ABSTRACT:

Objective:

To describe the global burden of disease due to road traffic accidents in Brazil and federated units in 1990 and 2015.

Methods:

This is an analysis of secondary data from the 2015 Global Burden of Disease study estimates. The following estimates were used: standardized mortality rates and years of life lost by death or disability, potential years of life lost due to premature death, and years of unhealthy living conditions. The Mortality Information System was the main source of death data. Underreporting and redistribution of ill-defined causes and nonspecific codes were corrected.

Results:

Around 52,326 deaths due to road traffic accidents were estimated in Brazil in 2015. From 1990 to 2015, mortality rates decreased from 36.9 to 24.8/100 thousand people, a reduction of 32.8%. Tocantins and Piauí have the highest mortality risks among the federated units (FU), with 41.7/100 and 33.1/100 thousand people, respectively. They both present the highest rates of potential years of life lost due to premature deaths.

Conclusion:

Road traffic accidents are a public health problem. Using death- or disability-adjusted life years in studies of these causes is important because there are still no sources to know the magnitude of sequelae, as well as the weight of early deaths. Since its data are updated every year, the Global Burden of Disease study may provide evidence to formulate traffic security and health attention policies, which are guided to the needs of the federated units and of different groups of traffic users.

Keywords:
Accidents, traffic; External causes; Violence; Mortality; Disability-adjusted life years

INTRODUCTION

A total of 1.2 million deaths due to road traffic accidents (RTA) occurred all over the world in 2012, mainly affecting male individuals aged 15-29 years¹1. World Health Organization (WHO). Global status report on road safety 2015. Geneva: World Health Organization; 2015. Disponível em: Disponível em: http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/ (Acessado em 20 de outubro de 2016).
http://www.who.int/violence_injury_preve... . According to the Global Burden of Disease (GBD) study, there was a decrease in the rates of death- or disability-adjusted life years (DALYs), between 1990 and 2013, due to injuries from traffic accidents worldwide (-15.7%). However, this reduction occurred mainly in high-income countries, whereas an increase in low- and medium-income countries was observed²2. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 2016; 22: 3-18..

In Brazil, two population studies showed that 2.5 and 3.1% of the population older than 18 years suffered traffic accident injuries during a 12-month period, in the years of 2008 and 2013, respectively³3. 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. Cien Saúde Coletiva 2011; 16(9): 3679-87.^,44. Morais Neto OL, Andrade AL, Guimarães RA, Mandacarú PMP, Tobias GC. Regional disparities in road traffic injuries and their determinants in Brazil, 2013 Int J Equity Health 2016; 15(1): 142., with important regional inequalities. With regard to the number of deaths, the Brazilian Mortality Information System (SIM, acronym in Portuguese) registered an increase from 28,885 to 42,844 deaths due to RTA between 2000 and 2010, which corresponds to a 32.3% increase. This increase was observed among automobile occupants and motorcycle riders. There has been a decrease of pedestrian deaths since 2007⁵5. 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. Ciên Saude Coletiva 2012, 17(9): 2223-36.. In 2013, there were 42,266 deaths with a mortality rate of 21/100 thousand people and 1.3 million of potential years of life lost due to injuries in younger age ranges⁶6. Andrade SSCA, Mello-Jorge MHP. Mortality and potential years of life lost by road traffic injuries in Brazil, 2013. Rev Saude Pública 2016; 50: 59..

