1. 4/19/2015 Injury Free Coalition for Kids 1 Wheeled Vehicles and Injury Risk to Children Michael A. Gittelman, MD Associate Professor, Division of Emergency Medicine Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio

2. 4/19/2015 Injury Free Coalition for Kids 2 2003 Emergency Department Case 10 y/o female 15 mph on flat surface No helmet or seatbelt Sharp turn & vehicle flipped Suffered traumatic brain injury Pt died in the ICU 3 days later

3. 4/19/2015 Injury Free Coalition for Kids 3 Objectives Understand the magnitude of childhood injuries Discuss properties of wheeled vehicles (eg.ATVs, dirtbikes, bicycles) making them risks for injury Learn specific risk factors for these type of injuries Discuss the public health approach to prevention As a group discuss potential interventions

4. 4/19/2015 Injury Free Coalition for Kids 4 The Injury Problem Leading cause of death from ages 1-44 years Results in more deaths in children than all other diseases combined #1 cause of years of potential life lost Costs hundreds of billions of dollars annually in US

5. 4/19/2015 Injury Free Coalition for Kids 5 Restraint systems, road design Pool fences, flotation devices Smoke alarms, smoking cessation ??? ATV/Dirtbikes

6. 4/19/2015 Injury Free Coalition for Kids 6 Bicycle Injuries Rollerblade/Scooter/ Skateboard Injuries

7. 4/19/2015 Injury Free Coalition for Kids 7 Injury Definitions  “Any intentional or unintentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen.”  Force (Mass X Speed) = Magnitude of injury  Catastrophic Injury = Injuries that result in permanent, severe neurologic disability or death -National Committee for Injury Prevention and Control, 1989

8. 4/19/2015 Injury Free Coalition for Kids 8 Motorized Recreational Vehicles All-terrain Vehicles (ATVs)—off-road use, no license, > 40,000 injuries/yr (roughly 200 deaths/yr) – age < 15 Powered off-road cycles—use on rough terrain; no license, > 23,000 injuries/yr – age < 19 –Minibikes—small, bicycle frame, lawn mower engine –Minicycles—miniature motorcycles, more horsepower –Trail bikes—larger, more powerful than minicycles Powered Street-use Cycles— 10,000 injuries/yr (roughly 350 deaths/yr) – ages < 21 –Mopeds—bicycles with small motors, may not need license –Scooters—enclosed engine, small wheels, larger engine –Motorcycles—greater speeds, license required, 20 x > risk of death than MVC Golf cart injuries roughly 5000 injuries/yr

9. 4/19/2015 Injury Free Coalition for Kids 9 ATV Characteristics Gasoline powered Knobby tires High center of gravity Engine displacement 50-500 cm 3 Speeds > 70 MPH Mainly designed for a single rider and off-road use

10. 4/19/2015 Injury Free Coalition for Kids 10 ATV Injury Risks Children under 16 years old 5x greater risk –14% of ATV drivers but ~35% of injuries and deaths Most children killed (95%) are operating vehicles rated for adults Rural white males are typical victims (Male 2x > Female) Three-wheeled vehicles—50% more likely to be injured Inexperienced drivers, Recreational use, Alcohol Deaths occur in: Collisions (56%) ( more than half with fixed object) Overturns (35%) ( backward more common than forward) Only 1% occur on ATV trails

11. 4/19/2015 Injury Free Coalition for Kids 11 ATV Injury Trends 1 Roughly 40,000 ED injuries to kids < 16 yrs of age http://www.atvsafety.gov/stats.html Year Reported Deaths¹ Estimated Deaths Estimated Number of Emergency-Room Treated Injuries 2008 1 410*135,100 2007699816150,900 2006832907146,600 2005804932136,700 2004753855136,100 2003653762125,500 2002548606113,900 2001517593110,100 2000450551 92,200 1999397534 82,000 1998 251 287 67,800 1997 241 291 52,800 46% increase, yet some decline 2007 & 2008 49% increase ED visits

12. 4/19/2015 Injury Free Coalition for Kids 12 ATV Injury Patterns Mean age = 11.1 years Body parts injured –32% face/head, 13% lower ext, spinal cord, abd injuries Types of injuries sustained –31% fractures, 12% lacs, 11% organ,6% ICI 14% occurred on the street (60% of deaths) 70% home/other site 72% No protective gear or helmet Gittelman, Pediatrics 2006

13. 4/19/2015 Injury Free Coalition for Kids 13 Dirtbike Characteristics Two-wheeled, motorized vehicles (minibikes, trailbikes, dirtbikes, mopeds, etc.) used for recreation and transportation. Many are illegally operated at excessive speeds, by minors, on public roads. US Consumer Product Safety Commission estimated 40,000 ED visits nationwide due to two- wheeled off-road vehicles (26% to children < 15 years old) –Mean age of pediatric moped injuries is < 13 years.

