The Evaluation of Blood Alcohol Concentration of Drivers Involved in Traffic Accidents or Suspected for Alcohol in The Roadside Controls in Four Big Cities of Turkey

Objective: Previous studies have revealed a relationship between the driving under the influence of alcohol (DUIA) and/or driving under the influence drugs (DUID) and the increased risk of death and injury in traffic accidents. The aim of this study was to investigate of blood alcohol concentration (BAC) of drivers after involved in a traffic accident or for suspected for drunkenness in the roadside traffic control in the Turkey’s four major cities. Methods: In this study, we retrospectively reviewed the laboratory registrations in university hospitals in four big cities of Turkey (Van, Manisa, Diyarbakır and Samsun) for BAC for five years (from 1 January 2015 to 31 December 2019) of the drivers. Results: In 342 cases (7.1%), BACs were above the cut-off value (0.01 g/100 mL). Of the cases sent for alcohol determination, 11.3% were women and 88.7% were men, and their mean age was 35.3±13.1. In 342 alcohol positive cases, BACs were above 0.101% in 58.8% of cases. BAC positivity of the cases was 9.4% in Manisa, 6.3% in Van, 5.3% in Samsun, and 5% in Diyarbakır. BAC was found to be positive in 4.4% (n=24) of females and 7.4% (n=318) of males (p<0.05). Conclusion: This study is one of the limited number of multicentre studies in this field; it was concluded in the study that zero tolerance should be for drunk driving in traffic, the deterrence of fines should be increased, and roadside screening tests should be used more widely.


INTRODUCTION
According to the World Health Organization (WHO) data for 2020, approximately 1.35 million people die each year due to road traffic accidents, 20 to 50 million people suffer non-fatal injuries, and many people experience disabilities as a result of their injuries. Road traffic accidents are the leading cause of death for children and young adults aged 5-29. Accidents also cause significant economic losses for individuals, their families and their nations as a whole. Treatment costs and other losses such as productivity losses of the injured or dependent family members corresponds to 3% of the gross domestic product of most countries (1). Previous studies have revealed a relationship between the driving under the influence of alcohol (DUIA) and/or driving under the influence drugs (DUID) and the increased risk of death and injury in traffic accidents (2,3). According to an article published in South Korea in 2016, 41.8% of the drivers convicted of DUIA between 2010 and 2014 committed the same crime again after their first crime. 18.5% were convicted of DUIA three or more times. It has been stated that DUIA is a recurrent crime due to habits and/or addictions, causing significant dangers on the roads (4). Previous studies have shown that every 0.02 g/100 mL increase in blood alcohol concentration (BAC) doubles the risk of death in traffic accidents compared to the blood values of nonalcoholic drivers. In cases where BAC reaches values between 0.05 g/100 mL and 0.07 g/100 mL it has been stated that this risk increases between 4 and 10 times (5,6). In 87% of 1118 drivers died in the traffic accidents in Finland, Norway, Portugal and Sweden between 2006 and 2009, BAC were 0.05 g/100 mL or over (7). In 90.5% among the drivers who had positive BAC and involved to the serious traffic accident in Belgium, Denmark, Finland, Italy, Lithuania, and the Netherlands, between 2007 and 2010, BAC were 0.05 g/100 mL or over, too (8).
In Turkey, according to the 48 th sentence of the Turkish Road Traffic Law, which came into force in 1983, driving on the road under the influence of narcotics or euphoric substances or loosing safe driving skills due to influence of alcohol, were clearly made illegal. The regulations added to this law in 2013 emphasized that imprisonment and heavy fines will be applied for drivers under the influence of narcotics, and that their driving licence will be revoked for an indefinite period. However, these imprisonments and heavy fines and revocations of driving licence for definite or indefinite periods were described in detail only for drivers who also exceeded the limits of alcohol use. To compensate for this, the 179 th sentence of Turkish Penal Code came into force in 2005, adding heavy imprisonments for drivers who lost their safe riding skills due to effects of alcohol or narcotics. In Turkey, the BAC limit for professional drivers is defined to be 0.021% and 0.05% for other drivers. If the alcohol level is in between 0.031% and 0.1% according to breath or blood measurements, it is accepted that the driver must be medically examined to decide about the presence or absence of safe driving skills; if the alcohol level surpasses 0.101%, it is accepted that the driver has lost safe driving skills in the applications of forensic medicine and of the legal authorities (2,3). In Turkey, 6,096,074 road accidents occurred between 1995 and 1999. In 15% of these accidents, deaths and/or injuries occurred, and 34,405 people died and 1,498,921 people were injured in these accidents (9). In the period between January 1, 2016 and July 1, 2019, the driving licenses of 452,354 drivers due to DUIA and 3,746 drivers due to DUID were revoked for definitive or indefinite periods. In this study, it is aimed to investigate of BAC of drivers sent to emergency laboratories of the university hospitals after involved in a traffic accident or for suspected for drunkenness in the roadside traffic control in the Turkey's four major cities.

