INTRODUCTION

For several years, the United Nations Organization (UNO) has recognized urban traffic accidents as a serious public health problem worldwide, since they are accompanied by a high rate of morbidity and mortality¹.

Traffic causes the death of approximately 1.3 million people and the disability of millions more. About 90 percent of road traffic deaths and injuries occur in low- and middle-income countries. For several years, both the United Nations and its member WHO states have recognized that road traffic injuries and deaths are a major problem².

Traffic accidents are the third leading cause of death in the world; in the last decades, great transformations have occurred in Brazil, mainly in the advances in the automobile industries that generate multiplying effects of urban and social transformations. The unsatisfactory quality of public transportation has led people to opt for individual means of transportation, culminating in traffic problems in large cities³.

It is known that these accidents represent a relevant global public health problem and are associated with behavioural factors, vehicle maintenance, precariousness of urban space, and traffic control. They are configured as important causes of morbidity and mortality due to the increasing number of vehicles, changes in lifestyle, and risk behaviours in the general population⁴.

Land transport accidents (ATT) are a serious public health problem, since they are responsible for a high mortality rate and temporary and permanent disabilities, and there are many more non-fatal or disabled victims, especially in emerging countries. The WHO estimates a 40% increase in global mortality from this group of causes by 2030 if effective preventive measures are not taken⁵.

Several Brazilian studies point out that mortality from ATT is high among men, especially young men (more than 50% of deaths occur between 15 and 44 years of age) and the proportion of motorcyclists among these victims is relevant, ranging from 30% to 50%^6,7.

It is estimated that, every year, 50 million people worldwide suffer injuries and sequelae from traffic accidents. About 60% of the deaths occur in ten countries; Brazil occupies the fifth position, preceded by China, India, Russia, and the United States. Thus, accidents must be approached from the perspective of Public Health, which integrates aspects of the health of the inhabitants of the attributes of the built environment⁷.

In Brazil, the number of deaths and serious injuries exceeds 150 thousand victims/year, with annual expenditures of around 28 billion Reals, besides the high social costs resulting from the assistance, material losses, social security expenses and the immeasurable suffering of the victims and their families⁷.

The World Health Organization (WHO) estimates that the annual losses due to traffic accidents exceed US$ 500 billion. In Brazil, the number of deaths and serious injuries exceeds 150,000 people and the Institute of Applied Economic Research (IPEA) estimates that the total costs of traffic accidents are approximately R$ 28 billion per year. Considered one of the countries with the most violent traffic in the world in recent years, Brazil is trying to contain the high number of accidents and reduce hospital expenses⁸.

The city of São Paulo experienced the most dramatic increase in fatalities involving motorcyclists; in 2007, the number of fatalities involving motorcyclists exceeded by a wide margin (66%) the total number of fatalities involving occupants of other vehicles, an unprecedented fact in the city’s history. Fatalities involving motorcyclists are still higher than those involving pedestrians⁹.

Among the fatalities involving motorcyclists in 2005, 40% occurred without the interference of another vehicle, i.e., they were related only to the motorcycle and its driver. Among those killed, 37% were motorcycle couriers working in the delivery of goods. Finally, motorcycles were responsible for the death of 85 pedestrians (10% of the total). In 2007, 20% of the fatalities occurred with people between 10 and 19 years old, and 72% occurred with people between 20 and 39 years old, that is, 92% of those killed on motorcycles were at most 39 years old⁹.

Another important variable to highlight is that in Brazil, in 2013, there were 170,805 hospitalizations resulting from (ATT) recorded in the (SIH/SUS), representing a rate of 85 hospitalizations per 100,000 inhabitants. The highest rates of hospitalization due to (ATT) were observed in male individuals (134.5 hospitalizations per 100,000 men) and in the 20 to 39 age group (123.9 hospitalizations per 100,000 inhabitants of that age). More than half of the hospitalizations for ATT were for motorcyclists, followed by pedestrians¹⁰.

The total expenditure on hospital admissions resulting from (ATT) in 2013, under the Unified Health System (SUS), was R$ 231,469,333.13, of which R$ 188,025,095.94 corresponded to expenditure on hospital services and R$ 43,361,377.01 on professional services. The average value of hospitalization per (ATT) in the studied period was R$1,355.17¹⁰.

Motorcyclists were the victims with the longest hospital stay (546,024 days) and the highest total expenditure (R$114,810,444.93). However, the highest average hospitalization cost was represented by truck occupants (R$ 1,902.79), who also accounted for the longest average hospital stay (7.2 days), followed by pedestrians (6.8 days)¹⁰.

