Abstract:

Objectives:

To describe the profile of the victims of road accidents presenting physical sequelae, according to the criteria established by researchers and analyze the trends in hospitalization for this cause in Brazil, from 2000 to 2013.

Methods:

An ecological time-series study was performed using the data from the Hospital Information System of the National Health System (SUS). Trends in hospitalization were estimated using Prais-Winstein regression.

Results:

During this period, a total of 1,747,191 hospitalizations for traffic accidents were registered; 410,448 were victims with physical sequelae. About 77.7% of them were male subjects, 26.5% belonged to the age group of 20 - 29 years, 46.4% lived in Southeast Brazil, 44.0% were pedestrians, and 31.1% were motorcyclists. In total, 51,189 cases were "confirmed" sequelae (12.5%), and pedestrians accounted for 43.8% of cases. There were 359,259 hospitalizations for the diagnosis of "possible" sequelae, and motorcyclists accounted for 43.3% of these cases. There was a trend of stability for all the patients with confirmed and possible sequelae, but there was a significant rise in hospitalization rates owing to confirmed sequelae among the men in North and Central-West regions.

Conclusion:

The hospitalizations associated with physical sequelae were responsible for about one-fourth of the hospitalizations in the Hospital Information System in the studied period. Most events involved men, young adults, residents in Southeast Brazil, and pedestrians. Hospitalization rates for traffic accidents associated with physical sequelae were stable in Brazil and regions, but a significant increase was observed for confirmed sequelae among men in the North and Central-West regions.

Keywords:
Accidents, Traffic Complications; Temporal distribution; External causes; Information systems; Brazil.

INTRODUCTION

Traffic accidents are a major cause of death, injury and disability and they impact the health sector owing to overload of emergency and urgency services and demand for specialized care, social assistance, and rehabilitation¹1. World Health Organization (WHO). Global status report on road safety: time for action. Geneva: World Health Organization, 2009.^,22. Minayo MCS. Violência e Saúde. Rio de Janeiro: Fiocruz. 2006.^,33. Organização Pan-Americana de Saúde. Informe sobre el estado de la seguridad vial en la Región de Las Américas. Wahingnton DC: Organização Pan-Americana de Saúde, 2009.. Many accidents do not have death as a consequence but sequelae with effects throughout the whole life of a person, including disabilities⁴4. Chandran A, Hyder AA, Peek-Asa C. The Global Burden of Unintentional Injuries and an Agenda for Progress. Epidemiol Rev 2010; 32: 110-20..

Worldwide, 20 to 50 million people are estimated to be victims of nonfatal injuries in road accidents (RAs), which contributes to the increased prevalence of disabilities⁵5. World Health Organization (WHO). United Nations Road Safety Collaboration. Global plan for the Decade of Action for Road Safety 2011-2020. Geneva: World Health Organization; 2011.. Overall, in 2000, RAs accounted for 69,138,531 disability-adjusted life years (DALY), representing a global burden of 2.4% of DALYs from all causes and ranking 10 among the 20 leading causes of mortality. In 2012, RAs reached the eighth position on the list of 20 leading causes of DALY with 78,723,890 years⁶6. World Health Organization. Health Estimates for the years 2000-2012. 2012. Disponível em: Disponível em: http://www.who.int/healthinfo/global_burden_disease/estimates/en/ (Acessado em 05 de março de 2015).
http://www.who.int/healthinfo/global_bur... .

Literature lacks information on the prevalence of people with disabilities owing to RAs, especially when it comes to permanent disability. However, there is evidence that the prevalence ranges from less than 1% in countries such as Croatia, Mexico, and Russia to 25% in Poland. On an average, 1 of 20 victims of road traffic accidents will be permanently disabled⁷7. World Health Organization (WHO). WHO global status report on road safety 2013: supporting a decade of action. Geneva: World Health Organization, 2013..

