**3. Risk factors of traffic accidents**

An integral vision of risk factors for traffic accidents and its consequences should consider those related with the man (drivers or pedestrian), the vehicle and the roads (WHO, 2009). Classically it has been postulated that an important proportion of the risk is contributed by the man, basically drivers, with smaller participation of other factors. Researchers have indicated that only one of them is the cause of each traffic accident, although it would be necessary to consider the influence of several factors in their genesis.

Among more importance factors they are those related with technical deficiencies of vehicles (for example, controls, tires, suspension), atmospheric factors (darkness, fog, rain, hail, snow, ice, others), the design and conservation of roads, but it is the human factor the one that explains most of the accidentality.

In Cuba most of companies vehicles are government's property, about which the information that we present information in Tabla 2 (ONE, 2010). Bus and passengers transported in these they possess very similar values in the period 2004 - 2007, with an increment in the years 2008 and 2009. Bus constitutes the main way of the population's transport as much in the cities as in rural areas, in which is reflected an important variability of makers and years of construction, modern (Ej. Yuton, China) and old (Girón, built in Cuba with Soviet Union components), being able to observe in the roads of the Havana a Leylan Bus built in the United Kingdom in the seventies. In a similar way it happens to the trucks and taxis.

The technological variability of vehicles determines the frequent observation of vehicles without good conditions for its roads circulations, in relation to the natural deterioration of its components, the difficulties of purchase replacement pieces adapted for their repair, with the frequent adaptation of components of other classes of vehicles to maintain their operation (fig 6).

In rural areas is more frequent to observe the massive transportation of passengers in trucks or in vehicles of animal traction, where it is equally more frequent the use of bicycles as a fundamental way of population's and goods transport, example agricultural products and little animals. In the Cuban cities, including the capital of the country, the bicycles are used as rent vehicles, calls in Castilian "bicitaxis", being able to be used in the transport of goods for small business.

account the direct and indirect costs involved, as should be considered medical assistance and rehabilitation. Main biomedical publications deal fundamentally with clinical aspects, centering on the description of injuries (Scielo Cuba, 2011). A study in the province of Villa Clara which is one with a high incidence of traffic accidents, first semester of 2009, described the use of hospital services by traffic injuries patient (Guanche, 2008). About 25% of patients were admitted to critical care units, 30% underwent major surgery and 31.3% were prescribed antibiotics. Rough estimates using the abovementioned information give that traffic accidents in Cuba account for some 50

According to the National Statistic Office (ONE, 2010), damages caused by traffic accidents to public or private property amounted to 5 978,2 million of pesos in 2008 and 4 390,4 million of pesos in 2009. The global economic loses due to road traffic injuries are estimated to be US\$ 518 billion with a particular impact in low and middle income countries (WHO,

An integral vision of risk factors for traffic accidents and its consequences should consider those related with the man (drivers or pedestrian), the vehicle and the roads (WHO, 2009). Classically it has been postulated that an important proportion of the risk is contributed by the man, basically drivers, with smaller participation of other factors. Researchers have indicated that only one of them is the cause of each traffic accident, although it would be

Among more importance factors they are those related with technical deficiencies of vehicles (for example, controls, tires, suspension), atmospheric factors (darkness, fog, rain, hail, snow, ice, others), the design and conservation of roads, but it is the human factor the

In Cuba most of companies vehicles are government's property, about which the information that we present information in Tabla 2 (ONE, 2010). Bus and passengers transported in these they possess very similar values in the period 2004 - 2007, with an increment in the years 2008 and 2009. Bus constitutes the main way of the population's transport as much in the cities as in rural areas, in which is reflected an important variability of makers and years of construction, modern (Ej. Yuton, China) and old (Girón, built in Cuba with Soviet Union components), being able to observe in the roads of the Havana a Leylan Bus built in the United Kingdom in the seventies. In a similar way it happens to the

