Global Health Issue of Road Traffic Accidents

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8th Feb 2020 Health Reference this

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Epidemiology

Road traffic accidents are a major growing but neglected global health problem causing more than 1.2 million deaths per year. Every minute, more than two people die as a result of these accidents (Unece.org, 2018). The mortality rate represents only the tip of the iceberg of the total burden, with the number of injured people reaching as high as 50 million, which equates to the population of 5 of the world’s largest cities combined (WHO, 2004).  With the economic growth, motorisation and without any changes to present prevention policies, the road fatalities are forecast to rise by 65% in 2020 compared to 2000. A lot more dramatic increase is estimated in low- and middle-income countries, where the rate can increase by in excess of 100% (Ameratunga, Hijar, Norton, 2006). Road traffic accidents are the leading cause of death in the young population aged 5-14 and 15-29, along with being number 3 in the 30-49 group (Figure 1). In addition, approximately 50% of all collisions occur in the most productive age group (15-44) leading to major economic losses. WHO (2004) predicts road collisions to rise to the 6th place for mortality rate worldwide with the rise to the 3rd place for the cause of DALYs lost by 2020.

Rank

5-14 years

15-29 years

30-49 years

All ages

1

Road injury

Road injury

HIV/AIDS

Ischaemic heart disease

2

Diarrhoeal diseases

Self-harm

Ischaemic heart disease

Stroke

3

Lower respiratory infections

Interpersonal violence

Road injury

COPD

4

Drowning

Maternal conditions

Tuberculosis

Lower respiratory infections

5

Malaria

HIV/AIDS

Stroke

Alzheimer disease and other dementias

6

Meningitis

Tuberculosis

Liver cirrhosis

Trachea, bronchus, lung cancer

7

HIV/AIDS

Diarrhoeal diseases

Self-harm

Diabetes mellitus

8

Congenital anomalies

Lower respiratory infections

Interpersonal violence

Road injury

9

Collective violence

Collective violence

Maternal conditions

Diarrhoeal disease

10

Protein-energy malnutrition

Ischaemic heart disease

Lower respiratory infections

Tuberculosis

 

Figure 1: Leading causes of death by age group in 2016 (adapted from WHO, 2018)

Paradoxically, low- and middle-income countries account for approximately 90% of the total traffic fatalities despite the fact that this region has only around 54% of the world’s vehicles (Figure 2). This can be partly explained by the fact that a large number of deaths occur among the vulnerable road users such as pedestrians, cyclists and motorcyclists. The global rate of road fatalities is 17.4 per 100 000, however, there are significant disparities among countries depending on the economic status. While the high-income countries have a rate of 9.2 per 100 000, both low- and middle-income countries have rates twice as high (18.4 and 24.1 per 100 000 respectively) (Figure 2, WHO, 2015). The highest mortality rates are found in the African region. In addition, people from low socioeconomic backgrounds even in high-income countries have also higher rates demonstrating the link between accidents and poverty (WHO, 2018).

Figure 2: Population, road traffic deaths, and motorised vehicles by proportion and road traffic deaths per 100 000 populations, by country income states 2015 (adapted from WHO, 2015)

 

Why is it a public health concern?

Infectious diseases and more recently non-communicable diseases have dominated the public health effort with road traffic accidents never appearing as a global health concern until the second half of the twentieth century (Borowy, 2013). Funding for research and development for traffic collisions is at the bottom of a league table with a value of less than $1 per disability-adjusted life year (DALY) compared to $26 per DALY for HIV/AIDS (WHO, 1996). One of the possible reasons for the historical lack of attention is the view of accidents as random uncontrollable events that are an inevitable part of life (Johal, Schemitsch, Bhandar, 2014, Loimer, Guarnieri, 1996). Traditionally, the traffic collisions were perceived as the sole responsibility of the road users. It has been argued that although human error can trigger a crash, it might not be the underlying causative factor and indirect influences such as infrastructure, vehicle safety features, traffic laws and their enforcement contribute significantly (Rumar, 1999). Therefore, road crashes are not entirely random, but they are in fact comparable to any disease with an agent (road user), host (vehicle), and vector (transfer of acute energy that causes the disruption in the normal human physiology) (Hyder, 2004). A systematic approach needs to be adopted addressing all risk factors and areas for intervention. The idea of injury prevention control framework was first described by Haddon that identified three phases of an accident– pre-collision, collision, and post-collision (Figure 3, WHO, 2004).