The distribution of these occurrences is uneven across the countries. For those with high income, in 2004, 2.8 and 1.1 million cases of moderate or severe disability were reported in the age group of 0 to 59 years and 60 or more years, respectively⁸8. World Health Organization (WHO). The global burden of disease: 2004 updat. Geneva: World Health Organization, 2008.. However, for countries with medium and low income, 35.4 million people aged 0 to 59 years and 5.7 million aged older than 60 years would present moderate or severe disabilities. In the Americas, over 5 million people are accounted for injuries subsequent to traffic accidents every year³3. Organização Pan-Americana de Saúde. Informe sobre el estado de la seguridad vial en la Región de Las Américas. Wahingnton DC: Organização Pan-Americana de Saúde, 2009..

In Brazil, mortality rates from RAs have declined partly owing to the implementation of the Traffic Code in 1998, but it has been increasing over the last decade. However, a large number of survivors exhibit significant physical and psychological sequelae, especially young adults⁹9. Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MHP, Da Silva CMFP, Minayo MCS. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. The Lancet 2011, 377(9781): 1962-75..

According to the data from the Violence and Injury Survey (VIVA) conducted in emergency and urgency rooms in 23 capitals and the Federal District in 2011, the leading causes of hospital admissions by external causes were falls, followed by RAs. Most cases (67%) progressed to hospital discharge in the first 24 hours after emergency care, while 23.1 and 6.6% were referred to hospital or other services, respectively¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: Vigilância de Violências e Acidentes, 2009, 2010 e 2011. Brasília: Ministério da Saúde, 2013..

The National Households Survey, 2008 points out that 4.8 million people were involved in traffic accidents; of them, 30.7% stopped performing daily activities owing to the accident¹¹11. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística - IBGE. Pesquisa Nacional por Amostra de Domicílios. Um Panorama da Saúde no Brasil: acesso e utilização dos serviços, condições de saúde e fatores de risco e proteção à saúde, 2008. Rio de Janeiro: IBGE, 2010.. Current data from the National Health Survey, conducted in a sample representative of the entire Brazilian territory, show that more than two million adults (aged ≥ 18 years) had been involved in traffic accidents with injury in the 12 months preceding the survey. Among them, 15.1% reported sequelae and/or disability resulting from this event, with the highest prevalence among women (18.6%) aged 40 to 59 years (21.3%) and individuals with low education (19.3%)¹²12. Brasil. Ministério do Planejamento, Orçamento e Gestão. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2013: acesso e utilização dos serviços de saúde, acidentes e violências. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2015..

In addition, external causes in general and, particularly, RAs result in high emotional and social costs, such as absence and leave from work, mental and emotional damage to the victims and their families, and the years of productivity or life lost²2. Minayo MCS. Violência e Saúde. Rio de Janeiro: Fiocruz. 2006.^,33. Organização Pan-Americana de Saúde. Informe sobre el estado de la seguridad vial en la Región de Las Américas. Wahingnton DC: Organização Pan-Americana de Saúde, 2009.. Psychological sequelae and posttraumatic stress disorder after RAs are potentially disabling in the long term, and although this is extremely relevant, it is little studied.

The aim of this study was to depict the profile of victims who were hospitalized owing to RA in Brazil between 2000 and 2013 and presenting physical sequelae and analyze the temporal trend in this period.

METHODS

An ecological time-series study was conducted with RA victims who showed diagnosis suggestive of physical sequelae in Brazil, from 2000 to 2013. Data on hospitalizations were obtained from the Hospital Information System of the National Health System (SIH/SUS), made available by the SUS Department of Informatics (DATASUS/Ministry of Health) through its website.

SIH/SUS includes the information about admissions in public and insured to SUS hospital¹³13. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003 - 2008. Ciênc Saúde Coletiva 2011; 16(9): 3807-16.^,1414. Bittencourt SA, Camacho LAB, Leal MC. O Sistema de informação hospitalar e sua aplicação na saúde coletiva. Cad Saúde Pública 2006; 22(1): 19-30.. Annual rates of hospitalization owing to physical consequences of RA were calculated according to sex, age, and geographic region. For these rates, data were first selected in the SIH database regarding hospitalizations with secondary diagnosis with codes V01-V89, 20th chapter of the 10th revision of International Statistical Classification of Diseases and Related Health Problems (ICD-10)¹⁵15. World Health Organization (WHO). CID-10 Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde 1997; 10a revisão. São Paulo: Universidade de São Paulo.corresponding to RA.