The technological variability of vehicles determines the frequent observation of vehicles without good conditions for its roads circulations, in relation to the natural deterioration of its components, the difficulties of purchase replacement pieces adapted for their repair, with the frequent adaptation of components of other classes of vehicles to maintain their

In rural areas is more frequent to observe the massive transportation of passengers in trucks or in vehicles of animal traction, where it is equally more frequent the use of bicycles as a fundamental way of population's and goods transport, example agricultural products and little animals. In the Cuban cities, including the capital of the country, the bicycles are used as rent vehicles, calls in Castilian "bicitaxis", being able to be used in the transport of goods

necessary to consider the influence of several factors in their genesis.

million pesos a year.

trucks and taxis.

operation (fig 6).

for small business.

**3. Risk factors of traffic accidents** 

one that explains most of the accidentality.

2009).

Fig. 6. Antique and modern vehicles in urban roads and risk of accidents


Source: ONE, 2010

Table 2. Government vehicles and passengers transported. Cuba 2004 – 2009.

Related with quality of road infrastructure, was evident an important deterioration in the nineties, that included physical damage of roads and deficiencies in signalings (horizontal and vertical). The construction activities and maintenance of roads net is responsibility of state entities. Recently, in correspondence with the economic recovery, a program of improvement of roads has been developed, included the construction of asphalt factories and solutions to signaling deficiencies (Salgado, 2010).

Is important consider that in national road infrastructure they are few alternatives to protect pedestrians, elevated bridges for traffic of vehicles in the cities and others, partly determined by financial possibilities for their implementation. Also, the employment of exclusive roads for the circulation of bicycles that was used during the nineties, has decreased in a significant way, although its circulations continues in urban and rural roads, which increased vulnerability to occurrence of traffic accidents. WHO Report of Road Safety (WHO, 2009) define as vulnerable road user to pedestrians, cyclist and user of motorized of two wheelers.

Epidemiology and Prevention of Traffic Accidents in Cuba 189

more than 15 years old are alcoholic (abuse or alcoholic dependence), not including in these

The main studies on drink and driving in Cuba were carried out between 2001 and 2006, which were published by our team in national biomedical journals (Scielo Cuba,2011) and in Gaceta Sanitaria (Gaceta Sanitaria, Elsevier, 2005 - 2008). We demonstrate that drinking and driving constitutes an important and frequent risk factor for traffic accidents, wich is underestimate in official statistics. In these the main violations are not assist the vehicles control and not respect the right of road circulation identified in 29% of accidents, while alone in 3% of drivers was found under the effect (ONE, 2010). The results above mentioned related with the systems and procedures of detection of drivers under the effect of alcohol. For decades they are known in Cuba the equipment for mensuration of alcohol in exhaled air, initially equipment of qualitative mensuration as knows as ¨globitos¨, and in recent years more modern have been used that allow to quantify the amount of alcohol present in exhaled air. However the use of these technologies has been for short periods, given its low readiness, not existing in our country a methodology of surveillance of drivers under the effect of alcohol, and still to certify if a driver ingested alcohol the testimonial of a doctor is demanded, by means of a legal written document (Ministerio de Salud Pública, no date). An important proportion of population drive vehicles take medications, some of which can alter driving capacity. Important to mention between this drugs those that generate bigger risk like those used for treatment of psiquiatric disorders, hypoglicemians, antiallergic with depressor effects in central nervous system. Due to it is essential that healhtcare professionals know the effects of drugs commonly used and its effects in driving capacity and they can

those with non advisable consumption patterns (Gonzalez, 2008).

make recommendations to diminish the risk of occurrence of traffic accidents.

**4. National prevention program and activities for prevention of traffic** 

the technical revision of the vehicles and for population education in this topic.

depressors effects in central nervous system.