Phase

Human

Vehicle

Environment

Pre-collision – crash prevention

Information

Attitudes

Impairment

Police enforcement

Roadworthiness

Lighting

Braking

Handling

Speed management

Road design and road layout

Speed limits

Pedestrians facilities

Collision – injury prevention

Helmet use

Restraint use

Occupant restraints

Other safety devices

Crash-protective design

Crash-protective roadside objects

Post-collision- life-sustaining

First-aid skills

Access to medics

Ease of access

Fire risk

Rescue facilities

Access and response

Figure 3: Haddon matrix, areas for intervention in road traffic injuries (adapted from WHO, 2004).

The global impact

National level

Globally it is estimated that 3% of GDP is lost as a result of road fatalities and injuries. The effect is even bigger in low- and middle-income countries where it can be as high as 5% (Dahdah, McMahon, 2008). The estimated impact corresponds to $518 billion per annum out of which $100 billion occurred in developing countries. The economic loss in these countries is twice as high as the annual amount of financial assistance they receive demonstrating the magnitude of the impact (United Nations, 2003).

Healthcare system

Road collisions place significant a strain on the healthcare systems, especially in developing countries. An epidemiolocal review in developing countries showed that between 30% and 86% of all trauma admissions are accounted to road traffic accidents. In some countries, traffic collision casualties represented 48% of bed occupancy within surgical wards, in addition to these patients also being the most frequent users of operating theatres and intensive care units (Odero, Garner, Zwi, 1997). Therefore, prevention of road accidents would not only save money and resources but would also relieve pressure on hospitals and healthcare professionals (WHO, 2004).

Individual and family level

Many families are pushed into poverty as a result of the costs associated with medical care, disabilities, funeral or simply the loss of income. A study conducted in Bangladesh showed that 70% of households reported decrees in their income and food consumption in addition to ¾ reported lower standards of living (Babtie Ross Silcock, Transport Research Laboratory, 2003).  Furthermore, in some instances, it might lead to families selling its property or taking loans (Mock et al., (2003). Death or disability has an impact not only on the family financial situation but also on health and social status of the children left behind. For example, road accidents fatalities are the second commonest cause of children being orphaned in Mexico (Hijar, Vazquez-Vela, Arreola-Risa, 2003). Adding to this picture is the effect on the individuals involved in road traffic collision. This ranges from by physical disability, loss of employment to psychological effects (WHO, 2004).

Causes and preventions

Infrastructure

Poor infrastructure, one of the most important causative factors, plays a major role in developing countries where a wide range of road users from trucks, buses, cars, motorcycles, bicycles and pedestrians occupy the same road without separation and therefore exposing the vulnerable group (WHO, 2004). A recent study on road safety in 60 countries showed that more than 50% of roads had poor infrastructure. Improvement in the 10% of roads with the lowest standards has the potential to prevent around 2.3 million deaths and 40 million serious injuries over 20 years (World Road Association, 2015). Safety designs, such as widening roads, raised pedestrian crossings, separate paths for bicycles and motorcycles, roundabouts, traffic calming devices, warning signs, have a profound effect in reducing the likelihood of accidents when planning as well as updating existing roads. Safety assessment and identification of the most dangerous roads is an example of affordable measures that can have a significant impact (WHO, 2015).

Policies

 Speed limitations decrease the likelihood of accidents along with the reduction in severity should they happen. It attributes between 30-50% of accidents worldwide (Chisholm et al., 2012). However, according to WHO (2017), only 47 countries, that equates to 13% of the world population, have laws that comply with the best practice in urban areas (Figure 4).

Figure 4: Urban speed laws by county (WHO, 2015)

Alcohol has the opposite effect, increasing the risks of accidents. Yet again only 34% of countries have laws enforcing best practice. In addition, injury severity and the risk of death can be further reduced by the use of seatbelts, helmets, appropriate child restrains as well as use of vehicles with basic safety standards. However, a similar pattern in legislation concerning these protecting features is found worldwide (WHO, 2017). It has been shown that most effective intervention is joint enforcement on speeding, alcohol limits and helmet use laws due to their synergistic action and relative marginal cost of adding safety checks. One DALY saved costs $ 1000-3000 in the developing world, which is less than yearly income per capita, suggesting the intervention is cost-effective (Chisholm, Naci, 2008).

