Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Fatal self-injury in the United States, 1999-2018: Unmasking a national mental health crisis.

BACKGROUND: Suicides by any method, plus 'nonsuicide' fatalities from drug self-intoxication (estimated from selected forensically undetermined and 'accidental' deaths), together represent self-injury mortality (SIM)-fatalities due to mental disorders or distress. SIM is especially important to examine given frequent undercounting of suicides amongst drug overdose deaths. We report suicide and SIM trends in the United States of America (US) during 1999-2018, portray interstate rate trends, and examine spatiotemporal (spacetime) diffusion or spread of the drug self-intoxication component of SIM, with attention to potential for differential suicide misclassification. METHODS: For this state-based, cross-sectional, panel time series, we used de-identified manner and underlying cause-of-death data for the 50 states and District of Columbia (DC) from CDC's Wide-ranging Online Data for Epidemiologic Research. Procedures comprised joinpoint regression to describe national trends; Spearman's rank-order correlation coefficient to assess interstate SIM and suicide rate congruence; and spacetime hierarchical modelling of the 'nonsuicide' SIM component. FINDINGS: The national annual average percentage change over the observation period in the SIM rate was 4.3% (95% CI: 3.3%, 5.4%; p<0.001) versus 1.8% (95% CI: 1.6%, 2.0%; p<0.001) for the suicide rate. By 2017/2018, all states except Nebraska (19.9) posted a SIM rate of at least 21.0 deaths per 100,000 population-the floor of the rate range for the top 5 ranking states in 1999/2000. The rank-order correlation coefficient for SIM and suicide rates was 0.82 (p<0.001) in 1999/2000 versus 0.34 (p = 0.02) by 2017/2018. Seven states in the West posted a ≥ 5.0% reduction in their standardised mortality ratios of 'nonsuicide' drug fatalities, relative to the national ratio, and 6 states from the other 3 major regions a >6.0% increase (p<0.05). INTERPRETATION: Depiction of rising SIM trends across states and major regions unmasks a burgeoning national mental health crisis. Geographic variation is plausibly a partial product of local heterogeneity in toxic drug availability and the quality of medicolegal death investigations. Like COVID-19, the nation will only be able to prevent SIM by responding with collective, comprehensive, systemic approaches. Injury surveillance and prevention, mental health, and societal well-being are poorly served by the continuing segregation of substance use disorders from other mental disorders in clinical medicine and public health practice. FUNDING: This study was partially funded by the National Centre for Injury Prevention and Control, US Centers for Disease Control and Prevention (R49CE002093) and the US National Institute on Drug Abuse (1UM1DA049412-01; 1R21DA046521-01A1).

Trends in cervical cancer mortality in the Americas

This article presents an assessment of cervical cancer mortality trends in the Americas based on PAHO data. Trends were estimated for countries where data were available for at least 10 consecutive years, the number of cervical cancer deaths was considerable, and at least 75 percent of the deaths from all causes were registered. In contrast to Canada and the United States, whose general populations had been screened for many years and where cervical cancer mortality has declined steadily (to about 1.4 and 1.7 deaths per 100,000 women, respectively, as of 1990), most Latin American and Caribbean countries with available data have experienced fairly constant levels of cervical cancer mortality (typically in the range of 5-6 deaths per 100,00 women). In addition, several other countries (Chile, Costa Rica, and Mexico) have exhibited higher cervical cancer mortality as well as a number of noteworthy changes in this mortality over time. Overall, while actaul declining trends could be masked by special circumstances in some countries, cervical cancer has not declined in Latin America as it has in developing countries. Correlations between declining mortality and the intensity of screening in developing countries suggest that a lack of screening or screening programs shortcomings in Latin America could account for this. Among other things, where large-scale cervical cancer screening efforts have been instituted in Latin America and Caribbean, these efforts have generally been linked to family planning and prenatal care programs serving women who are typically under 30; while the real need is for screening of older women who are at substantially higher risk.(AU)

Effect of human T-lymphotropic virus type I infection on non-Hodgkin's lymphoma incidence