Studies on traffic accidents (AT) in Brazil are scarce, prevention and control actions are just beginning, and little is known about driver and pedestrian behavior, road and vehicle safety conditions, traffic engineering, the human and environmental costs of motor vehicle use, and the traumatic consequences resulting from these accidents¹¹.

Therefore, this study addressed the associated factors on mortality from traffic accidents with motorcyclists and pedestrians, as well as, analyzed the hospital costs of these injuries in the capital city of São Paulo, in the period and 1999-2019.

METHODS

RESULTS

In the city of São Paulo, from 1999 to 2019, there were 144,186 thousand deaths resulting from land transport accidents (ATT), projecting 5,293 thousand deaths specifically with motorcyclists, an average of 252.04, and 10,903 thousand deaths involving pedestrians with an average of 519.04 (table A1).

Still in table A1, the proportional mortality was higher in the age group of 29 years old on average (174.61), 39 years old on average (125.00), followed by individuals between 49 years old on average (102.33), predominantly males, with an average of 605.04 deaths, highlighting the race/color of the white skin with an average of 465.19, followed by the brown skin at 238.18.

As for education, the individuals with up to 7 years of schooling, average of 262.23, and up to 11 years, average of 227.91, stood out. As for the marital status variable, singles predominated, with a mean of 418.77, followed by married people, mean of 180.01. The place of occurrence was hospitals, mean (551.48), and public roads, mean (189.71) (table A1).

In table A2, when linear regression was used for mortality, the following variables were statistically significant (p < 0.005): education, with “no education” and “more than 11 years of education”, both statistically significant, with 0.003 and 0.040, respectively; place of occurrence, with “other healthcare facilities”, with 0.044; age, involving “4, 9 and 14 years of age”, with 0.000, 0.000 and 0.001, respectively.

In table A3, when we characterize the costs per death, the highlight is motorcyclists with an average of R$49,078.18. Regarding deaths by sex, the male predominated substantially in relation to the female, with an average of R$43,691.92 and the female with R$13,25885. In the race/skin color variable, the blacks stood out with an average of R$ 410,170.60, followed by the yellows with an average of R$ 170,012.90. In this context, the value for the ignored variable with an average of R$ 119,817.30 calls our attention. As for the age bracket variable, we noticed that the average age bracket was 50-59 years old (R$ 6,863,341.31), followed by 20-29 years old (R$ 3,178,251.00).

Taking into consideration tables A4 and A5, a statistical difference p <0.005 was identified in almost all the variables analyzed in relation to costs. Differences were observed in all of them (gender, race/color, age group, table A4), which coincides with table A5 that gave a difference in the two variables (pedestrian and motorcyclist cost, table A5).

For the linear regression in the cost variable (table A5) for cause (V20-V29) pedestrians with (R$: 1+817,525.00) and pedestrians (V01-V09) with (R$: 588,094.10) both predominated with a -p value >0.005.

In relation to the variable hospital costs by cause of death, motorcyclists stood out, with an average of R$19,598,878.50 million. We highlight in this analysis the sale of motorcycles in this period, which reached an average of R$ 1,188,244.10 (table A6).

DISCUSSION

Proportional mortality was predominant in the most active age group (29 to 49 years), with the majority being male. The majority of this population was single. As for the costs per death, motorcyclists stood out, with an average of R$ 49,078.18. Regarding deaths by sex, the male predominated substantially in relation to the female, with an average of R$ 43,691.92 and the female with R$ 13,258.85. In the race/skin color variable, the blacks stood out with an average of R$ 410,170.60. In this context, the value for the ignored variable with an average of (R$ 119,817.30) calls our attention. As for the age bracket variable, the average age was 50-59 years with an average of (R$ 6,863,341.31).

In the world traffic accidents kill more and more people all over the planet, with 1.35 million deaths a year, warns the World Health Organization (WHO), worried about the lack of security measures in the poorest countries. In its world report on road safety, the WHO also states that traffic accidents are currently the leading cause of death among children and young people between 5 and 29 years old. In recent years, the number of road deaths around the world has steadily increased, with 1.35 million deaths recorded in 2018².

A study by Conceição and collaborators (2021)¹³, states that according to the World Health Organization (WHO), speed is one of the most important factors in determining a traffic accident and the severity of the injury is particularly critical for the most vulnerable users, such as pedestrians, cyclists, and motorcyclists, as well as for children and the elderly.

Land Transport Accidents (LTAs) are a serious public health problem, not only in Brazil, where the development and quality of roads have not kept up with the significant increase in demand for cargo flow, but also worldwide. They generate high morbidity and mortality rates, in addition to high costs to the health system and social security benefits¹⁴.

