The relation between the Number of Hours that authorize the sale of liquors Beverages and traffic Injuries, the Peruvian

Experiences

Dr. Hernán Málaga

“Evaluación de intervenciones en seguridad vial: componente clave de la Década de Acción”.

2

The Peruvian problem

• During 2007, there were registered 76.928 wounded in traffic accidents in a population of 27.148.1014.

• 3510 fatal victims (12, 9 per 100 000).• 78% of them male5.

• An index of 25 deaths every 10.000 vehicles6.• Mortality rate of 21,5 per 100.000 inhabitants7.

3

The relation with alcohol consumption

• In middle-income countries between 33 to 69% of fatally injured drivers and between 8 to 29% of non fatally injured drivers, would have consumed alcohol before their crash12.

To reduce the burden of disease caused by alcohol, there are at least 10 evidenced-based public health measures:

• Reduction in hours for alcoholic beverages authorized selling.• Reduction in the days for alcoholic beverages authorized selling.• Limit the number of alcoholic beverages selling stores. • Legal responsibility for the alcoholic beverages seller. • Supervise the firm control of the already established law. • Brief interventions in alcohol-positive traffic casualties. • To restrict advertising and patrician of alcohol .• Minimum age to buy alcoholic beverages• Measures to control traffic accidents.13

Evidenced based measures against alcohol consumption

4

External injuries by group on weekends (FSS) or not (MTWT) - HNCH, 2004

DayGroup 1 Group 2 Total

n % n % n %FSS 4 210 57.54 3 107 42.46 7 317 100MTWT 4 943 66.80 2 456 33.19 7 399 100

Total 9 153 62.20 5 563 37.80 14 716 100

OR = 1.49 (1.39 – 1.59) 95%

Group 1: Occupational and recreational.Group 2: Aggressions, and traffic accidents.

Hour of attentionGroup 1 Group 2 Total

n % n % n %00:01- 05:59 814 37.91 1 333 62.09 2 147 10006:00-24:00 8 339 66.35 4 230 33.65 12 569 100

Total 9 153 62.20 5 563 37.80 14 716 100

OR = 3.23 (2.94 – 3.55) 95%

External Injuries by group and hour of attention.(00:01 - 5:59 vs 06:00 - 24:00), HNCH, 2004

Violent deaths tree problem

5

HIGH INCIDENCE OFVIOLENT DEATHS

Traffic accidentsand agrettions

Conductoresnegligentesy violentos

Expuestos enlas madrugadas Disponibilidad

de arma de fuego

Acceso inadecuadoal alcohol y drogas

Controles inadecuados

Política nacionalposterga elmedio rural

Instituciones desarticuladas ydesprestigiadas

CinturonesUrbano

marginales

Inadecuada distribuciónde riquezas

Bajaescolaridad

Alcohol andDrugs

Consumption

Inappropriate Use of Free Time

Vacations, Holidays, Weekends,

Pay Half

Nocturnality

Bad habitsand life style Ambiental Biológico

Respuestas del Estado

y de la sociedad

Varones 15-40 años

Desempleo Verano

6

Change of habits and life style

Limit Nocturnality

Ambiental

Incrementar Escolaridad

Fomentar Empleo

Equidad Distribución Riqueza

Programa Desarrollo Urbano-Marginal

Biológico

RecreaciónAlternativa para jóvenes Respuestas Estado y de la

Sociedad

Priorizar Desarrollo Población

Rural Excluida

Fortalecer Instituciones

de control

Limit Consume of Alcohol and Drugs

Cambio de Armas por Dinero?

Restricción porte de armas Control

Alcoholemia

Reduction of traffic injuries and aggressions

Disminuye migración

campo-ciudad

Violence Reduction

Restriction on the hours of sell

Monitory External Injuries Cases

Controles de velocidad y buen estado de los

vehículos

Objectives tree: Reduction of violence

7

• This police was originally designed to reduce Violence in Colombia and Brazil.• Bogota, Cali and Medellin in Colombia, Asunción in Paraguay, and Diadema in Brazil 14-17, have

applied successfully, restrictions of schedules for alcoholic beverages authorized selling, in order to reduce violence and traffic accidents.

