International Journal of Injury Control and Safety Promotion
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A study into blood alcohol concentration in fatal accidents among vulnerable road users in a tertiary care hospital Sri Lanka Anuruddhi Samanthika Edirisinghe, Indira Deepthi Kitulwatte & Udara Dilrukshi Senarathne To cite this article: Anuruddhi Samanthika Edirisinghe, Indira Deepthi Kitulwatte & Udara Dilrukshi Senarathne (2015) A study into blood alcohol concentration in fatal accidents among vulnerable road users in a tertiary care hospital Sri Lanka, International Journal of Injury Control and Safety Promotion, 22:2, 158-164, DOI: 10.1080/17457300.2013.857696 To link to this article: http://dx.doi.org/10.1080/17457300.2013.857696
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International Journal of Injury Control and Safety Promotion, 2015 Vol. 22, No. 2, 158–164, http://dx.doi.org/10.1080/17457300.2013.857696
A study into blood alcohol concentration in fatal accidents among vulnerable road users in a tertiary care hospital Sri Lanka Anuruddhi Samanthika Edirisinghe*, Indira Deepthi Kitulwatte and Udara Dilrukshi Senarathne Department of Forensic Medicine, Faculty of Medicine, University of Kelaniya, Thallagolla Road, Ragama 11010, Sri Lanka
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(Received 28 June 2013; accepted 14 October 2013) Reckless driving behaviour associated with alcohol has been well known. In Sri Lanka, research on blood alcohol concentration (BAC) in road fatalities is scares. Thus, we studied the BAC in vulnerable road users (VRUs) encountered in medico-legal autopsies. A retrospective descriptive study based on case records of VRU fatalities from 2005 to 2012 referred for a tertiary care unit for post-mortem examination was conducted. A pro-forma was developed to extract data from the post-mortem blood alcohol reports. Data were analysed using percentages and p-values. There were 119 cases from the 328 autopsies to investigate blood alcohol tests. A total of 51% (n ¼ 61) out of 119 had BAC above 80 mg/ 100 ml and mean level was 103 mg/100 ml. 2/3 of pedestrians had a BAC above 80 mg/100 ml with a mean level of 139 mg/dl. The highest mean blood alcohol (158 mg/dl) was reported from three-wheeler users. Majority of cases with more than 80 mg/100 ml BAC was reported in the age group of 40–60 years, while 40% of the elderly too had a BAC above 80 mg/100 ml. The comparison between pedestrians having above 80 mg/100 ml of BAC with that of other VRUs (active road users) showed a significant statistical difference (p ¼ 0.017). The study results suggest that alcohol influence among pedestrians represent a significant risk factor for fatal road traffic accidents. Keywords: vulnerable road user (VRU); blood alcohol concentration (BAC); road traffic fatalities; legal limit for drunken drivers
Introduction/background Human factors in road fatalities are preventable. Alcohol and its relationship to road traffic accidents has been recognised for a long time (Editorial Lancet, 1907), but the scientific reasoning of blood alcohol levels and risk of crash was established in 1964, with a case control study carried out in Michigan, United States, popularly known as the Grand Rapids study (Borkenstein et al., 1964). The results of this study provided the basis for the future setting of legal blood alcohol limits for motor vehicle drivers in many countries around the world, typically at 80 mg/ 100 ml. Sri Lanka too adapted the legal limit of blood alcohol level as 80 mg/100 ml of blood for drivers of a motor vehicle in 1984 (Government of Sri Lanka, 1984). Although majority of countries around the world still has the legal limit for motorist as 80 mg/100 ml, several countries in Europe and Australia have further reduced the legal limit to 50 mg/100 ml or 40 mg/100 ml considering the results of later research findings that included behavioural and experimental studies (Hurst, Harte, & Frith, 1994; McLean & Holubowycz, 1981). It is also worthy to note that there are 89 countries in the world having comprehensive drink-driving law, defined as a blood alcohol concentration (BAC) of 50 mg/100 ml or less, in-line with best practice recommended by World Health Organization (WHO, 2009). Continuing on the *Corresponding author. Email: [email protected] Ó 2013 Taylor & Francis
same line of prevention considerable number of countries has adopted zero blood alcohol for motorists, while many more have introduced zero blood alcohol limits for young novice drivers (WHO, 2009). ‘Vulnerable road user’ (VRU) is a term applied to those who are at more risk in traffic, i.e. those who are unprotected by an outside shield. Therefore, pedestrians, pedal cyclists and motor cyclists, three-wheeler drivers and occupants, as well as a passengers who are travelling on the footboard or the hood of an overcrowded bus or minibus, are also considered as vulnerable since they benefit from little or no external protective devices that would absorb energy during a collision (Peden et al., 2004; WHO, 2009). According to the statistics of the Sri Lankan Police, the number of road fatalities from 2004 to 2009 has been fluctuating around 2300–2500 deaths per year with the latest figure being 2721 deaths in 2011, showing an upward trend (Sri Lanka Police, 2008, 2011; WHO, 2009). Although police statistics do not categorise VRUs separately, the percentage of pedestrian fatalities has been around 31%–34% while drivers and riders amount to 41%–45% and the rest being passengers. Common reasons such as speeding, overtaking, drunken drivers, nonadherence to road rules, poor road conditions though seen in Sri Lanka, unique problems like poor law enforcement has been highlighted (Dharmaratne & Ameratunga, 2004;