**accidents** 

In Cuba the illicit drugs are little consumed, being those most used marijuana and cocaine. Their deleterious influence is known in conduction capacity by its effects on central nervous system. (Ministry of the Interior, 2004). Equally it should be considered the mixture of medications with alcohol, especially in young population, which produces stimulating or

Traffic accidents prevention activities constitutes a world priority, with special focus in those countries where they constitute fundamental cause of morbilidity and mortality, and produce an important economic impact. Many have been strategies applied in prevention activities, that in general pretend to act on their potential causes: man, roads and vehicles (OMS, 2004), that includes activities for the prevention of accidents and its consequences. In 1987 the Law 60, Code of Traffic, was approved (Asamblea Nacional del Poder Popular, 1987) that established the main regulations related with the prevention of traffic accidents. This law was modified in 2010 by means of the Law 109, which introduced as novel elements the definition of *beginner driver's* to refers to those with less than two years experiences in driving, and of *pedestrian with disability* to refers to those with any type of disability (motor, visual, other), also valuable modifications focus on risk controls like drinking and driving, use of drugs or substances that alter capacity to drive, the employment of cycles or animal traction vehicles, the massive transportation of passengers, passengers' of vehicles procedures and pedestrians. It highlights the recommendations for

According to National Highway Traffic Safety Administration (USA), the human factor is implied between the 71 and 93% of the cases, the roads factors 12 and 34%, and those related to vehicles between the 4,5 and 13% (NHTSA, 2010).

At the present time they are recognized a series of risk factors of the driver that affect capacity to drive motor vehicles. Among these they are diseases or conditions that can affect the conscience, for example myiocardial infaction and other acute coronary syndromes, high blood pressure, cerebrovascular disease, rupture of the aorta, vasovagal syncope, epilepsy and hypoglycemia. Also known the transitory influences of alcohol, certain medications, the drugs and the fatigue. Other factors are related with the training level and style in driving, the knowledge and fulfillment of regulations and laws, psychophysical condictions (sensorial, physical and mental), the disposition to act (attitudes and motivation) and the efficiency, capacity, know-how, psycomotor coordination , and skills to overcome situations during driving.

Among man related factors, we wish highlighting the existence of diseases and psycophysical, as well as the effect of alcohol and drugs (legal or not) that can interfere in driving capacity. Non communicable diseases or chronic conditions as diabetes mellitus, hypertension and ischaemic hearth diseases, bronchial asthma, chronic obstructive pulmonary disease and stroke are frequent in Cuban population (DNE, 2010).

Diabetes mellitus is estimate to be affects 8% of Cuban population's , alone 50% has been diagnosed, and constitutes the eighth cause of death (Dominguez, 2008). In relation with accident risks depends on the effect of the variability glycaemia in neurological system, including the increased risk of hypoglicemya, conditioned by antidiabetic drugs and non adherence to the treatment. Also it should be considered the adverse effects of retinopathy in visual acuity, neuropathy in sensibility and strength in extremities, and mascrovascular complications and the risk of cerebral or heart ischaemia (Ministerio del Interior, 2004).

High blood pressure affects 30% of Cuban population, more frequent in adults, and is associated to the incidence and mortality of iscahemic hearth disease and cerebrovascular diseases, which constitute the first and third cause of the Cuban population's death (DNE, 2010; Buergo, 2008). The possibilities of ischaemic symtoms and signs n this diseases and its effect on the level of conscience and the degree of attention constitute elements compactly associated with risk of accidents (Ministry of the Interior, 2004).

Also cancer, that constitutes the second cause of the population's death, has demonstrated growing incidence in the last decades, in correspondence with the world tendencies (DNE, 2010). Its relationship with risk accidents associated with this health problems, not depends alone of the own clinical manifestations but of the effects of the treatments. Should be considered the increment of its survival of current therapeutic resources. (Ministry of the Interior, 2004).

