassani DG, et al. Factors Associated with Physician Agreement on 39 40 Verbal Autopsy of over 11500 Injury Deaths in India. PLoS ONE 2012;7:e30336. 41 42 43 37 Singh H, Dhattarwal SK. Pattern and distribution of injuries in fatal road traffic accidents in on October 2, 2021 by guest. Protected copyright. 44 45 Rohtak (Haryana). Journal of Indian Academy of Forensic Medicine 2004;26:20–3. 46 47 48 38 Dandona R, Mishra A. Deaths due to road traffic crashed in Hyderabad city in India: need 49 50 51 for strengthening surveillance. Natl Med J India 2004;17:74–9. 52 53 54 39 Sahdev P, Lacqua MJ, Singh B, et al. Road traffic fatalities in Delhi: causes, injury patterns, 55 56 and incidence of preventable deaths. Accident Analysis & Prevention 1994;26:377–84. 57 58 59 60 20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 21 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 40 Bhattacharjee J, Bora D, Sharma RS, et al. Unnatural deaths in Delhi during 1991. Med Sci 4 5 6 Law 1996;36:194–8. 7 8 9 41 Jain A, Menezes RG, Kanchan T, et al. Two wheeler accidents on Indian roads a study 10 11 from Mangalore, India. J Forensic Leg Med 2009;16:130–3. 12 13 14 42 Gururaj G, Shastry KVR, Chandramouli AB, et al.Traumatic brain injury. Bangalore: 15 For peer review only 16 National Institute of Mental Health and Neuro Sciences, 2005. 17 18 19 43 Colohan AR, Alves WM, Gross CR, et al. Head injury mortality in two centers with different 20 21 22 emergency medical services and intensive care. J Neurosurg Pediatrics 1989;71:202–7. 23 24 25 44 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2011. Ministry of 26 27 Home Affairs, Government of India2011. 28 29 30 45 Transport Research Wing, Ministry of Road Transport & Highways. Basic Road Statistics of 31 32 India. Government of India 2012. 33
34 http://bmjopen.bmj.com/ 35 36 46 Transport Research Wing, Ministry of Road Transport & Highways. Road Transport Year 37 38 Book (2009 10 & 2010 11). Government of India 2012. 39 40 41 47 Registrar General of India and Centre for Global Health Research. Causes of Death in 42 43 India, 2001-2003: Sample Registration System. Government of India 2009. on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49
50 51 52 53 54 55 56 57 58 59 60 21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 22 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 FIGURE LEGENDS 4 5 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 6 7 8 0-69 years) across states and regions of India, by gender. 9 10 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol 11 12 size is proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, 13 14 Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 15 For peer review only 16 19 female deaths from Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N 17 18 Islands, Daman & Diu, Lakshadweep, and Goa. CHT=Chhatisgarh. 19 20 21 22 23 Figure 2: Deceased mode of transportation, place of death, and timing of death. 24 25 (A) Deceased mode of transportation in present study compared to National Crime Records 26 27 Bureau 2005 Report. Shaded line represents vulnerable road users (defined as road users 28 29 without a rigid barrier protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, 30 31 and three wheelers). Percentages from present study are weighted by state and rural/urban 32 33 residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death
34 http://bmjopen.bmj.com/ 35 36 and (C) timing of death based on verbal autopsy narratives. Shaded lines represent deaths that 37 38 are reported as occurring at the scene of collision or occurring instantly (defined as within 5 39 40 minutes). 41 42
on October 2, 2021 by guest. Protected copyright. 43 44 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI 45 46 47 deaths). 48 49 Percentages refer to those in each row with given injury (columns). *Values in bold denote two 50 51 by two chi square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were 52 53 also reported but not shown due to small numbers (61 and 25 cases, respectively). 54 55 56 57 58 59 60 22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 23 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 LIST OF ACRONYMS 4 5 6 7 8 CI Confidence interval 9 th 10 ICD 10 International Statistical Classification of Diseases and Related Health Problems, 10 11 12 Revision 13 14 LMIC Low and middle income countries 15 For peer review only 16 MDS Million Death Study 17 18 19 NCRB National Crime Records Bureau 20 21 RGI Registrar General of India 22 23 RTI Road traffic injury 24 25 SRS Sample registration system 26 27 UN United Nations 28 29 WHO World Health Organization 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 24 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 0-69 years) 31 across states and regions of India, by gender. 32 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol size is 33 proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 19 female deaths from
34 http://bmjopen.bmj.com/ 35 Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N Islands, Daman & Diu, Lakshadweep, 36 and Goa. CHT=Chhatisgarh.
37 160x111mm (300 x 300 DPI) 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 25 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 Figure 2: Deceased mode of transportation, place of death, and timing of death. 42 (A) Deceased mode of transportation in present study compared to National Crime Records Bureau 2005 43 Report. Shaded line represents vulnerable road users (defined as road users without a rigid barrier on October 2, 2021 by guest. Protected copyright. 44 protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, and three wheelers). Percentages 45 from present study are weighted by state and rural/urban residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death and (C) timing of death based on verbal autopsy 46 narratives. Shaded lines represent deaths that are reported as occurring at the scene of collision or 47 occurring instantly (defined as within 5 minutes). 48 49 178x182mm (300 x 300 DPI) 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 26 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 For peer review only 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI deaths). Percentages refer to those in each row with given injury (columns). *Values in bold denote two by two chi 48 square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were also reported but not 49 shown due to small numbers (61 and 25 cases, respectively). 50 141x191mm (300 x 300 DPI) 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Injury Reported Injury
Deceased Mode of Transportation Mode Deceased
Place of Death Place BMJ Open http://bmjopen.bmj.com/
There are no missing values for age, sex, and location in the study population. The chi square test was used to to used was test square chi The population. study inthe location and sex, age, for values missing no are There Timing of Death Timing on October 2, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
For peer review only
Narrative section Narrative
