July 2004 volume 20 number 07 Child safety takes a back seat in Georgia Introduction Motor vehicle crashes are the leading cause of death among persons 5 to 34 years in Georgia (Table 1).1 Among children, car safety seats, booster seats, and rear-seat positioning reduce the risk of fatal injury.2,3 However, in the United States, almost half of the children <15 years killed or injured in a motor vehicle crash were not restrained, and many were restrained improperly for their age and seated in the front seat.1 Booster seat use is especially low among children aged 5-8 years; a previous study demonstrated that <1% of children older than 5 years were restrained in a booster seat.4 Children in this age group may be too large for safety seats and not yet large enough for seat belts designed for adult passengers. The American Academy of Pediatrics (AAP)5 and the National Highway Traffic Safety Administration (NHTSA)6 recommend that children who have outgrown child safety seats should be properly restrained in booster seats until they are 4'9" tall and 80 pounds. Vehicle safety belts alone should not be used until the shoulder belt can be positioned across the chest with the lap belt low and snug across the thighs, and the child should fit against the vehicle's seat back with his or her feet hanging down when the legs are bent at the knees. A belt-positioning booster seat should be used until the vehicle safety belt fits well. Children aged <13 years should ride in the rear seat.5,6 Child passenger protection laws vary by state. Currently Georgia law requires that children 4 years and younger be secured in an approved child safety restraint system, O.C.G.A. Section 40-8-76(b)(1).7 Children ages 5 years and older have been required only to wear seat belts. However, as of July 1, 2004, children aged 5 years will be required to use a booster seat while riding in a car. The new law will also require children < 5 years to sit in the rear seat.. Methods We examined data from Uniform Traffic Accident Reports submitted by Georgia law enforcement agencies on crashes on public roadways that occurred during 2001.* Law enforcement agencies are required to submit reports to the Georgia Division of Motor Vehicle Safety on all motor vehicle crashes that occur on public roads, streets, or highways that cause injury, death, or damage over $500. The reports include information on the characteristics of the crash, the vehicles involved, the driving conditions, and the drivers and occupants involved. Police coded injuries as fatal, serious, visible, complaint, or no injury. "Taken to treatment" was noted if a person was reported to be taken for treatment either by emergency medical services or by other means. We defined death, serious injury, or taken to treatment as "substantial injury." Seating position was coded as front, rear, trunk, outside the vehicle, or pedestrian. We excluded accidents that occurred to pedestrians, bicyclists, and passengers on motorcycles, mopeds, and farm equipment from the analysis. Restraint use was coded as car safety seat, shoulder belt, lap belt, lap and shoulder belt, unknown or none. We equated "car safety seat" with "booster seat" for children aged 5-8 years because there was no separate code for "booster seat," although some small children ages 5-8 years may have been in "car safety seats". We used these data to determine the incidence of substantial injuries and the percentage of children aged 5-8 years involved in car crashes who were appropriately restrained and riding in the rear seat. We examined the association of restraint use and seating position with risk for injury. We used logistic regression modeling to adjust for other factors associated with substantial injury, such as speeding and age of driver. Results In 2001, 22,131 children aged 5-8 years in 17,492 vehicles were involved in 17,459 motor vehicle crashes.** Injuries included 15 Table 1: Leading caauses of death among persons aged 1 through 34 years in Georgia, 2002. Rank 1-4 years 5-14 years 15-24 years 25-34 years 1 NonMV injury (47) Motor vehicle (63) Motor vehicle (347) Motor vehicle (252) 2 Motor vehicle (26) NonMV injury (42) Homicide (197) Homicide (174) 3 Congenital (18) Cancer (26) NonMV injury (114) NonMV injury (169) NonMV injury = any unintentional injury not related to motor vehicles Congenital = congenital malformation, chromosomal abnormality Table 2: Characteristics of passengers aged 5-8 years involved in motor vehicle crashes, Georgia 2001 Passenger characteristics Number (%) Age 5 years 5,887 (26.6) 6 years 5,501 (24.8) 7 years 5,347 (24.2) 8 years 5,396 (24.4) Injury Not injured 19,137 (86.5) Killed 15 (0.1) Serious 91 (0.4) Visible 780 (3.5) Complaint 2,108 (9.5) Taken for treatment Yes 1,618 (7.3) No 20,513 (92.7) Safety equipment None 1,073 (4.9) Seat belt alone (lap, shoulder, or both) 17,592 (79.5) Booster seat 1,243 (5.6) Unknown 2,223 (10.0) Seating position Front seat 5,360 (24.2) Rear seat (2nd row) 14, 826 (67.0) Trunk (in trunk, 3rd or 4th row seat) 1, 811 (8.2) Outside (in back of pickup truck) 134 (0.6) Not an unduplicated count. 