All-Terrain Vehicle Fatalities --- West Virginia, 1999--2006

An all-terrain vehicle (ATV) is a motorized vehicle designed for off-road use with low-pressure tires, a seat that is straddled by the operator, and handlebars for steering. Currently, only four-wheeled models are produced in the United States; production of three-wheeled ATVs ended in 1987 because of safety concerns. During the 1990s, West Virginia led the United States in per capita deaths from ATV crashes, with rates approximately eight times higher than the national average (1). In an attempt to curtail this trend, West Virginia enacted legislation in 2004 to regulate ATV use (2). This law prohibited ATV operation on paved roads with a center line, unless the vehicle was traveling a distance of <10 miles and at a speed of <25 miles per hour. The statute also required helmet use and training for ATV riders aged <18 years, regardless of where the ATV was ridden. To guide further prevention campaigns and identify appropriate populations for targeted educational interventions, the West Virginia Department of Health and Human Resources used data from death certificates of 1999--2006 ATV fatalities to analyze demographic and socioeconomic trends. Trends by age and crash classification (i.e., traffic versus nontraffic) also were evaluated in the context of the 2004 law. Results of that analysis indicated that, after the ATV law was enacted in West Virginia, the ATV-related death rate in the state among children did not decline, and total ATV-related traffic fatalities increased from 0.72 per 100,000 population in 2004 to 1.32 in 2006. Higher annual ATV death rates occurred among males, persons aged 10--17 years, residents of the most impoverished counties, and persons aged >25 years who had not completed high school. Further preventive measures aimed at reducing ATV-related fatalities should be considered, such as targeted educational interventions and more stringent provisions of the law.

West Virginia death certificates for 1999--2006 with International Classification of Diseases, 10th Revision (ICD-10) codes correlating to occupants of an ATV injured during traffic or nontraffic crashes* (i.e., V86.0, V86.1, V86.3, V86.5, V86.6, and V86.9) were selected for the analysis (3). Descriptive analyses were performed to identify temporal and spatial trends and demographic variations. Census data from 2000 were used to calculate death rates per 100,000 population, and rate ratios with corresponding 95% confidence intervals were calculated by comparing these death rates (4). Analyses were limited to West Virginia residents. Poverty prevalence in the decedent's county of residence was evaluated by categorizing the 55 West Virginia counties into quartiles based on the percentage of families with annual income in 1999 below the poverty line (5). The threshold used to determine poverty status depended on family size and composition, as defined by the U.S. Census Bureau (6).

According to death certificate data, 250 persons died from ATV crashes occurring in West Virginia during 1999--2006; of these, 215 (86%) were West Virginia residents. For the period of analysis, the average annual ATV-related death rate among West Virginia residents was 1.49 deaths per 100,000 population (Table). Males accounted for 186 (87%) of the fatalities and had an ATV-related death rate approximately seven times greater than the rate for females. Decedents from ATV crashes were primarily white (98%) and non-Hispanic (100%).^† The mean age of decedents was 35 years; the median age was 31 years. Among all age groups, persons aged 10--17 years had the highest ATV-related death rate (2.70 per 100,000 population).

During 1999--2006, ATV fatalities increased by an average of 14% per year. The ATV-related death rate among children aged <18 years was relatively constant, whereas the rate among adults increased steadily (Figure 1). The death rate per 100,000 population for children ranged from a low of 0.25 in 2001 to a high of 1.53 in 2002 for traffic deaths. For adults, the death rate per 100,000 population ranged from a low of 0.14 in 2000 to a high of 1.40 in 2006 for traffic deaths. Temporal trends for traffic and nontraffic crashes were similar among adults and children, with traffic crashes accounting for 111 (52%) of all fatalities. Two thirds of fatal ATV crashes occurred during April--September. Time of crash information was available for 168 fatalities, of which 79 (47%) occurred during 4--8 p.m.

The rate of ATV-related deaths also varied by socioeconomic factors (Table). ATV-related death rates increased across each successive quartile of poverty in the county of residence (chi-square for trend p<0.001), with a peak rate of 3.2 per 100,000 population in the most impoverished counties. A similar analysis was performed to evaluate population density in the decedents' county of residence; however, no clear trend was observed. Analysis of the average annual ATV-related death rate by county of crash identified higher rates among specific counties in southwestern West Virginia (Figure 2). Crashes occurred in the decedent's county of residence in 179 (83%) fatalities. Higher ATV-related death rates also occurred among less educated persons, with rates decreasing successively among each category of higher education attained (p<0.001). The ATV-related death rate of persons aged >25 years who had not completed high school (2.73 per 100,000 population) was 11 times higher than that of those with at least some college education (0.25 per 100,000 population). Among different marital status groups, the highest ATV-related death rates occurred among persons who had never been married (3.13 per 100,000 population) and those who were divorced (2.37 per 100,000 population).

Reported by: J Helmkamp, PhD, Injury Control Research Center, West Virginia Univ, Morgantown. D Bixler, MD, J Kaplan, MD, West Virginia Dept of Health and Human Resources. A Hall, DVM, EIS Officer, CDC.