n (%) n (%) n (%) p n (%) n (%) p n (%) n (%) p n (%) n (%) p n (%) n (%) p 4 (8.2) 4 (8.2) 45 (91.8) 18 (36.7) 31 (63.3) 15 (30.6) 34 (69.4) 10 (20.4) 39 (79.6) 25 (51.0) 24 (49.0) 0 (0.0) 0 (0.0) 122 (100.0) 30 (24.6) 92 (75.4) 18 (14.8) 104 (85.3) 12 (9.8) 110 (90.2) 51 (41.8) 71 (58.2) 24 (6.1) 24 (6.1) 372 (93.9) 121 (30.6) 275 (69.4) 105 (26.5) 291 (73.5) 33 (8.3) 363 (91.7) 203 (51.3) 193 (48.7) 12 (2.9) 12 (2.9) 402 (97.1) 0.002 106 (25.6) 308 (74.4) 0.015 90 (21.7) 324 (78.0) 0.133 37 (8.9) 377 (91.1) 0.687 199 (48.1) 215 (51.9) 0.172 16 (3.2) 16 (3.2) 487 (96.8) 121 (24.1) 382 (75.9) 97 (19.3) 406 (80.7) 46 (9.2) 457 (90.9) 241 (47.9) 262 (52.1) 17 (3.1) 17 (3.1) 534 (96.9) 144 (26.1) 407 (73.9) 110 (20.0) 441 (80.0) 51 (9.3) 500 (90.7) 279 (50.6) 272 (49.4) 81 (5.2) 81 (5.2) (94.8) 1478 459 (29.4) (70.6) 1100 360 (23.1) (76.9) 1199 134 (8.6) (91.4) 1425 793 (50.9) 766 (49.1) 60 (8.1) 60 (8.1) 679 (91.9) 0.006 243 (32.9) 496 (67.1) 0.094 205 (27.7) 534 (72.3) 0.016 60 (8.1) 679 (91.9) 0.701 381 (51.6) 358 (48.4) 0.757 Missing Missing missing Not Missing missing Not Missing missing Not Missing missing Not Missing missing Not 118 (6.2) 118 (6.2) (93.8) 1785 0.916 582 (30.6) (69.4) 1321 0.991 461 (24.2) (75.8) 1442 0.336 161 (8.5) (91.5) 1742 0.934 972 (51.1) 931 (48.9) 0.946 125 (7.2) 125 (7.2) (92.9) 1623 0.001 559 (32.0) (68.0) 1189 0.009 456 (26.1) (73.9) 1292 0.004 143 (8.2) (91.8) 1605 0.429 896 (51.3) 852 (48.7) 0.799 130 (6.9) 130 (6.9) (93.1) 1755 597 (31.7) (68.3) 1288 476 (25.3) (75.0) 1409 157 (8.3) (91.7) 1728 976 (51.8) 909 (48.2) 1 (100.0) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) 0 (0.0) 1 (100.0) 1 (100.0) 0 (0.0) 126 (7.5) 126 (7.5) (92.5) 1548 0.001 552 (33.0) (67.0) 1122 0.000 451 (26.9) (73.1) 1223 0.001 136 (8.1) (91.9) 1538 0.468 883 (52.8) 791 (47.3) 0.057
(n=2299) (n=2299) 142 (6.2) (93.8) 2157 703 (30.6) (69.4) 1596 566 (24.6) (75.4) 1733 194 (8.4) (91.6) 2105 (51.1) 1175 (48.9) 1124
data. missing of Summary 1: Table Supplementary missing missing worker worker non worker non worker occupation missing missing primary and above and above primary 100 (7.7) (92.3) 1196 396 (30.6) 900 (69.4) 321 (24.8) 975 (75.2) 104 (8.0) (92.0) 1192 682 (52.6) 614 (47.4) below primary primary below 38 (4.0) 916 (96) 0.000 289 (30.3) 665 (69.7) 0.894 230 (24.1) 724 (75.9) 0.719 80 (8.4) 874 (91.6) 0.757 468 (49.1) 486 (50.9) 0.094 education missing missing high high low low neighbourhood asset neighbourhood urban urban rural rural location female female male male sex ≥20 years years ≥20 <20 years years <20 age all RTI
determine the p values and excluded deaths with missing neighbourhood asset, education, or occupation. occupation. or education, asset, neighbourhood missing with deaths excluded and values p the determine Page 27 of 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from Page 28 of 53 Odds ratios Odds
1.2-2.5*
OR 99% CI 1.7* Adjusted Adjusted
Head Injury was Reported
OR 99% CI (%) n Adjusted Adjusted
BMJ Open Place of was PrehospitalDeath http://bmjopen.bmj.com/
OR 99% CI (%) n on October 2, 2021 by guest. Protected copyright. Adjusted Adjusted For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
Timing ofwas Death Instant n (%) n 37 (40.2) 0.5 0.3 1.0 55 (51.4) 0.5 0.3 1.0 46 (25.1) 0.8 0.5 1.4 245 (52.0) 0.8 0.5 1.1 306 (59.2) 0.6 0.4 1.0 256 (43.5) 170 (58.6) ref 223 (69.5) ref 125 (31.5) ref 338 (58.5) 1.1 0.7 1.7 425 (69.1) For 1.1 0.7 1.7 peer 192 (24.9) 0.8 review 0.5 1.1 only
reported. injuries head and of death, place death, of timing the and transportation of mode deceased between Association 2: Table Supplementary comparison between difference significant statistically denote bold in *Value education. and asset, neighbourhood sex, rural/urban, age, deceased's for areadjusted unknown three ridersanimal & wheelers 93 (56.4) 0.9 0.5 1.6 117 (67.6) 0.9 0.5 1.7 72 (33.0) 1.2 0.7 1.9 bicyclist bicyclist & motorcyclist pedestrian vulnerable road users: non vulnerable road users Deceased Mode Transportationof
groups. groups. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
5.7 6.4 0.4 53.4 20.7 63.3 26.5 45.0 79.9 15.9 74.0 24.7 60.6 37.4 36.2 70.4 46.4 78.0 55.6 51.1 43.0 Rate Crude RTICrude Death % Under reporting% of *Excludes railroad deaths since NCRB does not doesnot NCRB since deaths railroad *Excludes Rate in 2005 in Rate BMJ Open (per 100,000)* Crude RTICrude Death http://bmjopen.bmj.com/ Number of of Number RTI deaths indeaths 2005* MDS NCRB MDS NCRB on October 2, 2021 by guest. Protected copyright. For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml 6559 1077 854 16.4 13.0 66154 14808 13961 22.4 21.1 86499 9363 4364 10.8 5.0 11120 2335 857 21.0 7.7 63375 9237 6793 14.6 10.7 13211 3610 724 27.3 5.5 57141 8172 6876 14.3 12.0 14121 4037 1589 28.6 11.3 55926 6987 5264 12.5 9.4 33785 5051 3161 15.0 9.4 16289 2161 2023 13.3 12.4 23688 6128 3282 25.9 13.9 26455 7380 1622 27.9 6.1 81934 10991 10944 13.4 13.4 29150 3277 1456 11.2 5.0 39485 5083 2895 12.9 7.3 122181 13172 3430 10.8 2.8 106386 16638 10613 15.6 10.0 186591 33287 9860 17.8 5.3 1130618 178520 98254 15.8 8.7 2005 UN For peer review only population estimates (inestimates '000)
Himachal PradeshHimachal Maharashtra Gujarat Karnataka Delhi NaduTamil Rajasthan Madhya PradeshMadhya + CDH 90568 15726 7686 17.4 8.5 Kerala Orissa Assam West Bengal Haryana PradeshAndhra Total Other StatesOther Uttar Pradesh Kashmir Jammu & Bihar + Jharkhand Punjab
Northeast StatesNortheast Supplementary Table 3: Comparison between present study (MDS) estimates and National Crime Records Bureau (NCRB) (NCRB) Bureau Records Crime National and estimates (MDS) study present between Comparison 3: Table Supplementary and Meghalaya. Other States include Pondicherry, Chandigarh, Uttaranchal, Dadra & Nagar Haveli, A & N Islands, Daman & Diu, Diu, & Daman Islands, N & A Haveli, Nagar & Dadra Uttaranchal, Chandigarh, Pondicherry, include States Other Meghalaya. and *100%. rate death MDS / death rate) NCRB rate death (MDS = reporting %under Chhatisgarh. = CDH Goa. and Lakshadweep, police reports of the number of RTI deaths and crude death rate, by state. by rate, death crude and deaths of RTI number the of reports police publish state level railroad death figures. Northeast States include Sikkim, Arunachal Pradesh, Nagaland, Manipur, Mizoram, Tripura, Tripura, Mizoram, Manipur, Nagaland, Arunachal Pradesh, Sikkim, include States Northeast figures. death railroad state level publish
Page 29 of 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 BMJ Open Page 30 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3MILLION DEATH STUDY COLLOBORATORS 4 5Indian Academic Partners (in alphabetical order): 61. Department of Community Medicine Gujarat Medical College, Ahmedabad: DV Bala, P Seth, KN Trivedi 72. Department of Community Medicine Kolkatta Medical College, Kolkatta: SK Roy 83. Department of Community Medicine Regional Institute of Medical Sciences, Imphal: L Usharani 94. Department of Community Medicine S.C.B. Medical College Cuttack, Orissa: Dr. B Mohapatra 105. Department of Community Medicine SMS Medical College Jaipur: AK Bharadwaj, R Gupta 116. Epidemiological Research Center, Chennai: V Gajalakshmi, CV Kanimozhi 127. Gandhi Medical College, Bhopal: RP Dikshit, S Sorangi 13 8. Healis Seskarhia Institute of Public Health, Navi Mumbai: PC Gupta, MS Pednekar, S Sreevidya 14 159. Apollo Institute of MedicalFor Sciences & peerResearch, Hyderabad: review P Bhatia only 1610. St. John’s Academy of Health Sciences, Bangalore: A Kurpad, P Mony, M Vaz, S Srinivasan, A Shet, AS Shet, D Xavier, 17 S Rathi, V Habbare 1811. King George Medical College, Lucknow: S Awasthi 1912. Najafgarh Rural Health Training Centre, Ministry of Health Government of India, New Delhi: N Dhingra, J Sudhir, I 20 Rawat (until 2007) 2113. Regional Medical Research Center, ICMR Institute, Bhubaneshwar: AS Karketta, SK Dar 2214. School of Preventative Oncology, Patna: DN Sinha 2315. School of Public Health Post Graduate Institute of Medical Education and Research, Chandigarh: N Kaur, R Kumar, JS 24 Thakur 2516. Tata Memorial Cancer Hospital, Mumbai: RA Badwe, RP Dikshit, M Mallath, K Panse, A Budukh 26 27 28Lead Partners: 291. Office of the Registrar General India, RK Puram, New Delhi India: C Chandramouli (Registrar General of India [RGI]), 30RC Sethi, B Mishra (until 2012), S Jain (until 2008), DK Dey, AK Saxena, MS Thapa, N Kumar; JK Banthia and DK Sikri 31(former RGIs) 32 332. Million Death Study Coordinating Centre for Global Health Research (CGHR) Li Ka Shing Knowledge Institute, St.
