Notes from the Field: Emergency Department Visits for Nonfatal Pedal Cyclist Injuries Before and During the COVID-19 Pandemic, United States, 2019–2020

Weekly / July 14, 2023 / 72(28);769–771

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Livia Navon, MS1; Keming Yuan, MS1; Laurie Beck, MPH1 (View author affiliations)

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During the early months of the COVID-19 pandemic, many jurisdictions implemented stay-at-home orders (1). Vehicle miles traveled (VMT)* in April 2020 declined by 40% compared with VMT in April 2019; annual VMT in 2020 declined by 13% compared with those in 2019 (2). Despite decreased VMT, pedal cyclist traffic crash fatalities increased by 10% from 859 in 2019 to 948 in 2020 (3). In 2021, pedal cyclist fatalities increased to 966, the highest number reported since 1975 (3,4). Given the increase in pedal cyclist fatalities despite the decline in VMT in 2020, emergency department (ED) visits for nonfatal pedal cyclist injuries in 2019 and 2020 were compared.

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Investigation and Outcomes

ED visits for nonfatal pedal cyclist injuries† were identified from the 2019–2020 National Electronic Injury Surveillance System–All Injury Program (NEISS-AIP). NEISS-AIP data are collected from a stratified probability sample of hospitals and provide weighted national estimates of ED visits for nonfatal injuries. The monthly proportions of injury-related ED visits accounted for by pedal cyclist injuries in 2020 and 2019 were compared using pairwise t-tests in SAS-callable SUDAAN (version 11.0.3; RTI International); comparison of the changes in monthly proportions by age group and sex was assessed using logistic regression. Variance was estimated using Taylor series linearization. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§

During the early months of the COVID-19 pandemic (March–April 2020), ED visits for nonfatal injuries declined by 31% compared with March–April 2019; the total number of nonfatal injury–related ED visits in 2020 declined by 15% compared with 2019. Despite the decline in total injury-related ED visits, the number of ED visits for pedal cyclist injuries in 2020 (356,630 visits [95% CI = 265,330–447,931]) was 8% higher than in 2019 (328,903 visits [95% CI = 255,096–402,711]). During March–August 2020 and in November 2020, monthly proportions of injury-related ED visits accounted for by pedal cyclist injuries were significantly higher than during the same months in 2019 (Table). The age group with the largest increase during most months was children and adolescents aged <18 years. For example, pedal cyclist injuries in this age group accounted for 6.0% of injury-related ED visits in April 2020, which was 2.9 times higher than in April 2019 (2.1%). In April 2020, pedal cyclist injuries among adults aged ≥18 years accounted for 1.5% of injury-related ED visits, which was 1.5 times higher than in April 2019 (1.0%); among adults aged ≥50 years, the proportion of pedal cyclist ED visits in April 2020 (1.7%) was 2.1 times higher than in April 2019 (0.8%). Increases among children and adolescents aged <18 years were sustained during February–November 2020; among adults aged ≥18 years, increased monthly proportions of pedal cyclist ED visits were observed primarily during March–June 2020.

Although the monthly proportions of injury-related ED visits accounted for by pedal cyclist injuries were consistently higher among males in both 2019 and 2020, increases in the proportions of pedal cyclist ED visits during March–May and July–August 2020 were higher among females than males. For example, in April 2020, pedal cyclist injuries accounted for 1.7% of injury-related ED visits among females, which was 2.4 times as high as those in April 2019 (0.7%). The proportion of pedal cyclist ED visits among males in April 2020 (2.5%) was 1.6 times higher than in April 2019 (1.6%). Increases among females were sustained during March–August 2020; among males, increased monthly proportions of pedal cyclist ED visits were observed during February–June 2020.

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Preliminary Conclusions and Analysis

The proportion of injury-related ED visits accounted for by pedal cyclist injuries increased in the first year of the COVID-19 pandemic; increases were largest among children and adolescents aged <18 years, adults aged ≥50 years, and females. These findings, coupled with the recent increase in the number of pedal cycling fatalities (3), highlight the need for additional pedal cycling safety interventions. To reduce pedal cyclist injury risk, engineering and roadway designs that incorporate safety features for pedal cyclists (e.g., bicycle lanes) can be implemented, and states and localities can consider helmet laws for pedal cyclists of all ages to increase helmet use (5).

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Acknowledgments

Dana Flanders, Mark Stevens, National Center for Injury Prevention and Control, CDC; Nimeshkumar Patel, Center for Forecasting and Outbreak Analytics, CDC; Erin Sauber-Schatz, Global Health Center, CDC.

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Corresponding author: Livia Navon, lnavon@cdc.gov.

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1Division of Injury Prevention, National Center for Injury Prevention and Control, CDC.