In addition to the high mortality rate, RTA have a strong impact on health services and on the society in general. Cost estimates of RTA for the Brazilian society, which were calculated by the Institute for Applied Economic Research (IPEA, acronym in Portuguese) have revealed a value of BRL 40 billion of road accidents and BRL 10 billion in urban areas⁷7. Instituto de Pesquisa Econômica Aplicada (IPEA); Polícia Rodoviária Federal (PRF). Acidentes de Trânsito nas Rodovias Federais Brasileiras: Caracterização, Tendências e Custos para a Sociedade. Relatório de Pesquisa. 2015.. In a study carried out in emergency services from Brazilian capitals, 25% of the attendance for external causes were due to traffic accidents⁸8. Malta DC, Bernal RTI, Mascarenhas MDM, Monteiro RA, Bandeira de Sá NN, Andrade SSCA , et al. Atendimentos por acidentes de transporte em serviços públicos de emergência em 23 capitais e no Distrito Federal - Brasil, 2009. Epidemiol Serv Saúde 2012; 21(1): 31-42.. Approximately 15% of hospitalizations for external causes in Brazilian public hospitals during the 2002-2011 period presented the diagnosis of injuries by RTA⁹9. Mascarenhas MDM , Barros MBA. Evolução das internações hospitalares por causas externas no sistema público de saúde - Brasil, 2002 a 2011. Epidemiol Serv Saúde 2015; 24(1): 19-29.. In addition, with regard to hospitalizations due to RTA in the Brazilian Unified Health System (SUS) during 2000-2013, 410.448 people (23.5%) were identified with diagnosis suggestive of physical sequelae and predominance of young men aged 20-29 years, mainly pedestrians and motorcycle riders¹⁰10. Andrade SSCA , Mello-Jorge MHP . Estimativa de sequelas físicas em vítimas de acidentes de transporte terrestre internadas em hospitais do Sistema Único de Saúde. Rev Bras Epidemiol 2016; 19(1): 100-11.. However, few studies have analyzed both the burden of mortality and sequelae and disability due to RTA in the Brazilian population during the last few decades.

The GBD study provided a wider view by comparing the incidence and prevalence estimates of these damages and impacts on mortality and occurrence of disabilities for all countries and regions in the world, through the disability-adjusted life years indicator (DALY)¹¹11. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996.. The first studies to use this methodology were published in 1996 and identified accidents and violence among the main causes of morbidity and mortality in the world¹¹11. Murray CJL, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge: Harvard University Press; 1996.^,1212. World Health Organization (WHO). The global burden of disease: 2004 update. Geneva: World Health Organization; 2008.^,1313. Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva: World Health Organization ; 2002.^,1414. World Health Organization (WHO). Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organization ; 2009.. The 2010 GBD study extended the analysis to 291 diseases and injuries, including 187 countries in 21 regions in the world¹⁵15. Murray CJL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: design, definitions, and metrics. The Lancet 2012; 380(9859): 2063-6.. In 2015, a specific analysis on accidents and violence that used 2013 GBD data was published²2. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 2016; 22: 3-18.. The 2015 GBD study updated the estimates and analysis of trend in the period from 1980 to 2015, due to the inclusion of new data and revision of methods. For the first time, sub-national data of several countries, including Brazil, were added. Therefore, data from 27 federated units (FU) are available, thus allowing the comparison with other countries¹⁶16. GBD 2015 Mortality and causes of death collaborators. Global, regional, and national life expectancy, all-cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2016; 388 (10053): 1459-544..

The aim of this study was to analyze the indicators of mortality and DALY due to RTA, between 1990 and 2015, in Brazil and in the FU, using the estimates produced in the 2015 GBD study.

METHODS

This is a study based on secondary data estimated for the Brazilian population through the 2015 GBD study, upon partnership between Institute for Health Metrics and Evaluation (IHME), from Washington University, the Brazilian Department of Health and GBD Brasil¹⁷17. Institute for Health Metrics and Evaluation (IHME). Data Visualization. Disponível em: Disponível em: http://www.healthdata.org/results/data-visualizations (Acessado em: 11 de novembro de 2016).
http://www.healthdata.org/results/data-v... . Considering that the conceptual principles and procedures of the GBD methodology have been updated since its first publication¹⁵15. Murray CJL, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: design, definitions, and metrics. The Lancet 2012; 380(9859): 2063-6., the burden of disease was estimated according to the methodology developed by the IHME in 2015. The results can be accessed in their webpage¹⁷17. Institute for Health Metrics and Evaluation (IHME). Data Visualization. Disponível em: Disponível em: http://www.healthdata.org/results/data-visualizations (Acessado em: 11 de novembro de 2016).
http://www.healthdata.org/results/data-v... .