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International Journal of Injury Control and Safety Promotion Dharmaratne & Stevenson, 2006; WHO, 2009). For past 2 years, increasing trend in the reckless behaviours of drunken drivers resulting other road user deaths, initiating a social dialogue demanding stricter law enforcement is apparent in print media (Panagoda & Fazlulhaq, 2012; Wickremasekera, 2011; Wijesiri, 2012). Research on road fatalities in Sri Lanka is scarce and association of blood alcohol levels to fatalities are hardly found. Salgado and Colomboge (1988) reported that 51.4% were pedestrians out of 524 autopsies carried out on the victims of road accident over a 2-year period in Colombo, while 24.4% and 10.1% were pedal cyclist and motor cyclists, respectively. Further, highest number of fatalities was reported in the age group of 20–29 years, while cranio-cerebral injury was the commonest cause of death. A recent study on estimating the incidence of road traffic fatalities and injuries in Sri Lanka reported death rate of road traffic accident as 12.1 per 100,000 people (Bhalla et al., 2010). Although both studies addressed the epidemiological aspect of fatalities and injuries, no assessment of the association of BAC to the accident has been analysed. Contribution of alcohol to the death of an individual is important to the judiciary. The alcohol-related mortality risk in natural and non-natural death is well established in forensic literature through analysis of large autopsy databases and meta-analysis (Smith, Branas, & Miller, 1999; T€ oro, Dunay, R ona, Klausz, & Feher, 2009). A forensic pathologist when attending to an autopsy of a road fatality reports not only on the injuries and the cause of death but also on contributory factors like ethanol effects. Thus, a comprehensive medical opinion armed with blood alcohol levels helps the judiciary to find the contributory negligence in more realistic manner. Blood alcohol testing or toxicology screening for illicit drugs is not mandatory in all traffic deaths in Sri Lanka unlike in many European Union countries (Costa et al., 2012). Therefore, alcohol and toxicological screening of road traffic deaths are done on the discretion of the specialist in forensic medicine or non-specialist doctor who conducts the post-mortem examination. In the authors’ institution, best practice guidelines on post-mortem examination at institutional levels direct the doctor in decision making on whether to take post-mortem blood or not, technique of obtaining a sample and transportation Objective To study levels of BAC in different types of VRUs encountered in medico-legal autopsies. Study design After obtaining ethical clearance, a retrospective descriptive study was carried out based on the case records of VRUs referred for post-mortem examination at a teaching
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unit of a tertiary care hospital from 2005 January to 2012 December in the Western Province of Sri Lanka, closer to two motorways (Colombo-Negombo (Airport) and Colombo-Kandy). A deceased VRU was defined as a pedestrian/rider, pillion rider of a motor bicycle, moped or scooter/foot cyclist/driver of a three wheeler/occupant of a three wheeler/rider of a bullock cart or a traveller in the foot board of an overcrowded bus. Analysis of the type of the VRU was based on the police information, eyewitness records aided by final interpretation of the post-mortem report. A pro-forma was developed to extract data from the case records. Post-mortem reports and toxicological reports on post-mortem blood samples (blood alcohol) sent by the Government Analyst Department were perused. Post-mortem blood samples have been obtained from femoral blood according to the institution autopsy examination guidelines and they were analysed at the Department of the Government Analyst as the routine practice. Post-mortem reports where quality data cannot be extracted were excluded from the study. The pro-forma contained data on age, sex, type of VRU and the time of the accident. Time of the accident was analysed as traffic hours and non-traffic hours, where traffic hours were defined as the time period between 6.00 am–9.00 am, 12.00 pm–2.30 pm and 4.00 pm–8.00 pm, where more policemen are seen on the road during rush hours. Further data included whether a post-mortem blood was taken to send to the Government Analyst Department, what type of requests made (i.e. whether to test for blood alcohol or other toxicology screening such as drugs of abuse or common poisons), post-mortem ethanol levels as well as data on cause of death and relevant opinions. The data were analysed using percentages and p-values. The analysis of BAC was divided into five groups according to clinical effects (Stark & Norfolk, 2005). The comparisons were done on BAC less than 80 mg/100 ml with those above 80 mg/100 ml using chi-square test, since 80 mg/100 ml of BAC is the legal limit for drivers in Sri Lanka. The type of the VRU was also grouped into active users and non-active (passive user). The active road users included those in vehicles (riders or passengers), while non-active users were pedestrians. Results During the study period of January 2005 to December 2012, a total of 7266 post-mortem examinations were conducted at the tertiary care hospital where the study was conducted. Although 840 deaths of road traffic fatalities underwent post-mortem examination, only 504 deaths belonged to VRU group. Out of all VRUs post-mortem conducted during this period 328 cases became eligible for the study considering the quality of the data. A blood sample was taken to send to the Government Analyst
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Table 1. The availability of BAC of VRUs. Type of VRUs
BAC available
BAC not available
Total
p-Value
42 77
115 94
157 171
0.001
119
209
328
Non-active road user (pedestrians) Active road user (two-wheeled vehicle rider/passengers, three-wheeler driver/passenger, other persons going on bullock carts or foot board of a bus, etc.) Total
Table 2. The distribution of BAC among different types of VRUs.