From the identification of hospitalizations owing to RAs, the case definition was used for people suffering sequelae according to the methodology developed by Mello Jorge and Koizumi¹⁶16. Mello Jorge MHP, Koizumi MS. Internações hospitalares, Brasil, 2008: um estudo dos pacientes hospitalizados por lesões decorrentes de acidentes de transporte terrestre. Relatório de Pesquisa. São Paulo; 2010., who worked with visible sequelae according to primary diagnosis of "confirmed" sequel: bone crushing (ICD-10: S07, S17, S28, S38, S47, S57, S67, S77, S87, S97, T04, T.14.7), amputation (ICD-10: S08, S18, S28, S38, S48, S58, S68, S78, S88, S98, T05, T09.6, T14.7, T11.6, T13.6), nerve injury (ICD-10: S04, S44, S54, S64, S74, S84, S94, T06.2, T14.4 , T11.3), spinal cord injury (ICD-10: S14, S24, S34, T06.0, T06.1, T09.3, T09.4), and sequelae (ICD-10: S90 to S94); and "possible" sequel: traumatic brain injury (ICD-10: S06) and burn (ICD-10: The T20 T32). Psychological sequelae will not be considered in this work.

Population estimates provided by the Brazilian Institute of Geography and Statistics (IBGE), as projected for the period 2000-2060¹⁷17. Instituto Brasileiro de Geografia e Estatística - IBGE (Brasil). Projeção da população do Brasil por sexo e idade para o período 2000/2060. Rio de Janeiro: IBGE, 2013. Disponível em: Disponível em: http://www.ibge.gov.br/home/estatistica/populacao/projecao_da_populacao/2013/default.shtm (Acessado em 20 de dezembro de 2013).
http://www.ibge.gov.br/home/estatistica/... , were used as denominators to calculate the hospitalization rates. Analysis of trend of admission owing to physical sequelae resulting from RAs in 2000-2013 was made with Prais-Winstein autoregression model. This method is recommended for time-series analysis, because it corrects the autocorrelation of residue¹⁸18. Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos JL. Gender and racial inequalities in trends of oral cancer mortality in Sao Paulo, Brazil. Rev Saúde Publica 2013; 47(3): 470-8.. Significant trend was when the estimated model obtained p ≤ 0.05.

Variation in annual hospitalization rates (%) for physical sequelae resulting from RAs during the period was estimated using the log of hospitalization rate as the outcome (Y) in the Prais-Winstein regression model. The regression coefficient obtained was then applied to the formula of variation in annual rate (%): (-1 + 10ˆb) × 100. The 95% confidence intervals (95%CI) of the variation in annual rate were determined by the following formula: b ± t EP, where t is Student's t -test value in the specific table and EP is the standard error of outcome of the coefficient provided by regression¹⁸18. Antunes JLF, Toporcov TN, Biazevic MGH, Boing AF, Bastos JL. Gender and racial inequalities in trends of oral cancer mortality in Sao Paulo, Brazil. Rev Saúde Publica 2013; 47(3): 470-8.. Analyses were performed using Microsoft Excel software (version 10) and Stata 11.

The data used in this study have public access, without identification of the patients. In addition, the ethical principles governing research involving human beings were complied with, according to the resolution of the National Health Council No. 466 of December 12, 2012. This study is part of the project approved by the Ethics Committee on Public Health School of Universidade de São Paulo, protocol 85973/2012.