It is estimate that 2,5 million people die worldwide from harmful use of alcohol a year standing out deaths related with traffic accidents (WHO, 2011). Numerous studied carried out have been demonstrated the important paper of alcohol in traffic accidents. In this investigations it has been evidenced that accidents related with alcohol, are of more prejudicial results, what increases the risk of suffering mortal lesions, partly to the reduction of answer to trauma, besides other circumstances that surround him (Hingson, 2003). According to studies carried out in USA, of the population of drivers 32% are abstemious, 45% moderate social drinkers, and 23% strong social drinkers, frequent drinkers or alcoholic (Korelitz, 1993). In Cuba it has been considered that at least 5% of the population's with

According to National Highway Traffic Safety Administration (USA), the human factor is implied between the 71 and 93% of the cases, the roads factors 12 and 34%, and those related

At the present time they are recognized a series of risk factors of the driver that affect capacity to drive motor vehicles. Among these they are diseases or conditions that can affect the conscience, for example myiocardial infaction and other acute coronary syndromes, high blood pressure, cerebrovascular disease, rupture of the aorta, vasovagal syncope, epilepsy and hypoglycemia. Also known the transitory influences of alcohol, certain medications, the drugs and the fatigue. Other factors are related with the training level and style in driving, the knowledge and fulfillment of regulations and laws, psychophysical condictions (sensorial, physical and mental), the disposition to act (attitudes and motivation) and the efficiency, capacity, know-how, psycomotor coordination , and skills to overcome situations

Among man related factors, we wish highlighting the existence of diseases and psycophysical, as well as the effect of alcohol and drugs (legal or not) that can interfere in driving capacity. Non communicable diseases or chronic conditions as diabetes mellitus, hypertension and ischaemic hearth diseases, bronchial asthma, chronic obstructive

Diabetes mellitus is estimate to be affects 8% of Cuban population's , alone 50% has been diagnosed, and constitutes the eighth cause of death (Dominguez, 2008). In relation with accident risks depends on the effect of the variability glycaemia in neurological system, including the increased risk of hypoglicemya, conditioned by antidiabetic drugs and non adherence to the treatment. Also it should be considered the adverse effects of retinopathy in visual acuity, neuropathy in sensibility and strength in extremities, and mascrovascular complications and the risk of cerebral or heart ischaemia (Ministerio del

High blood pressure affects 30% of Cuban population, more frequent in adults, and is associated to the incidence and mortality of iscahemic hearth disease and cerebrovascular diseases, which constitute the first and third cause of the Cuban population's death (DNE, 2010; Buergo, 2008). The possibilities of ischaemic symtoms and signs n this diseases and its effect on the level of conscience and the degree of attention constitute elements compactly

Also cancer, that constitutes the second cause of the population's death, has demonstrated growing incidence in the last decades, in correspondence with the world tendencies (DNE, 2010). Its relationship with risk accidents associated with this health problems, not depends alone of the own clinical manifestations but of the effects of the treatments. Should be considered the increment of its survival of current therapeutic resources. (Ministry of the

It is estimate that 2,5 million people die worldwide from harmful use of alcohol a year standing out deaths related with traffic accidents (WHO, 2011). Numerous studied carried out have been demonstrated the important paper of alcohol in traffic accidents. In this investigations it has been evidenced that accidents related with alcohol, are of more prejudicial results, what increases the risk of suffering mortal lesions, partly to the reduction of answer to trauma, besides other circumstances that surround him (Hingson, 2003). According to studies carried out in USA, of the population of drivers 32% are abstemious, 45% moderate social drinkers, and 23% strong social drinkers, frequent drinkers or alcoholic (Korelitz, 1993). In Cuba it has been considered that at least 5% of the population's with

pulmonary disease and stroke are frequent in Cuban population (DNE, 2010).

associated with risk of accidents (Ministry of the Interior, 2004).

to vehicles between the 4,5 and 13% (NHTSA, 2010).

during driving.

Interior, 2004).

Interior, 2004).

more than 15 years old are alcoholic (abuse or alcoholic dependence), not including in these those with non advisable consumption patterns (Gonzalez, 2008).

