Dr Holger Möeller is an epidemiologist in the injury division at The George Institute for Global Health, Australia, with expertise in injury epidemiology and the analysis of longitudinal linked health data. His research interests lie in injury epidemiology, health inequalities, quantitative health impact assessment and the use of linked data to inform policy and decision making.

What is the context for your recent research on novice motorcycle riders?

We know that compared to other road users, motorcycle riders have a disproportionately high risk of crashes that result in serious injury or death. Previous studies have linked measures of rider characteristics (e.g. age, gender, education), riding behaviour (e.g. speeding, riding errors, stunts), reason for riding and riding conditions (e.g. commuting, work, recreation, rain, darkness, heavy traffic), riding experience, type of motorcycle, alcohol use, and road conditions with the risk of motorcycle crashes.

Few studies have investigated multiple crash risk factors and their inter-relationship at the same time, thereby making it possible to identify the factors most strongly associated with the risk of a crash. Also there have been limited studies involving novice riders who have the highest risk of crashing.

What did this research find?

Similar to previous studies - when only considering confounders (age, sex and riding exposure) in the analysis, novice motorcycle riders in this cohort were more likely to have been involved in a crash if they:

• had participated in a pre-learner course;
• held their learner permit and licence for a shorter time;
• did not have prior off-road riding experience;
• rode more kilometres;
• rode more frequently in challenging conditions (heavy traffic, darkness or adverse weather);
• had crashed or reported three or more near-crash events prior to the study or,
• were more prone to errors or engaging in risky riding behaviours.

How does this study contribute new information to existing literature?

After adjusting for rider characteristics, rider training and experience, riding behaviour, riding conditions, purpose of riding, type of motorcycle and riding exposure in the multivariable analysis, only the following measures remained statistically significantly associated with crashing - participation in a pre-learner course, combined time on learner permit and licence, riding exposure before the study, involvement in a near-crash and in a crash before the study.

This indicates that measures of training and riding experience were the strongest predictors of crashing in this group of novice motorcycle riders.

What are the interpretations and implications of this research?

At the time of the study there was no compulsory rider training to obtain a learner permit in the State of Victoria, where it was conducted. It is plausible that riders who voluntarily participated in an unregulated pre-learner course prior to obtaining a learner permit became or remained at high risk of crash after obtaining a rider licence. This may be due to certain characteristics of those who attend such courses (such as being less experienced) or the inability of the range-based programs to sufficiently transfer to on-road environments.

Nonetheless, the findings highlight the need to evaluate the safety benefits of such courses, distinguishing between mandatory versus voluntary courses and whether on-road training is included.

Results also suggest a possible safety benefit of lengthening the time a rider stays on a novice licence (combined learner permit and probationary or restricted licence period).

Since the completion of this this study, Victoria has introduced a graduated licensing system with the aim to improve riding skills and experience and reduce the overrepresentation of novice riders in crash fatalities.

The program comprises three courses: pre-learner (Motorcycle Permit Assessment), learner (Check Ride), and pre-licence (Motorcycle Licence Assessment). Having an interim course between that for the learner permit and the licence is likely to extend the novice licence period and all courses include mandatory on-road training and/or assessment components.

Our findings support the view that such a program might be successful in reducing motorcycle crash rates in novice riders should it provide additional experience for novices. The safety benefits of Victoria’s graduated licensing program and similar initiatives in other jurisdictions should be evaluated to determine if such benefits are realised.

We asked The George Institute’s respiratory expert Professor Christine Jenkins about what the latest data on COVID-19 is telling us, particularly in relation to high risk groups.

What are we learning from China about how the virus is behaving? 

We’re learning a great deal about the clinical illness as papers from Wuhan are published, describing the pattern of COVID illness in large numbers of patients, every week now in the leading medical journals. The most obvious public health learning from China is the value of lockdown, which was implemented later than would have been ideal, but was highly effective in Wuhan. Despite the rapid rise in the number of cases, patients admitted to hospital and deaths, it achieved a rapid reduction in deaths and subsequently a dramatic fall in the number of new cases over a period of only six to eight weeks.  Several papers have since been published which clearly indicate that increasing age is a risk factor for death from COVID-19, although people can die at any age.  Further, it is obvious that coronavirus is quite different to the influenza virus in several key ways.  It is more infectious but it does not appear to infect children at a high rate, which is most unusual for a respiratory virus.  The majority of transmissions are therefore from adult to adult, in a roughly 1:2 ratio (i.e. one infects two others). The lockdown in Wuhan placed a limit on the extent to which other parts of China were affected although it still remains perplexing that the virus did not seriously affect most of the rest of the population in other parts of mainland China. Many questions remain unanswered, in particular how much very mild illness occurred and therefore the size of the “Denominator” – all the people infected with virus. Only when we know this number can we say what the true death rate is from coronavirus infection.

How are people with existing respiratory conditions responding? 