We previously reported from a case-control analysis that T-cell non-Hodgkin's lymphoma (NHL) was strongly associated with human T-lymphomphotropic virus type I (HTLV-I) infection in Jamaica and Trinidad and that the relative risk for HTLV-I infection was very high in younger patients. Purpose: the objective of this study was to estimate the age-specific incidence rates of NHL among HTLV-I-infected and HTLV-I-uninfected adults in Jamaica and Trinidad. Methods: Population rates of HTLV-I infection were calculated from available census reports and serosurvey data. Incidence rates for NHL were calculated from all incident cases in Jamaica during 1984-1987 (n = 135) and from all incident cases in Trinidad during 1986-1990 (n = 117). Using biopsy material, we determined whether the immunophenotype or the tumor cells was T cell, B cell, or other. NHL incidence rates were computed according to HTLV-I status, age, sex, and tumor phenotype for each country separately and for both countries combined by weighting to the relative population size of each country. Results: The age-standardized NHL incidence rate (mean ñ SE) in Jamaica was 1.9 ñ 0.2 per 100,000 person-years (PY). In Trinidad, the rate was 2.9 ñ 0.4 per 100,000 PY. Overall, the incidence of NHL increased with age and was higher in males than in females. In the HTLV-I-infected population, the incidence of NHL was inversely related to age, and age-specific rates were higher in males than in females. The NHL incidence in those estimated to have acquired HTLV-I infection in childhood, however, showed no sex difference, and one in 1300 such carriers (95 percent confidence interval: one in 1100 to one in 1600) per annum were estimated to be at such risk. For T-cell NHL, as proxy for adult T-cell lymphoma/leukemia, incidence was highest in those patients infected with HTLV-I early in life (perinatally or via breast milk), with high, sustained risk from early adulthood in both sexes. Conclusions: While overall NHL incidence rates reveal that HTLV-I endemicity does not impose an exaggerated lymphoma burden on these populations, the risk for lymphoma among carriers who acquire infection early in life is dramatic and is consistent with the hypothesis that virus exposure early in life is most important for lymphomagenesis. Implications: Studies of HTLV-I carriers known to be infected in childhood may provide insight into markers intermediate in the lymphomagnetic process. Strategies to disrupt early-life transmission of HTLV-I, notably mother-infant transmission, may be critical in reducing the burden of lymphoreticular disease in these populations (AU)

Modelos para el estudio de la epidemia del SIDA en el Caribe de habla inglesa / Modellings the HIV/AIDS epidemic in the English-speaking Caribbean

En este estudio se examinan los efectos pasados y las posibles repercusiones futuras de la infección por el virus de la inmunodeficiencia adquirida en 19 países del Caribe de habla inglesa. Para contrastar dos hipótesis sobre la prevalencia de la infección por el virus de la inmunodeficiencia humana, se empleo el modelo DemProj de proyección demográfica. En la hipótesis de valores bajos, la prevalencia del virus de la inmunodeficiencia humana en los adultos se estabiliza en 2 por ciento en el año 2000 y en la de valores altos, en 5 por ciento. En el año 2010, la incidencia anual del síndrome de inmunodeficiencia adquirida excede los 11 000 y 28 000 casos en una y otra hipótesis respectivamente. En ambas, 70 por ciento de los casos son adultos jóvenes de 20 a 45 años y 12 por ciento, niños de 0 a 15 años. La mortalidad aumenta a más del doble entre los 20 y los 40 años en la hipótesis de valores bajos y a más del cuádruple en la de valores altos. El efecto en las tasas de mortalidad es tambien severo para los niños de 0 a 10 años. Los costos totales anuales de la epidemia se acercarán a US$ 500 millones (en US$ constantes de 1989) o a 2 por ciento del producto interno bruto en la hipótesis de valores bajos y US$ 1 200 millones o 5 por ciento del producto interno bruto en la de valores altos

Modeling the HIV/AIDS epidemic in the English speaking Caribbean

The study reported here examines the past and potential future impact of HIV/AIDS in 19 nations of the primarily English-speaking Caribbean. The authors use DemProj, a demographic projection model, to explore two different HIV scenarios. In the low scenario adult HIV prevalence stabilizes at 2 percent in the year 2000, and in the high scenario adult HIV prevalence stabilizes at 5 percent. By the year 2010, annual AIDS incidence exceeds 11,000 cases in the low scenario and 28,000 in the high scenario. In both scenarios 70 percent of the cases are in the young adults 20-45 years old and 12 percent are in children 0-15. Age-specific mortality is more than doubled in the 20-40 age range in the low scenario and more than quadrupled in the high scenario. The impact on death rates is also severe among children 0-15. In assessing the economic impact, the authors estimate that the total annual costs of the epidemic will approach US$ 500 million (in constant 1989 US$) or 2 percent of GDP in the low scenario, and will exceed US$ 1,200 million or 5 percent of gdp in the high scenario. (AU)