934 children were involved in more than one accident during the year. * Data were compiled in August 2003. A few more records subsequently were added to the database. **Not an unduplicated count. 934 children were involved in more than one accident during the year The Georgia Epidemiology Report Via E-Mail To better serve our readers, we would like to know if you would prefer to receive the GER by e-mail as a readable PDF file starting in 2004. If yes, please send your name and e-mail address to Gaepinfo@dhr.state.ga.us. (0.1%) fatalities, 91 (0.4%) children seriously injured, and 1,536 (6.9%) not killed or seriously injured but taken for medical treatment (Table 2), for a total of 1,642 (7.4%) children meeting our definition of substantially injured. Of the 22,131 children aged 5-8 years in crashes, only 1,243 (5.6%) were in car safety seats or booster seats, 17,592 (79.5%) were wearing seat belts alone, 1,073 (4.9%) were not restrained, and for 2,223 (10%) restraint use was unknown (Table 2). Car safety/booster seat use varied with age, from 13.9% of 5-year-olds to 1.5% of 8year-olds (Figure 1). Rear seat position prevalence ranged from 77.1% of 5-yearolds to 68.9% of 8-year-olds. The proportion of children appropriately restrained in a booster seat placed in the rear seat position similarly decreased with age, from 10.9% of 5-year-olds to 1.1% of 8-year-olds (Figure 1). Children in booster seats were less likely (4.3%) to suffer substantial injury than were those using seat belts alone (6.8%) or not restrained (23.9%) (Figure 2). Children in rear (2nd row) seats were less likely (6.3%) than those in front seats (9.9%) to suffer substantial injury (Figure 3). Of children in booster seats AND in a rear seat position, 3.6% suffered substan- Table 3: Characteristics of drivers and crashes with passengers aged 5-8 years involved in motor vehicle crashes, Georgia 2001* Characteristic Driver age Driver condition Road of occurrence Road surface condition Speed Vehicle type Aged < 25 years Aged 25 years or older Under the influence of alcohol or drugs, or drinking alcohol Not under the influence of alcohol or drugs, or drinking alcohol Not known if under the influence Physical impairment Apparently fell asleep Interstate State road County road City street Dry Wet, rain, snow, ice, other Excessive speed or too fast for conditions Not speeding Passenger car Pickup truck Van Utility passenger vehicle Bus Other Number (%) 2,534 (11.5) 19,588 (88.5) 211 (1.0) 21,523 (97.2) 336 11 50 2,019 7,724 6,155 6,233 18,330 3,771 384 21,747 12,683 1,826 3,456 3,189 788 169 (1.5) (0.1) (0.2) (9.1) (34.9) (27.8) (28.2) (82.9) (17.1) (1.7) (98.3) (57.3) (8.3) (15.6) (14.4) (3.6) (0.8) * 22,131 children aged 5-8 years were involved in crashes involving 17,492 motor vehicles. Each child passenger is associated with one driver in the database. Therefore, if there were more than one child passenger in a vehicle involved in a crash, the driver would be counted more than once. Figure 1: Car seat/booster seat use and rear seat position among children aged 5-8 years involved in motor vehicle crashes, by age Georgia 2001 % of children appropriately restrained 20 18 16 13.9 14 12 10.9 10 8 6 6.1 5.0 4 2 0 2.6 1.9 1.5 1.1 5 6 7 8 AgeA(gyee(ayresa) rs) Booster alone Booster and rear seat Figure 2: Percentage of children ages 5-8 years involved in motor vehicle crashes who were taken to treatment, seriously injured, or killed in a motor vehicle crash, by restraint use Georgia 2001 % of children substantially injured 20 18 16 14 12 10 8 6 4.3 4 2 0 Booster Seat 6.8 Seat belt 23.9 No restraint TyTpyepeofofRReesstrtraaiint Figure 3: Percentage of children aged 5-8 years involved in motor vehicle crashes who were taken to treatment, seriously injured, or killed in a motor vehicle crash, by seat position Georgia 2001 %of children substantially injured 20 18 16 14 12 10 8 6.3 6 4 2 0 Rear seat 9.9 Front seat SeSaetapt opsoistiiotinon Figure 4: Percentage of children aged 5-8 years involved in motor vehicle crashes who were taken to treatment, seriously injured, or killed in a motor vehicle crash, by booster seat use and seat position Georgia 2001 % of children substantially injured 20 18 16 14 12 10 8 6 4 2 0 -2 - 10.2 6.6 3.6 Booster seat & rear No booster seat & rear No booster seat & seat seat front