MATERIALS and METHODS
In this study, we retrospectively reviewed the laboratory registrations in university hospitals in four big cities of Turkey (Van, Manisa, Diyarbakır and Samsun) for BAC for five years (from 1 January 01 to 31 December 2019) of the drivers. These drivers were involved in traffic accidents or suspected for alcohol in the roadside controls. All toxicological BAC analysis were performed at the request of the judicial authorities and/ or police departments. Locations, population, the number of licensed drivers and the number of traffic accidents belong these four big cities are shown in Table 1.

Alcohol Analysis:
BAC (g alcohol/100 mL blood) analyses were performed in each province with the devices described below.
Van: In laboratory of Van Yuzuncu Yil University Hospital, alcohol analysis was carried out by Architrct C8000 autoanalyzer (Abbott Laboratories From USA) using commercially available kits based on the principle of alcohol dehydrogenase enzymatic method. Cut-off value of this method was 0.01%. Manisa: In laboratory of Manisa Celal Bayar University Hospital, alcohol analysis was carried out by an enzymatic rate method (Beckman Coulter AU600 and Beckman Coulter AU5821 Analysers). Cut-off value of this method was 0.01%.    Drug analysis was requested in only 23 cases, and the results of these analyses were not included in the study.

Statistical Analysis
Results were statistically evaluated by the chi-square test. Level of significance was p≤0.05.

Ethical Approval
The study was conducted with the approval (dated: 11.12.2020 and number: 2020/10-13) of the Van Yuzuncu Yil University Non-Invasive Clinical Research Ethics Committee.

Limitation of Study
In this study, it was noted as a limitation that the law enforcement officers conducting traffic control sent people who objected in their control with alcoholometry or who did not blow on the alcoholometry device for blood control. In the hospital laboratory registry systems, information about whether the person who came in 93.4% of the cases came as a result of an accident or traffic control could not be reached. Likewise, information about the accident/traffic control time could not be accessed in 97.3% of the cases. For this reason, it was not possible to classify the cases as accident or traffic control and to make back calculations for the accident/control time.

RESULTS
In the five-year study period from January 01, 2015 to December 31, 2019, there were 4,828 alcohol analysis for drivers involved in traffic accidents or suspected for alcohol in the roadside controls in four big cities of Turkey (Van, Manisa, Diyarbakır and Samsun). In 342 cases (7.1%), BACs were above the cut-off value. While the highest positivity rate of BAC per was in Manisa (9.4%), the lowest rate in Diyarbakır (5.0%) (  Table 3. Most of the BAC positive cases (48%) (p<0.05), and the maximum BAC positivity (7.8%) were detected in the 19-30 age group.