Modeling the HIV/ AIDS epidemic in the English speaking Caribbean

The study reported here examines the past and potential future impact of HIV/AIDS in 19 nations of the primarily English-speaking Caribbean. The authors use DemProj, a demographic projection model, to explore two different HIV scenarios. In the low scenario adult HIV prevalence stabilizes at 2 percent in the year 2000, and in the high scenario adult HIV prevalence stabilizes at 5 percent. By the year 2010, annual AIDS incidence exceeds 11 000 cases in the low scenario and 28 000 in the high scenario. In both scenarios, 70 percent of the cases are in young adults 20-45 years old and 12 percent are in children 0-15. Age specific mortality is more than doubled in the 20-40 age range in the low scenario, and more than quadrupled in the high scenario. The impact on death rates is also severe among children 0-10. In assessing the economic impact, the authors estimate that the total annual costs of the epidemic will approach US$ 500 million (in constant 1989 US$) or 2 percent of GDP in the low scenario, and will exceed US$ 1 200 million or 5 percent of GDP in the high scenario

The control of tuberculosis in the Caribbean

A survey of the Ministries of Health in the English-speaking Caribbean countries was conducted with the purpose of collecting information about current capacity in the prevention and control of tuberculosis. A response rate of 78.9 percent was achieved. The results of this survey indicate that tuberculosis control programmes in the English-speaking Caribbean are limited, and inadequately address issuse relating to multi-drug resistant disease and co-infection with human immunodeficiency virus (HIV). Limitations and implications of this survey are discussed. (AU)

Epidemiology training initiatives in the English-speaking Caribbean: preliminary evaluation - abstract

An important mandate of the Caribbean Epidemiology Centre, (CAREC) is the development of epidemiological capacity among member states. From 1979 to 1985, the Centre received a USAID grant for epidemiology training. However, migration, promotion and other demands led to a subsequent decline in overall epidemiological capacity. The call to renew training activities came from CAREC's Scientific Advisory Committee in 1990 and from Caribbean National Epidemiologists in 1991. Technical assistance was secured from the Emory School of Public Health, funded by the Fogarty International Center (NIH), while financial support was provided by the British Development Division in the Caribbean (BDDC), in late 1992. The resulting programme includes three operational objectives: to strengthen epidemiological skills for disease surveillance; outbreak investigation; evaluation of screening methods and to conduct community surveys; to increase knowledge of and facilitate experience with the design, organization and implementation of field research, questionnaire design data collection; and to increase microcomputer knowledge and skills for data analysis and interpretation. The programme applies adult education principles within a series of workshops and complementary field study activities. Trining activities commenced in the second quarter of 1993, and over 60 individuals had participated by the end of the year. Several evaluation instruments reveal positive outcomes in each of three sites to date. Major gains in knowledge have been demonstrated in pre/post-course testing. Multiple regression analysis reveals that the strongest predictor of post-course performance (including epidemiology, statistics, and computing) is pre-course performance in computing (AU)

Modelos para el estudio de la epidemia del SIDA en el Caribe de habla inglesa / Modellings the HIV/AIDS epidemic in the English-speaking Caribbean

En este estudio se examinan los efectos pasados y las posibles repercusiones futuras de la infección por el virus de la inmunodeficiencia adquirida en 19 países del Caribe de habla inglesa. Para contrastar dos hipótesis sobre la prevalencia de la infección por el virus de la inmunodeficiencia humana, se empleo el modelo DemProj de proyección demográfica. En la hipótesis de valores bajos, la prevalencia del virus de la inmunodeficiencia humana en los adultos se estabiliza en 2 por ciento en el año 2000 y en la de valores altos, en 5 por ciento. En el año 2010, la incidencia anual del síndrome de inmunodeficiencia adquirida excede los 11 000 y 28 000 casos en una y otra hipótesis respectivamente. En ambas, 70 por ciento de los casos son adultos jóvenes de 20 a 45 años y 12 por ciento, niños de 0 a 15 años. La mortalidad aumenta a más del doble entre los 20 y los 40 años en la hipótesis de valores bajos y a más del cuádruple en la de valores altos. El efecto en las tasas de mortalidad es tambien severo para los niños de 0 a 10 años. Los costos totales anuales de la epidemia se acercarán a US$ 500 millones (en US$ constantes de 1989) o a 2 por ciento del producto interno bruto en la hipótesis de valores bajos y US$ 1 200 millones o 5 por ciento del producto interno bruto en la de valores altos