seat Restraint use and seat position Restraint use and seat position Table 4: Select characteristics associated with substantial injury among children aged 5-8 years involved in motor vehicle crashes, adjusting for other factors Georgia 2001 Characteristic No restraint Seat belt only Front seat Driver aged < 25 years Driver U.I. or using drugs or alcohol Vehicle other than van or utility passenger vehicle Wet or icy road surface Dirt, gravel, tar and gravel, or other road composition Excessive speed Adjusted 95% Confidence Odds Ratio Interval 5.2 4.1-6.6 1.2 1.0-1.4 1.5 1.3-1.7 1.7 1.4-2.0 3.9 2.8-5.4 1.2 1.1-1.4 1.4 1.2-1.6 1.6 1.1-2.3 2.3 1.7-3.0 tial injury, compared with 10.2% of children who were not in a booster seat and in a front seat position (Figure 4). There were no fatalities among children restrained in a booster seat. Children seated in the front seat were more than three times as likely to suffer fatal injury (7/5360) than were children seated in the back seat (6/14,826). Characteristics of drivers and motor vehicle crashes involving children aged 5-8 years are listed in Table 3. Factors associated with substantial injury included young driver age (less than 25 years old), driver under the influence of drugs or alcohol, vehicle other than a van or sports utility passenger vehicle (SUV), wet or icy road surface condition, dirt or gravel road composition, and excessive speed. No restraint (adjusted odds ratio = 5.2), using a seat belt only (adjusted odds ratio = 1.2), and front seat position (adjusted odds ratio = 1.5) were associated with substantial injury compared with children that were appropriately restrained in a booster seat in the rear position, even controlling for other factors associated with substantial injury, including driver age, driver condition, vehicle type, surface condition, road composition, and speed (Table 4). Discussion Booster seats and rear seat position appear to lessen the risk of substantial injury among children aged 58 years who were involved in motor vehicle crashes in Georgia in 2001. Our data support current recommendations from national advisory authorities for booster seat use and rear seat positioning of children.5,6 In 2001, however, booster seat use was rare and rear seating levels were suboptimal among children aged 5-8 years involved in motor vehicle crashes in Georgia. An observational study of booster seat use and seating position for children in vehicles stopped at routine roadblocks in Georgia also indicated low booster seat use (12%) and suboptimal rear seat position (80%).8 Our study is subject to several limitations. First, our data depend on police observation and, in many situations, parental report of restraint use by children. This may have led to misclassification of restraint use, given that parents have a tendency to overreport use of child restraints. Additionally, we made the assumption that a "child safety seat" was a booster seat for children aged > 4years, as children have typically outgrown a forward-facing convert- ible child safety seat by this age. Some children aged 5-8 years may still have been in a child safety seat rather than a booster seat. Seating position definitions may have varied across law enforcement agencies; for example, third row seats could have been coded as either second row or as "trunk". "Taken for treatment" was indicated for a child passenger that may have been transported by personal vehicle, by ambulance, or not taken at all; therefore, this variable may not have reflected the severity of injury in certain situations. Despite these limitations, our findings show that booster seat use and rear seat positioning among children in Georgia fall short of recommended practices, and suggest that this has contributed to injury and death of children in Georgia. Drivers should be encouraged to adopt safer practices for children. Studies have indicated that barriers to booster seat use and rear seat position include lack of parental knowledge of the danger of front seat position and the increased risk for injury for children less than 4'9" and 80 pounds who are not in a booster seats.9 Furthermore, the discrepancy between state passenger safety laws and optimal restraint recommendation may be confusing to parents. Because parents often rely on state law for guidance and instruction, child passenger safety laws mandating better protection for children > 5 years are needed. Interventions that have proven to increase the use of child safety seats for children aged 0-4 years have included child safety seat laws, communitywide information and enhanced enforcement campaigns, distribution and education programs, and incentive and education programs.10 These methods should be implemented to improve passenger safety for children aged 5-8 years. Written by Martha Iwamoto, M.D., M.P.H., Kristen Mertz, M.D., M.P.H., Ken Powell, M.D., M.P.H., Lisa Dawson, Manxia Wu, M.D., M.P.H., and Denise Yeager. References 1. National Highway Traffic Safety Administration (NHTSA). Traffic Safety Facts 2002: Children. Available at http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/ NCSA/TSF2002/2002chdfacts.pdf. Accessed June 10, 2004. 