Reduction in hours for alcoholic beverages authorized selling The Latin American Experience

8

• In the District of La Victoria, due to the serious violence problem, in January 2007, a local restriction was established, in this regard. Alcohol beverage is sold until midnight on Sunday, Monday, Tuesday and Wednesday, and until 3:00 am on Thursdays, Fridays and Saturdays 18, 19.

• The study should be considered as ecological 20 with a chronological and geographical comparison between two districts: La Victoria, with the restriction and Cercado de Lima without the ban.

La Victoria Studies

Materials and Method

• The participants in the study were all the patients from a local National Hospital, with aggressions, from fighting, or were wounded in traffic accidents. There are other hospitals that could receive patients from those districts, but there’s an early study that shows that an important quantity of those lesions are being attended there21. For the violent deaths: homicides, suicides and deaths in traffic accidents that occur in both districts we use data from the Institute of Forensic Medicine, as numerator.

Ley Zanahoria in La Victoria

9

• In La Victoria there was a reduction of the aggressions of 40.7% in 2007 and 36.4% in 2008, with regard to 2006 ,with a significant negative tendency (P≤ 0,014). In Cercado, although aggressions declined in 2007 in 16%, in 2008, they increased in 7%, with regard to the 2006. They were more frequent in men in 2006 than in the 2007 and 2008 (Pearson chi 2

(1) = 4.4260 Pr ≤ 0,035), OR=1.2 (95% CI 1, 0-1.4%) (P ≤0,035) in 2006.(Table N°1).

• The male aggressions diminish in all ages, especially in younger’s. In Cercado, the behavior is similar in the 3 years (Figure Nº 1). Woman has almost one fifth of aggressions less, than men and diminished it at all ages after the restriction. No changes where observed in Cercado.

Results of the study on injuries of external cause admitted to a National Hospital

10

Rate of men aggressions x 10.000 according to ages groupsCercado – La Victoria 2006 – 2008, HN2DM

11

Rate/100.000 Inhabitants

Males

Females+,

, ,, , , , , , , , , , , ,++

++

+++++

+

+++

+

< 5

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

>65

0

100

200

300

400

500

1994

, ,, , , , , , , , , , , ,++

++

+++

+++++++

< 5 5-

9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

>65

0

100

200

300

400

500

1997

2001

, ,, , , , , , , , , , , ,+ +++

+++

+++++++

< 5

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

>65

0

100

200

300

400

500

88: Sistema de Vigilancia de Violencia y Accidentalidad . CISALVA Con datos de: Med. Legal, Policia,Fiscalia, Sijin, Cdav

Age and sex specific homicide rates /100.000Cali. 1994 - 1997 - 2001

12

510

1520

2530

.75 .8 .85 .9 .95 1Weights

Frequency of Aggressions Fitted values

XY 32.2725.11

Relationship between the sales of liquors measured on fraction of day and aggressions in La Victoria

13

• Numbers and crude incidence rates per 100.000 person-years of interpersonal violence and unintentional injury deaths during the periods of days when the alcohol control policies were in effect. Cali, Colombia, 2004-08. (The most restrictive policies prohibited alcohol consumption and sales between 2 a.m. and 10a.m. The moderately restrictive policies prohibited alcohol consumption and sales between 3 a.m. and 10 a.m. The lax policies prohibited alcohol consumption and sales between 4 a.m. and 10 a.m.

Source: Sanchez A. et al 2011

14

• The dead by traffic accidents increased 5.5% in Cercado and 11.2% in La Victoria.

The difference of La Victoria, with Bogota and Asunción13, 36, 37 could be related to:• The victims came mainly from people that does not leave in La Victoria.• The time of occurrence.

How to explain that deaths by traffic accidents did not decline

Frequency distribution of deaths, on traffic accidents for the periods 2005-06 and 2007-08, by hour of occurrence, in La Victoria District.

Source: Institute of Forensic Medicine, 2009

Hour of Ocurrence2005-06 2007-08

n % n %0-2 8 7.1% 8 6.5%

3-5 11 9.7% 11 8.9%

6-8 16 14.2% 28 22.6%

9-11 10 8.8% 21 16.9%

12-14 15 13.3% 14 11.3%

15-17 18 15.9% 16 12.9%

18-20 23 20.4% 14 11.3%

21-23 12 10.6% 12 9.7%

Total 113 100% 124 100%

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Local Ban 1568 Secure Hour

C: First we have to finish the beers handsome prince... After midnight I will give you my crystal shoe and every thing else...