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Blood alcohol concentration (BAC) mg/100 ml Type of VRU Pedestrians Two-wheeled vehicle (rider/passengers) Three wheeler (driver/passenger) Other Total
0–50 (slight)
50–80 (mild)
80–140 (moderate)
141–300 (severe)
>300 (very severe)
Total
9 30 3 1 43(36%)
5 9 0 0 14(12%)
10 10 1 0 21(18%)
10 13 4 0 27(22%)
8 5 1 0 14(12%)
42(35%) 67(56%) 9(8%) 1(1%) 119 (100%)
Department in 37% of the cases (n ¼ 122), while a report from the Government Analyst was available in 119 (36%) case records. The discrepancy of three reports to the number of request made was due to long delays encountered in receipt of blood alcohol reports. All 119 samples were tested for ethanol. No sample was tested for drugs of abuse, but two samples were tested for common poisons that resulted negative. Both were elderly pedestrians subjected to hit and run accidents. The comparative analysis to the different types of VRUs and the availability of the blood alcohol report showed that almost half of (47%) of active road users were subjected to alcohol examination, while just above one fourth (27%) of the pedestrians (non-active road users) underwent blood alcohol examination. The comparison of the two groups revealed a significant difference (p ¼ 0.001; Table 1). The analysis of the 119 VRU fatalities where a BAC was available revealed that 56% (n ¼ 67) were twowheeler riders or passengers, while 35% (n ¼ 42) were pedestrians; 8% (n ¼ 9) were three-wheeler drivers or
passengers, while 1% (n ¼ 1) belonged to the other category, i.e. rider/passenger of a bullock cart, passenger travelling in the foot board of a bus. Analysis of the BAC revealed that just about half (52%) of the group were above 80 mg/100 ml, while 12% of the group were between 50 mg/100 ml and 80 mg/100 ml of alcohol. Another 12% (n ¼ 14) had a very severe level, i.e. blood alcohol of above 300 mg/100 ml, which can produce coma or death from alcohol poisoning alone. Majority of the very severe group were pedestrians. It was also worth to mention that nine two-wheeler riders had a BAC between 50 mg/100 ml and 80 mg/100 ml, while five pedestrians had a similar amount (Table 2). Analysis of the BACs of different types of VRUs revealed that 67% of pedestrians and 42% of two-wheeler riders/pillion riders were above 80 mg/100 ml, while 67% of the deceased three-wheeler drivers/passengers were also above the legal limit. The comparison between pedestrians having above 80 mg/100 ml of BAC with that of other VRUs (active road users) showed a significant statistical difference (p ¼ 0.017; Table 3).
Table 3. The distribution of BAC (80 mg/100 ml) among active and non-active road users. Type of VRU Non-active road users (pedestrians) Active road users
Pedestrians Two-wheeled vehicle(rider/passenger) Three wheeler(driver/passenger) Other Total
BAC < 80 mg/ 100 ml
BAC > 80 mg/ 100 ml
Total
p-Value
14(33%) 39(58%) 3(33%) 1(100%) 57(48%)
28(67%) 28(42%) 6(67%) 0(0%) 62(52%)
42(35%) 67(56%) 9(8%) 1(15%) 119(100)
0.017
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Table 4. Distribution of VRU age groups and BAC. BAC > 80 mg/dl Age group of VRU 20 years
BAC < 80 mg/dl
Number
%
Number
1 19 28 14 62
02 31 45 22 100
5 20 12 20 57
60 Total
% 9 35 21 35 100
Total Number
%
p-Value
6 39 40 34 119
5 33 34 28 100
0.066
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Table 5. Distribution of BAC of VRUs according to the alleged time of the incident (traffic hours and non-traffic hours). BAC > 80 mg/dl
Traffic hours Non-traffic hours Total
BAC < 80 mg/dl
Total
Number
%
Number
%
Number
%
p-Value
27 35 62
44 56 100
30 27 57
53 47 100
57 62 119
48 52 100
0.317
Analysis of the age groups showed that one out of six young persons (>20 years) tested for alcohol recorded above 80 mg/100 ml BAC, while more middle-aged men were found to be above the same. However, there was no significant difference (p ¼ 0.066) between less than 20 age group with that of others (Table 4). Time of the incident was analysed as traffic hours and non-traffic hours. The analysis revealed that 64% of the deaths occurred during non-traffic hours, especially at night. The analysis of the time of the incident (traffic hours to non-traffic hours) to BAC above 80 mg/100 ml showed that there was no significant difference between two groups (Table 5). The analysis of the blood alcohol levels revealed the highest level as 428 mg/100 ml, which was recorded in a pillion rider, while negative BAC tests were recorded in 25 fatalities. The mean and the median blood alcohol level among the tested VRUs were above 80 mg/100 ml (Table 6). Analysis of the opinion given showed that although the blood alcohol report was available in 119 cases, an opinion regarding alcohol level was given only in 24 cases although 62 cases had an above legal limit. In 19 cases
where blood alcohol was above 80 mg/100 ml, an opinion on intoxication was reported to the courts as a possible contributory factor.