The GBD uses several sources in each country, such as vital record, verbal autopsy, mortality surveillance, censuses, population researches, and data from hospitals and institutes of legal medicine²2. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 2016; 22: 3-18.^,1717. Institute for Health Metrics and Evaluation (IHME). Data Visualization. Disponível em: Disponível em: http://www.healthdata.org/results/data-visualizations (Acessado em: 11 de novembro de 2016).
http://www.healthdata.org/results/data-v... . As to external causes, registrations of the police and of transportation agencies are also used in the three spheres, such as traffic accident event reports. Studies from Brazilian agencies and institutional research have been used, such as the Crime Trends survey from the United Nations (UN)¹⁸18. United Nations Office On Drugs and Crime (UNODC). United Nations Surveys of Crime Trends and Operations of Criminal Justice Systems (UN-CTS). Disponível em: https://www.unodc.org/unodc/en/data-and-analysis/statistics.html (Acessado em: 20 de outubro de 2016).
https://www.unodc.org/unodc/en/data-and-... and the World Health Organization (WHO) report about the global status of road safety¹1. World Health Organization (WHO). Global status report on road safety 2015. Geneva: World Health Organization; 2015. Disponível em: Disponível em: http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/ (Acessado em 20 de outubro de 2016).
http://www.who.int/violence_injury_preve... ^,1919. World Health Organization (WHO). Global status report on road safety: time for action. Geneva: World Health Organization ; 2009. Disponível em: Disponível em: http://www.who.int/violence_injury_prevention/road_safety_status/2009/en/ (Acessado em: 20 de outubro de 2016).
http://www.who.int/violence_injury_preve... . The GBD discloses the sources used in each country, state, or other subnational geographic unit, which were used in the respective years²⁰20. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380(9859): 2095-128.^,2121. Naghavi M, Wang H, Lozano R, Davis A, Liang X, Zhou M, et al. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. 2015. The Lancet 385(9963): 117-7.. In countries with a good quality of vital record, police records are only used if the reported number of deaths due to injuries exceeds that of the vital record. In Brazil, the main source of information used for mortality analysis was the SIM database from the Department of Health²²22. Brasil. Sistema de Informações sobre Mortalidade (SIM). Brasília: CGIAE/Secretaria de Vigilância em Saúde-SVS. Disponível em: Disponível em: http://tabnet.datasus.gov.br/cgi/deftohtm.exe?sim/cnv/ext10br.def (Acessado em: 20 de outubro de 2016).
http://tabnet.datasus.gov.br/cgi/deftoht... .

In the calculation of GBD estimates of external causes, first all data sources for diseases and injuries are mapped. Next, garbage code adjustments are performed, which are then redistributed into other defined causes. Details on the grouping of causes using ICD-9 and ICD-10 reviews and also the classification errors have already been described²⁰20. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380(9859): 2095-128.. Finally, statistical models and modeling are applied to estimate data by age, sex, country, year, and cause. The DisMod-MR 2.1, which is a meta-regression tool to calculate simultaneous estimates of incidence, prevalence, remission, incapacity, and mortality, was also used¹⁶16. GBD 2015 Mortality and causes of death collaborators. Global, regional, and national life expectancy, all-cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet 2016; 388 (10053): 1459-544.^,2323. Foreman KJ, Lozano R, Lopez AD, Murray CJL. Modeling causes of death. An integrated approach using CODEm. Popul Health Metr 2012; 10: 1. DOI: 10.1186/1478-7954-10-1..