P: Cheers Cinderella!

R: By midnight her car will be transformed in a carrot.

• Analyze date of homicides, suicides and deaths on traffic accidents, after the local ban 1568• To coordinate efforts between: National Forensic Institute, Peruvian National Police, Direction

of Epidemiology, Health of Person MINSA,DEVIDA, and Gerencial Structures of the Metropolitan City Hall of Lima.

• To design interventions for different institutions that will contribute to our common goal.

Objectives

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00:00 - 02:59 03:00 - 05:59 06:00 - 08:59 09:00 - 11:59 12:00 - 14:59 15:00 - 17:59 18:00 - 20:59 21:00 - 23:59

40

0 2 14 5 5

1

31

0 2 3 1 30 2

Antes Después

Domingo Lunes Martes Miércoles Jueves Viernes Sábado

1114

11

15 14

10

24

11

7

15

5 64

8

Antes Después

First week and injuries due to traffic accidents in three hospitals by day and hour of occurrence in Metropolitan Lima

Source: DGE

17

Deaths in traffic accidents by day of the weekDec-2010 vs Dec-2011

Source: IML

18

• Reduction on Deaths by traffic accidents and homicides by 11%, • Reduction on death bodies with alcohol of traffic accidents of 28.5% and in homicides of

19%.• The reduction occurs all days of the week except on Fridays.• The reduction occurs at all hours of the day, but specially by 00:00 and 02:59 am

Behavior of violent deaths, one year after

Death causeDec-10 to Nov-11 Dec-11 to Nov-12

N° of cases AlcoholPositives % N° of cases Alcohol

Positives %

Homicide 344 105 31 307 86 28Traffic Accidents 480 130 27 427 93 22Suicides 271 42 15 265 53 20Total 1 095 277 25 999 232 23

Source: IML - Lima Metropolitana. 2011 - 2012

Deaths by External Cause lesion with or without alcohol in their bodiesDec-10 to Nov-12

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District of occurrence injuries by traffic accidents2011 vs 2012

Source: DGE 2013

Districts 2011 2012Pueblo Libre 119 0Puente Piedra 901 667Punta Hermosa 1 0Punta Negra 2 1Rimac 307 165San Bartolo 7 0San Borja 83 19San Isidro 44 14San Juan de 1 0San Juan de Luri 76 41San Juan de Mira 216 26San Luis 84 51San Martin de P 0 298San Martin de Po 1149 110San Miguel 73 98Santa Anita 43 21Santa Rosa 5 1Santiago de 1 1Santiago de Surc 469 177Surquillo 182 22Villa el Sa 47 35Villa el Salvado 79 22Villa Maria 15 2Villa Maria del 127 32(en blanco) 26 1Total general 10320 5845

Districts 2011 2012Ancon 66 55Ate 1782 720Barranco 162 13Breda 101 0Breña 0 80Carabayllo 321 331Chaclacayo 13 22Chorrillos 344 53Cieneguilla 0 1Comas 796 865El Agustino 75 46Independencia 160 93Jesus Maria 79 55La Molina 33 29La Victoria 568 400Lima 918 786Lince 67 48Los Olivos 278 211Lurigancho 101 48Lurin 15 1Magdalena del M 1 0Magdalena del Ma 35 65Magdalena Vieja 0 93Miraflores 333 22Pachacamac 6 4Pucusana 9 0

The injuries by traffic have

decreased by 43%.

i

20

Relationship between the sales of liquors measured on fraction of day and traffic accidents deaths in Metropolitan LimaDec-2010 Aug-2011 Dec-2011 Aug-2012

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• Reduction on Deaths by traffic accidents of 11.04%.• Reduction in both sexes, and in all ages with the exception of the older than 50 years.• Reduction of alcoholized bodies in males of 27%.• Reduction occurs mainly in Bachelors.• The largest increase comes from Puente Piedra and Comas.• Reduction occurs all the days of the week, excepted on Fridays.