Discussion The results of the study showed that almost two thirds of the pedestrians (non-active VRUs) and more than half of the active VRUs who died in accidents when tested for alcohol were above 80 mg/100 ml. This indicates that the on-going social dialogue regarding the contribution of intoxication to road traffic fatalities was built on a basis. However, the decision made by a forensic doctor for blood alcohol estimation in deceased VRUs depends on various factors. For example, if death occurred many days after treatment of injuries there is no necessity to take blood for alcohol estimation since it has already eliminated from the body. Another reason is the autopsy examination conducted on a putrefied body after several days/ weeks after the accident makes it impossible to take a sample of blood. On the other hand, interpretation of low blood alcohol level in a post-mortem sample has to be
Table 6. The average and the highest BAC among different VRUs. Type of VRU Pedestrians Two-wheeled vehicle (rider/ passengers) Three wheeler (driver/passenger) Other Total sample mean Total sample median
Mean BAC (mg/100 ml)
Highest BAC (mg/100 ml)
139 98 158 0 103 96
352 428 330 0
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done with caution since microbial activities in the corpses are known to produce alcohol. The analysis of the data of BAC showed that the mean as 103 mg/100 ml and the median as 96 mg/100 ml. Both the figures indicate that the levels are considerably higher than the legal limit of blood alcohol of 80 mg/100 ml for drivers, i.e. the mean being 1.3 times higher, while the median being 1.2. A total of 67% of pedestrians were above 80 mg/100 ml with a mean of 139 mg/100 ml. Blood alcohol analysis of two-wheeler group showed that 42% of motor cyclists pillion riders were above 80 mg/ 100 ml and the recorded mean blood alcohol level was 96 mg/100 ml despite having a legal limit for riding. Research on blood alcohol levels based on autopsy studies around the world also recognises high BAC in pedestrians as a significant problem. Many studies quote different percentages of pedestrians as having high BAC from 19%–78% of the sample with mean blood alcohol levels ranging from 150 to 200 mg/dl (Chao, Lo, Bloodworth, & Tan-Siew, 1992; Kuruc, Sidlo, Valent, Mlynar, & Murarikova, 2009; T€ oro et al., 2005; Rao et al., 2013). Despite the fact that the law does not prohibit any drunken pedestrian from using the roads, the effects of alcohol on motor and sensory cortices cannot be overlooked, as those effects makes them more vulnerable for accidents. These effects on central nervous system start to appear around blood alcohol levels of 30–40 mg. In our sample, there were nine pedestrians with blood alcohol level between 30 mg/100 ml and 80 mg/100 ml. Three wheelers were introduced to Sri Lanka in latter part of 1978. They have become a common mode of transport in both urban and rural areas. Although it is a common, popular mode of transport, three-wheeler drivers have been associated with aggressive driving behaviours and increased risk of accidents (Akalanka, Fujiwara, Desapriya, Peiris, & Scime, 2012). The six deaths associated with three wheelers in our study had a mean BAC of 158 mg/100 ml. Four deaths were drivers of three wheelers while two were passengers. Highest reading, i.e. 428 mg/100 ml, of the blood alcohol in this study population was also seen in this group. De Silva et al. in a hospital base study in 2001 reported that 89% of three-wheeler drivers and 28.1% of pedestrians involved in threewheeler collisions as being under the influence of alcohol. Further analysis of BAC above 80 mg/100 ml of to those with less than 80 mg/100 ml BAC with traffic to non-traffic hours also resulted no relationship between groups. This clearly shows that when implementing prevention strategies, the law enforcement officers have to be vigilant in both traffic and non-traffic hours regarding alcohol intoxication. In this study, just above 40% of two- and three-wheel fatalities were above the legal limit to drive a vehicle. This also shows that there are gaps in the detection of drunken drivers by the police, hence inability to prevent
an accident and fatality. In Sri Lanka, preventing strategies of alcohol-related accidents have been targeted mainly on drunk drivers. Frequent advertisement boards on drunk driving appearing on the motorway are common in urban Sri Lankan roads. Considering our finding of a significant proportion of pedestrians having a BAC above 80 mg/100 ml we have to think of preventing strategies in a new direction. It is sad to notice that neither the public nor traffic police have taken preventive steps to remove a heavily drunk pedestrian from using the road who is going to be a threat to himself as well as to the drivers of a motorway. Over the years, professionals as well as media men have raised their concerns about increased alcohol consumption and related issues in many forums (de Silva, Samarasinghe, & Gunawardena, 2009; Kulatunga, 2013; Wijesundere, 2012). According to Administrative report of the Commissioner General of Excise for the year 2011 production of hard and soft liquor has been on increase for past few years. According to the Global status report on alcohol and health released in 2011 based on 2003– 2005 data states total consumption rate for Sri Lanka as that of 0.8 litres of pure alcohol. If the alcohol production is on steady increase it is expected to increase the alcohol consumption too. This in turn will have an effect on VRUs; hence, the problem is expected to increase more in future. Although we did not analyse the increase or the decrease of alcohol-related road traffic fatalities over the study period of 2005–2012, such analysis as well as carrying out blood alcohol level examination in all fatalities may help to understand the issue in depth. This study was carried out at a tertiary care hospital situated between two motorways in the western province of the country. Thus, a large number of urban traffic accidents are represented in the study compared with semiurban or rural area traffic accidents. Since the hospital is not equipped with a neurosurgical unit, majority of head injury fatalities are transferred to the National Hospital in Colombo, where death may occur later. The other reason is that all road traffic deaths that underwent autopsy examination where blood alcohol level can be conducted (non-putrefied) were not done in our sample. Therefore, the analysis of the road traffic fatalities does not give a holistic view of the blood alcohol trends in the western province of Sri Lanka. Conclusion The results of the study revealed that though the majority of VRUs belong to 20–60 years age group, elderly were more among the deceased pedestrians. Analysis of the BAC revealed that about 1/2 (52%) of the deceased VRUs were above 80 mg/100 ml with a mean of 103 mg/ 100 ml. The lowest mean blood alcohol level was in the two-wheeler group with BAC of 98 mg/100 ml, while the
International Journal of Injury Control and Safety Promotion highest was in three-wheeler group with a mean BAC of 158 mg/100 ml. This analysis reveals that the proportion of deceased pedestrians above BAC of 80 mg/100 ml is significantly more than other types of VRUs. The study results suggest that alcohol influence among pedestrians represent a significant risk factor for fatal road traffic accidents. Although law does not prohibit drunken pedestrians, contribution of their blood alcohol levels for accident is important to the courts.
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Recommendations We suggest that more in depth research should be conducted in this area. Therefore, we recommend that all patients suffering from severe injuries or life-threatening injuries due to road traffic accidents to undergo compulsory screening for blood alcohol levels at the time of admission to the hospital as well as at autopsy. We also recommend regular audits of post-mortem reports to improve the opinion writing since incorporating of the results of intoxication is important to the courts to find contributory negligence as well as for compensation. Acknowledgement Dr E.M.D.P. Ekanayake for assisting in data collection.