The following indicators were used in this study: mortality rates and DALY - standardized by age. DALY is an index composed of the potential years of life lost due to premature death (years of life lost - YLL) and damage caused by the disease, sequelae, or disability, given the different levels of severity of one or several diseases at the same time (years lived with disability - YLD). By adding the years of life lost due to premature mortality and years of unhealthy living conditions, the DALY aims at revealing the global burden that health loss imposes on countries and populations²⁴24. Marinho F, Passos VMA, França EB. Novo século, novos desafios: mudança no perfil da carga de doença no Brasil de 1990 a 2010. Epidemiol Serv Saúde 2016; 25(4): 713-24.^,2525. Murray CJL, Vos T, Lozano R, Naghavi M, Flaxman AD, Michaud C, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380(9859): 2197-23..

In order to classify the RTA, the International Classification of Diseases (ICD) was used: codes 800-999 and E800-E849 from ICD-9 and Chapter XIX (codes S00 to T98) and Chapter XX (codes: V01-V89) from ICD-10²2. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 2016; 22: 3-18..

The Research Ethics Committee from Universidade Federal de Minas Gerais (no. CAAE 62803316.7.0000.5149) approved the project.

RESULTS

A total of 134,931 deaths were registered due to external causes in 1990, whereas 168,018 were registered in 2015, with decrease of the mortality rate from 105.1 to 81.2/100 thousand people, a 22.8% decrease in the period. Deaths due to interpersonal violence were prevalent followed by RTA, accidents, or unintentional injuries, and suicides. The highest risk regarding RTA was seen for pedestrians and automobile occupants (Table 1).

The traffic accidents group had a decrease in its mortality rate of 30.6% between 1990 and 2015, and the RTA subgroup had a decrease of 32.8%. Among the victims categorized according to the type of transportation user, there was a higher decrease among pedestrians (47.5%) and automobile occupants (41.6%). Among motorcycle and bicycle riders, an increase of 49.9 and 33.9%, respectively, was observed. However, despite these alterations, in Brazil, between 1990 and 2015, the mortality rates of pedestrians (10.6/100 thousand) and automobile occupants (6.9/100 thousand) remain higher than the rates of motorcycle riders (5.9/100 thousand) and bicycle riders (1.0/100 thousand) (Table 1). The mortality rates due to RTA were four times higher in men. This risk is higher in all kinds of victims: 7.5 times in motorcycle riders and 3.4 times in automobile riders (data are not shown).

The RTA mortality rate decreased in 26 of the 27 Brazilian FU, but it was very heterogeneous with a variation from 2.5 (Tocantins) to 52.3% (Federal District). The only exception was the state of Piauí in the northeastern region, which showed a growth of 9.7%. Nevertheless, after examining the uncertainty intervals, significant changes were only seen in 13 states (signaled with * in Table 2).

The highest mortality rates were in the states of the north and northeastern regions, especially Tocantins (41.7/100 thousand), Piauí, and Maranhão (36.3/100 thousand) in 2015. Of the ten states with the highest mortality rates due to RTA, four belong to the northeastern region; three from the north; two from the middle-west; and one from the south region. The lowest rates were from São Paulo (18.3/100 thousand), Federal District (18.9/100 thousand), and Rio Grande do Sul (19.5/100 thousand) (Table 2).

The analysis of age-specific mortality rates showed a higher risk for 70-year-old people and for pedestrians, bicycle riders and automobile occupants. On the other side, for motorcycle riders, the highest death risk was seen in the 15- to 49-year-old group; however, in this age range, the risk is also high for automobile occupants (Figure 1). The death risk of pedestrians increases with age, whereas the motorcycle riders’ decreases in the age groups of individuals older than 35 years old.