34Michael’s Hospital, Dalla Lana School of Public Health, University of Toronto, Canada: P Jha (Principal Investigator), R http://bmjopen.bmj.com/ 35Kamadod, S Rathi, S Rao Seshadri, P Rodriguez, P Sati, J Sudhir, C Ramasundarahettige, W Suraweera 36 37Affiliated Partners: 381. Indian Council of Medical Research, New Delhi India: VM Katoch (Director General or DG from 2008), NK Ganguly 39 (DG to 2008), L Kant, B Bhattacharya, B Shah, DK Shukla 40 412. World Health Organisation, Geneva and SEARO Office, New Delhi: T Boerma, A Fric, S Habayeb (former WHO 42 Representative India), S Khanum, CD Mathers, DN Sinha, N Singh, P Singh (Deputy Regional Director) 433. Clinical Trial Service Unit and Epidemiological Studies Unit (CTSU), University of Oxford, England: N Bhala, J on October 2, 2021 by guest. Protected copyright. 44 Boreham, R Peto, G Whitlock 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 31 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 Road traffic injury mortality and its mechanisms in India: nationally 5 representative mortality survey of 1.1 million homes 6 7 8 Marvin Hsiao, Ajai Malhotra, JS Thakur, Jay K Sheth, Avery B Nathens, Neeraj Dhingra, 9 10 Prabhat Jha, for the Million Death Study Collaborators. 11 12 13 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 14 15 University of Toronto,For Toronto, peer Canada (M review Hsiao MD, Prof P Jha only DPhil); Division of General 16 17 Surgery, Department of Surgery, University of Toronto, Toronto, Canada (M Hsiao MD, Prof AB 18 Nathens MD); Department of Surgery, VCU Medical Center, Virginia Commonwealth University, 19 20 Richmond, USA (Prof A Malhotra MD); Department of Community Medicine, Post Graduate 21 Institute of Medical Education and Research, Chandigarh, India (JS Thakur MD); Smt. N.H.L. 22 23 Municipal Medical College, Ahmedabad, India (JK Sheth MD); Sunnybrook Research Institute, 24 25 Sunnybrook Health Sciences Centre, Toronto, Canada (Prof AB Nathens MD); National AIDS 26 Control Organization, New Delhi, India (N Dhingra MD) 27 28 29 30 31 Correspondence to: 32 Marvin Hsiao 33 Centre for Global Health Research, Li Ka Shing Knowledge Institute, St Michael’s Hospital, and
34 Division of General Surgery, Department of Surgery, University of Toronto http://bmjopen.bmj.com/ 35 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 36 [email protected] 37 +1 416 864 6042 (phone) / +1 416 864 5256 (fax) 38 39 Keywords: Road traffic injury; verbal autopsy; India; low and middle income countries 40
41 42 Word count: Text: 33613440 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 1 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 32 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ABSTRACT: 4 5 6 Objectives: To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. 7 8 Design: We conducted a nationally representative mortality survey where at least two 9 10 physicians coded each non medical field staff’s verbal autopsy reports. RTI mechanism data 11 12 were extracted from the narrative section of these reports. 13 14 Setting: 1.1 million homes in India. 15 For peer review only 16 Participants: Over 122 000 deaths at all ages from 2001 2003. 17 18 19 Primary and secondary outcome measures: Age and sex specific mortality rates, place and 20 21 timing of death, modes of transportation, and injuries sustained. 22 23 Results: The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or 24 25 about 2% of all deaths in 2005 nationally, of which 65% occurred in males between the ages of 26 27 15 59 years. The age adjusted mortality rate was greater in males than in females, in urban 28 29 than in rural areas, and was notably higher than that estimated from national police records. 30 31 32 Pedestrians (68 000), motorcyclists (36 000), and other vulnerable road users (20 000) 33 constituted 68% of RTI deaths (124 000) nationally. Among the study sample, the majority of all
34 http://bmjopen.bmj.com/ 35 36 RTI deaths occurred at the scene of collision (1005/1733, 58%), within minutes of collision 37 38 (883/1596, 55%), and/or involved a head injury (691/1124, 62%). Compared to non pedestrian 39 40 RTI deaths, about 55 000 (81%) of pedestrian deaths were associated with less education and 41 42 living in poorer neighbourhoods. on October 2, 2021 by guest. Protected copyright. 43 44 45 Conclusions: In India, RTI cause a substantial number of deaths, particularly among 46 47 pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce 48 49 injuries might address over half of the RTI deaths. Improved pre hospital transport and hospital 50 51 trauma care might address just over a third of the RTI deaths. 52 53 54 55 56 57 58 59 60 2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 33 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 ARTICLE SUMMARY 4 5 6 Article focus 7 8 • To directly estimate the age and sex specific mortality rates and describe the place and 9 10 timing of death, modes of transportation, and injuries sustained for road traffic injury 11 12 (RTI) deaths in India using a nationally representative mortality survey of 1.1 million 13 14 homes. 15 For peer review only 16 Key messages 17 18 19 • Road traffic injuries cause a substantial number of avertable deaths, particularly in males 20 21 of productive working age and among pedestrians and other vulnerable road users. 22 23 • Preventative interventions should be emphasized as the majority of all RTI deaths 24 25 occurred at the scene of collision, within minutes of collision, and/or involved a head 26 27 injury. 28 29 30 • Properly designed mortality survey with verbal autopsy narratives can provide much 31 32 needed data to assist RTI prevention efforts. 33
34 Strengths and limitations of this study http://bmjopen.bmj.com/ 35 36 • This study is the first nationally representative survey of the causes of death in India and 37 38 overcomes limitations of existing data sources including regional injury surveys, hospital 39 40 41 series, and national police reports. 42 43 • Limitations of the study include potential misclassification of deaths by physician coders, on October 2, 2021 by guest. Protected copyright. 44 45 the use of layperson narratives with a potential for recall bias and inaccuracies, and 46 47 limited ability to forward project study results given the rapid changes in motorization in 48 49 India. 50 51 52 53 54 55 56 57 58 59 60 3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 34 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 INTRODUCTION 4 5 6 Road traffic injuries (RTI) area large and growing public health burden, especially in low and 7 8 middle income countries (LMIC) where 90% of the world’s deaths due to RTI are estimated to 9 10 occur.[1] There are few high quality epidemiologic data on RTI to guide the development, 11 12 implementation, and surveillance of evidence based policy and programs in LMICs.[2 4] 13 14 15 For peer review only 16 The number of deaths due to RTI in India is projected to rise with increasing motorization.[1,5] 17 18 19 Aside from a few regional injury surveys,[6 11] the current data on the numbers and 20 21 mechanisms of RTI deaths in India rely on police or hospital records, both of which can 22 23 substantially underestimate death rates in the poor, rural, and uneducated people who still 24 25 constitute large proportions of the Indian population.[2 4,12,13] 26 27 28 29 The World Health Organization (WHO), using indirect modeling methods, estimated about 202 30 31 32 000 RTI deaths in India in 2004.[14,15] No study has validated this estimate with direct 33 measurement nor documented detailed RTI mechanism for India nationally. Here, we estimate