Deaths by traffic accidentsDec-2010 to Nov-2011 against Dec-2011 to Nov-2012

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Deaths in traffic accidents 2011 2012 Variation (%)Male 357 313 -12.32Female 123 114 -7.32

Total 480 427 -11.04

Deaths by traffic accidents by sex and ageDec-2010 to Nov-2012

Source: IML - Lima Metropolitana, Period 2011 - 2012

Deaths in traffic accidents 2011 2012 Variation (%)

0 - 9 32 21 -34.38

10-24 54 45 -16.67

25 - 49 183 131 -28.42

+ 50 211 230 9.00

Total 480 427 -11.04

Age

Sex

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Deaths in traffic accidents 2011 2012 Variation (%)With alcohol 130 93 -28.46Whitout alcohol 350 334 -4.57

Total 480 427 -11.04

Alcoholized bodies that came from traffic accidentsDec-2010 to Nov-2012

Male Deaths in traffic accidents 2011 2012 Variation (%)With alcohol 121 88 -27.27Without alcohol 236 225 -4.66

Total 357 313 -12.32

Male

Source: IML - Lima Metropolitana, Period 2011 - 2012

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Deaths by traffic accidents by day of the weekDec-10 to Nov-12

Source: IML - Lima Metropolitana, Period 2011 - 2012

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

2011 70 56 30 43 56 38 63

2012 56 45 29 39 43 43 38

5

15

25

35

45

55

65

75

26

Occurrence of violent deathsDec-2010, Dec-2011 and Dec-2012

Death cause

Dec-10 Dec-11 Dec-12

N° of cases Alcohol Positives % N° of cases Alcohol

Positives % N° of cases Alcohol Positives %

Homicide 33 9 27% 30 7 23% 21 6 29%

Traffic Accidents 60 17 28% 32 10 31% 30 9 30%

Suicide 31 10 32% 19 5 26% 28 7 25%

Total 124 36 29% 81 22 27% 79 22 28%

Source: IML - Lima Metropolitana, Dec-2011 to Dec-2012

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Saving in health in one year

Kind of Intervention n % Cost per Medical Attention

Hospitalized 94 2.1% $2,277.00 $214,038.00

Emergency 4328 97.9% $62.00 $268,336.00

Total 4422 100% - $482,374.00

Deaths 53 1.2% $514.00 $27,242.00

Total 4475 100% - $509,616.00

According to Bambaren on 2003, in Lima, the unit cost of:

• An emergency, is US$ 62.00.• An hospitalized ,is US$ 2 277.00.• A death, is US$ 514.00.

Being a total of 2.1% injuries, that require hospitalization.

Note

28

• Is possible that the ban has had an effect in the diminished of the deaths by traffic accidents, specially on those that were occasioned by alcohol. The main diminish came from the alcoholized death.

• The ban has possible diminished the deaths by traffic accidents in all days of the week, except Friday, This was possible due to the fact ,that the ban permit the sale of liquors on the night of the Thursday until 03:00am of Friday , and by this reason there has not been a cultural change.

• The initial effect of December 2011 and January 2012,was not sustained for the hole year, possible due to the initial display of announcements.

Local Ban 1568 Secure HourConclusions

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http://www.facebook.com/home.php?sk=group_176654789042977&ap=1

https://www.facebook.com/ley.zanahoria?fref=ts

Amigos de la ley zanahoria

• Málaga, H. - Horarios de venta de bebidas alcohólicas y su efecto en Violencia. Editorial Académica Española. LAP LAMBERT Academic Publishing GmbH&Co.KG. Saarbrücken, Alemania 2012.

• Malaga,H.; Gonzalez, M.; Huaco, C.; Sotelo, M. (2012) - The Relation between the Number of Hours That Authorize the Sale of Alcoholic Beverages and Violence. Health Promotion Perspectives, Vol. 2, No.1; P: 60-71

• Cisneros G; Bambaren, C. Málaga H, González M. Lesiones de Causa Externa en el Municipio de San Martín de Porres. Lima-Perú. 9a Conferencia Mundial sobre prevención de lesiones y promoción de la seguridad; 2008 Marzo 15-18; Mérida, México; 2008.

References