With regard to DALY per 100 thousand people, Table 3 presents the distribution of its components: YLL and YLD due to RTA, for Brazil and FU. For Brazil, the DALY rate was 1,175.5/100 thousand. Sixteen FU presented higher rates than the country’s rate. The states of Tocantins, Piauí, and Maranhão had the highest rates, whereas the lowest ones were found in Amazonas, Federal District, São Paulo, and Rio Grande do Sul. The main components of the DALY were the YLL, which accounted for 90% of the total amount, being less than 94% in FU such as São Paulo, Roraima, Rio de Janeiro, and Federal District, and higher than 96% in FU such as Paraná, Piauí, Pará, Bahia, Alagoas, Sergipe, Amazonas, Pernambuco, and Tocantins.

The DALY rates by the main external causes (Chart 1) had pedestrian accidents in the first position in 1990, which moved to the second position in 2015 - 51.4% decrease, being replaced by assaults with firearm, which occupied the second position in 1990. In addition, automobile occupants changed from the third position to the fourth - a 40.7% decrease. With an opposed trend, the DALY rates in motorcycle riders, which occupied the ninth position in 1990, occupied the fifth position in 2015 - a 53.7% increase.

DISCUSSION

When comparing Brazil with other South America countries, Brazil has the second highest rate of DALY due to RTA (1,230/100 thousand people) after Paraguay (1,270/100 thousand people) and also has higher rates than countries with worst socioeconomic indicators, such as Ecuador and Bolivia. In such region, Peru, Chile, Colombia, and Argentina have the lowest DALY rates - between 615 and 700/100 thousand people¹⁷17. Institute for Health Metrics and Evaluation (IHME). Data Visualization. Disponível em: Disponível em: http://www.healthdata.org/results/data-visualizations (Acessado em: 11 de novembro de 2016).
http://www.healthdata.org/results/data-v... . When Brazilian data are compared with data from the countries of the group called BRICS - Brazil, Russia, India, China, and South Africa - a relative similarity of the DALY rates due to traffic accidents between the countries is observed - between 1,010 and 1,230/100 thousand people - with the exception of South Africa, which rate reaches 1,914/100 thousand people¹⁷17. Institute for Health Metrics and Evaluation (IHME). Data Visualization. Disponível em: Disponível em: http://www.healthdata.org/results/data-visualizations (Acessado em: 11 de novembro de 2016).
http://www.healthdata.org/results/data-v... . The main component of DALY due to RTA in Brazil, China and India is pedestrians’ injuries. In Russia and in South Africa, the highest DALY rates are due to injuries in automobile occupants. In this group of countries, Brazil has the highest DALY rate among motorcycle rider - 358,2/100 thousand people.

The BRICS present a quite high DALY rate, which had a significant decrease in Brazil and Russia during 1990 to 2013, whereas the rates of South Africa, India, and China did not change significantly²2. Haagsma JA, Graetz N, Bolliger I, Naghavi M, Higashi H, Mullany EC, et al. The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 2016; 22: 3-18.. However, the mortality rates due to traffic accidents among the BRICS are even higher than in low-income countries²⁶26. Hyder AA, Vecino-Ortiz AI. BRICS: opportunities to improve road safety. Bull World Health Organ 2014; 92(6): 423-8.. The BRICS have experienced a fast economic growth during the last years, with increase of automobile traffic; however, they did not invest enough in systems to increase safety of the roads, and therefore it had an increase of injuries and deaths²⁶26. Hyder AA, Vecino-Ortiz AI. BRICS: opportunities to improve road safety. Bull World Health Organ 2014; 92(6): 423-8..

Brazil had an important decrease in the mortality rate due to RTA between 1990 and 2015. However, the decrease did not occur homogeneously among the main traffic user groups. If, on one hand, there was a decrease of pedestrians and automobile occupants’ death; on the other hand, there was an increase of deaths of motorcycle riders and less of bicycle riders.

