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					                                  POSITION STATEMENT
                                             ON
                              LEGISLATED HELMET USE
                                       BY
                    USERS OF NON-MOTORIZED WHEELED VEHICLES

                                 DR. ROBERT CUSHMAN
                                Medical Officer of Health
                                 Ottawa Public Health
                                     City of Ottawa

The Medical Officer of Health, Ottawa Public Health, supports the proposed
provincial legislation of Bill 129 to amend the Highway Traffic Act, Subsection 104
(2.1) and (2.2) and Section 160 as enacted by the Statutes of Ontario, 1993, chapter 18,
section 1, to protect non-motorized wheeled vehicle users on public roads.

The benefit: Properly fitted and worn helmets by users of non-motorized wheeled
vehicles (bicycles, scooters, skateboards, inline skates) reduce the risk of sustaining a
brain injury and mitigate the extent of such an injury.

The risks: Users of non-motorized wheeled vehicles are at significant risk of brain
injury related to:
      FALLS: These vehicles are relatively unstable as they have a narrow base,
         coupled with the mobility of the wheels. This makes users susceptible to loss of
         control and loss of balance. Further, non-motorized wheeled vehicles do require
         some degree of technical skill. The roads themselves, as a hard surface can
         increase the severity of an injury.
      COLLISIONS: Non-motorized wheeled vehicles are vulnerable road users.
         Injury and fatality rates increase with the proximity to motor vehicles especially
         at intersections in urban areas during rush hour. They also increase on rural
         roads and on highways with higher speeds.

The burden: The burden of brain injuries is tremendous in both direct and indirect costs,
at both a personal and societal level. We now know that even seemingly minor brain
injuries, such as concussions, can produce persistent and disabling problems. Many
survivors of brain injury have a diminished capacity of living evidenced by physical
disabilities, memory difficulties, headaches, fatigue and mood swings. Some are unable
to return to work or even live independently.

Our responsibility: It is ethically and fiscally responsible to ensure our public roadways
are as safe as possible for all users.

How: Fifteen years of helmet education and limited enforcement have made great strides
but now usage rates have plateaued. Best practice evidence endorses a multi-strategy
approach to injury prevention that includes all three elements of education, engineering
and enforcement. Research has demonstrated a positive correlation between enforced
legislation and increased helmet use and it is clear this is the next step we must take to
protect our population.

                                  Ottawa Public Health                                        1
                           Protecting you. Promoting a healthy city.
                                    SN/ November 29, 2004
    Rationale

What we know now:

         Non-motorized wheeled vehicles account for 29% of hospitalizations due to sports and
recreational activities.1 Head injuries are the second most common sports and recreational injury
accounting for 13% of hospitalizations.2 National data from Canadian Hospitals Injury Reporting and
Prevention Program (CHIRPP) reports that head injuries account for approximately 20% of scooter
injuries3, 16% of inline skating injuries4, 7% of cycling injuries5 (post 1995 helmet-for-children
legislation), and 6.5% of skateboarding injuries6 (local data). Two thirds of cyclists that require
hospitalization are due to a head injury.7 Even mild brain injuries, generally under estimated in
current surveillance systems, can have long term disabling effects.8
    Using non-motorized wheeled vehicles on roadways is associated with increased severity of the head
injury. 90% of bike related fatalities involve a motor vehicle collision.9 Transport Canada reports that
cyclists comprise 11% of all fatally injured and 15% of seriously injured crash victims10 on Canadian
roads. Identified risk factors include time of day, location, traffic controls, urban areas, rural roads and
highways and conspicuity.11
         Adults make up 51% of the population that are hospitalized due to sports and recreational
activities.12 Males are overrepresented (72% overall).13 There are pronounced peaks in hospitalization
numbers for the 10-14 age group and the 40- 44 age group.14 Unfortunately, older populations,
particularly over 65, may experience longer recovery periods and compromised functioning as a result of
injuries sustained during physical activity.15 16
         Helmets save lives by reducing the risk of brain injury by 88%.17 18 19 Helmet legislation
increases helmet use20 21 22 and has demonstrated a reduction in the incidence of brain injury by 45%.23 24
Helmet education linked with legislation results in better adoption rates than those with legislation only.25
Further, initial studies suggest helmet legislation is a cost effective intervention.26 This compares
favourably to the individual cost of a severe head injury, approximately $3 million (US figures).27 Some
estimates report that every dollar spent on a bike helmet saves society $30 in direct and indirect costs to
society.28
         Overall, statistics for bike helmet use in Canada are about 40% (1998) although notably,
frequency of helmet use goes down as severity of injuries goes up.29 Transport Canada reported that in
2001, 88% of bike related fatalities were not wearing a helmet.30 In Ottawa, current bicycle helmet use
rates have hit a ceiling around 65% for children.31 It is discouraging that the 2003 Rapid Risk Factor
Surveillance System (RRFSS) data has noted a 4% increase in children aged 5-17 who never use
helmets,32 even with legislation targeted to the under 18 age group and current safe cycling initiatives.
This may even be under reported as some research indicates parents tend to overestimate their child’s
compliance.33 Helmet use for inline skates, scooters and skateboards is much lower ranging from
13%34 to 50%.35