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All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

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* VMT is a measure of distance traveled by vehicles in a given region during a specified time. Data reported to the Federal Highway Administration by states and the District of Columbia include only motorized vehicles (e.g., cars, light trucks, sport utility vehicles, motorcycles, and heavy trucks); pedal cycle travel is not included. https://www.fhwa.dot.gov/policyinformation/tmguide/2022_TMG_Final_Report.pdf

† Pedal cyclist injuries are defined as injuries to a pedal cycle rider from a collision, loss of control, crash, or some other event. This category includes riders of bicycles, tricycles, mountain bikes, and unicycles. Injuries unrelated to riding a pedal cycle, such as repairing a bicycle or tripping over a bicycle are not included in this category. Injuries that occurred in traffic, not in traffic (such as in a driveway or other offroad location such as a bicycle trail), and where the location of injury was unspecified, were included in this analysis to capture all nonfatal pedal cyclist injuries. In 2020, 37% of pedal cyclist injuries occurred in traffic; 27% did not occur in traffic, and 37% had insufficient documentation to determine where the injury occurred. https://www.cdc.gov/injury/wisqars/nonfatal_help/index.html#nonfatal

§ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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References

  1. Moreland A, Herlihy C, Tynan MA, et al.; CDC Public Health Law Program; CDC COVID-19 Response Team, Mitigation Policy Analysis Unit. Timing of state and territorial COVID-19 stay-at-home orders and changes in population movement—United States, March 1–May 31, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1198–203. https://doi.org/10.15585/mmwr.mm6935a2 PMID:32881851
  2. US Department of Transportation. December 2020 traffic volume trends. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2020. https://www.fhwa.dot.gov/policyinformation/travel_monitoring/20dectvt/
  3. National Center for Statistics and Analysis. Bicyclists and other cyclists: 2021 data (traffic safety facts). Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2023. https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813484
  4. National Center for Statistics and Analysis. Traffic safety facts 2018 annual report: a compilation of motor vehicle crash data. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2020.
  5. Venkatraman V, Richard CM, Magee K, Johnson K; National Highway Safety Administration. Countermeasures that work: a highway safety countermeasures guide for State Highway Safety Offices. 10th ed. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration; 2020.