Access to healthcare

Most developing countries do not have basic emergency services. First aid at the scenes and transport, if any received, are delivered mostly by bystanders, relatives or police. Once reaching the hospital, the care in these countries is mostly delivered by general practitioners without any trauma training. Furthermore, there is a lack of surgeons, equipment, protocols and organisation within hospitals which result in delays and poorer outcomes (Mock, nii-Amon-Kotei, Maier, 1997). Studies have shown that over one-third of deaths could be prevented if developing countries had similar trauma outcomes as in high-income countries. However, these implementations are a lot harder to achieve and require significant global investment (Mock et al.,2012).

Conclusion

Despite the numbers being strikingly high, road traffic accidents attract less media attention compared to others less frequent and out of the ordinary diseases. Road traffic systems are complex and vary between country. A systematic approach that takes into account the needs of a specific country is required in order to achieve cost-effective and long-lasting changes to road safety. 

References

Epidemiology

Road traffic accidents are a major growing but neglected global health problem causing more than 1.2 million deaths per year. Every minute, more than two people die as a result of these accidents (Unece.org, 2018). The mortality rate represents only the tip of the iceberg of the total burden, with the number of injured people reaching as high as 50 million, which equates to the population of 5 of the world’s largest cities combined (WHO, 2004).  With the economic growth, motorisation and without any changes to present prevention policies, the road fatalities are forecast to rise by 65% in 2020 compared to 2000. A lot more dramatic increase is estimated in low- and middle-income countries, where the rate can increase by in excess of 100% (Ameratunga, Hijar, Norton, 2006). Road traffic accidents are the leading cause of death in the young population aged 5-14 and 15-29, along with being number 3 in the 30-49 group (Figure 1). In addition, approximately 50% of all collisions occur in the most productive age group (15-44) leading to major economic losses. WHO (2004) predicts road collisions to rise to the 6th place for mortality rate worldwide with the rise to the 3rd place for the cause of DALYs lost by 2020.

Rank

5-14 years

15-29 years

30-49 years

All ages

1

Road injury

Road injury

HIV/AIDS

Ischaemic heart disease

2

Diarrhoeal diseases

Self-harm

Ischaemic heart disease

Stroke

3

Lower respiratory infections

Interpersonal violence

Road injury

COPD

4

Drowning

Maternal conditions

Tuberculosis

Lower respiratory infections

5

Malaria

HIV/AIDS

Stroke

Alzheimer disease and other dementias

6

Meningitis

Tuberculosis

Liver cirrhosis

Trachea, bronchus, lung cancer

7

HIV/AIDS

Diarrhoeal diseases

Self-harm

Diabetes mellitus

8

Congenital anomalies

Lower respiratory infections

Interpersonal violence

Road injury

9

Collective violence

Collective violence

Maternal conditions

Diarrhoeal disease

10

Protein-energy malnutrition

Ischaemic heart disease

Lower respiratory infections

Tuberculosis

 

Figure 1: Leading causes of death by age group in 2016 (adapted from WHO, 2018)

Paradoxically, low- and middle-income countries account for approximately 90% of the total traffic fatalities despite the fact that this region has only around 54% of the world’s vehicles (Figure 2). This can be partly explained by the fact that a large number of deaths occur among the vulnerable road users such as pedestrians, cyclists and motorcyclists. The global rate of road fatalities is 17.4 per 100 000, however, there are significant disparities among countries depending on the economic status. While the high-income countries have a rate of 9.2 per 100 000, both low- and middle-income countries have rates twice as high (18.4 and 24.1 per 100 000 respectively) (Figure 2, WHO, 2015). The highest mortality rates are found in the African region. In addition, people from low socioeconomic backgrounds even in high-income countries have also higher rates demonstrating the link between accidents and poverty (WHO, 2018).

Figure 2: Population, road traffic deaths, and motorised vehicles by proportion and road traffic deaths per 100 000 populations, by country income states 2015 (adapted from WHO, 2015)

 

Why is it a public health concern?