What we can predict:

Unless we enact changes now we can predict increased injury rates secondary to increased use of non-
motorized wheeled vehicles that will result from:
    Physical activity promotions
    Clean air campaigns
    Marketing of novelty vehicles- Both skateboards36 and scooters37 have seen a sudden and
       profound increase in injury rates increasing by 124% and 700% respectively over a one to two
       year period.
    An aging population- Bicycling, in particular, is identified as a recreational activity of choice in
       older age groups.38
                                        Ottawa Public Health                                           2
                                 Protecting you. Promoting a healthy city.
                                          SN/ November 29, 2004
Recommendations:

1. Amend the Highway Traffic Act as proposed.

2. Develop an integrated strategy that will:
    Stage implementation with a one year education campaign about the legislation, its
      applications, and penalties before concerted enforcement begins
    Engage all potential stakeholders
    Identify potential opportunities to link with existing initiatives (ie. Programs already in
      the schools, workplaces.)
    Address financial, social and cultural barriers
    Ensure adequate financial, physical and human resources for each of the components of
      planning, education (including proper fitting of helmets), enforcement and evaluation.




                                     Ottawa Public Health                                          3
                              Protecting you. Promoting a healthy city.
                                       SN/ November 29, 2004
1
  Canadian Institute for Health Information. (August 2004). Sports and Recreational Injury Hospitalizations in
          Ontario, 2002-2003. Ontario Trauma registry Analytic Bulletin. Toronto, ON.
2
  ibid
3
   CHIRRP. (1998 to date). Injuries Associated with Non-Motorized Scooters. Downloaded on Nov. 11, 2004 from
          http://www.phac-aspc.gc.ca/injury-bles/chirpp/injrep-rapbles/scoot_e.html
4
  CHIRRP. (1998 to date). Injuries Associated with Inline skating. Downloaded on Nov. 11, 2004 from
          http://www.phac-aspc.gc.ca/injury-bles/chirpp/injrep-rapbles/inline_e.html
5
  MacKay, M., Scanlan, A., Olsen, I., Reid, D., Clark, M., McKim, K., Raina, P. (2004). Looking for evidence: a
          systematic review of prevention strategies addressing sport and recreational injury among children and
          youth. J. Sci Med Sport: 7(1): 58-73.
6
  CHEO CHIRPP Database. (nd). Skateboarding Injuries seen at CHEO Emergency Department from 1997-2001.
          Children’s Hospital of Eastern Ontario. Ottawa, ON.
7
  Rivara, F.P., Thompson, D. C., Patterson, M. Q., Thompson, R. S. (1998). Prevention of bicycle-related injuries:
          Helmets, education and legislation. Annual Review of Public Health. 19:293-318.
8
  Gerberding, J. L., Binder, S. (2003). Report to Congress on Mild Traumatic Brain Injury in the United States:
          Steps to Prevent a Serious Public Health Problem. National Center for Injury Prevention and Control.
          Atlanta, GA: Centers for Disease Control and Prevention.
9
  Morbidity and Mortality Weekly Report. 1995. Injury Control Recommendations: bicycle helmets. 44(RR-1):1-
          17.
10
   Transport Canada. 2004. Vulnerable Road User Safety: A Global Concern. Downloaded Nov. 29, 2004 from
          http://www.tc.gc.ca/roadsafety/tp2436/rs200403/menu.htm
11
   ibid
12
   Canadian Institute for Health Information. (August 2004). Sports and Recreational Injury Hospitalizations in
          Ontario, 2002-2003. Ontario Trauma registry Analytic Bulletin. Toronto, ON.
13
   ibid
14
   ibid
15
   Gerson, W. & Stevens, J. A. (2004). Recreational injuries among older Americans, 2001. Injury Prevention; 10
          (134-138)
16
   Hukkelhoven, C., Steyerberg, E., Rampen, Farace E., Habbema, J., Narsgakkm K., Murray, G, Maas, A. (2003).
          Patient age and outcome following sever traumatic brain injury: an analysis of 5600 patients. Journal of
          Neurosurgery 99:666-673.
17
   Howard, A. (2002). New survey reveals kids are not using helmets. Downloaded July 20, 2004 from
          http://www.safekidscanada.ca/ENGLISH/Media/Media_PressRelease5.html
18
   Foss, Robert, Beirness, Douglas. (2000). Bicycle Helmet Use in British Columbia: Effects of the Helmet Use
          Law. University of North Carolina/ Traffic Injury Research. Ottawa, ON
19
   Cook, A., Sheikh, A. (2003). Injury Prevention. 9:266-267
20
   ibid
21
   MacKay, M., Scanlan, A., Olsen, I., Reid, D., Clark, M., McKim, Kk., Raina, P. (2004). Looking for evidence: a
          systematic review of prevention strategies addressing sport and recreational injury among children and
          youth. J. Sci Med Sport: 7(1): 58-73.
22
   MacPherson, A., Parkin, P, To, T. (2003). Reply to Robinson. Injury Prevention.9: 382
23
   MacPherson, A. (2002). Sick Kids study shows bicycle helmet legislation leads to fewer bicycle-related head
          injuries in children. Downloaded July 32, 2004 from http://www.safekidscanada.ca/ENGLISH/
          Media/Media_PressRelease7.html.
24
   Henderson, M. (1995). The Effectiveness of Bicycle Helmets: A Review. Motor Accidents Authority of New
          South Wales. Australia
25
   MacKay, M., Scanlan, A., Olsen, I., Reid, D., Clark, M., McKim, Kk., Raina, P. 2001. Sports and Recreation
          Injury Prevention Strategies: Systematic Review and Best Practices. British Columbia Injury Research
          and Prevention Unit/ Plan-It- Safe, Children’s Hospital of Eastern Ontario.
26
   Hatziandreu, E., Sacks, J., Brown, J., Taylor, W., Rosenberg, M., Graham, J. (nd). The Cost Effectiveness of
          Three Programs to Increase Use of Bicycle Helmets Among Children. Source not available.
27
   Traumatic Brain Injury. (nd). Traumatic Brain Injury- Costs. Downloaded Nov. 11, 2004 from
          http://www.traumaticbraininjuryfyi.com/tbi_cost.html