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TABLE. Estimated monthly number of emergency department visits for total and pedal cyclist–related nonfatal injuries and monthly percentage of visits due to pedal cyclist injuries, by age group and sex — National Electronic Injury Surveillance System–All Injury Program, United States, 2019–2020Return to your place in the text
Characteristic/Yr Pedal cyclist–related injury ED visits
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Age group, yrs, % (95% CI)
2019
<18 0.5
(0.3–0.8)		 0.8
(0.3–1.2)		 1.3
(0.9–1.8)		 2.1
(1.7–2.5)		 2.8
(2.3–3.3)		 3.7
(3.2–4.2)		 3.1
(2.5–3.6)		 3.9
(3.0–4.8)		 2.8
(2.2–3.3)		 1.6
(1.2–1.9)		 1.0
(0.7–1.4)		 0.8
(0.4–1.3)
≥18 0.7
(0.3–1.1)		 0.7
(0.4–1.0)		 0.8
(0.4–1.1)		 1.0
(0.6–1.3)		 1.0
(0.8–1.3)		 1.1
(1.0–1.3)		 1.4
(1.1–1.6)		 1.3
(1.1–1.5)		 1.3
(1.0–1.5)		 1.1
(0.8–1.4)		 0.8
(0.5–1.0)		 0.7
(0.4–0.9)
18–49 0.7
(0.3–1.0)		 0.5
(0.3–0.7)		 0.7
(0.4–0.9)		 1.1
(0.7–1.4)		 1.0
(0.7–1.2)		 1.2
(1.0–1.4)		 1.4
(1.1–1.7)		 1.4
(1.1–1.6)		 1.5
(1.1–1.8)		 1.1
(0.8–1.4)		 0.7
(0.5–0.9)		 0.6
(0.4–0.9)
≥50 —* 0.9
(0.4–1.4)		 — 0.8
(0.4–1.3)		 1.1
(0.8–1.4)		 1.0
(0.8–1.3)		 1.3
(1.1–1.6)		 1.2
(0.8–1.6)		 1.0
(0.7–1.3)		 1.0
(0.7–1.4)		 0.9
(0.5–1.3)		 0.7
(0.3–1.1)
2020
<18 0.7
(0.4–1.0)		 1.2†
(0.8–1.7)		 2.2†
(1.7–2.7)		 6.0†
(4.8–7.2)		 5.7†
(4.8–6.6)		 5.4†
(4.4–6.5)		 5.3†
(4.6–6.1)		 5.1†
(4.1–6.1)		 3.9†
(2.9–4.9)		 2.4†
(1.9–2.8)		 1.8†
(1.3–2.2)		 1.1
(0.7–1.5)
≥18 0.8
(0.4–1.2)		 0.8
(0.4–1.1)		 1.1†
(0.6–1.7)		 1.5†
(0.9–2.0)		 1.7†
(1.2–2.2)		 1.5†
(1.2–1.8)		 1.4
(1.1–1.7)		 1.5†
(1.3–1.7)		 1.4
(1.2–1.6)		 1.2
(0.9–1.5)		 0.9
(0.6–1.2)		 0.7
(0.4–1.1)
18–49 0.8
(0.4–1.1)		 0.7
(0.4–1.0)		 0.9†
(0.6–1.3)		 1.2
(0.8–1.7)		 1.5†
(1.1–2.0)		 1.4
(1.1–1.7)		 1.5
(1.1–1.8)		 1.6
(1.2–1.9)		 1.4
(1.2–1.6)		 1.3
(0.9–1.6)		 0.8
(0.5–1.0)		 0.7
(0.4–0.9)
≥50 — 0.9
(0.4–1.4)		 — 1.7†
(0.9–2.6)		 1.9
(1.0–2.8)		 1.6†
(1.2–2.0)		 1.4
(1.0–1.7)		 1.4
(1.1–1.7)		 1.3
(1.0–1.7)		 1.2
(0.8–1.5)		 1.1
(0.6–1.5)		 —
Sex, % (95% CI)
2019
Female 0.4
(0.2–0.6)		 — 0.4
(0.2–0.7)		 0.7
(0.4–1.0)		 0.8
(0.6–1.0)		 1.0
(0.8–1.2)		 0.9
(0.7–1.1)		 0.8
(0.7–1.0)		 0.8
(0.6–1.1)		 0.6
(0.4–0.9)		 0.3
(0.2–0.5)		 0.3
(0.2–0.5)
Male 0.9
(0.5–1.4)		 0.9
(0.5–1.2)		 1.2
(0.8–1.7)		 1.6
(1.3–1.9)		 2.0
(1.7–2.3)		 2.2
(1.9–2.4)		 2.3
(2.0–2.6)		 2.6
(2.2–2.9)		 2.2
(1.8–2.5)		 1.6
(1.4–1.9)		 1.3
(0.9–1.6)		 1.0
(0.6–1.5)
2020
Female 0.5
(0.2–0.8)		 0.5
(0.2–0.7)		 0.9†
(0.5–1.3)		 1.7†
(1.1–2.3)		 1.7†
(1.2–2.2)		 1.5†
(1.3–1.7)		 1.4†
(1.1–1.6)		 1.4†
(1.1–1.7)		 1.1
(0.8–1.3)		 0.7
(0.5–1.0)		 0.5
(0.3–0.8)		 —
Male 1.0
(0.5–1.5)		 1.2†
(0.7–1.7)		 1.6†
(1.1–2.2)		 2.5†
(2.0–3.0)		 2.8†
(2.2–3.3)		 2.6†
(2.1–3.0)		 2.6
(2.2–3.0)		 2.6
(2.3–3.0)		 2.4
(2.1–2.7)		 1.9
(1.6–2.3)		 1.4
(1.0–1.9)		 1.0
(0.7–1.4)
Total, % (95% CI)
2019 0.7
(0.3–1.0)		 0.7
(0.4–1.0)		 0.9
(0.5–1.2)		 1.2
(0.9–1.5)		 1.4
(1.2–1.6)		 1.6
(1.4–1.8)		 1.7
(1.4–1.9)		 1.8
(1.6–2.0)		 1.6
(1.3–1.9)		 1.2
(1.0–1.4)		 0.8
(0.6–1.1)		 0.7
(0.4–1.0)
2020 0.8
(0.4–1.2)		 0.9
(0.5–1.2)		 1.3†
(0.8–1.8)		 2.2†
(1.7–2.6)		 2.3†
(1.9–2.7)		 2.1†
(1.8–2.4)		 2.1†
(1.8–2.4)		 2.1†
(1.9–2.4)		 1.8
(1.6–2.1)		 1.4
(1.1–1.7)		 1.0†
(0.7–1.3)		 0.8
(0.5–1.1)
ED visits, no.
2019
Pedal cyclist ED visits 13,954 12,984 19,228 25,958 33,993 38,565 42,655 44,668 38,422 26,965 17,165 14,348
Injury-related ED visits 2,067,565 1,879,084 2,196,156 2,180,453 2,386,593 2,352,969 2,543,118 2,479,241 2,425,673 2,289,238 2,046,299 2,063,942
2020
Pedal cyclist ED visits 16,613 17,471 22,592 27,920 42,471 43,696 44,090 45,058 36,447 27,932 18,683 13,658
Injury-related ED visits 2,134,526 2,038,440 1,729,883 1,288,572 1,839,591 2,062,185 2,138,277 2,142,528 1,999,441 1,987,562 1,814,376 1,711,755

Abbreviation: ED = emergency department.
* Dashes indicate estimate suppressed because coefficient of variation >30%.
† Difference in the pairwise comparison of the monthly percentage in 2020 compared with 2019 is statistically significant at p<0.05.

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Suggested citation for this article: Navon L, Yuan K, Beck L. Notes from the Field: Emergency Department Visits for Nonfatal Pedal Cyclist Injuries Before and During the COVID-19 Pandemic, United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2023;72:769–771. DOI: http://dx.doi.org/10.15585/mmwr.mm7228a3.

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