14. 4/19/2015 Injury Free Coalition for Kids 14 Off –Road vs Street Cycle Risks Illegal use on roadways Poor design –Small tires –Short wheelbase –Slow acceleration –Inadequate brakes No helmet Young age, inexperienced driver Males Alcohol > 1 rider Design issues –Lack of stability and protection in a crash –Insufficient acceleration, smaller engines No helmet < 20 y.o/Inexperienced driver High traffic roads Males Alcohol

15. 4/19/2015 Injury Free Coalition for Kids 15 Motorized Two-wheeled Injury Patterns Body parts injured –37% lower ext, 28% face/head –3x risk of serious head injuries in non-helmet wearers; cause most deaths Types of injuries sustained –54% fractures, 14% lacs, 6% ICI 40% occurred on the street 93% for recreational purposes > ½ of deaths are instantaneous Protective gear –59% no helmet, 97% no protective gear Pomerantz, Pediatrics 2005 Mean age = 12 years

16. 4/19/2015 Injury Free Coalition for Kids 16 Non-motorized Wheeled Vehicles Bicycles – 275,000 injuries/yr (roughly 140 deaths/yr) Scooters - 40,000 injuries/yr Rollerblades/skates – 38,000 injuries/yr Skateboarding - 61,000 injuries/yr Annual injuries by product –70% Bikes –14% Rollerblades/Skates –16% Skateboards Estimates of nonfatal injuries for children < 14 yrs of age

17. 4/19/2015 Injury Free Coalition for Kids 17 Small Wheeled Vehicle Risk Factors Males > Females –Scooters, rollerblades and skateboards –Females for roller skates Children < 15 y.o. Speed, risk-taking behaviors and loss of balance Usually occur first 2 weeks of obtaining product Obstacles and hard impact surfaces Lack of protective gear

18. 4/19/2015 Injury Free Coalition for Kids 18 Small Wheeled Vehicle Injury Patterns Body part injured –Wrist is most common –Lower extremity (knee, ankle) injuries –5% head injuries Types of injuries –30%-40% fractures for scooters, in-line and roller skates, 21% for skateboards –Traumatic brain injury <2% require hospitalization

19. 4/19/2015 Injury Free Coalition for Kids 19 Bicycles Responsible for more childhood injuries than any other consumer product except the automobile. More than 70% of all children ages 5-14 years ride bikes. Head injury is the leading cause of death in bicycle crashes –Non-helmeted riders are 14 times more likely to be involved in a fatal crash –98% of the bicyclists killed reportedly do not wear helmets. Bicycle helmets reduce the risk of head injury by 88% –National estimates report that bicycle helmet use among child bicyclists ranges from 15 percent to 25 percent. –Universal use of bicycle helmets could annually prevent 135 - 155 deaths 39,000 - 45,000 head injuries Lifetime medical cost totalling between $134 and $174 million.

20. 4/19/2015 Injury Free Coalition for Kids 20 Bicycle Injury Risk Factors Children 5-14 y.o. Males Riding environment –Traffic –Nighttime –Road Surface Riding Experience Equipment

21. 4/19/2015 Injury Free Coalition for Kids 21 Bicycle Injury Patterns Head/CNS injuries-most common cause of fatal debilitating injury –Helmets are 88% effective in preventing TBI Handlebar injuries Most other injuries-minor and self-limited

22. 4/19/2015 Injury Free Coalition for Kids 22 ATVs vs. Bicycles,Cars, & Motorcycles ATV injury severity significantly higher than bicycle injury for children ATV injury severity scores comparable to MVC More frequent head trauma (50%) among patients who sustained ATV rather than motorcycle injuries (30%) Brown, J Pediatric Surgery 2001 Acosta and Rodriguez, J of EM 2007