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ISSN: 1745-7300 (Print) 1745-7319 (Online) Journal homepage: http://www.tandfonline.com/loi/nics20
A study into blood alcohol concentration in fatal accidents among vulnerable road users in a tertiary care hospital Sri Lanka Anuruddhi Samanthika Edirisinghe, Indira Deepthi Kitulwatte & Udara Dilrukshi Senarathne To cite this article: Anuruddhi Samanthika Edirisinghe, Indira Deepthi Kitulwatte & Udara Dilrukshi Senarathne (2015) A study into blood alcohol concentration in fatal accidents among vulnerable road users in a tertiary care hospital Sri Lanka, International Journal of Injury Control and Safety Promotion, 22:2, 158-164, DOI: 10.1080/17457300.2013.857696 To link to this article: http://dx.doi.org/10.1080/17457300.2013.857696
Published online: 16 Dec 2013.
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Date: 06 November 2015, At: 04:51
International Journal of Injury Control and Safety Promotion, 2015 Vol. 22, No. 2, 158–164, http://dx.doi.org/10.1080/17457300.2013.857696
A study into blood alcohol concentration in fatal accidents among vulnerable road users in a tertiary care hospital Sri Lanka Anuruddhi Samanthika Edirisinghe*, Indira Deepthi Kitulwatte and Udara Dilrukshi Senarathne Department of Forensic Medicine, Faculty of Medicine, University of Kelaniya, Thallagolla Road, Ragama 11010, Sri Lanka
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(Received 28 June 2013; accepted 14 October 2013) Reckless driving behaviour associated with alcohol has been well known. In Sri Lanka, research on blood alcohol concentration (BAC) in road fatalities is scares. Thus, we studied the BAC in vulnerable road users (VRUs) encountered in medico-legal autopsies. A retrospective descriptive study based on case records of VRU fatalities from 2005 to 2012 referred for a tertiary care unit for post-mortem examination was conducted. A pro-forma was developed to extract data from the post-mortem blood alcohol reports. Data were analysed using percentages and p-values. There were 119 cases from the 328 autopsies to investigate blood alcohol tests. A total of 51% (n ¼ 61) out of 119 had BAC above 80 mg/ 100 ml and mean level was 103 mg/100 ml. 2/3 of pedestrians had a BAC above 80 mg/100 ml with a mean level of 139 mg/dl. The highest mean blood alcohol (158 mg/dl) was reported from three-wheeler users. Majority of cases with more than 80 mg/100 ml BAC was reported in the age group of 40–60 years, while 40% of the elderly too had a BAC above 80 mg/100 ml. The comparison between pedestrians having above 80 mg/100 ml of BAC with that of other VRUs (active road users) showed a significant statistical difference (p ¼ 0.017). The study results suggest that alcohol influence among pedestrians represent a significant risk factor for fatal road traffic accidents. Keywords: vulnerable road user (VRU); blood alcohol concentration (BAC); road traffic fatalities; legal limit for drunken drivers
Introduction/background Human factors in road fatalities are preventable. Alcohol and its relationship to road traffic accidents has been recognised for a long time (Editorial Lancet, 1907), but the scientific reasoning of blood alcohol levels and risk of crash was established in 1964, with a case control study carried out in Michigan, United States, popularly known as the Grand Rapids study (Borkenstein et al., 1964). The results of this study provided the basis for the future setting of legal blood alcohol limits for motor vehicle drivers in many countries around the world, typically at 80 mg/ 100 ml. Sri Lanka too adapted the legal limit of blood alcohol level as 80 mg/100 ml of blood for drivers of a motor vehicle in 1984 (Government of Sri Lanka, 1984). Although majority of countries around the world still has the legal limit for motorist as 80 mg/100 ml, several countries in Europe and Australia have further reduced the legal limit to 50 mg/100 ml or 40 mg/100 ml considering the results of later research findings that included behavioural and experimental studies (Hurst, Harte, & Frith, 1994; McLean & Holubowycz, 1981). It is also worthy to note that there are 89 countries in the world having comprehensive drink-driving law, defined as a blood alcohol concentration (BAC) of 50 mg/100 ml or less, in-line with best practice recommended by World Health Organization (WHO, 2009). Continuing on the *Corresponding author. Email: [email protected] Ó 2013 Taylor & Francis
same line of prevention considerable number of countries has adopted zero blood alcohol for motorists, while many more have introduced zero blood alcohol limits for young novice drivers (WHO, 2009). ‘Vulnerable road user’ (VRU) is a term applied to those who are at more risk in traffic, i.e. those who are unprotected by an outside shield. Therefore, pedestrians, pedal cyclists and motor cyclists, three-wheeler drivers and occupants, as well as a passengers who are travelling on the footboard or the hood of an overcrowded bus or minibus, are also considered as vulnerable since they benefit from little or no external protective devices that would absorb energy during a collision (Peden et al., 2004; WHO, 2009). According to the statistics of the Sri Lankan Police, the number of road fatalities from 2004 to 2009 has been fluctuating around 2300–2500 deaths per year with the latest figure being 2721 deaths in 2011, showing an upward trend (Sri Lanka Police, 2008, 2011; WHO, 2009). Although police statistics do not categorise VRUs separately, the percentage of pedestrian fatalities has been around 31%–34% while drivers and riders amount to 41%–45% and the rest being passengers. Common reasons such as speeding, overtaking, drunken drivers, nonadherence to road rules, poor road conditions though seen in Sri Lanka, unique problems like poor law enforcement has been highlighted (Dharmaratne & Ameratunga, 2004;