DISCUSSION
As it has been noted that there has been a rapid increase in the number of DUIA, which has played an important role in traffic accidents in the world in recent years, roadside alcohol screening tests come to the fore for the detection of these people (2). In the United States of America, deaths due to drunk driving take an important place among deaths in traffic accidents; In 2015, 31% of traffic deaths were caused by DUIA (10). Considering the traffic accidents that occur in Turkey due to drunk driving and the damage caused by the deaths, injuries and material damages caused by these accidents to the economy of our country, it is stated that driving under alcohol should be absolutely prohibited (11).
In the present study, the rate of positive BAC detection among cases sent to university hospitals in four major cities of Turkey for alcohol analysis was found to be 7.1% on average. The highest BAC positivity was in Manisa with 9.4%, and it followed by Van (6.3%), Samsun (5.3%) and Diyarbakır (5%) (p<0.05).
In the previous studies, the incidence of confirmed DUIA has been described as between 0.3% and 4 % for all drivers (12)(13)(14)(15), between 36% and 69% for drivers suspected of DUIA (15,16), between 32% and 90.5% for drivers involved and/or injured in traffic accidents (8,15), and between 9% and 87% for drivers who died in traffic accidents (7,12,15). The lower rate of positivity in Turkey among suspected DUIA cases can be explained by the fact that there is less alcohol consumption. While pure alcohol consumption among persons (age 15+) in litres per capita per year according to 2020 projection of WHO, is 1.9 in Turkey, it is 10.1 in the United States and 7.8-15.1 in European countries (17). In a study conducted in Turkey, it was stated that 70% of those who drive while under the influence of alcohol are college graduates (18). In the study conducted by Kabalcı and Metin (19), the education levels of Turkey by provinces were determined, considering the population over the age of 15, it was found that the education level was 5.3 in Van, 5.8 in Diyarbakır, 6.9 in Samsun and Manisa (for other provinces, the minimum: 4.8 maximum: 8.7). In the present study, among the DUIA cases, the province with the highest BAC was Manisa (9.4%). On the other hand, Diyarbakır was the province with the lowest BAC (5%) ( Table 2). The education levels of BAC positive cases were not determined in our study.
In the previous studies it was reported that, 26% and 30.5% of the total drunk drivers (12,13), 26% of the drunk drivers involved in the accident (13), 7.3% and 32.4% of the drunk drivers injured in the accident (8,(19)(20)(21), 17% and 21.1% of the drunk deceased drivers (7,12), were female drivers. In the present study, 11.3% of the drivers who requested BAC determination and 4.4% of the drivers who was BAC positive were females. Among the BAC positive cases, the rates of female drivers were 12.5% in Samsun, 8.3% in Diyarbakır, 6.8% in Manisa and 4.3% in Van (Table 3).
According to the data of the General Directorate of Security for 2011, the rates of female drivers were 17% in Samsun, 14.3% in Manisa, 11.8% in Diyarbakır and 11.7% in Van (20). In these cities, no significant relationship was found between the rates of female drivers and BAC positivity of female drivers in proportional comparison (p>0.05 In several studies involving European countries, it was defined that drivers positive for alcohol were mainly (from 41.9% to 70.6%) younger than 35 years (7,8,13), theirs mean age was between 34 and 38.6 (13,21). In another study conducted in Portugal, it was reported that ethanol detection was mainly from individuals aged between 21 and 30 years-old (26.6% of cases) (22). Similarly, the cases in the present study were concentrated in the 19-30 age group (48% of BAC positive cases) (p<0.05) ( Table 3). Karjalainen et al. (21) found BAC values above 0.12% in 86.8% of the cases in their series, between 0.05% and 0.12% in 6.6% and below 0.05% in 6.6%. In the study of Costa et al. (22), BAC values were higher than 0.12% in 54.1% -59.3% of the cases, between 0.08-0.12% in 11.1% -13%, between 0.05-0.08% in 7.3%. It was less than 0.05% in 20.3% -27.5% of cases. Acar et al. (3), it was stated that, BACs was higher than 0.101% in 47.5%, between 0.051-0.100 in 22.5%, between 0.031-0.050 in 2.5%, and 0.001-0.030 between in 27.5% of cases (3). In the current study, similar to previous studies, BACs were above 0.101% in 58.8%, between 0.051%-0.1% in 19.3%, between 0.031%-0.05% in 7.0% and between 0.011%-0.03% in 14.9% of cases (p<0.05) ( Table 4). This distribution was differing according to cities it is possible to explain this difference with thesis about the selectivity of police officers taking part in roadside screening tests reported by Senna et al. (23).

CONCLUSION
In this study, the incidence of BAC-positive cases was 7.1% in DUIA cases involved in traffic accidents or suspected on roadside scans. While the criminal relationship between traffic accidents and DUIA cases is well defined in road traffic accident statistics, the number of multicentre studies focusing on this issue and revealing the similarities and differences between provinces is limited in Turkey. We conclude that, zero tolerance for drunk driving in traffic, increasing the deterrence of fines and tightening roadside controls will prevent these deaths and injuries to a great extent.

Ethics
Ethics Committee Approval: The study was conducted with the approval (dated: 11.12.2020 and number: 2020/10-