Infectious diseases and more recently non-communicable diseases have dominated the public health effort with road traffic accidents never appearing as a global health concern until the second half of the twentieth century (Borowy, 2013). Funding for research and development for traffic collisions is at the bottom of a league table with a value of less than $1 per disability-adjusted life year (DALY) compared to $26 per DALY for HIV/AIDS (WHO, 1996). One of the possible reasons for the historical lack of attention is the view of accidents as random uncontrollable events that are an inevitable part of life (Johal, Schemitsch, Bhandar, 2014, Loimer, Guarnieri, 1996). Traditionally, the traffic collisions were perceived as the sole responsibility of the road users. It has been argued that although human error can trigger a crash, it might not be the underlying causative factor and indirect influences such as infrastructure, vehicle safety features, traffic laws and their enforcement contribute significantly (Rumar, 1999). Therefore, road crashes are not entirely random, but they are in fact comparable to any disease with an agent (road user), host (vehicle), and vector (transfer of acute energy that causes the disruption in the normal human physiology) (Hyder, 2004). A systematic approach needs to be adopted addressing all risk factors and areas for intervention. The idea of injury prevention control framework was first described by Haddon that identified three phases of an accident– pre-collision, collision, and post-collision (Figure 3, WHO, 2004).

Phase

Human

Vehicle

Environment

Pre-collision – crash prevention

Information

Attitudes

Impairment

Police enforcement

Roadworthiness

Lighting

Braking

Handling

Speed management

Road design and road layout

Speed limits

Pedestrians facilities

Collision – injury prevention

Helmet use

Restraint use

Occupant restraints

Other safety devices

Crash-protective design

Crash-protective roadside objects

Post-collision- life-sustaining

First-aid skills

Access to medics

Ease of access

Fire risk

Rescue facilities

Access and response

Figure 3: Haddon matrix, areas for intervention in road traffic injuries (adapted from WHO, 2004).

The global impact

National level

Globally it is estimated that 3% of GDP is lost as a result of road fatalities and injuries. The effect is even bigger in low- and middle-income countries where it can be as high as 5% (Dahdah, McMahon, 2008). The estimated impact corresponds to $518 billion per annum out of which $100 billion occurred in developing countries. The economic loss in these countries is twice as high as the annual amount of financial assistance they receive demonstrating the magnitude of the impact (United Nations, 2003).

Healthcare system

Road collisions place significant a strain on the healthcare systems, especially in developing countries. An epidemiolocal review in developing countries showed that between 30% and 86% of all trauma admissions are accounted to road traffic accidents. In some countries, traffic collision casualties represented 48% of bed occupancy within surgical wards, in addition to these patients also being the most frequent users of operating theatres and intensive care units (Odero, Garner, Zwi, 1997). Therefore, prevention of road accidents would not only save money and resources but would also relieve pressure on hospitals and healthcare professionals (WHO, 2004).

Individual and family level

Many families are pushed into poverty as a result of the costs associated with medical care, disabilities, funeral or simply the loss of income. A study conducted in Bangladesh showed that 70% of households reported decrees in their income and food consumption in addition to ¾ reported lower standards of living (Babtie Ross Silcock, Transport Research Laboratory, 2003).  Furthermore, in some instances, it might lead to families selling its property or taking loans (Mock et al., (2003). Death or disability has an impact not only on the family financial situation but also on health and social status of the children left behind. For example, road accidents fatalities are the second commonest cause of children being orphaned in Mexico (Hijar, Vazquez-Vela, Arreola-Risa, 2003). Adding to this picture is the effect on the individuals involved in road traffic collision. This ranges from by physical disability, loss of employment to psychological effects (WHO, 2004).

Causes and preventions

Infrastructure

Poor infrastructure, one of the most important causative factors, plays a major role in developing countries where a wide range of road users from trucks, buses, cars, motorcycles, bicycles and pedestrians occupy the same road without separation and therefore exposing the vulnerable group (WHO, 2004). A recent study on road safety in 60 countries showed that more than 50% of roads had poor infrastructure. Improvement in the 10% of roads with the lowest standards has the potential to prevent around 2.3 million deaths and 40 million serious injuries over 20 years (World Road Association, 2015). Safety designs, such as widening roads, raised pedestrian crossings, separate paths for bicycles and motorcycles, roundabouts, traffic calming devices, warning signs, have a profound effect in reducing the likelihood of accidents when planning as well as updating existing roads. Safety assessment and identification of the most dangerous roads is an example of affordable measures that can have a significant impact (WHO, 2015).