The main studies on drink and driving in Cuba were carried out between 2001 and 2006, which were published by our team in national biomedical journals (Scielo Cuba,2011) and in Gaceta Sanitaria (Gaceta Sanitaria, Elsevier, 2005 - 2008). We demonstrate that drinking and driving constitutes an important and frequent risk factor for traffic accidents, wich is underestimate in official statistics. In these the main violations are not assist the vehicles control and not respect the right of road circulation identified in 29% of accidents, while alone in 3% of drivers was found under the effect (ONE, 2010). The results above mentioned related with the systems and procedures of detection of drivers under the effect of alcohol.

For decades they are known in Cuba the equipment for mensuration of alcohol in exhaled air, initially equipment of qualitative mensuration as knows as ¨globitos¨, and in recent years more modern have been used that allow to quantify the amount of alcohol present in exhaled air. However the use of these technologies has been for short periods, given its low readiness, not existing in our country a methodology of surveillance of drivers under the effect of alcohol, and still to certify if a driver ingested alcohol the testimonial of a doctor is demanded, by means of a legal written document (Ministerio de Salud Pública, no date).

An important proportion of population drive vehicles take medications, some of which can alter driving capacity. Important to mention between this drugs those that generate bigger risk like those used for treatment of psiquiatric disorders, hypoglicemians, antiallergic with depressor effects in central nervous system. Due to it is essential that healhtcare professionals know the effects of drugs commonly used and its effects in driving capacity and they can make recommendations to diminish the risk of occurrence of traffic accidents.

In Cuba the illicit drugs are little consumed, being those most used marijuana and cocaine. Their deleterious influence is known in conduction capacity by its effects on central nervous system. (Ministry of the Interior, 2004). Equally it should be considered the mixture of medications with alcohol, especially in young population, which produces stimulating or depressors effects in central nervous system.

### **4. National prevention program and activities for prevention of traffic accidents**

Traffic accidents prevention activities constitutes a world priority, with special focus in those countries where they constitute fundamental cause of morbilidity and mortality, and produce an important economic impact. Many have been strategies applied in prevention activities, that in general pretend to act on their potential causes: man, roads and vehicles (OMS, 2004), that includes activities for the prevention of accidents and its consequences.

In 1987 the Law 60, Code of Traffic, was approved (Asamblea Nacional del Poder Popular, 1987) that established the main regulations related with the prevention of traffic accidents. This law was modified in 2010 by means of the Law 109, which introduced as novel elements the definition of *beginner driver's* to refers to those with less than two years experiences in driving, and of *pedestrian with disability* to refers to those with any type of disability (motor, visual, other), also valuable modifications focus on risk controls like drinking and driving, use of drugs or substances that alter capacity to drive, the employment of cycles or animal traction vehicles, the massive transportation of passengers, passengers' of vehicles procedures and pedestrians. It highlights the recommendations for the technical revision of the vehicles and for population education in this topic.

Epidemiology and Prevention of Traffic Accidents in Cuba 191

Fig. 7. Vehicles of animal traction in urban roads

Non governmental organizations (Cuban Federation of Women, Student organizations, others)

Fig. 8. Intersector system in prevention of traffic accidents in Cuba.

8. Medical evaluation of drivers (Ministerio de Salud Pública, no date)

a. The current methodology for medical exams of drivers, edited by the Ministry of

Others organizations, include private sector.

b. The medical exams to obtain or renovate the conduction license in carried out in communitarian healthcare services by a team of professionals that included general

c. Considering current knowledge on this topic is evident, that this methodology has several limitations due that includes health problem that at the moment are not considered that interfere with driving capacity, example hiperinsulinism, renal disease, epilepsy. Equally they are not defined differences in the requirements to

Public Health possesses more than two decades of having approved.

National strategies for prevention of traffic accidents

Ministries and central organisms of the state (Transport, Public Health, Justice, Justice, Culture, Education)

practitioner, specialists in ophthalmology, psychology and others.

drive vehicles for professional and non professional's drivers.

Next we will comment important aspects included national strategic plan for traffic accidents prevention.