People with existing respiratory conditions usually experience a greater level of symptoms when they have a viral respiratory infection. This is not surprising as they may already be symptomatic from the disease already affecting their lungs, whether it be asthma, COPD or pulmonary fibrosis. On the other hand, a critical question for these people is whether they are more vulnerable to catching the virus or to having a life-threatening consequence from infection.  At this stage it does not appear that they are more vulnerable to catching the virus, but are more vulnerable to serious outcomes from it. There is a very high rate of smoking amongst Chinese men in particular, but at present smoking has not been identified as a risk factor for getting COVID.  As well, the prevalence of smokers amongst people who died from coronavirus in China was no higher than the prevalence of smoking in the general population.

Tell us more about the reported cases of relapse into pneumonia? 

In some people the virus causes a very rapid progression from the onset of symptoms such as fever and cough through to the development of pneumonia, which is usually evidenced by marked breathlessness and low oxygen levels. The pneumonia caused by coronavirus can cause respiratory failure, when the lungs cannot supply adequate oxygen levels to the circulation and vital organs. This can worsen rapidly over a few hours, progressing to a requirement for intensive care admission and assisted ventilation.  In other patients there is a slower evolution of the symptoms and the initial coronavirus symptoms may be mild with a fairly typical illness which lasts three to five days and then appears to improve. Subsequently a few days later some people can deteriorate with pneumonia and respiratory failure.

What does the course of the disease look like in these people and how can they be identified? Is this just in the elderly? 

No, this is definitely not just in the elderly.  Although older people (by which we mean over 60), particularly those with chronic ill-health and comorbidities (such as diabetes, hypertension, lung and heart disease) are more vulnerable to dying from COVID, people can die at any age.  The reasons why somebody who is fit and healthy in their 30s or 40s can die from COVID remains unclear. There may be a constitutional vulnerability to severe effects of viral infection, or alternatively it may relate to the dose of virus they received when they first were exposed.  We have yet to explore the reasons for this in full.

What is your advice to people with existing respiratory conditions? 

People with pre-existing respiratory disease should see their doctors to make sure they are taking the right treatment, receiving their vaccinations, maintaining physical activity and looking after themselves as best as is possible.  This is particularly important in people aged over 60, and in all patients with asthma who tend to be rather relaxed about their preventer treatment if they are feeling well.  It is far better to control asthma well with daily preventer medication than to be vulnerable to a sudden attack when you develop a viral infection.  It is also important that people with asthma use a puffer and spacer to take their reliver medications, rather than nebulisers, as these can spread infection.  They should also ensure they have a written action plan to use in the case of any deterioration. I would encourage all patients with asthma and COPD to discuss their action plan with their GP and make sure they are on the right treatment. Finally but most critically, everyone with lung disease should be taking great care to reduce their risk of coronavirus infection, maintaining hand hygiene and social distancing as advised by health departments.

The George Institute for Global Health, India in its recent rapid evidence synthesis has pointed out that the Frontline Healthcare Workers are at increased risk during COVID-19 even in the course of their normal activities and should be provided with personal protective equipment. The World Health Organisation also has outlined a series of basic protective measures for the frontline health care workers (FLHW) who are at the forefront of fighting the COVID-19 pandemic. This includes protecting oneself and those who come into close contact with others in the community as well. 

However, masks and other personal protective equipment are in short supply in many rural and urban parts of the country and this may put the work of FLHWs at great risk especially when they come into contact with community members. Many frontline health workers confirm this from ground zero. Though this is largely anecdotal, it still underscores the need for the government to be prepared for providing adequate PPE to the FLHWs, a recommendation which the rapid evidence synthesis makes.  

“While working with communities in and around Ballabgarh in Haryana, we noticed that none of the field staff or ASHA worker in the villages had medical masks. It is also not available in local pharmacies,” said Amanpreet Kaur, Research Fellow, The George Institute India, adding the field staff told her that there were few places where they found medical masks, but prices were too high (five times the original price), and the same goes for sanitizers (4-5 times higher price than original).

The situation seems to be no better in villages in and around Palasa in Andhra Pradesh.

“No masks are available in shops and even in the community health centre in Palasa, there seems to be a shortage of masks and aprons,” said Dr Balaji Gummidi, Senior Project Manager, George Institute for Global Health, India who leads a project in Uddanam area of Srikakulam district.

The local administration is aware of the fact that there is scarcity of PPE, he adds.

A similar situation is seen in Vijayawada or in Rohtak.

“It is really heartening to note that the Ministry of Health and family Welfare has come up with guidelines on PPE. We hope that this will ensure that basic personal protective equipment like masks or hand gloves are available in sufficient numbers for the frontline health workers or the health care providers during this hour of crisis,” says Prof Vivekanand Jha, Executive Director, The George Institute India.     

The recently conducted rapid evidence synthesis by a team of researchers from the George Institute India has revealed that FLHWs will be at increased risk of COVID-19 even in the course of normal activities.

“My observation, based on short visits, is consistent with this finding. I can’t but agree with the recommendation that the availability of these life-saving items should be accompanied by training on proper usage in the early phases,” said Amanpreet

These finding acquire an urgent tone, since frontline health care are the backbone of our health activities and cannot practice physical distancing because of the nature of their jobs. It becomes a responsibility of the healthcare system to provide them with appropriate and adequate protection.