34 http://bmjopen.bmj.com/ 35 36 the regional, age and sex specific mortality rate and risk of RTI death in India using data from 37 38 the Million Death Study (MDS). We also report the modes of transportation, place and timing of 39 40 death, and injuries sustained in RTI deaths. 41 42 on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 35 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 METHODS 4 5 6 Study Design: The MDS is an on going nationally representative survey designed to determine 7 8 the causes and risk factors of death in India, organized by the Registrar General of India (RGI). 9 10 The design, methodology, and preliminary findings of the MDS have been described 11 12 elsewhere.[16 19] In brief, the MDS used an enhanced version of verbal autopsy (known as the 13 14 routine, reliable, representative, re sampled household investigation of mortality with medical 15 For peer review only 16 evaluation or RHIME) to monitor a nationally representative sample of 1.1 million households in 17 18 19 the Sample Registration System (SRS). Within six months of every death occurring in these 20 21 households from 2001 3, a trained, nonmedical RGI surveyor interviewed a relative or close 22 23 acquaintance of the deceased to obtain the symptoms and events around the death using 24 25 structured questions and a local language narrative guided by a specific symptom list. These 26 27 records were converted into electronic records and emailed to two of 140 trained physicians 28 29 who, independently and anonymously, assigned an underlying cause of death (with allocation 30 31 32 determined randomly based only on the physician’s ability to read the local language), using 33 guidelines for the major causes of death.[20] Records were assigned cause of death in three
34 http://bmjopen.bmj.com/ 35 36 digit International Statistical Classification of Diseases and Related Health Problems, 10th 37 38 revision (ICD 10).[21] Records where coders disagreed on the cause of death underwent 39 40 anonymous reconciliation. Continuing disagreements were adjudicated by a third senior 41 42 physician. Five percent of households were randomly resurveyed and the results were on October 2, 2021 by guest. Protected copyright. 43 44 45 consistent within families of ICD 10 codes.[16] Participation in the SRS is on a voluntary basis 46 47 and oral consent was obtained under the confidentiality and consent procedures of the 48 49 Registration of Births and Deaths Act, 1969. 50 51 52 53 Road Traffic Injury Deaths: The RTI deaths in this study were of people who died between 54 55 2001 and 2003 with a final assigned ICD 10 code within V01 V89. We translated the open 56 57 58 ended narratives into English from 14 local languages, and systematically extracted the modes 59 60 5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 36 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 of transportation, place and timing of death, and injuries sustained from 2157 of the 2299 RTI 4 5 6 deaths using a standardized data extraction tool and procedure (the remaining 142 deaths, 6%, 7 8 had missing or illegible narratives). For these four data elements, there were substantial inter 9 10 rater agreement between two investigators and two research assistants who were trained and 11 12 independently extracted data from the narratives of a random 10% of RTI deaths (lowest kappa 13 14 statistic was greater than 0.69 for all pair wise comparisons between the four data extractors; 15 For peer review only 16 data not shown). The two research assistants then independently extracted data from all 17 18 19 narratives. Adjudication was done by an investigator (MH) for discrepancies in extracted data. 20 21 22 23 Analysis: The age and sex specific proportion of RTI deaths within the 2001 2003 survey was 24 25 applied to the 2005 United Nations (UN) estimates of the number of deaths from all causes in 26 27 India, after weighting for sampling probability for each rural or urban stratum per state (although 28 29 such weighting made little difference because the study was nationally representative).[18,22] 30 31 32 The 2005 UN death estimates were used so as to correct for the slight undercounts reported in 33 the total death rates in the SRS [23,24] and to account for the 12% of enumerated deaths
34 http://bmjopen.bmj.com/ 35 36 without completed field visits (mostly due to out migration of the family or from incomplete field 37 38 records). The proportion of these missed deaths was similarly dispersed across sex, age, and 39 40 states. Use of 2003 or 2004 UN death totals yielded nearly identical results (data not shown). 41 42 The 99% confidence intervals (99%CI) for mortality rate were calculated based on the weighted on October 2, 2021 by guest. Protected copyright. 43 44 45 number of study deaths. State and rural/urban specific estimates of the number, mortality rate, 46 47 and lifetime risk of RTI death were calculated by partitioning the UN national death totals 48 49 according to relative SRS death rates as previously described.[18,25,26] Urban and rural status 50 51 was defined according to the Census of India. Logistic regression was used to compare the 52 53 socio demographic traits of pedestrian and non pedestrian RTI deaths. Household fuel type was 54 55 used as a measure of community wealth, based on earlier principal component analyses [18]: 56 57 58 high asset neighbourhoods had >50% of households that used gas, electricity, or kerosene; low 59 60 6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 37 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 asset or poor neighbourhoods used primarily coal, firewood, or other. Attributable proportion 4 5 6 was calculated for traits of pedestrian deaths compared to non pedestrian RTI deaths. 7 8 9 10 The MDS received ethics approval from the review boards of the Post Graduate Institute of 11 12 Medical Education and Research in Chandigarh, India; St Michael’s Hospital in Toronto, 13 14 Canada; and the Indian Council of Medical Research’s Health Ministry’s Screening Committee. 15 For peer review only 16 17 18 19 20 21 RESULTS 22 23 The 2299 RTI deaths in the 2001 2003 survey correspond to an estimated 183 600 (99%CI 173 24 25 800 193 400) RTI deaths in India in 2005. The majority of these RTI deaths occurred in males 26 27 (152 100 deaths, 82.8%; table 1). The age standardized RTI mortality rate for males (26.2 per 28 29 100 000, 24.6 27.7) was higher than for females (5.7 per 100 000, 5.0 6.4). While the RTI 30 31 32 mortality rate increased with age in both genders, the largest number of RTI deaths occurred in 33 males between 15 59 years of age (118 900, 64.8%).