23. 4/19/2015 Injury Free Coalition for Kids 23 Public Health Approach to Prevention Define the problem Identify causes or risk factors Develop or test interventions Implement intervention and measure prevention effectiveness

24. 4/19/2015 Injury Free Coalition for Kids 24 Haddon Matrix for ATV Injury Host/ Human Agent Physical Environment Socio- economic Environment Pre-event Driver experience, size, maturity Vehicle size, HP, safety features, stability Weather, Site of use, obstacles Training, Legislation (helmets, etc) EventHelmet use, other protective gear EMS systems Post- event Healthcare training Road/trail accessibility Insurance, Health Care, Rehab Trail design Vehicle size, speed INITIAL CAMPAIGN AREAS

25. 4/19/2015 Injury Free Coalition for Kids 25 Summary Pick high risk/catastrophic injuries Target a particular at risk group Intervention E’s –Education –Environment –Enforcement/Legislation –Engineering

26. 4/19/2015 Injury Free Coalition for Kids 26 Addendum Slides

27. 4/19/2015 Injury Free Coalition for Kids 27 ATV

28. 4/19/2015 Injury Free Coalition for Kids 28 ATV Education Industry-sponsored programs (SVIA) –<10% of new purchasers comply –Large secondary market with limited access –No formal evaluation published National 4H program –Consultant evaluation demonstrated increased helmet use and safety gear –Less effective with use on or along roads 4-H Community Safety Program, Changing Behaviors, Saving Lives, 2004 Other programs—hospitals, research

29. 4/19/2015 Injury Free Coalition for Kids 29 Key questions: Education What is the message—no ATV use or safer ATV use? What is the most important target audience—parents, adolescents? Dose of exposure needed to cause change in behavior? Does training really work? Can objective markers of physical readiness and/or maturity predict ATV risk? How effective is secondary prevention—can brief interventions work to motivate parents/youth after an ATV crash? Should we adopt a Graduated Driver’s Licensing approach to ATV safety?

30. 4/19/2015 Injury Free Coalition for Kids 30 ATV Enforcement/Legislation American Academy of Pediatrics Consumer Product Safety Commission Other Federal Agencies State level policies

31. 4/19/2015 Injury Free Coalition for Kids 31 Professional Society Policy American Academy of Pediatrics: –Education: motorcycle helmets; eye protection; and protective reflective clothing –Engineering: seat belts; roll bars; headlights; and speed governors –Legislation: helmet use; banning 3 wheelers; requirements for licensing/certification; minimum driver age 16 years; prohibition of alcohol, passengers, and ATV use at night Pediatrics, 105: 1352-54, June 2000

32. 4/19/2015 Injury Free Coalition for Kids 32 Federal ATV Policy 1983-86: 300% increase in ATV-related ED visits 1988-98: Consumer Product Safety Commission –Banned three-wheeled ATV’s –10 year consent decree warning labels, minimum age recommendations increased voluntary safety standards, nationwide training program 2002-04: Petition to CPSC to ban ATV sales to youth under 16 years 2006: Senate hearings on new rules for manufacturing standards and youth ATVs

33. 4/19/2015 Injury Free Coalition for Kids 33 Changing Rules at CPSC? Previous standards: –50 cc: ages 12 and under –90 cc: ages 12-16 –> 90 cc: ages 16 and older Proposed new standards: –Speed rather than size determines vehicles considered “youth models” –More rigid manufacturing standards –Restricts some offshore imports

34. 4/19/2015 Injury Free Coalition for Kids 34 Do laws work for ATVs? Study compared states with –No laws –Laws governing equipment only –Laws governing driver behavior States with no laws had injury rates twice as high as those with laws Several studies indicating a trend toward increased helmet use in jurisdictions with helmet laws Source: Helmkamp, AJPH, 2001

35. 4/19/2015 Injury Free Coalition for Kids 35 State-level Legislation 44 states have at least minimal ATV legislation ‐ Typical legislation includes parental supervision for young children, licensing/registration requirements, and bans on riding ATVs on public roads ‐ States without these laws have significantly higher death rates AJPH, 91: 1792-1795, November 2001

36. 4/19/2015 Injury Free Coalition for Kids 36 Acceptability of Legislation Recent wave of laws nationally indicates support Recent survey of Ohio voters: –90% supported legislation in general terms –78% supported helmet requirement Among ATV riders, helmet use would double if law passed –81% of voters supported passenger restriction and restriction for children <16 –77% supported training requirements Source: Center for Injury Research and Policy, Columbus, OH, 2007