RESULTS

In 2000-2013, there were 1,747,191 hospitalizations for RAs, with identification of 410,448 victims with diagnosis suggestive of physical sequelae across the country. Among the victims with sequelae, 77.7% were male subjects, 26.5% aged 20-29 years, 46.4% residents in the Southeast, and 32.5 and 31.1% pedestrians and motorcyclists, respectively. Considering the confirmed sequelae (bone crushing, amputation, nerve injury, spinal cord injury, and proper sequel) 51,189 cases of hospitalization resulting from RA associated with this cause were identified, being 76.4% male subjects, 24.1% aged 20 to 29 years, 48.5% living in the Southeast, and 43.8% pedestrians (Table 1).

There were 359,259 admissions in the period of study, with diagnosis suggestive possible sequelae (traumatic brain injury and burns). Of them, 77.9% were male subjects, 26.9% aged 20 to 29 years, and 46.1% residents in the Southeast region. Motorcyclists accounted for the majority of RAs-related hospitalizations with diagnosis of possible sequelae (31.6%) (Table 1).

Crude hospitalization rates for RA-related physical sequelae, in the whole country, were 13.3 and 16.3 admissions per 100,000 inhabitants in 2000 and 2013, respectively. The rates in 2000 were 1.7 admissions per 100,000 inhabitants with confirmed sequelae, and 11.6 admissions per 100,000 inhabitants with possible sequelae. In 2013, these numbers reached 2.5 and 13.8 per 100,000 inhabitants with confirmed and possible sequelae, respectively (Table 2).

By comparing the age-standardised hospitalization rates for RA-related physical consequences by region in 2000, the highest rates for both the confirmed and possible sequelae were seen in the Southeast. However, in 2013, the highest rates were found in the Northeast region for the total of physical sequelae and possible sequelae and in the Central-west region for confirmed sequelae (Table 2).

In Brazil and regions, stability was seen in age-standardised hospitalization rates for RA-related hospitalizations, with diagnosis of physical sequelae in 2000-2013; the crude rate was 1.2% (95%CI -19.1 - 26.5) for the country (Table 2). For the diagnosis of confirmed sequelae owing to RA, there was an increase in the trend of hospitalization rates in the North (range: 9.8%; 95%CI 1.3 - 38.1) and Central-west regions (range: 17.6%; 95%CI 2.5 - 85.1) (Table 2).

The rates of admission for RA with diagnosis of possible sequelae were stable for both Brazil (range: 0.7%, 95%CI -8.6 - 12.5) and the regions (Table 2). Among the female subjects, hospitalization rates owing to RA with diagnosis suggestive of physical consequences ranged from 6.1 admissions per 100,000 women in 2000 to 6.9 admissions per 100,000 women in 2013. The rates were stable for RA with sequelae (range: -0.5%; 95%CI -19.1 - 22.4), confirmed sequelae (range: 2.3%; 95%CI -10.4 - 19.5) and possible sequelae (range: -0.9%; 95%CI -9.8 - 9.0) among women from 2000 to 2013 (Table 3).

Hospitalization rates after RA with sequelae for male subjects were 20.52 and 25.79 hospitalizations per 100,000 men in 2000 and 2013, respectively. Stable behavior was observed in the hospitalization rates for RA with diagnosis suggestive of sequelae (range: 1.9%; 95%CI -15.7 - 23.3) and possible sequelae among the male subjects in the period studied (range: 1.4%, 95%CI -8.2 - 9.4). However, an increase in the trend was seen in the hospitalization rates for RA with confirmed sequelae among men (range: 6.5%; 95%CI 1.2 - 29.0) (Table 3).

DISCUSSION

Hospitalizations for RAs with diagnosis of physical sequelae accounted for more than one-fourth of all traffic-related cases recorded in the Hospital Information System (SIH) from 2000 to 2013. The highest proportions were observed among male young adults living in the Southeast region and among pedestrians. This profile was similar for both the types of sequelae (confirmed and possible), the latter differing as to the victims mostly affected: motorcyclists.

The regions with the highest hospitalization rates were Southeast and Northeast, in 2000 and 2013, respectively. The trend of hospitalization rates owing to RA associated with diagnosis suggestive of physical sequelae for Brazil and regions was stable. However, an increasing trend in the hospitalization rates for traffic-related diagnosis of confirmed sequelae was seen, especially in the North and Central-west regions among male subjects.