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International Journal of Injury Control and Safety Promotion Dharmaratne & Stevenson, 2006; WHO, 2009). For past 2 years, increasing trend in the reckless behaviours of drunken drivers resulting other road user deaths, initiating a social dialogue demanding stricter law enforcement is apparent in print media (Panagoda & Fazlulhaq, 2012; Wickremasekera, 2011; Wijesiri, 2012). Research on road fatalities in Sri Lanka is scarce and association of blood alcohol levels to fatalities are hardly found. Salgado and Colomboge (1988) reported that 51.4% were pedestrians out of 524 autopsies carried out on the victims of road accident over a 2-year period in Colombo, while 24.4% and 10.1% were pedal cyclist and motor cyclists, respectively. Further, highest number of fatalities was reported in the age group of 20–29 years, while cranio-cerebral injury was the commonest cause of death. A recent study on estimating the incidence of road traffic fatalities and injuries in Sri Lanka reported death rate of road traffic accident as 12.1 per 100,000 people (Bhalla et al., 2010). Although both studies addressed the epidemiological aspect of fatalities and injuries, no assessment of the association of BAC to the accident has been analysed. Contribution of alcohol to the death of an individual is important to the judiciary. The alcohol-related mortality risk in natural and non-natural death is well established in forensic literature through analysis of large autopsy databases and meta-analysis (Smith, Branas, & Miller, 1999; T€ oro, Dunay, R ona, Klausz, & Feher, 2009). A forensic pathologist when attending to an autopsy of a road fatality reports not only on the injuries and the cause of death but also on contributory factors like ethanol effects. Thus, a comprehensive medical opinion armed with blood alcohol levels helps the judiciary to find the contributory negligence in more realistic manner. Blood alcohol testing or toxicology screening for illicit drugs is not mandatory in all traffic deaths in Sri Lanka unlike in many European Union countries (Costa et al., 2012). Therefore, alcohol and toxicological screening of road traffic deaths are done on the discretion of the specialist in forensic medicine or non-specialist doctor who conducts the post-mortem examination. In the authors’ institution, best practice guidelines on post-mortem examination at institutional levels direct the doctor in decision making on whether to take post-mortem blood or not, technique of obtaining a sample and transportation Objective To study levels of BAC in different types of VRUs encountered in medico-legal autopsies. Study design After obtaining ethical clearance, a retrospective descriptive study was carried out based on the case records of VRUs referred for post-mortem examination at a teaching
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unit of a tertiary care hospital from 2005 January to 2012 December in the Western Province of Sri Lanka, closer to two motorways (Colombo-Negombo (Airport) and Colombo-Kandy). A deceased VRU was defined as a pedestrian/rider, pillion rider of a motor bicycle, moped or scooter/foot cyclist/driver of a three wheeler/occupant of a three wheeler/rider of a bullock cart or a traveller in the foot board of an overcrowded bus. Analysis of the type of the VRU was based on the police information, eyewitness records aided by final interpretation of the post-mortem report. A pro-forma was developed to extract data from the case records. Post-mortem reports and toxicological reports on post-mortem blood samples (blood alcohol) sent by the Government Analyst Department were perused. Post-mortem blood samples have been obtained from femoral blood according to the institution autopsy examination guidelines and they were analysed at the Department of the Government Analyst as the routine practice. Post-mortem reports where quality data cannot be extracted were excluded from the study. The pro-forma contained data on age, sex, type of VRU and the time of the accident. Time of the accident was analysed as traffic hours and non-traffic hours, where traffic hours were defined as the time period between 6.00 am–9.00 am, 12.00 pm–2.30 pm and 4.00 pm–8.00 pm, where more policemen are seen on the road during rush hours. Further data included whether a post-mortem blood was taken to send to the Government Analyst Department, what type of requests made (i.e. whether to test for blood alcohol or other toxicology screening such as drugs of abuse or common poisons), post-mortem ethanol levels as well as data on cause of death and relevant opinions. The data were analysed using percentages and p-values. The analysis of BAC was divided into five groups according to clinical effects (Stark & Norfolk, 2005). The comparisons were done on BAC less than 80 mg/100 ml with those above 80 mg/100 ml using chi-square test, since 80 mg/100 ml of BAC is the legal limit for drivers in Sri Lanka. The type of the VRU was also grouped into active users and non-active (passive user). The active road users included those in vehicles (riders or passengers), while non-active users were pedestrians. Results During the study period of January 2005 to December 2012, a total of 7266 post-mortem examinations were conducted at the tertiary care hospital where the study was conducted. Although 840 deaths of road traffic fatalities underwent post-mortem examination, only 504 deaths belonged to VRU group. Out of all VRUs post-mortem conducted during this period 328 cases became eligible for the study considering the quality of the data. A blood sample was taken to send to the Government Analyst
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Table 1. The availability of BAC of VRUs. Type of VRUs
BAC available
BAC not available
Total
p-Value
42 77
115 94
157 171
0.001
119
209
328
Non-active road user (pedestrians) Active road user (two-wheeled vehicle rider/passengers, three-wheeler driver/passenger, other persons going on bullock carts or foot board of a bus, etc.) Total
Table 2. The distribution of BAC among different types of VRUs.