Se publica en inglés en el Bull. PAHO Vol. 28(3), 1994

Modeling the HIV/ AIDS epidemic in the English speaking Caribbean

The study reported here examines the past and potential future impact of HIV/AIDS in 19 nations of the primarily English-speaking Caribbean. The authors use DemProj, a demographic projection model, to explore two different HIV scenarios. In the low scenario adult HIV prevalence stabilizes at 2 percent in the year 2000, and in the high scenario adult HIV prevalence stabilizes at 5 percent. By the year 2010, annual AIDS incidence exceeds 11 000 cases in the low scenario and 28 000 in the high scenario. In both scenarios, 70 percent of the cases are in young adults 20-45 years old and 12 percent are in children 0-15. Age specific mortality is more than doubled in the 20-40 age range in the low scenario, and more than quadrupled in the high scenario. The impact on death rates is also severe among children 0-10. In assessing the economic impact, the authors estimate that the total annual costs of the epidemic will approach US$ 500 million (in constant 1989 US$) or 2 percent of GDP in the low scenario, and will exceed US$ 1 200 million or 5 percent of GDP in the high scenario

This article will be published in Spanish in the BOSP. Vol. 117(4), October 1994

Attitudes and practices of pesticide users in Saint Lucia, West Indies

This article reports the results of a Saint Lucia survey, part of a larger program, that was the first to document the prevalence of suboptimal safety practices among vector control and farm workers using pesticides in the English-speaking Caribbean. Among other things, the survey found that many of 130 pesticide users surveyed were unaware that the skin and eyes were important potential routes of absorption. Over a quarter said had felt ill at some point as a result of pesticide use. About half the respondents said they had received more than "introductory" training in safe pesticide use, and most said they always found labels or directions affixed to pesticide containers. However, about half said they never or only sometimes understood the labels, and many of those who said they understood did not always follow the instructions. About a quarter of the smokers said they smoked while using pesticides; about a sixth of the survey subjects said they ate food while using pesticides; and over 60 percent said they never wore protective clothing

Attitudes and practices of pesticide users in Saint Lucia, West Indies

This article reports the results of a Saint Lucia survey, part of a larger program, that was the first to document the prevalence of suboptimal safety practices among vector control and farm workers using pesticides in the English-speaking Caribbean. Among other things, the survey found that many of 130 pesticide users surveyed were unaware that the skin and eyes were important potential routes of absorption. Over a quarter said had felt ill at some point as a result of pesticide use. About half the respondents said they had received more than "introductory" training in safe pesticide use, and most said they always found labels or directions affixed to pesticide containers. However, about half said they never or only sometimes understood the labels, and many of those who said they understood did not always follow the instructions. About a quarter of the smokers said they smoked while using pesticides; about a sixth of the survey subjects said they ate food while using pesticides; and over 60 percent said they never wore protective clothing

Epidemiological indicators and epidemiology of measles in the English-speaking Caribbean and Suriname

The main purpose of this article is to discuss the definitions and limitations of the indicators used to study the epidemiology of measles in the English-speaking Caribbean and Suriname. In addition, the epidemiology of measles over the past ten years is briefly reviewed, with a focus on recent epidemics. The predicted epidemioogical picture of measles over the next few years is also discussed and, finally, the difference between elimination and eradiction of measles is explained. (AU)

Leprosy control in CAREC member countries: epidemiology and future prospects - abstract

The most recent Annual Reports of the Leprosy Control Programme of CAREC member countries were reviewed to determine the current epidemiology of this disease in the sub-region. These data were supplemented with site visit reports and data concerning numbers of persons on multi-drug therapy. This epidemiological analysis, combined with a current knowledge of the human and financial resources available to, or required by, each country for their respective programmes, will serve as the first phase of a strategic plan for the long-term goal of eradication of leprosy in the Caribbean (AU)