Editorial Note:

This analysis determined that lower socioeconomic status, lower level of education attained, and single or divorced marital status were associated with higher rates of ATV-related deaths in West Virginia during 1999--2006. The associations between these factors and ATV-related fatalities, which might provide insights to help target community-based interventions, have not been previously described. Consistent with a previous study of ATV-related deaths in West Virginia during 1985--1997, the demographic groups identified with the highest ATV-related death rates in West Virginia include males and persons aged 10--17 years (7).

Since 1999, fatal ATV crashes in West Virginia have continued to increase, with an average of 27 deaths occurring annually and a peak of 46 fatalities in 2006. The West Virginia ATV law, which became effective in 2004, has resulted in no observed change in ATV fatalities among children, and ATV traffic fatalities among adults have continued to increase. One possible explanation for these findings is that the 2004 law effectively legalized ATV use on specific paved roads, contrary to manufacturer recommendations that ATVs be used off-road only. Also, various provisions of the law regarding ATV use on paved roads, such as whether a rider has traveled <10 miles on the road, make enforcement difficult. Finally, initial public awareness of the law was limited, and households that own ATVs have not universally agreed with or abided by provisions of the law (8).

The findings in this report are subject to at least two limitations. First, helmet use among ATV-related decedents was not consistently reported through vital records throughout the study period; therefore, a comparison of helmet use before and after enactment of the 2004 ATV regulations was not possible. Second, death rates based on the whole population were calculated in this study because reliable estimates of the population of ATV riders in West Virginia during 1999--2006 were unavailable. As of April 2007, approximately 147,000 ATVs were titled in the state, as required by law (M. Holmes, West Virginia Department of Transportation, personal communication, 2007). This represents <33% of the estimated 460,000 ATVs in West Virginia, as determined from results of a household survey conducted in 2005 (8). Without exposure-based fatality rates, assessment of whether the observed trends in fatalities were reflective of all ATV users or were affected by changes in the numbers or use of ATVs during the 8-year study period was not possible.

Studies are being conducted to further evaluate the circumstances and potential contributing factors (e.g., alcohol and helmet use) of fatal West Virginia ATV crashes and the injuries sustained, which will provide useful information for developing additional or more specific prevention recommendations. Previous studies addressing the effectiveness of ATV laws have recommended a law consistent with American Academy of Pediatrics recommendations (9). These include requiring an automobile driver's license and additional certification specific to ATV use, and prohibiting all ATV use by persons aged <16 years or while under the influence of alcohol. The recommendations also would prohibit passengers on ATVs and ATV use on all public highways or at night (10). Such provisions might make the West Virginia ATV law more effective at reducing ATV-related deaths. Community and school-based programs, particularly those targeting adolescents in poor communities, and emphasizing ATV safety also might reduce deaths. Finally, incentive-based prevention strategies, such as reduced insurance premiums or extended warranty coverage for both safety training and helmet use, might provide an impetus for safer ATV use and help reduce the public health burden exacted by ATV-related deaths.

Acknowledgments

The findings in this report are based, in part, on contributions by L Haddy, PhD, T Light, C Thayer, MS, G Thompson, West Virginia Dept of Health and Human Resources. D Bensyl, PhD, A De, PhD, Office of Workforce and Career Development, CDC.

References

1. Helmkamp JC. A comparison of state-specific all-terrain vehicle-related death rates, 1990--1999. Am J Public Health 2001;91:1792--5.
2. West Virginia Code. Chapter 17F, All-Terrain Vehicles (2004). Available at http://www.legis.state.wv.us/wvcode/code.cfm?chap=17f&art=1.
3. World Health Organization. International classification of diseases and health conditions. 10th revision. 2nd ed. Geneva, Switzerland: World Health Organization; 2005. Available at http://www.who.int/classifications/apps/icd/icd10online.
4. US Census Bureau. Census 2000. Available at http://factfinder.census.gov/servlet/DatasetMainPageServlet?_program=DEC&_submenuId=&_lang=en&_ts=.
5. Dalaker J, Proctor BD. Poverty in the United States: 1999. Current population reports. Washington, DC: US Census Bureau; 2000. Available at http://www.census.gov/prod/2000pubs/p60-210.pdf.
6. Bishaw A, Iceland J. Poverty 1999: Census 2000 brief. Washington, DC: US Census Bureau; 2003. Available at http://www.census.gov/prod/2003pubs/c2kbr-19.pdf.
7. CDC. All-terrain vehicle-related deaths---West Virginia, 1985--1997. MMWR 1999;48:1--4.
8. Althouse R, Kirby J, Helmkamp J. The public's knowledge and opinion about West Virginia's 2004 all-terrain vehicle safety law [Abstract]. Abstracts of the 2nd North American Congress of Epidemiology; June 21--24, 2006. Am J Epidemiol 2006;163(Suppl):S208.
9. Upperman JS, Schultz B, Gaines BA, et al. All-terrain vehicle rules and regulations: impact on pediatric mortality. J Pediatr Surg 2003;38: 1284--6.
10. American Academy of Pediatrics, Committee on Injury and Poison Prevention. All-terrain vehicle injury prevention: two-, three-, and four-wheeled unlicensed motor vehicles. Pediatrics 2000;105:1352--4.

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Date last reviewed: 3/26/2008