Policies

 Speed limitations decrease the likelihood of accidents along with the reduction in severity should they happen. It attributes between 30-50% of accidents worldwide (Chisholm et al., 2012). However, according to WHO (2017), only 47 countries, that equates to 13% of the world population, have laws that comply with the best practice in urban areas (Figure 4).

Figure 4: Urban speed laws by county (WHO, 2015)

Alcohol has the opposite effect, increasing the risks of accidents. Yet again only 34% of countries have laws enforcing best practice. In addition, injury severity and the risk of death can be further reduced by the use of seatbelts, helmets, appropriate child restrains as well as use of vehicles with basic safety standards. However, a similar pattern in legislation concerning these protecting features is found worldwide (WHO, 2017). It has been shown that most effective intervention is joint enforcement on speeding, alcohol limits and helmet use laws due to their synergistic action and relative marginal cost of adding safety checks. One DALY saved costs $ 1000-3000 in the developing world, which is less than yearly income per capita, suggesting the intervention is cost-effective (Chisholm, Naci, 2008).

Access to healthcare

Most developing countries do not have basic emergency services. First aid at the scenes and transport, if any received, are delivered mostly by bystanders, relatives or police. Once reaching the hospital, the care in these countries is mostly delivered by general practitioners without any trauma training. Furthermore, there is a lack of surgeons, equipment, protocols and organisation within hospitals which result in delays and poorer outcomes (Mock, nii-Amon-Kotei, Maier, 1997). Studies have shown that over one-third of deaths could be prevented if developing countries had similar trauma outcomes as in high-income countries. However, these implementations are a lot harder to achieve and require significant global investment (Mock et al.,2012).

Conclusion

Despite the numbers being strikingly high, road traffic accidents attract less media attention compared to others less frequent and out of the ordinary diseases. Road traffic systems are complex and vary between country. A systematic approach that takes into account the needs of a specific country is required in order to achieve cost-effective and long-lasting changes to road safety. 