The morbidity and mortality increase of motorcycle riders have been reported in several studies carried out in Brazil²⁷27. Silva DW, Andrade SM, Soares DFPP, Mathias TAF, Matsuo T, Souza RKT. Factors Associated with Road Accidents among Brazilian Motorcycle Couriers. The Scientific World Journal 2012. DOI: 10.1100/2012/605480.
https://doi.org/10.1100/2012/605480.... ^,2828. Chandran A, Sousa TRV, Guo Y, Bishai D, Pechansky F, The Vida no Trânsito Evaluation Team. Road Traffic Deaths in Brazil: Rising Trends in Pedestrian and Motorcycle Occupant Deaths. Traffic Inj Prev 2012; 13(Suppl. 1): 11-6.^,2929. Montenegro MMS, Duarte EC, Prado RR, Nascimento AF. Mortalidade de motociclistas em acidentes de transporte no Distrito Federal, 1996 a 2007. Rev Saúde Pública 2011; 45(3): 529-38.^,3030. Martins ET, Boing AF, Peres MA. Mortalidade por acidentes de motocicleta no Brasil: análise de tendência temporal, 1996-2009. Rev Saúde Pública 2013; 47(5): 931-41.. Among the main explanations for this death raise is the increasing use of this type of vehicle for different activities, both in the urban area and also in rural areas. Therefore, there has been a strong fleet growth, which was remarkably observed in the middle of the 1990s³¹31. Vasconcellos EA. Road safety impacts of the motorcycle in Brazil. Int J Inj Contr Saf Promot 2012 DOI: 10.1080/17457300.2012.696663.
https://doi.org/10.1080/17457300.2012.69... ^,3232. Bacchieri G, Barros AJD. Acidentes de trânsito no Brasil de 1998 a 2010: muitas mudanças e poucos resultados. Rev Saúde Pública 2011; 45(5): 949-63., with a 1,400% increase in the annual sale of motorcycles between 1991 and 2008³¹31. Vasconcellos EA. Road safety impacts of the motorcycle in Brazil. Int J Inj Contr Saf Promot 2012 DOI: 10.1080/17457300.2012.696663.
https://doi.org/10.1080/17457300.2012.69... . The acquisition of motorcycles could be associated with a period of the country’s economic scenario, from 2004 to 2013, when millions left the poverty line, with social and economic ascension; thus, people were able to acquire their first own vehicle, which was generally a motorcycle³⁰30. Martins ET, Boing AF, Peres MA. Mortalidade por acidentes de motocicleta no Brasil: análise de tendência temporal, 1996-2009. Rev Saúde Pública 2013; 47(5): 931-41.. With regard to the mortality rate per 10 thousand vehicles, between 2003 and 2008, there was a gradual decrease to 6.7/10 thousand people, which is possibly due to an increase of 85% in the fleet size³²32. Bacchieri G, Barros AJD. Acidentes de trânsito no Brasil de 1998 a 2010: muitas mudanças e poucos resultados. Rev Saúde Pública 2011; 45(5): 949-63..