37. 4/19/2015 Injury Free Coalition for Kids 37 Enforcement Poor enforcement of existing policies is a major downfall Even in areas with motivated enforcement, laws may not apply on private property Substantial local variability in support for legislation, including ATV use on paved surfaces

38. 4/19/2015 Injury Free Coalition for Kids 38 Key questions: Enactment Do existing policies work to decrease injuries? What combination of policies is required to achieve effective prevention? How can we improve enforcement? Are other avenues for policy (insurance, liability) potentially more effective than legislation?

39. 4/19/2015 Injury Free Coalition for Kids 39 ATV Engineering Little is known (outside the ATV manufacturing industry) about the real-life performance characteristics of ATVs Less is known about vehicle performance with children on board Little is known about the performance characteristics of protective gear –Helmet effectiveness—reduction of 42% for mortality; 62% reduction in any head injury - Rodgers, Accident Anal Prev,1990 –Yet no significant difference in mean ISS between helmeted and non-helmeted riders. Helmet usage was not associated with a reduction in head/facial injuries. –Gittelman, Pediatrics, 2006 Engineering research from objective sources is lacking

40. 4/19/2015 Injury Free Coalition for Kids 40 ATV Stability Project 45% of ATV crashes result from the machine tipping over –43% lateral (side to side) –57% longitudinal (front to back) Objective: Determine if tipping increases with –engine size –weight of person –number of passengers

41. 4/19/2015 Injury Free Coalition for Kids 41 ATV testing

42. 4/19/2015 Injury Free Coalition for Kids 42 Results 301.4 lbs

43. 4/19/2015 Injury Free Coalition for Kids 43 The Oregonian, May 18, 2007

44. 4/19/2015 Injury Free Coalition for Kids 44 Key questions: Engineering Can vehicles be modified to make them safe(r) for children? –If so, how: Speed regulators, stability control, roll bar/seat belts? Which is more important in safety: speed control or size of vehicle? –Will such vehicles be produced? –If produced, will they appeal to consumers? Can helmets be improved (more appealing, lighter, cooler) and retain effectiveness?

45. 4/19/2015 Injury Free Coalition for Kids 45 Small Wheeled Vehicle Interventions Protective gear –Helmets –Wrist guards (except for scooters) –Knee and elbow pads Proper equipment maintenance Anticipatory guidance and education No skateboards for kids < 10 y.o ; no scooters for kids < 8 y.o.

46. 4/19/2015 Injury Free Coalition for Kids 46 Bicycle-Related Interventions Bicycle helmets Education of parents and children Proper bicycle size and maintenance Environmental modifications

47. 4/19/2015 Injury Free Coalition for Kids 47 Bike Helmet Legislation vs Education Dannenberg, Gielen – 1993 Am J Public H –8 to 13% and 7 to 11% where education involved only –11-37% with education and law Cochrane database 2008 –2 studies significant reduction in head injury after legislation

48. 4/19/2015 Injury Free Coalition for Kids 48 Non-legislative Efforts to Promote Helmet Use Royal – Inj Prev 2007 –Best effect with community based programs and those providing free helmets compared to in school or subsidized helmets –Education did not increase ownership of helmets Increase bike helmet use when parent uses helmet

49. 4/19/2015 Injury Free Coalition for Kids 49 Injury Control Strategies Human –Education/Empowerment Industry-sponsored programs 4 H Program Hospital, schools, etc. Agent –Engineering/Technology Tipping, seatbelts, rollbars, engine size Environmental modifications –Enforcement/Legislation AAP Policy, CPSC, State Govt –Safe places to ride Collaborative effort Multidisciplinary A variety of settings

50. 4/19/2015 Injury Free Coalition for Kids 50 Summary Significant injuries occur to children as a result of ATVs and Dirtbikes ATV/Dirtbike injury prevention challenges many accepted paradigms of injury control –May be some successes as deaths have declined Many questions exist about effective prevention strategies Successful ATV injury prevention will require: – Collaboration across all stakeholders – Rigorous application of behavioral, public health, and engineering sciences – New and creative approaches – Long term perspective

51. 4/19/2015 Injury Free Coalition for Kids 51 Questions?