References

  • Ameratunga, S., Hijar, M. and Norton, R. (2006) ‘Road-traffic injuries: confronting disparities to address a global-health problem.’ The Lancet, 367(9521), pp.1533-1540. Available at: https://www.ncbi.nlm.nih.gov/pubmed/16679167 (Accessed 5 November 2018).
  • Babtie Ross Silcock, Transport Research Laboratory (2003) Guidelines for estimating the cost of road crashes in developing countries. London, Department for International Development. Available at: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.431.6245&rep=rep1&type=pdf (Accessed 8 November 2018).
  • Borowy, I. (2013) ‘Road Traffic Injuries: Social Change and Development. ‘Medical History, 57(01), pp.108-138. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3566732/ (Accessed 6 November 2018).
  • Chisholm, D., Naci, H., Hyder, A., Tran, N. and Peden, M. (2012)’ Cost effectiveness of strategies to combat road traffic injuries in sub-Saharan Africa and South East Asia: mathematical modelling study.’ BMJ, 344:e612. Available at: https://www.bmj.com/content/344/bmj.e612 (Accessed 9 November 2018).
  • Chisholm, D., Naci, H. (2008) Road traffic injury prevention: an assessment of risk exposure and intervention cost-effectiveness in different world regions. Geneva: WHO. Available at: http://www.who.int/choice/publications/d_2009_road_traffic.pdf (Accessed 9 November 2018).
  • Dahdah, S., McMahon, K. (2008) The true cost of road crashes: valuing life and the cost of a serious injury. Washington: International Road Assessment Programme, World Bank Global Road Safety Facility. Available at: https://www.alternatewars.com/BBOW/ABM/Value_Injury.pdf (Accessed 7 November 2018).
  • Hijar M, Vazquez-Vela E, Arreola-Risa C (2003) ‘Pedestrian traffic injuries in Mexico: a country update.’ Injury Control and Safety Promotion, vol. 10, pp. 37–43. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12772484 (Accessed 8 November 2018).
  • Hyder A. A. (2004) Road safety is no accident: a call for global action. Geneva: Bulletin of the World Health Organisation, 82, p.240. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2585968/pdf/15259249.pdf (Accessed 6 November 2018).
  • Johal, H., Schemitsch, E. and Bhandari, M. (2014) ‘Why a Decade of Road Traffic Safety?’ Journal of Orthopaedic Trauma, 28, pp. S8-S10. Available at: https://journals.lww.com/jorthotrauma/Fulltext/2014/06001/Why_a_Decade_of_Road_Traffic_Safety_.2.aspx (Accessed 6 Nov. 2018).
  • Loimer, H., Guarnieri, M. (1996) ‘Accidents and acts of God a history of terms. ‘American Journal of Public Health, 86:101–107. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380373/ (Accessed 6 November 2018).
  • Mock, CN. et al., (2003) ‘Economic consequences of injury and resulting family coping strategies in Ghana.’ Accident Analysis and Prevention, 35 pp. 81–90. Available at: https://www.sciencedirect.com/science/article/pii/S0001457501000926?via%3Dihub (Accessed 8 November 2018).
  • Mock, CN., nii-Amon-Kotei, D., Maier, RV. (1997) ‘Low utilization of formal medical services by injured persons in a developing nation: health service data underestimate the importance of trauma.’Journal of Trauma, 42:504–513. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9095119 (Accessed 9 November 2018).
  • Mock, CN., Joshipura, M., Arreola-Risa, C. and Quansah, R. (2012) ‘An estimate of the number of lives that could be saved through improvements in trauma care globally.’ World Journal of Surgery, 36, pp. 959-963. Available at: https://link.springer.com/content/pdf/10.1007%2Fs00268-012-1459-6.pdf (Accessed 9 November 2018).
  • Odero, W., Garner, P. and Zwi, A. (1997) ‘Road traffic injuries in developing countries: a comprehensive review of epidemiological studies. ‘Tropical Medicine and International Health, 2, pp. 445–460. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-3156.1997.tb00167.x (Accessed 6 November 2018).
  • Rumar, K. (1999) Transport safety visions, targets and strategies: beyond 2000. Brussels, European Transport Safety Council. Available at: http://www.etsc.be/ eve.htm (Accessed 6 November 2018).
  • United Nations (2003). Global Road Safety Crisis, General Assembly: United Nations. Available at: http://www.unece.org/fileadmin/DAM/trans/roadsafe/docs/SG_report_e.pdf (Accessed 7 November 2018).
  • United Nations (2015) Together with UNECE on the road to safety. New York: United Nations, p.1. Available at: http://www.unece.org/fileadmin/DAM/trans/main/wp1/wp1doc/ECE_TRANS_255_FINAL.pdf (Accessed 5 November 2018).
  • World Health Organization (2018) Road traffic injuries. Available at: http://www.who.int/en/news-room/fact-sheets/detail/road-traffic-injuries (Accessed 7 Nov. 2018).
  • World Health Organization (2018) Global Health Observatory (GHO) data Top 10 causes of death. Available at: http://origin.who.int/gho/mortality_burden_disease/causes_death/top_10/en/ (Accessed 18 November 2018).
  • World Health Organization (2017) 10 facts on global road safety. Available at: http://www.who.int/features/factfiles/roadsafety/en/ (Accessed 9 Nov. 2018).
  • World Health Organization (2015) Global Status Report on Road Safety 2015. Geneva; World Health Organization. Available at:http://www.who.int/violence_injury_prevention/road_safety_status/2015/en (Accessed 7 November 2018).
  • World Health Organisation (2004) World report on road traffic injury prevention. Geneva: World Health Organization. Available at: http://apps.who.int/iris/bitstream/handle/10665/42871/9241562609.pdf?sequence=1 (Accessed 5 November 2018).
  • World Health Organization (1996) Ad hoc committee on health research relating to future intervention options. Investing in health research and development. Geneva: World Health Organisation. Available at: http://apps.who.int/iris/handle/10665/63024 (Accessed 6 November 2018).
  • World Road Association (2015) Road safety manual: a manual for practitioners and decision makers on implementing safe system infrastructure. Paris: World Road Association, Available at: https://roadsafety.piarc.org/en (Accessed 9 November 2018).

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