Traffic accident mortality rates in Brazil are currently lower than in the early 1990s, partly owing to the application of the New Traffic Law in 1998. However, a high number of survivors show significant physical and psychological sequelae, especially among young adults⁹9. Reichenheim ME, Souza ER, Moraes CL, Mello Jorge MHP, Da Silva CMFP, Minayo MCS. Violence and injuries in Brazil: the effect, progress made, and challenges ahead. The Lancet 2011, 377(9781): 1962-75.^,1919. Souza MFM, Malta DC, Conceição GMS, Silva MMA, Carvalho CG, Morais Neto OL. Análise descritiva e de tendência de acidentes de transporte terrestre para políticas sociais no Brasil. Epidemiol. Serv Saúde 2007; 16(1): 33-44..

Across the country, there are no data showing the burden of physical sequelae in any type of RA. The first general estimates of the situation were made by Mello Jorge and Koizumi¹⁶16. Mello Jorge MHP, Koizumi MS. Internações hospitalares, Brasil, 2008: um estudo dos pacientes hospitalizados por lesões decorrentes de acidentes de transporte terrestre. Relatório de Pesquisa. São Paulo; 2010., starting from some selected diagnoses (including the spine injuries with spinal cord impairment and amputations) of victims of traffic accidents, and they estimated that about 20% of cases that evolve to hospital discharge showed some type of sequel.

In the United States, data from the National Health Interview Survey Disability 1995, estimated 1,275,172 people with disabilities related to traffic accidents, with the highest proportions among women and adults aged 55 to 64 years²⁰20. Shults RA, Jones BH, Kresnow MJ, Langlois JA, Guerrero JL. Disability among adults injured in motor-vehicle crashes in the United States. J Safety Res 2004; 35(4): 447-52.. A study conducted in Yorkshire, England, with a cohort of 1,239 adults (aged ≥ 18 years) and data collected from 1993 to 1999, showed a prevalence of 18.3% of sequelae from foot injuries and demanding change in occupation²¹21. Jeffers RF, Tan HB, Nicolopoulos C, Kamath R, Giannoudis PV. Prevalence and patterns of foot injuries following motorcycle trauma. J Orthop Trauma 2004; 18(2): 87-91..

The prevalence of accident-related disability (falls, occupational events, traffic accidents, among others) in a population-based study in Ghana was 0.83% (95%CI 0.67 - 1.01%), with no difference between the men and women, and collisions between vehicles being the most frequent type of accident. Pedestrian injuries were the second most common cause of disabling injuries²²22. Mock C, Boland E, Acheampong F, Adjei S. Long-term injury related disability in Ghana. Disabil Rehabil 2003; 25(13): 732-41..

A study conducted in the city of Maringá (PR), with 3,468 victims of traffic accidents in 2000, established these risk factors associated with hospitalization: being a pedestrian, cyclist or motorcyclist, being aged > 50 years, facing heavy transport or bus collision, dawn or afternoon accidents, with the driver living in the city²³23. Soares DFPP, Barros MBA. Fatores associados ao risco de internação por acidentes de trânsito no Município de Maringá-PR.Rev Bras Epidemiol 2006; 9(2): 193-205.. Although this research does not mention physical sequelae, it agrees to this study as to the type of victim hospitalized in two studies: mostly pedestrians. However, there is a difference in age group. The authors stated that most seniors involved in RA were pedestrians, which increases vulnerability to RA.