In the city of São Paulo, from 1999 to 2019, there were 144,186 thousand deaths resulting from land transportation accidents (ATT), projecting 5,293 thousand deaths specifically with motorcyclists (V20-V29) and 10,903 thousand deaths involving pedestrians (V01-V09), specifically, not to mention other modalities of transportation.

The improvement in safety for motorcyclists and pedestrians is less than that for people in other types of vehicles. In a recent research by Leitão et al., (2022)¹⁵, they observed that the highest mortality rate occurs among men, aged 26 to 35 years old, as well as data on the safety of vulnerable road users, who are not protected in traffic accidents, such as pedestrians, cyclists, motorcyclists and moped riders, corroborating the findings, which showed higher mortality among men of the same age, occurring by place of residence in the city of São Paulo, in the studied period.

Mendonça et al., (2017)¹, conducted an ecological study through secondary data on urban traffic accidents of the SAMU in Recife, where it was evidenced the predominance of male victims between 20 to 29 years of age. These events are associated on a high scale due to the irregular traffic culture; greater male and young exposure, thus they are more exposed to the risks of driving (high speed, dangerous manoeuvres, alcohol consumption). In these findings corroborate in part, because in the same way, the age group that predominated the most was 29 years to 39 years, being male and single. This shows that the more active age is more susceptible to accidents with mortality.

In a fourteen-year time series in Brazil, there were 48,879 hospitalizations for pedestrian collisions in the city of São Paulo. Pedestrian collisions occurred mainly by automobiles (21.0%), motorcycles (10.1%), buses (4.0%) and bicycles (1.5%). During the years analysed, there was an increase in pedestrian collisions, with 70.1% being male. Lower limb injuries are the most frequent. Therefore, the prevention of traffic accidents is essential in view of the morbidity and mortality and the costs they cause¹⁶.

Motorcyclists were the most frequently attended victims in the emergency department, outnumbering victims of pedestrian accidents, falls, car accidents, and physical aggression. In Brazil, accidents involving motorcyclists are frequent, often serious, and have their own characteristics. Among traffic accident victims, research has found pedestrians to have the highest fatality rates⁹.

A study conducted in the Midwest and Northeast regions of the country revealed that this profile of hospitalized patients generated public spending of more than R$ 230 million in an average length of stay of one week¹⁰.

These divergences in the literature corroborate the findings of this research, which brings us important values, approximately R$103 million, about R$10.5 million per year for the motorcycle category, and for pedestrians about R$88.5 million, almost R$4.5 million per year, with values higher than R$4.5 million for males, only in the city of São Paulo, during the studied period, i.e., a time lapse of 20 years.

When evaluating the hospital costs of victims based on race/skin color in this study, it was noted that there is a prevalence of black skin, however, there is many ignored which becomes suggestive of a failure in the adequate recording of patient data. Leading to notifications with absence of information and inconsistent data for better studies of the profile of the victims.

In a study conducted in the United States of America (USA), it was identified that advances can be made to reduce ATT mortality rates, as well as in other developing countries, because most injuries caused by accidents are predictable and preventable¹⁷.

Furthermore, there is no doubt that the public health problems generated by the unbridled consumption of alcohol, besides directly affecting mortality rates, data associating the use of alcohol to certain events, among them traffic accidents⁶.

Studies identify the use of alcohol associated with motorcycle driving, with an increase in accidents on weekends. In addition to post-accident traumas, due to the absence of helmets, which leads to head trauma, besides other injuries on the body (Santos et al., 2008)¹⁸. Golias et al., (2013)¹⁹infer that the instability of motorcycles, greater exposure of the body, difficulties of viewing and inappropriate behaviour of riders are contributing factors to traffic accidents.

Additionally, the difficulty of viewing motorcycles by other drivers, the greater exposure of the body, and the negligence in the use of protective equipment place these users in an especially susceptible category. The resulting injuries suffered by motorcyclists are usually more severe, often to the head and upper and lower limbs, resulting in long hospital stays and severe, sometimes fatal, sequelae⁵.

Therefore, the existence of ignored information and/or information that is difficult to access in the public information platforms (Big Date’s), should be considered for decision making, and thus contribute to the politicians and/or public managers, plan, create strategies and public policy actions, as a priority in reducing land accidents and with a clear reduction of deaths in the city of São Paulo, especially in Brazil.

CONCLUSION

It is evident that, although we did not mention the direct relation between the reasons for the accidents, such as high speed, drunkenness, poorly signalled roads, among other factors, there was a high rate of deaths, both in motorcyclists and pedestrians, the latter having a higher average. In this population, the majority were male, single and of working age, and, consequently, the hospital costs were high for the city of São Paulo.

Thus, these findings provide relevant information of the magnitude of the public health problem to guide us on control strategies for these causes.