34 http://bmjopen.bmj.com/ 35 36 37 38 At these death rates and in the theoretical absence of other causes of death, males in India had 39 40 a 2.1% (2.0 2.3) risk of dying from RTI before age 70, with the highest risks at ages 30 59 41 42 years; females had a 0.5% (0.4 0.5) risk of dying from RTI before age 70. Males in Haryana, on October 2, 2021 by guest. Protected copyright. 43 44 45 Punjab, Tamil Nadu, and Uttar Pradesh had significantly higher risks (3.0 4.1%) than the 46 47 national risk (figure 1). In contrast, males in Bihar, Jharkhand, Andhra Pradesh, Orissa, Gujarat, 48 49 and West Bengal had significantly lower risks (1.3 1.6%) than the national risk of RTI deaths. 50 51 Males living in urban areas had slightly higher age standardized mortality rates and risks of RTI 52 53 deaths (27.6 per 100 000; 2.4%, 2.1 2.6) compared to males living in rural areas (24.9 per 100 54 55 000; 2.0%, 1.8 2.1). By contrast, female RTI mortality rates and risks before age 70 varied much 56 57 58 less across states and were similar in rural and urban areas (data not shown). 59 60 7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from
Page 38 of 53
Period risk for RTI death†
5.7 0.5%† 15.5 1.3%† 26.2 2.1%† 16.2 1.3%† RTI death rateΨ (99% CI)
per 100 000 *Proportion of RTI deaths deaths RTI of *Proportion
3.8 3.2 (2.0 4.4) 0.03% 8.5 6.6 (4.9 8.3) 0.1% 9.1 64.5(49.1 80.0) 5.0 8.1 (7.1 9.1)¶ 0.04% 4.9 7.4 (6.5 8.4)¶ 0.04% 3.5 21.6(13.4 29.9) 4.4 4.1 (2.7 5.5) 0.1% 5.3 3.5 (2.4 4.6) 0.1% 3.7 14.8(9.8 19.9) 0.2% 6.0 8.6 (5.9 11.3) 0.1% 10.6 44.0(34.6 53.4) 0.5% 28.0 38.4(33.2 43.6) 0.6% 43.8 37.9(33.7 42.1) 0.6% 47.1 28.9(25.9 31.9) 0.4% 31.5 171.0 183.6 152.1 All India,All 2005 (27.5 35.6) (5.0 6.4) (0.4 0.5) (173.8 193.4) (15.4 17.1) (1.3 1.4) (161.5 180.4) (14.7 16.4) (1.3 1.4) (143.2 161.0) (24.6 27.7) (2.0 2.3)
Estimated RTI deaths§, thousands
0.9 / 24 0.9 / 73 1.3 / 14 1.2 / 61 1.2 / 67 1.3 / 16 0.6 / 25 0.5 / 69 5.3 / 585 4.5 / 546 0.2 / 118 0.6 / 115 0.2 / 129 0.4 / 163 0.3 / 106 0.3 / 150 7.2 / 1100 9.8 / 1131
All deaths / populationAll (millions, 2005 UN estimates)
8
immediately immediately agree BMJ Open http://bmjopen.bmj.com/ (89.5%) (90.4%)
(88.1%) (89.8%)
Rural (%**)Rural coders Two
tudy deaths, 2001-2003 on October 2, 2021 by guest. Protected copyright. Proportion RTI*
S For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml
44 / 1955 2.3% 38 (80.1) 43 97 / 1926 5.2% 86 (84.1) 87 54 / 9016 0.6% 42 (68.6) 52 70 / 6402 1.1% 55 (70.9) 61 59 / 4055 1.4% 39 (59.0) 50 72 / 4394 1.5% 53 (60.5) 63 529 / 6817 7.7% 385 (67.0) 477 605 / 4727 13.0% 462 (68.9) 558 50 / 11492 0.4% 46 (93.4) 45 44 / 11719 0.4% 37 (76.7) 44 For peer47 / 17343 review 0.3% 33 (61.8) 35 only 396 / 54657 0.7% 306 (69.8) 349 149 / 12120 1.2% 117 (71.8) 133 356 / 11731 3.0% 249 (60.9) 312 123 / 18732 0.6% 106 (81.2) 98 190367772 / 2.8% 1442(68.9) 1709 212986354 / 2.4% 1609(68.5) 1925 2299122429 / 1.8% 1748(69.0) 2058 deaths / all deaths coded deaths
Number of of Number RTI
compared to all deaths, weighted by state and residence (rural/urban). **Percentage rural is weighted by state and residence (rural/urban). §Obtained by by §Obtained (rural/urban). residence and state by weighted is rural **Percentage (rural/urban). residence and state by weighted deaths, all to compared estimated Nations United the 2005 to standardized ΨAge proportions. the weighted by 2005 in deaths total estimated Nations United the multiplying physician on based those than CI wider in result which deaths, study of number weighted on based calculated are CI shown 99% population; Indian by years 0 69 between calculated is risk which the forlifetime except range, age of the duration by multiplied rate death RTI †Annual agreement. rate. death ¶Crude risks. period specific the age of summation gender. and age by 2005, for totals national estimated and study present the in deaths injury traffic 1: Road Table (% or 99% CI) Total male Total and female, all agesmale (% or 99% CI) Total male Total and female, <70 male years
(% or CI) 99% All ages All >70 >70 60 69 45 59 30 44 15 29 5 14 0 4 Female - Female age yearsin
(% or CI) 99% All ages All >70 >70 60 69 45 59 30 44 15 29 5 14 0 4 Male - age yearsin
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Page 39 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 The deceased mode of transportation was described in the narratives of 2105 (92%) of the RTI 4 5 6 deaths. National estimates for the deceased mode of transportation were calculated, as those 7 8 with unknown and known modes of transportation did not appear to differ with respect to the 9 10 major socio demographic traits (Supplementary Table 1). Vulnerable road users are those 11 12 without a rigid barrier protecting against traumatic forces and include pedestrians, motorcyclists, 13 14 bicyclists, and three wheelers. They constituted a majority (68%; n=124 000, 99%CI 115 000 15 For peer review only 16 131 000) of RTI deaths, led by pedestrians (37%; n=68 000, 62 000 73 000) and motorcyclists 17 18 19 (20%; n=36 000, 31 000 40 000) (figure 2). Drivers and passengers of motorized four wheelers 20 21 comprised 16% (n=31 000, 27 000 35 000) of RTI deaths. By contrast, the 2005 police reports, 22 23 which use a different but compatible classification system to ICD 10, recorded only 33000 24 25 vulnerable road user deaths and only 9000 pedestrian deaths.[27] The most common types of 26 27 vehicle to collide into the decedents were heavy transport vehicles and buses (37%; n=68 000, 28 29 61 000 74 000), followed by cars and vans (15%; n=28 000, 24 000 32 000). Single vehicle 30 31 32 incidents comprised 9% of deaths (n=17 000, 14 000 20 000). The most frequent combinations, 33 resulting in 23% (n=42 000, 37 000 47 000) of RTI deaths, were collisions of heavy transport
34 http://bmjopen.bmj.com/ 35 36 vehicles or buses with pedestrians and motorcyclists (data not shown). 37 38 39 40 The place and timing of death were described in the narratives of 1733 (75%) and 1596 (69%) 41 42 of the RTI deaths respectively (figure 2; see supplementary table 1 for a summary of missing on October 2, 2021 by guest. Protected copyright. 43 44 45 data from the narratives with respect to deceased characteristics). For these narratives, only the 46 47 study proportion and not national estimates were made. Most RTI deaths occurred at the scene 48 49 of collision (58%, 1005/1733) or instantly, defined as within 5 minutes (55%, 883/1596). Only 3% 50 51 (45/1733) were labeled as potentially avertable with better pre hospital transport as they 52 53 occurred on scene but not instantly. Another 35% of deaths occurred en route (7%, 124/1733) or 54 55 in hospital (28%, 481/1733). 