	- a. Professional drivers cannot drive under the effect of alcohol. Similar restrictions should fulfil the beginner drivers and applicants during the period of learning, elements of new introduction in the law.
	- b. In non professional drivers are accepted a low level of alcohol as permissible. This level are not defined in the law, assigning to the Ministry of Public Health the responsibility of determining the levels of concentration of alcohol in blood, exhaled air or in other corporal fluids incompatible with driving.
	- c. Also, constitutes a novel element in law, the prohibition of ingestion of alcoholic drinks inside vehicles or their transportation in the compartments dedicated to the driver and the passengers
	- a. The education and promotion program constitute an essential component in the preventive strategies, being reflected in the articles 239 - 248 of the Law 109.
	- b. Prevention program focus in children and adolescents includes the use of massive means of diffusion (television, radio, newspapers) and scholars programs address to the population's sensitization about the topic , offering information on risk factors, consequences and accidents prevention (Comisión Nacional de Prevención de Accidentes, 2010).
	- c. Related with the conduction under the effect of alcohol. National promotion programs have demonstrated to be very effective for the confrontation of other health problems, measures have been applied as: control of prices of beverages containing alcohol, actions on localization, schedules of opening and density of places of distribution of drinks, control of the social readiness, community education in general and to drivers.

Next we will comment important aspects included national strategic plan for traffic

a. Professional drivers cannot drive under the effect of alcohol. Similar restrictions should fulfil the beginner drivers and applicants during the period of learning,

b. In non professional drivers are accepted a low level of alcohol as permissible. This level are not defined in the law, assigning to the Ministry of Public Health the responsibility of determining the levels of concentration of alcohol in blood,

c. Also, constitutes a novel element in law, the prohibition of ingestion of alcoholic drinks inside vehicles or their transportation in the compartments dedicated to the

2. Regulations about the circulation of cycles (article 112). Prohibits the conduction of cycles to individuals smaller than 12 years old, not being clearly defined the obligatory

3. For massive transportation of people (article 135). Consider the frequent use of massive transportation of people in load vehicles (ex. Trucks) is established that these they

a. The education and promotion program constitute an essential component in the preventive strategies, being reflected in the articles 239 - 248 of the Law 109. b. Prevention program focus in children and adolescents includes the use of massive means of diffusion (television, radio, newspapers) and scholars programs address to the population's sensitization about the topic , offering information on risk factors, consequences and accidents prevention (Comisión Nacional de Prevención

c. Related with the conduction under the effect of alcohol. National promotion programs have demonstrated to be very effective for the confrontation of other health problems, measures have been applied as: control of prices of beverages containing alcohol, actions on localization, schedules of opening and density of places of distribution of drinks, control of the social readiness, community

6. School for drivers. These entities are made responsible of preparing the applicants to driver's licenses, and the training of professional drivers, as well as of promoting

7. Animal traction vehicles (fig 7). Drivers of vehicles of animal traction should have more than 16 years old, and these they won't be able to traffic for roads of quick circulation (e.g. Freeways), neither in night hours. They will also possess measures of security for

should circulate to inferior speeds with security conditions for the passengers. 4. Technical vehicles revision (article 211). The technical revision of vehicles using specialized equipment is carried out by Ministry of Transport as a requirement for determination of state of security systems and other excellent aspects as emission of combustion gases. Bigger emphasis must be attributes to vehicles dedicated to passenger's transport or those driven by professionals, which should carry out revision

exhaled air or in other corporal fluids incompatible with driving.

1. Drinking and driving (article No. 93 and 95 of Law 60)

elements of new introduction in the law.

driver and the passengers

use of the protective helmet for their drivers.

5. Education related to prevention of traffic accidents.

education in general and to drivers.

preventive strategies in the population.

accidents prevention.

every two years.

its restrain.

de Accidentes, 2010).

Fig. 7. Vehicles of animal traction in urban roads

Fig. 8. Intersector system in prevention of traffic accidents in Cuba.

8. Medical evaluation of drivers (Ministerio de Salud Pública, no date)


Epidemiology and Prevention of Traffic Accidents in Cuba 193

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