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Blood alcohol concentration (BAC) mg/100 ml Type of VRU Pedestrians Two-wheeled vehicle (rider/passengers) Three wheeler (driver/passenger) Other Total
0–50 (slight)
50–80 (mild)
80–140 (moderate)
141–300 (severe)
>300 (very severe)
Total
9 30 3 1 43(36%)
5 9 0 0 14(12%)
10 10 1 0 21(18%)
10 13 4 0 27(22%)
8 5 1 0 14(12%)
42(35%) 67(56%) 9(8%) 1(1%) 119 (100%)
Department in 37% of the cases (n ¼ 122), while a report from the Government Analyst was available in 119 (36%) case records. The discrepancy of three reports to the number of request made was due to long delays encountered in receipt of blood alcohol reports. All 119 samples were tested for ethanol. No sample was tested for drugs of abuse, but two samples were tested for common poisons that resulted negative. Both were elderly pedestrians subjected to hit and run accidents. The comparative analysis to the different types of VRUs and the availability of the blood alcohol report showed that almost half of (47%) of active road users were subjected to alcohol examination, while just above one fourth (27%) of the pedestrians (non-active road users) underwent blood alcohol examination. The comparison of the two groups revealed a significant difference (p ¼ 0.001; Table 1). The analysis of the 119 VRU fatalities where a BAC was available revealed that 56% (n ¼ 67) were twowheeler riders or passengers, while 35% (n ¼ 42) were pedestrians; 8% (n ¼ 9) were three-wheeler drivers or
passengers, while 1% (n ¼ 1) belonged to the other category, i.e. rider/passenger of a bullock cart, passenger travelling in the foot board of a bus. Analysis of the BAC revealed that just about half (52%) of the group were above 80 mg/100 ml, while 12% of the group were between 50 mg/100 ml and 80 mg/100 ml of alcohol. Another 12% (n ¼ 14) had a very severe level, i.e. blood alcohol of above 300 mg/100 ml, which can produce coma or death from alcohol poisoning alone. Majority of the very severe group were pedestrians. It was also worth to mention that nine two-wheeler riders had a BAC between 50 mg/100 ml and 80 mg/100 ml, while five pedestrians had a similar amount (Table 2). Analysis of the BACs of different types of VRUs revealed that 67% of pedestrians and 42% of two-wheeler riders/pillion riders were above 80 mg/100 ml, while 67% of the deceased three-wheeler drivers/passengers were also above the legal limit. The comparison between pedestrians having above 80 mg/100 ml of BAC with that of other VRUs (active road users) showed a significant statistical difference (p ¼ 0.017; Table 3).
Table 3. The distribution of BAC (80 mg/100 ml) among active and non-active road users. Type of VRU Non-active road users (pedestrians) Active road users
Pedestrians Two-wheeled vehicle(rider/passenger) Three wheeler(driver/passenger) Other Total
BAC < 80 mg/ 100 ml
BAC > 80 mg/ 100 ml
Total
p-Value
14(33%) 39(58%) 3(33%) 1(100%) 57(48%)
28(67%) 28(42%) 6(67%) 0(0%) 62(52%)
42(35%) 67(56%) 9(8%) 1(15%) 119(100)
0.017
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Table 4. Distribution of VRU age groups and BAC. BAC > 80 mg/dl Age group of VRU 20 years
BAC < 80 mg/dl
Number
%
Number
1 19 28 14 62
02 31 45 22 100
5 20 12 20 57
60 Total
% 9 35 21 35 100
Total Number
%
p-Value
6 39 40 34 119
5 33 34 28 100
0.066
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Table 5. Distribution of BAC of VRUs according to the alleged time of the incident (traffic hours and non-traffic hours). BAC > 80 mg/dl
Traffic hours Non-traffic hours Total
BAC < 80 mg/dl
Total
Number
%
Number
%
Number
%
p-Value
27 35 62
44 56 100
30 27 57
53 47 100
57 62 119
48 52 100
0.317
Analysis of the age groups showed that one out of six young persons (>20 years) tested for alcohol recorded above 80 mg/100 ml BAC, while more middle-aged men were found to be above the same. However, there was no significant difference (p ¼ 0.066) between less than 20 age group with that of others (Table 4). Time of the incident was analysed as traffic hours and non-traffic hours. The analysis revealed that 64% of the deaths occurred during non-traffic hours, especially at night. The analysis of the time of the incident (traffic hours to non-traffic hours) to BAC above 80 mg/100 ml showed that there was no significant difference between two groups (Table 5). The analysis of the blood alcohol levels revealed the highest level as 428 mg/100 ml, which was recorded in a pillion rider, while negative BAC tests were recorded in 25 fatalities. The mean and the median blood alcohol level among the tested VRUs were above 80 mg/100 ml (Table 6). Analysis of the opinion given showed that although the blood alcohol report was available in 119 cases, an opinion regarding alcohol level was given only in 24 cases although 62 cases had an above legal limit. In 19 cases
where blood alcohol was above 80 mg/100 ml, an opinion on intoxication was reported to the courts as a possible contributory factor.