A possible explanation to more frequent hospitalizations related to RA with diagnosis of physical sequelae among young adults is the increased exposure of this risk group to situations such as alcohol abuse, driving after taking alcohol, risky exposures when conducting vehicles, exceeding speed limits, inexperience, and fatigue¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: Vigilância de Violências e Acidentes, 2009, 2010 e 2011. Brasília: Ministério da Saúde, 2013.^,2424. Malta DC, Bernal RTI, Nunes ML, Oliveira MM, Iser BPM, Andrade SSCA, et al. Prevalence of risk and protective factors for chronic diseases in adult population: cross-sectional study, Brazil 2012. Epidemiol Serv Saúde 2014; 23(4): 609-22.^,2525. Abreu AMM, Lima JMBD, Matos LN, Pillon SC. Uso de álcool em vítimas de acidentes de trânsito: estudo do nível de alcoolemia. Rev Latino-Am Enfermagem 2010; 18(Spe): 513-20.^,2626. Malta DC, Bernal RTI, Silva MMA, Claro RM, Silva Júnior JB, Reis AAC. Consumption of alcoholic beverages, driving vehicles, a balance of dry law, Brazil, 2007-2013. Rev Saúde Pública 2014; 48(4): 692-966.^,2727. Bastos YGL, Andrade SM, Soares DA. Características dos acidentes de trânsito e das vítimas atendidas em serviço pré-hospitalar em cidade do Sul do Brasil, 1997/2000. Cad Saúde Pública 2005; 21(3): 815-22.^,2828. Oliveira NLB, Sousa RMC. Retorno à atividade produtiva de motociclistas vítimas de acidentes de trânsito. Acta Paul Enferm 2006; 19(3): 284-9.^,2929. Cabral APS, Souza WV, Lima MLC. Serviço de atendimento móvel de urgência: um observatório dos acidentes de transportes terrestre em nível local. Rev Bras Epidemiol 2011; 14(1): 3-14..

The predominance of hospitalizations associated with sequelae and its upward trend in male subjects is consistent with other studies showing that men and young adults are the group mostly affected by RA¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: Vigilância de Violências e Acidentes, 2009, 2010 e 2011. Brasília: Ministério da Saúde, 2013.^,2525. Abreu AMM, Lima JMBD, Matos LN, Pillon SC. Uso de álcool em vítimas de acidentes de trânsito: estudo do nível de alcoolemia. Rev Latino-Am Enfermagem 2010; 18(Spe): 513-20.^,2727. Bastos YGL, Andrade SM, Soares DA. Características dos acidentes de trânsito e das vítimas atendidas em serviço pré-hospitalar em cidade do Sul do Brasil, 1997/2000. Cad Saúde Pública 2005; 21(3): 815-22.^,2828. Oliveira NLB, Sousa RMC. Retorno à atividade produtiva de motociclistas vítimas de acidentes de trânsito. Acta Paul Enferm 2006; 19(3): 284-9.^,2929. Cabral APS, Souza WV, Lima MLC. Serviço de atendimento móvel de urgência: um observatório dos acidentes de transportes terrestre em nível local. Rev Bras Epidemiol 2011; 14(1): 3-14.. In 2006, the leading cause of hospitalizations among men aged 15 to 59 years was external³⁰30. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise de Situação em Saúde. Perfil da Saúde no homem. In: Brasil. Ministério da Saúde. Saúde Brasil 2007: uma análise da situação de Saúde. Brasília: Ministério da Saúde; 2007. p. 509-36.. In 2010, 929,893 hospital admissions were reported owing to external causes, traffic accidents accounting for 15.7% of all cases and increased risk for men aged 20 to 59 years³¹31. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Análise de Situação em Saúde. Epidemiologia das causas externas no Brasil: morbidade por acidentes e violências. In: Brasil. Ministério da Saúde. Saúde Brasil 2010: uma análise da situação de saúde e de evidências selecionadas de impacto de ações de vigilância em saúde. 2011. p. 205-24.. Sociocultural factors (misogyny, power relations, competitiveness, aggressiveness, and others) that establish male behavior in society may be related to their increased exposure to health-damaging situations²⁹29. Cabral APS, Souza WV, Lima MLC. Serviço de atendimento móvel de urgência: um observatório dos acidentes de transportes terrestre em nível local. Rev Bras Epidemiol 2011; 14(1): 3-14.^,3232. Alves RF, Silva RP, Ernesto MV, Lima AGB, Souza FM. Gênero e saúde: o cuidar do homem em debate. Psicologia: teoria e prática 2011; 13(3): 152-66.^,3333. Gomes R. Sexualidade Masculina, Gênero e Saúde. Rio de Janeiro: Fiocruz; 2008..