                                         Ottawa Public Health                                                   4
                                  Protecting you. Promoting a healthy city.
                                           SN/ November 29, 2004
28
   Bicycle Helmet Safety Institute. (2004.) Statistics. Arlington, VA. Downloaded Nov. 19, 2004 from
          http://www.helmets.org/index.htm
29
   McFaull, S. (2000). Bicycle injuries- analysis of 1998 hospital admissions with a focus on the injury hazard
          associated with handlebars. CHIRPP. Downloaded Nov. 29, 2004 from http://www.phac-
          aspc.gc.co/publicat/chirpp-schirpt/18jun00/index.html
30
   Transport Canada. 2001. Bicycle Helmet Safety Institute. Statistics. Arlington, VA. Downloaded Nov. 19, 2004
          from http://www.helmets.org/stats.htm
31
   RRFSS. (2004). Bike Helmet Use by Type of Use in Households with Children Aged 5-17, City of Ottawa 2001-
          2003.
32
   RRFSS. (2004). Bike Helmet Use by Type of Use in Households with Children Aged 5-17, City of Ottawa 2001-
          2003.
33
   Foss, Robert, Beirness, Douglas. (2000). Bicycle Helmet Use in British Columbia: Effects of the Helmet Use
          Law. Univerity of North Carolina/ Traffic Injury Research. Ottawa, ON
34
   McKay, K., Ray, R. (2004). Injury Prevention Strategy Proposal- Recreational Sport Safety.
35
   CHIRRP. (1998 to date). Injuries Associated with Inline skating. Downloaded on Nov. 11, 2004 from
          http://www.phac-aspc.gc.ca/injury-bles/chirpp/injrep-rapbles/inline_e.html
36
   CHEO CHIRPP Database. (nd). Skateboarding Injuries seen at CHEO Emergency Department from 1997-2001.
37
   Brain Association of BC. (2003). The Brain Association of British Columbia (BABC) Position Paper on Helmet
          Use when Operating Small Wheel Vehicles.
38
   ibid




                                         Ottawa Public Health                                                5
                                  Protecting you. Promoting a healthy city.
                                           SN/ November 29, 2004

				
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