56 57 58 59 60 9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 40 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 Injuries sustained by the deceased were reported from1124 narratives (49%). Head injuries 4 5 6 were the most commonly reported (62%, 691/1124), of which 76% (524/691) were reported as 7 8 isolated head injuries (figure 3). A greater percentage of motorcyclists (78%, 188/241) had head 9 10 injuries reported compared to non motorcyclists (57%, 457/807). After adjusting for age, sex, 11 12 rural/urban, neighbourhood asset, and education, bicyclists and motorcyclists were more likely 13 14 to have head injuries reported compared to non vulnerable road users (adjusted OR 1.7, 1.2 15 For peer review only 16 2.5) (supplementary table 2). 17 18 19 20 21 Compared to non pedestrian RTI deaths, pedestrian deaths occurred to those who had less 22 23 education (or in the case of children age <15 years, have less educated parents) (adjusted OR 24 25 2.9, 99%CI 2.0 4.2), lived in poorer neighbourhoods (1.7, 1.1 2.5), were children or elderly 26 27 adults (<15 years: 2.9, 1.8 4.5; >59 years: 1.7, 1.2 2.4), were female (1.5, 1.2 2.2), and lived in 28 29 urban areas (1.5, 1.1 2.2) (table 2). If pedestrian deaths had the same proportion of secondary 30 31 32 or higher education as non pedestrian RTI deaths, there would be 406/825 (49%) fewer 33 pedestrian deaths, corresponding to approximately 33 000 deaths nationally in 2005. The
34 http://bmjopen.bmj.com/ 35 36 corresponding attributable proportion for living in richer versus poorer neighbourhoods would be 37 38 265/825 (32%) or approximately 22 000 deaths nationally. Within the narratives we could code, 39 40 there were no differences between pedestrians and non pedestrian RTI deaths in timing of 41 42 death, place of death, reported injuries, or reported routine use of alcohol or smoking (data not on October 2, 2021 by guest. Protected copyright. 43 44 45 shown). 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 41 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 7 8 Attributable 9 Pedestrian / Pedestrian Deaths 10 Non Pedestrian Adjusted OR^ (% of all 825 11 Total=825/1280 (99% CI) pedestrian deaths) 12 Education* 13 Secondary or higher 112/382 ref 14 Primary or middle 248/450 1.8 (1.3 2.6) 110 406 (49%) 15 Below primary For peer451/423 review 2.9 (2.0 4.2) only 296 16 Unknown 14/25 1.6 (0.6 4.2) N/A 17 18 Neighbourhood Asset 19 High 137/320 ref 20 Low 643/895 1.7 (1.1 2.5) 265 (32%) 21 Unknown 45/65 1.5 (0.8 2.8) N/A 22 Age in years 23 15 59 (driving ages) 497/1046 ref 24 <15 (children) 144/74 2.9 (1.8 4.5) 94 170 (21%) 25 >59 (elderly adults) 184/160 1.7 (1.2 2.4) 76 26 Sex 27 Male 621/1121 ref 28 Female 204/159 1.5 (1.1 2.2) 68 (8%) 29 Location 30 31 Rural 643/962 ref 32 Urban 182/318 1.5 (1.1 2.2) 61 (7%) 33 Occupation Salaried / Wage Earner / Professional 229/517 ref
34 http://bmjopen.bmj.com/ 35 Cultivator / Agricultural labour / Other 162/300 0.9 (0.6 1.3) N/A 36 Non worker / Children <15 years 433/463 1.2 (0.9 1.6) N/A 37 Unknown 1/0 N/A N/A 38 Routine Alcohol Use** 39 No 494/877 ref 40 Yes 145/260 1.1 (0.7 1.5) N/A 41 Unknown 42/69 1.0 (0.5 1.9) N/A 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 Table 2: Characteristics of pedestrian RTI deaths and attributable proportions. *Education 46 of deceased adults or, in cases of deceased children <15 years, education of respondent. 47 **Excludes 218 children. ^Odds ratios are adjusted for all other variables in this table except for 48 alcohol use; the odds ratios for alcohol use are adjusted for all other variables in this table. 49 50 51 52 53 DISCUSSION 54 55 56 RTI is an important cause of death in India, causing 183 600 deaths in 2005, or about 2% of all 57 58 deaths.[22] Much of the deceased were men between ages 15 59 years. Males had a four fold 59 60 11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 42 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 higher cumulative risk of RTI death compared to females before the age of 70. Among the major 4 5 6 states, there was approximately 3 fold variation in the age standardized RTI death rate and 7 8 cumulative risk for males. 9 10 11 12 Our estimated number of RTI deaths is more than 50% greater than the 118 265 deaths 13 14 reported in the official police statistics of the National Crime Records Bureau (NCRB) in 15 For peer review only 16 2005.[27] Compared to our estimates, the extent of under reporting of the crude death rate in 17 18 19 major states by NCRB ranged from <1% to about 80% (supplementary table 3). Existing 20 21 regional population based injury surveys in India support our findings and also report higher 22 23 crude RTI death rates than NCRB statistics.[8,11] Under reporting of RTI deaths in police 24 25 statistics has been reported in India and other LMIC.[28 30] A study in urban India comparing 26 27 both hospital and community based RTI data to police records identified factors contributing to 28 29 under reporting that included the deceased believed to be at fault, collision resulting from hit 30 31 32 and runs, limited police resources, and the lack of a standard police reporting protocol by 33 hospitals.[28] The factors contributing to police under reporting, especially in rural India, require
34 http://bmjopen.bmj.com/ 35 36 further examination. Our estimated number of RTI deaths in 2005 was consistent with the WHO 37 38 estimate for 2004.[14] However, we observed a slightly higher male proportion (83% MDS vs. 39 40 77% WHO, all ages) and a higher proportion of male deaths between 15 59 years (65% MDS 41 42 vs. 61% WHO). on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 Almost three quarters of all RTI deaths in India were of pedestrians and other vulnerable road 48 49 users. In contrast, a much lower proportion (27%) was reported by the NCRB (figure 2). This 50 51 difference equated to 59 000 pedestrian and 32 000 other vulnerable road user deaths that were 52 53 not included in the 2005 NCRB records. Existing RTI studies based on regional surveys and 54 55 hospital series also reported a high proportion (>60%) of vulnerable road user deaths similar to 56 57 58 our findings.[11,12,30 32] Since the majority of vulnerable road users were pedestrians, our 59 60 12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 43 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 findings suggested that RTI deaths in individuals who were less educated, poor, female or live in 4 5 6 urban areas may have been disproportionally excluded from the NCRB records. While poverty 7 8 and education are not likely to be in the direct causal pathway of pedestrian deaths, they 9 10 nonetheless point to other associated risk factors. Indeed, 55 000 pedestrian deaths in 2005 11 12 (81%) was associated with lower education or living in poorer neighbourhoods compared to non 13 14 pedestrian RTI deaths. While the less educated and the poor likely travelled more often by foot, 15 For peer review only 16 they might also be exposed to undetermined environmental (neighbourhoods with unsafe 17 18 19 roads), biological (poor vision or decreased mobility due to poor health), and behavioral (alcohol 20 21 or other substance use) risk factors for pedestrian death.[12, 33, 34] Further studies are needed 22 23 to better understand pedestrian deaths in LMIC. 24 25 26 27 Over half of RTI deaths occurred instantly at the scene of collision and/or had head injury 28 29 reported. These findings, together with existing RTI hospital series and regional surveys in India, 30 31 32 make a strong argument that investments in primary and secondary prevention could potentially 33 avert the greatest proportion of RTI deaths. To address the high proportion of instant deaths and