A systematic review of RA injuries reported that 35 to 40% of them show serious injuries, the main victims being male pedestrians aged between 19 and 29 years. The head injury is the most common type of injury in severe and fatal cases with a greater potential to generate sequels³⁴34. Calil AM, Sallum EA, Domingues CA, Nogueira LS. Mapeamento das lesões em vítimas de acidentes de trânsito: revisão sistemática da literatura. Rev Latino-Am Enfermagem 2009; 17(1): 120-5..

Our data on geographic distribution of hospitalizations for RA with sequelae shows that the Southeast and Northeast regions are the most affected, corroborating a study showing that, in 2003, the Southeast was proportionally the geographic portion with the highest concentration of deaths resulting in RA (41%), followed by the Northeast (22%)¹⁹19. Souza MFM, Malta DC, Conceição GMS, Silva MMA, Carvalho CG, Morais Neto OL. Análise descritiva e de tendência de acidentes de transporte terrestre para políticas sociais no Brasil. Epidemiol. Serv Saúde 2007; 16(1): 33-44.. The Northeast region also showed an increased risk of death from ATT between 2000 and 2010³⁵35. Morais Neto OL, Montenegro MMS, Monteiro RA, Siqueira Júnior JB, Silva MMA, Lima CM, et al. Mortalidade por acidentes de transporte terrestre no Brasil na última década: tendência e aglomerados de risco. Ciênc Saúde Coletiva 2012; 17(9): 2223-36..

Motorcyclists were the most common victim in traffic-related hospital admissions with diagnosis of possible sequelae. The motorcycle was involved in 56.8% of all RA (n = 7,451) referred to urgency and emergency services in 24 state capitals and the Federal District, as investigated by the Violence and Injury Survey (VIVA) in 2011¹⁰10. Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos Não Transmissíveis e Promoção da Saúde. Viva: Vigilância de Violências e Acidentes, 2009, 2010 e 2011. Brasília: Ministério da Saúde, 2013.. The use of safety devices such as helmet minimizes the severity of accidents and, consequently, the occurrence of sequelae³³33. Gomes R. Sexualidade Masculina, Gênero e Saúde. Rio de Janeiro: Fiocruz; 2008.. However, data from a time series of 1980 through 2003 indicate an increased mortality by RAs among the motorcyclists; the most probable hypothesis is related to the growth of motorcycle fleet in the country¹⁹19. Souza MFM, Malta DC, Conceição GMS, Silva MMA, Carvalho CG, Morais Neto OL. Análise descritiva e de tendência de acidentes de transporte terrestre para políticas sociais no Brasil. Epidemiol. Serv Saúde 2007; 16(1): 33-44..

The reasons for the increase in motorcycle fleet can be attributed to the precariousness of public transportation, tele-delivery services, the possibility of job for young people, and the easiness of buying a motorcycle³⁴34. Calil AM, Sallum EA, Domingues CA, Nogueira LS. Mapeamento das lesões em vítimas de acidentes de trânsito: revisão sistemática da literatura. Rev Latino-Am Enfermagem 2009; 17(1): 120-5.. Motorcyclists pointed that the risk of traffic accidents are related to personal and social interests to meet the demands involving money, speed, and time³⁵35. Morais Neto OL, Montenegro MMS, Monteiro RA, Siqueira Júnior JB, Silva MMA, Lima CM, et al. Mortalidade por acidentes de transporte terrestre no Brasil na última década: tendência e aglomerados de risco. Ciênc Saúde Coletiva 2012; 17(9): 2223-36..