2. Durbin DR, Elliott MR, Winston FK. Belt-positioning booster seats and reduction in risk of injury among children in vehicle crashes. JAMA 2003;289:2835-2840. 3. Braver ER, Whitfield R, Ferguson SA. Seating positions and children's risk of dying in motor vehicle crashes. Injury Prevention 1998:4; 181-7. 4. Winston FK, Durbin DR, Kallan MJ, Moll EK. The danger of premature graduation to seat belts for young children. Pediatrics 2000;105;1179-1183. 5. American Academy of Pediatrics. Selecting and using the most appropriate car safety seats for growing children: guidelines for counseling parents. Pediatrics 2002;109:550-553. 6. NHTSA. Child passenger safety. Available at http://www.nhtsa.dot.gov/people/injury/childps/. Accessed June 10, 2004. 7. State of Georgia. Seat belt law. Available at http://www.gohs.state.ga.us/seatbeltlaw.html. Accessed June 10, 2004. 8. Staunton CE, Davidson SC, Kegler SR, Dawson LD, Powell KE, Dellinger AM. Critical gaps in child passenger safety practices, surveillance, and legislation Georgia, 2001. In review. 9. Simpson EM, Moll EK, Kassam-Adams N, Miller GJ, Winston FK. Barriers to booster seat use and strategies to increase their use. Pediatrics 2002;110;729-736. 10. Zaza S, Sleet DA, Thompsom RS, Sosin DM, Bolen JC. Reviews of evidence regarding interventions to increase use of child safety seats. AM J Prev Med 2001;21 (suppl):31-41. Division of Public Health http://health.state.ga.us Kathleen E. Toomey, M.D., M.P.H. Director State Health Officer Epidemiology Branch http://health.state.ga.us/epi Paul A. Blake, M.D., M.P.H. Director State Epidemiologist Mel Ralston Public Health Advisor Georgia Epidemiology Report Editorial Board Carol A. Hoban, M.S., M.P.H. Editor Kathryn E. Arnold, M.D. Paul A. Blake, M.D., M.P.H. Susan Lance-Parker, D.V.M., Ph.D. Kathleen E. Toomey, M.D., M.P.H. Angela Alexander - Mailing List Jimmy Clanton, Jr. - Graphic Designer -3 - Division of Public Health Two Peachtree St., N.W. Atlanta, GA 30303-3186 Phone: (404) 657-2588 Fax: (404) 657-7517 Georgia Department of Human Resources Please send comments to: Gaepinfo@dhr.state.ga.us The Georgia Epidemiology Report Epidemiology Branch Two Peachtree St., NW Atlanta, GA 30303-3186 PRESORTED STANDARD U.S. POSTAGE PAID ATLANTA, GA PERMIT NO. 4528 July 2004 Volume 20 Number 07 Reported Cases of Selected Notifiable Diseases in Georgia Profile* for April 2004 Selected Notifiable Diseases Campylobacteriosis Chlamydia trachomatis Cryptosporidiosis E. coli O157:H7 Giardiasis Gonorrhea Haemophilus influenzae (invasive) Hepatitis A (acute) Hepatitis B (acute) Legionellosis Lyme Disease Meningococcal Disease (invasive) Mumps Pertussis Rubella Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent Syphilis - Other** Syphilis - Congenital Tuberculosis Total Reported for April 2004 2004 34 1370 5 8 67 540 12 36 64 1 1 1 0 3 0 70 59 7 23 22 29 0 36 Previous 3 Months Total Ending April 2002 2003 2004 124 116 110 8547 9098 6636 27 24 34 7 5 10 183 170 173 4327 4235 2692 21 22 35 147 147 93 105 128 164 4 7 4 1 3 4 10 12 2 2 1 0 7 11 7 0 0 1 224 191 185 263 280 147 25 27 24 76 117 73 174 208 100 223 234 109 7 3 0 123 125 120 Previous 12 Months Total Ending in April 2002 2003 2004 625 666 607 33810 35707 32920 159 117 142 51 44 32 915 923 838 18793 18723 15840 101 79 99 868 515 729 436 527 720 13 24 28 2 8 12 42 34 27 4 1 2 24 35 29 0 0 1 1740 1924 2060 1027 1918 929 103 111 132 300 396 425 698 753 598 837 797 695 24 11 6 544 561 545 * The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office, and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia. ** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis. Report Period Latest 12 Months: 07/03 - 06/04 Five Years Ago: 07/99-06/00 Cumulative: 7/81 - 06/04 Total Cases Reported* <13yrs >=13yrs Total 5 1,972 1,977 10 1,330 1,340 216 28,335 28,551 Percent Female AIDS Profile Update Risk Group Distribution (%) MSM IDU MSM&IDU HS Blood Unknown 26.9 34.4 6.4 1.6 14.0 1.5 41.9 27.0 32.9 13.5 3.7 20.4 1.7 27.8 18.6 46.5 16.4 5.2 14.3 1.9 15.7 Race Distribution (%) White Black Other 22.6 73.8 3.6 20.1 76.7 3.2 32.7 64.7 2.6 MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual * Case totals are accumulated by date of report to the Epidemiology Section - 4 -