Despite the increase of mortality rates among motorcycle riders, the rates of pedestrians and automobile occupants still remained as the highest. This finding is not in agreement with other studies⁵5. 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. Ciên Saude Coletiva 2012, 17(9): 2223-36.^,3030. Martins ET, Boing AF, Peres MA. Mortalidade por acidentes de motocicleta no Brasil: análise de tendência temporal, 1996-2009. Rev Saúde Pública 2013; 47(5): 931-41., considering that the number of deaths and the mortality rate of motorcycle riders during the last years surpassed the other victims³³33. Brasil. Ministério da Saúde. DATASUS. Estatísticas Vitais. Disponível em: Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/ext10uf.def (Acessado em 10 de novembro de 2016).
http://tabnet.datasus.gov.br/cgi/tabcgi.... . The study of Morais Neto et al.⁵5. 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. Ciên Saude Coletiva 2012, 17(9): 2223-36. identified that, in the 2000-2010 period, the mortality rates of motorcycle riders had overcome those of automobile occupants and pedestrians. In addition, a high growth in the mortality rate of motorcycle riders was observed in the study of Chandran et al.²⁸28. Chandran A, Sousa TRV, Guo Y, Bishai D, Pechansky F, The Vida no Trânsito Evaluation Team. Road Traffic Deaths in Brazil: Rising Trends in Pedestrian and Motorcycle Occupant Deaths. Traffic Inj Prev 2012; 13(Suppl. 1): 11-6.. In the end of the analysis period (2008), the rates were similar (4.7/100 thousand people) to the mortality rates of pedestrians (5.4/100 thousand people). Andrade and Mello-Jorge⁶6. Andrade SSCA, Mello-Jorge MHP. Mortality and potential years of life lost by road traffic injuries in Brazil, 2013. Rev Saude Pública 2016; 50: 59. found that the mortality rates per 100 thousand residents, from 2011 on, among motorcycle riders had already overcome those of pedestrians and automobile occupants, which remained unchanged in 2012 and 2013. This discrepancy in the mortality rates of motorcycle riders, pedestrians, and automobile occupants, if we compare GBD data with those from the SIM, can be due to the process of death codes redistribution and adjustments of garbage codes used in the GBD. This procedure, which is carried out by means of regression equations, redistributes to the other groups of victims those deaths due to traffic accidents in which the victim has not been identified, which may also attributes a larger weight to pedestrians. As the percentage of deaths with unspecified victims is approximately 20% of the total RTA³³33. Brasil. Ministério da Saúde. DATASUS. Estatísticas Vitais. Disponível em: Disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/ext10uf.def (Acessado em 10 de novembro de 2016).
http://tabnet.datasus.gov.br/cgi/tabcgi.... , it may be the cause of the discrepancy. Another finding was that the rates showed variations among the states within the Brazilian regions. Although there has been a decrease in the mortality rate in almost all FU - with the exception of Piauí, in the northeastern region - the magnitude of decrease had a wide variation, with more emphasis in the FU of the south and southeastern regions. However, the Federal District had the largest decrease, which is equal to the result found in a study on RTA mortality trends in this FU⁵5. 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. Ciên Saude Coletiva 2012, 17(9): 2223-36..

Several studies indicated an increase of the mortality per RTA in the states of the north and northeastern regions, especially in the risk among motorcycle riders, with emphasis on the northeastern region⁵5. 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. Ciên Saude Coletiva 2012, 17(9): 2223-36.^,3434. Lima MLC, Cesse EAP, Abath MP, Oliveira Jr. FJM. Tendência de mortalidade por acidentes de motocicleta no estado de Pernambuco, no período de 1998 a 2009. Epidemiol Serv Saúde 2013; 22(3): 395-402.. In 2011, in these same regions, motorcycles were already the main vehicles in the total fleet³⁵35. Brasil. Departamento Nacional de Trânsito. Relatórios Estatísticos. Disponível em: Disponível em: http://www.denatran.gov.br/index.php/estatistica/237-frota-veiculos (Acessado em 3 de janeiro de 2017).
http://www.denatran.gov.br/index.php/est... . Morais Neto et al.⁴4. Morais Neto OL, Andrade AL, Guimarães RA, Mandacarú PMP, Tobias GC. Regional disparities in road traffic injuries and their determinants in Brazil, 2013 Int J Equity Health 2016; 15(1): 142., using data from the Brazilian Health Research, found a prevalence of RTA in the states of the north and northeastern regions higher than those of the south region, with high percentages of motorcycle riders. The southeast region showed the lowest mortality rates, which are similar to those found in the study of Andrade and Mello-Jorge⁶6. Andrade SSCA, Mello-Jorge MHP. Mortality and potential years of life lost by road traffic injuries in Brazil, 2013. Rev Saude Pública 2016; 50: 59..