The trend of increase in traffic-related hospitalization rates, with confirmed sequelae, mainly in the Central-west region, match data regarding RA mortality, which states that the region showed the highest mortality rates in 2003²²22. Mock C, Boland E, Acheampong F, Adjei S. Long-term injury related disability in Ghana. Disabil Rehabil 2003; 25(13): 732-41.. The main risk factors involved in traffic-related sequelae are: availability of urgency services, injury severity, time to prehospital care, and spinal cord damage³⁴34. Calil AM, Sallum EA, Domingues CA, Nogueira LS. Mapeamento das lesões em vítimas de acidentes de trânsito: revisão sistemática da literatura. Rev Latino-Am Enfermagem 2009; 17(1): 120-5.^,3939. Montenegro MMS, Duarte EC, Prado RC, Nascimento AF. Mortalidade de motociclistas em acidentes de transporte no Distrito Federal, 1996 a 2007. Rev Saúde Publica 2011; 45(3): 529-38.^,4040. Malta DC, Mascarenhas MDM, Bernal RTI, Silva MMA, Pereira CA, Minayo MCS, et al. Análise das ocorrências das lesões no trânsito e fatores relacionados segundo resultados da Pesquisa Nacional por Amostra de Domicílios (PNAD) Brasil, 2008. Ciênc Saúde Coletiva 2011; 16(9): 3679-87.^,4141. Leal-Filho MB, Borges G, Almeida BR, Aguiar AAX, Dantas KDS, Morais RKPD, et al. Spinal Cord injury: epidemiological study of 386 cases with emphasis on those patients admitted more than four hours after the trauma. Arq Neuropsiquiatr 2008; 66(2-B): 365-8.^,4242. Malm S, Krafft M, Kullgren A, Ydenius A, Tingvall C. Risk of permanent medical impairment (RPMI) in road traffic accidents. Ann Adv Automot Med 2008: 52: 93..

A limitation of this study was the use of database related only to admissions in services linked to SUS. However, these admissions account for about 70% of hospitalizations in the country¹³13. Silva ZP, Ribeiro MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003 - 2008. Ciênc Saúde Coletiva 2011; 16(9): 3807-16.^,1414. Bittencourt SA, Camacho LAB, Leal MC. O Sistema de informação hospitalar e sua aplicação na saúde coletiva. Cad Saúde Pública 2006; 22(1): 19-30.. Another limitation was the exclusion of psychological sequelae.

CONCLUSION

Prevention of RA and sequelae in Brazil is directly related to prehospital and hospital care of the victims, the monitoring of violence accidents, and the adoption of educational and legislative measures of road safety to contribute to the reduction the morbidity and mortality from these cases, according to the guidelines of National Policy for Morbidity and Mortality Reduction on Violence and Health⁴⁰40. Malta DC, Mascarenhas MDM, Bernal RTI, Silva MMA, Pereira CA, Minayo MCS, et al. Análise das ocorrências das lesões no trânsito e fatores relacionados segundo resultados da Pesquisa Nacional por Amostra de Domicílios (PNAD) Brasil, 2008. Ciênc Saúde Coletiva 2011; 16(9): 3679-87.^,4343. Brasil. Ministério da Saúde. Portaria n. 723, de 16 de maio de 2001. Dispõe sobre a Política Nacional de Redução de Morbimortalidade por Acidentes e Violência. Disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/politica_reducao_morbimortalidade_acidentes_2ed
http://bvsms.saude.gov.br/bvs/publicacoe... . Rehabilitation has shown a rapidly increasing importance with the rise of confirmed sequelae in the country. However, rehabilitation services are still insufficient, inadequate, and show low coverage⁴⁴44. Minayo MCS, Deslandes SF. Análise da implantação da rede de atenção às vítimas de acidentes e violências segundo diretrizes da Política Nacional de Redução da Morbimortalidade sobre Violência e Saúde. Ciênc Saúde Coletiva 2009; 14(5): 1641-9.. It is, therefore, recommended an increased investment in the prevention of RA and rehabilitation of victims with sequelae, reducing social impact in such cases. Brazil lacks and needs public health policies and strategies, which allow access to both the preventive and rehabilitation actions.

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