34 http://bmjopen.bmj.com/ 35 36 head injuries among RTI deaths in India, specific interventions that are effective and based on 37 38 studies in LMIC should be emphasized; these may include speed bumps, motorcycle helmets, 39 40 and increasing fines and license suspensions for rule infractions.[33] In contrast, improving pre 41 42 hospital transport and hospital trauma care, could only potentially affect the 38%who died on on October 2, 2021 by guest. Protected copyright. 43 44 45 scene with delayed hospital transport (3%), en route to hospital (7%), or in hospital (28%). 46 47 48 49 Our study is the first nationally representative survey of the causes of death in India. The simple 50 51 descriptive statistics provide clear evidence on the large and avertable burden from RTI, 52 53 particularly among productive age adults and pedestrians. To the best of our knowledge, only 54 55 one recent study in Vietnam has used similar methods to analyze RTI deaths and policy 56 57 58 implications on a national scale.[35] 59 60 13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 44 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 4 5 6 Our study faced certain limitations. First, we might have misclassified certain causes of death 7 8 including suicide as RTI deaths. However, the extent of misclassification should be minimal 9 10 since the RHIME verbal autopsy method was shown to be robust in discerning between types of 11 12 injury deaths[36] and since the immediate two physician agreement was high for RTI 13 14 deaths(89.5%, table 1). Furthermore, suicides cause about 200 000 deaths in India annually but 15 For peer review only 16 few are due to RTI.[19] Second, since the modes of transportation, place and timing of death, 17 18 19 and injuries sustained were extracted from layperson open ended narratives, the data accuracy 20 21 may be in question. For example with the deceased mode of transportation, the extent of 22 23 misclassification (by our study) or misreporting (by NCRB) that contributed to the differences 24 25 between the two sources is uncertain. With reported injuries, our findings from these narratives 26 27 most likely undercounted less visible injuries (chest, abdomen, and spine) compared to highly 28 29 visible injuries such as bleeding and deformity for head and extremity injuries. Nevertheless, our 30 31 32 findings are consistent with available Indian regional surveys and hospital series on the mode of 33 transportation[11,12,30 32,37] place and timing of death,[1,37 41] and injuries
34 http://bmjopen.bmj.com/ 35 36 sustained.[12,37,42,43] Third, since the narrative was not designed specifically to capture RTI 37 38 death characteristics, over 25% of deaths had missing data for mode of transportation, place of 39 40 death, timing of death, or reported injuries (supplementary table 1). Thus, our findings for these 41 42 elements extracted from the narratives may be less representative of the decedents who lived in on October 2, 2021 by guest. Protected copyright. 43 44 45 rural or poor areas. Finally, reliable forward projection of the number of RTI deaths beyond 2005 46 47 was not possible since the increase in the NCRB reported number of RTI deaths of 140% from 48 49 2005 to 2011 appeared to outpace the rate of population growth.[44] As the proportion of 50 51 vulnerable road user deaths remained stable during this period in the NCRB reports, we 52 53 postulated that this increase represented an actual increase in RTI death totals rather than more 54 55 accurate reporting. Furthermore, given the rapid economic expansion and concurrent changes 56 57 58 in motorization including the types of vehicle sharing the road and road infrastructure,[45,46] our 59 60 14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 45 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 results on deceased mode of transportation, place and timing of death, and injuries sustained 4 5 6 may not reflect the current Indian scenario. An analysis of the trend from 2001 2014 is planned 7 8 pending ongoing data collection in the MDS. 9 10 11 12 In India, RTI is a significant cause of preventable death, particularly in males of productive 13 14 working age and among pedestrians, bicyclists, and motorcyclist. We have shown that properly 15 For peer review only 16 designed simple verbal autopsy narratives can document the much needed surveillance data on 17 18 19 the numbers, rates, risks, and basic RTI mechanism such as modes of transportation, timing of 20 21 death, place of death, and injuries sustained. Our findings suggested that investment in primary 22 23 and secondary prevention could address a large proportion of avoidable RTI deaths. 24 25 26 27 ACKNOWLEDGEMENTS 28 29 We thank the Office of the RGI for the ongoing productive collaboration on the MDS, C 30 31 32 Ramasundarahettige for technical assistance, M Puri and S Levitt for data extraction. The 33 opinions expressed in this article are those of the authors and do not necessarily represent
34 http://bmjopen.bmj.com/ 35 36 those of the Government of India or the RGI. 37 38 39 40 COMPETING INTERESTS 41 42 We declare that we have no competing interests. on October 2, 2021 by guest. Protected copyright. 43 44 45 46 47 FUNDING 48 49 This study is supported by grants from the John E Fogarty International Center of the National 50 51 Institutes of Health (R01 TW05991–01 and TW07939 01), the Bill & Melinda Gates Foundation 52 53 through the Disease Control Priorities Network Project, and the University of Toronto (to PJ); the 54 55 Canada Research Chair Programme (to PJ and ABN); and the Canadian Institutes of Health 56 57 58 Research Doctoral Award (to MH). The funding sources had no role in the study design; data 59 60 15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 46 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 collection, analysis, interpretation; writing of the manuscript; or decision to submit for publication. 4 5 6 The senior author had full access to all the data in the study and had final responsibility for the 7 8 decision to submit this study for publication. 