Discussion The results of the study showed that almost two thirds of the pedestrians (non-active VRUs) and more than half of the active VRUs who died in accidents when tested for alcohol were above 80 mg/100 ml. This indicates that the on-going social dialogue regarding the contribution of intoxication to road traffic fatalities was built on a basis. However, the decision made by a forensic doctor for blood alcohol estimation in deceased VRUs depends on various factors. For example, if death occurred many days after treatment of injuries there is no necessity to take blood for alcohol estimation since it has already eliminated from the body. Another reason is the autopsy examination conducted on a putrefied body after several days/ weeks after the accident makes it impossible to take a sample of blood. On the other hand, interpretation of low blood alcohol level in a post-mortem sample has to be
Table 6. The average and the highest BAC among different VRUs. Type of VRU Pedestrians Two-wheeled vehicle (rider/ passengers) Three wheeler (driver/passenger) Other Total sample mean Total sample median
Mean BAC (mg/100 ml)
Highest BAC (mg/100 ml)
139 98 158 0 103 96
352 428 330 0
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done with caution since microbial activities in the corpses are known to produce alcohol. The analysis of the data of BAC showed that the mean as 103 mg/100 ml and the median as 96 mg/100 ml. Both the figures indicate that the levels are considerably higher than the legal limit of blood alcohol of 80 mg/100 ml for drivers, i.e. the mean being 1.3 times higher, while the median being 1.2. A total of 67% of pedestrians were above 80 mg/100 ml with a mean of 139 mg/100 ml. Blood alcohol analysis of two-wheeler group showed that 42% of motor cyclists pillion riders were above 80 mg/ 100 ml and the recorded mean blood alcohol level was 96 mg/100 ml despite having a legal limit for riding. Research on blood alcohol levels based on autopsy studies around the world also recognises high BAC in pedestrians as a significant problem. Many studies quote different percentages of pedestrians as having high BAC from 19%–78% of the sample with mean blood alcohol levels ranging from 150 to 200 mg/dl (Chao, Lo, Bloodworth, & Tan-Siew, 1992; Kuruc, Sidlo, Valent, Mlynar, & Murarikova, 2009; T€ oro et al., 2005; Rao et al., 2013). Despite the fact that the law does not prohibit any drunken pedestrian from using the roads, the effects of alcohol on motor and sensory cortices cannot be overlooked, as those effects makes them more vulnerable for accidents. These effects on central nervous system start to appear around blood alcohol levels of 30–40 mg. In our sample, there were nine pedestrians with blood alcohol level between 30 mg/100 ml and 80 mg/100 ml. Three wheelers were introduced to Sri Lanka in latter part of 1978. They have become a common mode of transport in both urban and rural areas. Although it is a common, popular mode of transport, three-wheeler drivers have been associated with aggressive driving behaviours and increased risk of accidents (Akalanka, Fujiwara, Desapriya, Peiris, & Scime, 2012). The six deaths associated with three wheelers in our study had a mean BAC of 158 mg/100 ml. Four deaths were drivers of three wheelers while two were passengers. Highest reading, i.e. 428 mg/100 ml, of the blood alcohol in this study population was also seen in this group. De Silva et al. in a hospital base study in 2001 reported that 89% of three-wheeler drivers and 28.1% of pedestrians involved in threewheeler collisions as being under the influence of alcohol. Further analysis of BAC above 80 mg/100 ml of to those with less than 80 mg/100 ml BAC with traffic to non-traffic hours also resulted no relationship between groups. This clearly shows that when implementing prevention strategies, the law enforcement officers have to be vigilant in both traffic and non-traffic hours regarding alcohol intoxication. In this study, just above 40% of two- and three-wheel fatalities were above the legal limit to drive a vehicle. This also shows that there are gaps in the detection of drunken drivers by the police, hence inability to prevent
an accident and fatality. In Sri Lanka, preventing strategies of alcohol-related accidents have been targeted mainly on drunk drivers. Frequent advertisement boards on drunk driving appearing on the motorway are common in urban Sri Lankan roads. Considering our finding of a significant proportion of pedestrians having a BAC above 80 mg/100 ml we have to think of preventing strategies in a new direction. It is sad to notice that neither the public nor traffic police have taken preventive steps to remove a heavily drunk pedestrian from using the road who is going to be a threat to himself as well as to the drivers of a motorway. Over the years, professionals as well as media men have raised their concerns about increased alcohol consumption and related issues in many forums (de Silva, Samarasinghe, & Gunawardena, 2009; Kulatunga, 2013; Wijesundere, 2012). According to Administrative report of the Commissioner General of Excise for the year 2011 production of hard and soft liquor has been on increase for past few years. According to the Global status report on alcohol and health released in 2011 based on 2003– 2005 data states total consumption rate for Sri Lanka as that of 0.8 litres of pure alcohol. If the alcohol production is on steady increase it is expected to increase the alcohol consumption too. This in turn will have an effect on VRUs; hence, the problem is expected to increase more in future. Although we did not analyse the increase or the decrease of alcohol-related road traffic fatalities over the study period of 2005–2012, such analysis as well as carrying out blood alcohol level examination in all fatalities may help to understand the issue in depth. This study was carried out at a tertiary care hospital situated between two motorways in the western province of the country. Thus, a large number of urban traffic accidents are represented in the study compared with semiurban or rural area traffic accidents. Since the hospital is not equipped with a neurosurgical unit, majority of head injury fatalities are transferred to the National Hospital in Colombo, where death may occur later. The other reason is that all road traffic deaths that underwent autopsy examination where blood alcohol level can be conducted (non-putrefied) were not done in our sample. Therefore, the analysis of the road traffic fatalities does not give a holistic view of the blood alcohol trends in the western province of Sri Lanka. Conclusion The results of the study revealed that though the majority of VRUs belong to 20–60 years age group, elderly were more among the deceased pedestrians. Analysis of the BAC revealed that about 1/2 (52%) of the deceased VRUs were above 80 mg/100 ml with a mean of 103 mg/ 100 ml. The lowest mean blood alcohol level was in the two-wheeler group with BAC of 98 mg/100 ml, while the
International Journal of Injury Control and Safety Promotion highest was in three-wheeler group with a mean BAC of 158 mg/100 ml. This analysis reveals that the proportion of deceased pedestrians above BAC of 80 mg/100 ml is significantly more than other types of VRUs. The study results suggest that alcohol influence among pedestrians represent a significant risk factor for fatal road traffic accidents. Although law does not prohibit drunken pedestrians, contribution of their blood alcohol levels for accident is important to the courts.
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Recommendations We suggest that more in depth research should be conducted in this area. Therefore, we recommend that all patients suffering from severe injuries or life-threatening injuries due to road traffic accidents to undergo compulsory screening for blood alcohol levels at the time of admission to the hospital as well as at autopsy. We also recommend regular audits of post-mortem reports to improve the opinion writing since incorporating of the results of intoxication is important to the courts to find contributory negligence as well as for compensation. Acknowledgement Dr E.M.D.P. Ekanayake for assisting in data collection.
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