The limitations of this study refer to data source and to corrections used, such as redistribution of garbage codes. In Brazil, the SIM increased registration collection and improved their quality; however, in previous years and in some states, there are some non-collected deaths, incomplete records, raised proportion of garbage codes³⁶36. Szwarcwald CL, Morais Neto OL, Frias PG, Souza Júnior PRB, Escalante JJC, Lima RB, et al. Busca ativa de óbitos e nascimentos no Nordeste e na Amazônia Legal: estimação das coberturas do SIM e do Sinasc nos municípios brasileiros. In: Brasil. Ministério da Saúde (MS). Saúde Brasil 2010: uma análise da situação de saúde. Brasília: Ministério da Saúde; 2011. p. 79-97.^,3737 França E, Teixeira R, Ishitani L, Duncan BB, Cortez-Escalante JJ, Morais Neto OL, et al. Causas mal definidas de óbito no Brasil: método de redistribuição baseado na investigação do óbito. Rev Saúde Pública 2014; 48(4): 671-81.^,3838. Soares Filho AM, Cortez-Escalante JJ, França E. Revisão dos métodos de correção de óbitos e dimensões de qualidade da causa básica por acidentes e violências no Brasil. Ciên Saúde Colet 2016; 21 (12): 3803-18.. Therefore, it is important to compare GBD data with Brazilian information to improve the estimates.

CONCLUSION

The efforts developed in the three government spheres, the improvement of information, and the establishment of a national legal framework - the Brazilian Traffic Code, which came into force in 1998 -, with continued improvement, are fundamental elements for Brazil’s progress in decreasing the social impact of traffic accidents. The laws promoted a series of interventions directed to the institutionalization of the Traffic National System and to the promotion of road safety.

In the health sector, after publication of the National Policy for the Reduction of Morbidity and Mortality by Accidents and Violences³⁹39. Brasil. Ministério da Saúde. Política Nacional de Redução da Morbimortalidade por Acidentes e Violências. Brasília: Ministério da Saúde ; 2001. and of the Project on Reduction of Morbidity and Mortality by Traffic Accidents⁴⁰40. Brasil. Ministério da Saúde (MS). Portaria GM/MS 344 de 19/02/2002, que institui o Projeto de Redução de Morbimortalidade por Acidentes de Trânsito - Mobilizando a sociedade e promovendo a saúde. Brasília: Ministério da Saúde ; 2002., the main guideline for health promotion was established within a complex view of the situations that need to be faced.

The implementation of the Projeto Vida no Trânsito in 2010, which was inserted in the international context of mobilization for reaching the goal of the Decade of Actions for Road Safety 2011-2020 of the UN, also represented an advance by seeking to build partnerships, qualify information, and execute articulated, inter-sectorial and integrated interventions⁴¹41. Silva MMA, Morais Neto OL, Lima CM, Malta DC, Silva Jr. JB. Projeto Vida no Trânsito - 2010 a 2012: uma contribuição para a Década de Ações para a Segurança no Trânsito 2011-2020 no Brasil. Epidemiol Serv Saúde 2013; 22(3): 531-6..

According to the WHO global status report on road safety 2015¹1. World Health Organization (WHO). Global status report on road safety 2015. Geneva: World Health Organization; 2015. Disponível em: Disponível em: http://www.who.int/violence_injury_prevention/road_safety_status/2015/en/ (Acessado em 20 de outubro de 2016).
http://www.who.int/violence_injury_preve... , Brazil is in a better position compared with other densely populated countries in the world in terms of best legislative practices. Brazil has implemented legislation on the use of helmet, seat belt, and adequacy of children’s vehicular transportation, and has the most restricted laws of the world on driving after drinking alcoholic beverages.

Despite the advances achieved in the last few years, with decrease of the mortality rates and DALY, there is still a significant challenge ahead in addressing the RTA in the country due to the magnitude of the negative impacts on the population’s health.

Finally, it is important to highlight that the GBD results are valuable for a better understanding of the health problems in our country, and GBD is a tool to analyze and prioritize groups of victims, FU, and age ranges as targets for public policies which aim at road safety interventions and the necessary monitoring of results.

References

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