9 10 11 12 AUTHOR’S CONTRIBUTION 13 14 PJ and the MDS Collaborators (appendix) designed, planned, the executed the MDS in close 15 For peer review only 16 collaboration with the Office of the Registrar General of India (RGI). MH and PJ performed the 17 18 19 data analysis. All authors contributed to data interpretation, revisions of the manuscript, and 20 21 provided final approval. PJ is the guarantor for this report. 22 23 24 25 DATA SHARING STATEMENT 26 27 Data used in this study are the property of the Registrar General of India and the overall 28 29 mortality results have been published in 2009.[47] This specific analyses is produced under an 30 31 32 agreement with CGHR. 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 47 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 REFERENCES 4 5 6 7 1 Peden M, Scurfield R, Sleet D, et al. World report on road traffic injury prevention: World 8 9 Health Organization 2004;1–244. 10 11 12 2 Chisholm D, Naci H, Hyder AA, et al. Cost effectiveness of strategies to combat road traffic 13 14 injuries in sub Saharan Africa and South East Asia: mathematical modelling study. BMJ 15 For peer review only 16 2012;344:e612. 17 18 19 3 The PLoS Medicine Editors. Preventing Road Deaths—Time for Data. PLoS Med 20 21 22 2010;7:e1000257. 23 24 25 4 Barffour M, Gupta S, Gururaj G, et al. Evidence based road safety practice in India: 26 27 assessment of the adequacy of publicly available data in meeting requirements for 28 29 comprehensive road safety data systems. Traffic Inj Prev 2012;13 Suppl 1:17–23. 30 31 32 5 Kopits E, Cropper ML. Traffic fatalities and economic growth. World Bank Development 33
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34 http://bmjopen.bmj.com/ 35 2012;12:561. 36 37 38 36 Hsiao M, Morris SK, Bassani DG, et al. Factors Associated with Physician Agreement on 39 40 Verbal Autopsy of over 11500 Injury Deaths in India. PLoS ONE 2012;7:e30336. 41 42 43 37 Singh H, Dhattarwal SK. Pattern and distribution of injuries in fatal road traffic accidents in on October 2, 2021 by guest. Protected copyright. 44 45 Rohtak (Haryana). Journal of Indian Academy of Forensic Medicine 2004;26:20–3. 46 47 48 38 Dandona R, Mishra A. Deaths due to road traffic crashed in Hyderabad city in India: need 49 50 51 for strengthening surveillance. Natl Med J India 2004;17:74–9. 52 53 54 39 Sahdev P, Lacqua MJ, Singh B, et al. Road traffic fatalities in Delhi: causes, injury patterns, 55 56 and incidence of preventable deaths. Accident Analysis & Prevention 1994;26:377–84. 57 58 59 60 20 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 51 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 40 Bhattacharjee J, Bora D, Sharma RS, et al. Unnatural deaths in Delhi during 1991. Med Sci 4 5 6 Law 1996;36:194–8. 7 8 9 41 Jain A, Menezes RG, Kanchan T, et al. Two wheeler accidents on Indian roads a study 10 11 from Mangalore, India. J Forensic Leg Med 2009;16:130–3. 12 13 14 42 Gururaj G, Shastry KVR, Chandramouli AB, et al.Traumatic brain injury. Bangalore: 15 For peer review only 16 National Institute of Mental Health and Neuro Sciences, 2005. 17 18 19 43 Colohan AR, Alves WM, Gross CR, et al. Head injury mortality in two centers with different 20 21 22 emergency medical services and intensive care. J Neurosurg Pediatrics 1989;71:202–7. 23 24 25 44 National Crime Records Bureau. Accidental Deaths and Suicides in India, 2011. Ministry of 26 27 Home Affairs, Government of India2011. 28 29 30 45 Transport Research Wing, Ministry of Road Transport & Highways. Basic Road Statistics of 31 32 India. Government of India 2012. 33
34 http://bmjopen.bmj.com/ 35 36 46 Transport Research Wing, Ministry of Road Transport & Highways. Road Transport Year 37 38 Book (2009 10 & 2010 11). Government of India 2012. 39 40 41 47 Registrar General of India and Centre for Global Health Research. Causes of Death in 42 43 India, 2001-2003: Sample Registration System. Government of India 2009. on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49
50 51 52 53 54 55 56 57 58 59 60 21 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml BMJ Open Page 52 of 53 BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 FIGURE LEGENDS 4 5 Figure 1: Road traffic injury deaths, age-standardized death rate, and cumulative risk (age 6 7 8 0-69 years) across states and regions of India, by gender. 9 10 Death rates are standardized to the 2005 United Nations estimated Indian population. Symbol 11 12 size is proportional to sample size. Northeast states include Sikkim, Arunachal Pradesh, 13 14 Nagaland, Manipur, Mizoram, Tripura, and Meghalaya. Total estimates include the 80 male and 15 For peer review only 16 19 female deaths from Pondicherry, Chandigarh, Uttarakhand, Dadra & Nagar Haveli, A&N 17 18 Islands, Daman & Diu, Lakshadweep, and Goa. CHT=Chhatisgarh. 19 20 21 22 23 Figure 2: Deceased mode of transportation, place of death, and timing of death. 24 25 (A) Deceased mode of transportation in present study compared to National Crime Records 26 27 Bureau 2005 Report. Shaded line represents vulnerable road users (defined as road users 28 29 without a rigid barrier protecting against traumatic forces, i.e. pedestrian, bicyclist, motorcyclist, 30 31 and three wheelers). Percentages from present study are weighted by state and rural/urban 32 33 residence. T=estimated/reported number of deaths in 2005 (in thousands). (B) Place of death
34 http://bmjopen.bmj.com/ 35 36 and (C) timing of death based on verbal autopsy narratives. Shaded lines represent deaths that 37 38 are reported as occurring at the scene of collision or occurring instantly (defined as within 5 39 40 minutes). 41 42
on October 2, 2021 by guest. Protected copyright. 43 44 Figure 3: Reported injuries from 1124 verbal autopsy narratives (49% of all 2299 RTI 45 46 47 deaths). 48 49 Percentages refer to those in each row with given injury (columns). *Values in bold denote two 50 51 by two chi square tests with p<0.05 (excluding unknowns). Abdominal and spinal injuries were 52 53 also reported but not shown due to small numbers (61 and 25 cases, respectively). 54 55 56 57 58 59 60 22 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml Page 53 of 53 BMJ Open BMJ Open: first published as 10.1136/bmjopen-2013-002621 on 19 August 2013. Downloaded from 1 2 3 LIST OF ACRONYMS 4 5 6 7 8 CI Confidence interval 9 th 10 ICD 10 International Statistical Classification of Diseases and Related Health Problems, 10 11 12 Revision 13 14 LMIC Low and middle income countries 15 For peer review only 16 MDS Million Death Study 17 18 19 NCRB National Crime Records Bureau 20 21 RGI Registrar General of India 22 23 RTI Road traffic injury 24 25 SRS Sample registration system 26 27 UN United Nations 28 29 WHO World Health Organization 30 31 32 33
34 http://bmjopen.bmj.com/ 35 36 37 38 39 40 41 42 43 on October 2, 2021 by guest. Protected copyright. 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 23 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml