Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach.

BACKGROUND: Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide. PURPOSE: The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide. HIGHLIGHTS: Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors. OUTCOMES: The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised. PRACTICAL APPLICATIONS: Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

Unintentional Firearm Injury Deaths Among Children and Adolescents Aged 0-17 Years - National Violent Death Reporting System, United States, 2003-2021.

In the United States, unintentional injury is the fourth leading cause of death among infants (i.e., children aged <1 year) and is the top cause of death among children and adolescents aged 1-17 years; firearms are a leading injury method. Unsecured firearms (e.g., unlocked and loaded) are associated with risk for unintentional childhood firearm injury death. Data recorded during 2003-2021 by the National Violent Death Reporting System (NVDRS) from 49 states, the District of Columbia, and Puerto Rico were used to characterize unintentional firearm injury deaths of U.S. infants, children, and adolescents aged 0-17 years (referred to as children in this report). NVDRS identified 1,262 unintentional firearm injury deaths among children aged 0-17 years: the largest percentage (33%) of these deaths were among children aged 11-15 years, followed by 29% among those aged 0-5 years, 24% among those aged 16-17 years, and 14% among persons aged 6-10 years. Overall, 83% of unintentional firearm injury deaths occurred among boys. The majority (85%) of victims were fatally injured at a house or apartment, including 56% in their own home. Approximately one half (53%) of fatal unintentional firearm injuries to children were inflicted by others; 38% were self-inflicted. In 9% of incidents, it was unknown whether the injury was self- or other-inflicted. Approximately two thirds (67%) of shooters were playing with or showing the firearm to others when it discharged. Overall, firearms used in unintentional injury deaths were often stored loaded (74%) and unlocked (76%) and were most commonly accessed from nightstands and other sleeping areas (30%). Unintentional firearm injury deaths of children are preventable. Secured firearm storage practices (e.g., storing firearms locked, unloaded, and separate from ammunition) have been identified as protective factors against child firearm injuries and deaths, underscoring the importance of policymakers, health care professionals (e.g., pediatricians), and others partnering with parents, caregivers, and firearm owners to promote secure firearm storage.

Firearm Homicides of US Children Precipitated by Intimate Partner Violence: 2003-2020.

OBJECTIVES: Examine characteristics associated with firearm homicides of children aged 0-17 years precipitated by intimate partner violence (IPV). METHODS: Data were from the Center for Disease Control and Prevention's National Violent Death Reporting System (49 states, District of Columbia, Puerto Rico; 2003-2020). Logistic regression was used to examine associations between various characteristics and IPV among child firearm homicides. RESULTS: From 2003-2020, a total of 11 594 child homicides were captured in the National Violent Death Reporting System, of which 49.3% (n = 5716) were firearm homicides; 12.0% (n = 686) of child firearm homicides were IPV-related. Among IPV-related child firearm homicides, 86.0% (n = 590) were child corollary victims (ie, children whose death was connected to IPV between others); 14.0% (n = 96) were teens killed by a current or former dating partner. Child firearm homicides had greater odds of involving IPV when precipitated by conflict, crises, and cooccurring with the perpetrator's suicide compared with those without these characteristics. Over half of IPV-related firearm homicides of child corollary victims included homicide of the adult intimate partner, of which 94.1% were the child victim's mother. Child firearm homicides perpetrated by mothers' male companions (adjusted odds ratio, 6.9; 95% confidence interval, 3.9-12.1) and children's fathers (adjusted odds ratio, 4.5; 95% confidence interval, 3.0-6.8) had greater odds of involving IPV compared with those perpetrated by mothers. CONCLUSIONS: Multiple factors were associated with greater odds of child firearm homicides being IPV-related. Strategies promoting healthy intimate partner relationships starting at a young age; assessment of danger to children in IPV situations; strengthening economic supports for families; creating safe, stable, and nurturing relationships and environments for children; and addressing social and structural inequities are important for preventing firearm homicides of children, including those involving IPV.

Trends in Homicide Rates for US Children Aged 0 to 17 Years, 1999 to 2020.

Importance: Homicide is a leading cause of death among children in the US. Objective: To examine trends in child homicide rates and characteristics most commonly associated with these deaths. Design, Setting, and Participants: In this cross-sectional study, the study team used National Vital Statistics System WONDER mortality data for 38 362 homicide victims aged 0 to 17 years for 1999 to 2020 and National Violent Death Reporting System data for child homicide victims for 2003 to 2019 in 45 states, Washington, DC, and Puerto Rico. WONDER data are based on death certificates for US residents. National Violent Death Reporting System data include characteristics of violent deaths, linking information from death certificates, and law enforcement, coroner, and medical examiner reports. Exposures: Child homicide was defined using underlying cause-of-death codes U01 to U02, X85 to Y09, and Y87.1 from the International Classification of Diseases, Tenth Revision, Clinical Modification. Main Outcomes and Measures: Trends in homicide rates per 100 000 children were tested using joinpoint regression analysis; differences in rates from 2019 to 2020 were evaluated using z tests. Circumstances of child homicides were described. Results: This study included 38 362 homicide victims (69.4% male). The overall child homicide rate (per 100 000 children) has increased annually, on average 4.3% since 2013, with a precipitous rise from 2019 to 2020 (2019 rate, 2.2; 2020 rate, 2.8; overall increase of 27.7%). Homicide rates recently increased significantly for boys (2018 rate, 2.9; 2020 rate, 4.1; overall increase of 16.1%), 6- to 10-year-olds (2014 rate, 0.5; 2020 rate, 0.8; overall increase of 5.6%), 11- to 15-year-olds (2018 rate, 1.3; 2020 rate, 2.2; overall increase of 26.9%), 16- to 17-year-olds (2018 rate, 6.6; 2020 rate, 10.0; overall increase of 19.0%), Black children (2012 rate, 5.9; 2018 rate, 6.8; 2020 rate, 9.9; overall increase of 16.6% from 2018 to 2020), Hispanic children (2014 rate, 1.6; 2020 rate, 2.2; overall increase of 4.7%), children in the South (2013 rate, 2.1; 2020 rate, 3.5; overall increase of 6.4%), and in rural (2011 rate, 1.8; 2020 rate, 2.4; overall increase of 3.2%) and urban areas (2013 rate, 1.9; 2020 rate, 2.9; overall increase of 4.4%). Since 1999, homicide rates have decreased for girls (1999 rate, 1.9; 2020 rate, 1.5; overall decrease of 1.4%), infants (1999 rate, 8.7; 2020 rate, 6.6; overall decrease of 1.3%), 1- to 5-year-olds (1999 rate, 2.1; 2020 rate, 1.8; overall decrease of 1.0%), Asian or Pacific Islander children (1999 rate, 2.0; 2020 rate, 0.5; overall decrease of 4.4%), White children (1999 rate, 1.5; 2020 rate, 1.3; overall decrease of 0.7%), and children in the Northeast (1999 rate, 2.0; 2020 rate, 1.7; overall decrease of 1.4%). Homicides of children 10 years or younger were most commonly precipitated by abuse/neglect, perpetrated by parents/caregivers. Homicides of 11- to 17-year-olds were most commonly precipitated by crime and arguments and perpetrated by someone known to them, especially friends and acquaintances. Conclusions and Relevance: The decline in homicide rates for some geographic and child demographic groups is encouraging; however, rates recently increased across several subpopulations, with some racial and ethnic disparities persisting for more than 20 years. More targeted strategies are needed to (1) protect 6- to 10-year-olds, 11- to 17-year-olds, and children in certain geographic areas and (2) urgently address firearm violence, racism, and inequities at the root of youth violence.

Vital Signs: Changes in Firearm Homicide and Suicide Rates - United States, 2019-2020.

INTRODUCTION: The majority of homicides (79%) and suicides (53%) in the United States involved a firearm in 2020. High firearm homicide and suicide rates and corresponding inequities by race and ethnicity and poverty level represent important public health concerns. This study examined changes in firearm homicide and firearm suicide rates coinciding with the emergence of the COVID-19 pandemic in 2020. METHODS: National vital statistics and population data were integrated with urbanization and poverty measures at the county level. Population-based firearm homicide and suicide rates were examined by age, sex, race and ethnicity, geographic area, level of urbanization, and level of poverty. RESULTS: From 2019 to 2020, the overall firearm homicide rate increased 34.6%, from 4.6 to 6.1 per 100,000 persons. The largest increases occurred among non-Hispanic Black or African American males aged 10-44 years and non-Hispanic American Indian or Alaska Native (AI/AN) males aged 25-44 years. Rates of firearm homicide were lowest and increased least at the lowest poverty level and were higher and showed larger increases at higher poverty levels. The overall firearm suicide rate remained relatively unchanged from 2019 to 2020 (7.9 to 8.1); however, in some populations, including AI/AN males aged 10-44 years, rates did increase. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: During the COVID-19 pandemic, the firearm homicide rate in the United States reached its highest level since 1994, with substantial increases among several population subgroups. These increases have widened disparities in rates by race and ethnicity and poverty level. Several increases in firearm suicide rates were also observed. Implementation of comprehensive strategies employing proven approaches that address underlying economic, physical, and social conditions contributing to the risks for violence and suicide is urgently needed to reduce these rates and disparities.

Surveillance for Violent Deaths - National Violent Death Reporting System, 42 States, the District of Columbia, and Puerto Rico, 2019.

PROBLEM/CONDITION: In 2019, approximately 67,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 42 states, the District of Columbia, and Puerto Rico in 2019. Results are reported by sex, age group, race and ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. PERIOD COVERED: 2019. DESCRIPTION OF SYSTEM: NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner records, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2019. Data were collected from 39 states with statewide data (Alabama, Alaska, Arizona, Colorado, Connecticut, Delaware, Georgia, Hawaii, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming), three states with data from counties representing a subset of their population (30 California counties, representing 57% of its population, and 47 Illinois counties and 40 Pennsylvania counties, representing at least 80% of their populations), the District of Columbia, and Puerto Rico. NVDRS collates information for each violent death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident. RESULTS: For 2019, NVDRS collected information on 50,374 fatal incidents involving 51,627 deaths that occurred in 42 states (39 states collecting statewide data, 30 California counties, 47 Illinois counties, and 40 Pennsylvania counties), and the District of Columbia. In addition, information was collected for 831 fatal incidents involving 897 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 51,627 deaths, the majority (64.1%) were suicides, followed by homicides (25.1%), deaths of undetermined intent (8.7%), legal intervention deaths (1.4%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement. Demographic patterns and circumstances varied by manner of death. The suicide rate was higher for males than for females. Across all age groups, the suicide rate was highest among adults aged 45-54 years. In addition, non-Hispanic American Indian or Alaska Native (AI/AN) and non-Hispanic White (White) persons had the highest suicide rates among all racial and ethnic groups. Among males, the most common method of injury for suicide was a firearm, whereas poisoning was the most common method of injury among females. Among all suicide victims, suicide was most often preceded by a mental health, intimate partner, or physical health problem or by a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was higher for males than for females. Among all homicide victims, the homicide rate was highest among persons aged 20-24 years compared with other age groups. Non-Hispanic Black (Black) males experienced the highest homicide rate of any racial or ethnic group. Among all homicide victims, the most common method of injury was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Nearly all victims of legal intervention deaths were male, and the legal intervention death rate was highest among men aged 25-29 years. The legal intervention death rate was highest among AI/AN males, followed by Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault or homicide. The three most frequent circumstances reported for legal intervention deaths were as follows: the victim's death was precipitated by another crime, the victim used a weapon in the incident, and the victim had a mental health or substance use problem (other than alcohol use). Unintentional firearm deaths were most frequently experienced by males, White persons, and persons aged 15-24 years. These deaths most frequently occurred while the shooter was playing with a firearm and were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. The rate of deaths of undetermined intent was highest among males, particularly among Black and AI/AN males, and among adults aged 30-44 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances. INTERPRETATION: This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2019. The suicide rate was highest among AI/AN and White males, whereas the homicide rate was highest among Black males. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death. PUBLIC HEALTH ACTION: Violence is preventable, and data can guide public health action. NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs, policies, and practices to reduce and prevent violent deaths. For example, the New Hampshire Violent Death Reporting System (VDRS), Indiana VDRS, and Colorado VDRS have used their VDRS data to guide suicide prevention efforts and generate reports highlighting where additional focus is needed. In New Hampshire, VDRS data have been used to monitor the increase in suicide rates during 2014-2018 and guide statewide collaborative prevention efforts. Indiana VDRS used local data to demonstrate differences in suicide and other related mental health problems among Black persons and highlight a need for improved suicide awareness and culturally competent mental health care. The Colorado VDRS conducted geospatial and demographic analysis, considering local VDRS data with existing suicide prevention efforts and resources, to identify regions with high suicide rates regions and populations at high risk for suicide. Similarly, states participating in NVDRS have used their VDRS data to examine related to homicide in their state. In North Carolina for example, where homicide rates among AI/AN and Black persons were approximately 2.5 times higher than the statewide homicide rate, the North Carolina VDRS program aims to partner with historically Black colleges and universities in the state to train researchers to use VDRS data to address health equity issues in and around their immediate community.

Surveillance for Violent Deaths - National Violent Death Reporting System, 34 States, Four California Counties, the District of Columbia, and Puerto Rico, 2017.

PROBLEM/CONDITION: In 2017, approximately 67,000 persons died of violence-related injuries in the United States. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) on violent deaths that occurred in 34 states, four California counties, the District of Columbia, and Puerto Rico in 2017. Results are reported by sex, age group, race/ethnicity, method of injury, type of location where the injury occurred, circumstances of injury, and other selected characteristics. PERIOD COVERED: 2017. DESCRIPTION OF SYSTEM: NVDRS collects data regarding violent deaths obtained from death certificates, coroner and medical examiner reports, and law enforcement reports. This report includes data collected for violent deaths that occurred in 2017. Data were collected from 34 states (Alaska, Arizona, Colorado, Connecticut, Delaware, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, Utah, Vermont, Virginia, Washington, West Virginia, and Wisconsin), four California counties (Los Angeles, Sacramento, Shasta, and Siskiyou), the District of Columbia, and Puerto Rico. NVDRS collates information for each death and links deaths that are related (e.g., multiple homicides, homicide followed by suicide, or multiple suicides) into a single incident. RESULTS: For 2017, NVDRS collected information on 45,141 fatal incidents involving 46,389 deaths that occurred in 34 states, four California counties, and the District of Columbia; in addition, information was collected on 961 fatal incidents involving 1,027 deaths in Puerto Rico. Data for Puerto Rico were analyzed separately. Of the 46,389 deaths in the 34 states, four California counties, and District of Columbia, the majority (63.5%) were suicides, followed by homicides (24.9%), deaths of undetermined intent (9.7%), legal intervention deaths (1.4%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force acting in the line of duty, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision, and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns and circumstances varied by manner of death. The suicide rate was higher among males than among females and was highest among adults aged 45-64 years and ≥85 years and non-Hispanic American Indians/Alaska Natives and non-Hispanic Whites. The most common method of injury for suicide was a firearm among males and poisoning among females. Suicide was most often preceded by a mental health, intimate partner, or physical health problem or a recent or impending crisis during the previous or upcoming 2 weeks. The homicide rate was highest among persons aged 20-24 years and was higher among males than females. Non-Hispanic Black males had the highest homicide rate of any racial/ethnic group. The most common method of injury for homicide was a firearm. When the relationship between a homicide victim and a suspect was known, the suspect was most frequently an acquaintance or friend for male victims and a current or former intimate partner for female victims. Homicide most often was precipitated by an argument or conflict, occurred in conjunction with another crime, or, for female victims, was related to intimate partner violence. Among intimate partner violence-related homicides, the largest proportion occurred among adults aged 35-54 years, and the most common method of injury was a firearm. When the relationship between an intimate partner violence-related homicide victim and a suspect was known, most female victims were killed by a current or former intimate partner, whereas approximately half of male victims were killed by a suspect who was not their intimate partner. Almost all legal intervention deaths were among males, and the legal intervention death rate was highest among men aged 25-29 years. Non-Hispanic American Indian/Alaska Native males had the highest legal intervention death rate, followed by non-Hispanic Black males. A firearm was used in the majority of legal intervention deaths. When a specific type of crime was known to have precipitated a legal intervention death, the type of crime was most frequently assault/homicide. The most frequent circumstances for legal intervention deaths were reported use of a weapon by the victim in the incident and a mental health or substance use problem (other than alcohol use). Unintentional firearm deaths more frequently occurred among males, non-Hispanic Whites, and persons aged 15-24 years. These deaths most often occurred while the shooter was playing with a firearm and most frequently were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. The rate of death when the manner was of undetermined intent was highest among males, particularly among non-Hispanic Black and non-Hispanic American Indian/Alaska Native males, and persons aged 30-34 years. Poisoning was the most common method of injury in deaths of undetermined intent, and opioids were detected in nearly 80% of decedents tested for those substances. INTERPRETATION: This report provides a detailed summary of data from NVDRS on violent deaths that occurred in 2017. The suicide rate was highest among non-Hispanic American Indian/Alaska Native and non-Hispanic White males, whereas the homicide rate was highest among non-Hispanic Black males. Intimate partner violence precipitated a large proportion of homicides for females. Mental health problems, intimate partner problems, interpersonal conflicts, and acute life stressors were primary circumstances for multiple types of violent death. PUBLIC HEALTH ACTION: NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in developing, implementing, and evaluating programs and policies to reduce and prevent violent deaths. For example, South Carolina VDRS and Colorado VDRS are using their data to support suicide prevention programs through systems change and the Zero Suicide framework. North Carolina VDRS and Kentucky VDRS data were used to examine intimate partner violence-related deaths beyond homicides to inform prevention efforts. Findings from these studies suggest that intimate partner violence might also contribute to other manners of violent death, such as suicide, and preventing intimate partner violence might reduce the overall number of violent deaths. In 2019, NVDRS expanded data collection to include all 50 states, the District of Columbia, and Puerto Rico, providing more comprehensive and actionable violent death information for public health efforts to reduce violent deaths.

Youth Suicide: An Opportunity for Prevention.

In the United States, youth suicide is a large and growing public health problem that contributes to health care costs, lost productivity, morbidity, and premature death. In 2017, an estimated 199,877 youths aged 10 to 24 years were treated in emergency departments in the United States for self-harm,1 and 7.4% of high school students reported that they attempted suicide one or more times in the past year.2 Suicide was the second leading cause of death among youths aged 10 to 24 years in 2017,1 and the suicide rate increased significantly for both male and female youths from 1999 to 2017.3.

Suicides Among Lesbian and Gay Male Individuals: Findings From the National Violent Death Reporting System.

INTRODUCTION: Information regarding the epidemiology of suicide among lesbian and gay male individuals is limited, and comprehensive information is needed. This study seeks to describe the characteristics and precipitating circumstances of suicide among lesbian and gay male decedents when compared with non-lesbian and non-gay male decedents. METHODS: An analysis was conducted of National Violent Death Reporting System data from 18 U.S. states for the years 2003-2014. Sociodemographic characteristics and precipitating circumstances of suicide among lesbian and gay male decedents were compared with non-lesbian and non-gay male decedents. Logistic regression analysis was conducted to examine the association between precipitating circumstances and suicide by sexual orientation. The analysis was conducted in December 2017. RESULTS: There were a total of 123,289 suicide decedents from 18 states participating in National Violent Death Reporting System during 2003-2014; of those, 621 (0.5%) were identified as lesbian, gay, bisexual, or transgender. The majority of lesbian, gay, bisexual, or transgender decedents were identified as gay male (53.9%), followed by lesbian (28.0%), transgender (10.4%), and bisexual (7.5%). The analysis revealed several differences by age, mechanism of injury, and precipitating circumstances, including intimate partner problems among lesbian decedents, suicide planning and intent for both lesbian and gay male decedents, and mental health problems among gay male decedents. CONCLUSIONS: Findings highlight differences in the characteristics of suicide among lesbian and gay male and non-lesbian and non-gay male decedents. It is important for suicide prevention efforts to be culturally sensitive and consider the needs of sexual minority populations.

Efforts and Opportunities to Understand Women's Mortality Due to Suicide and Homicide Using the National Violent Death Reporting System.

Women's mortality due to violent deaths is a public health issue that has received national attention. Many data systems only collect death certificate data, which provide very limited information about the circumstances surrounding a violent death. The Centers for Disease Control and Prevention's (CDC's) National Violent Death Reporting System (NVDRS) is the first and only surveillance system to capture data from death certificates, coroner/medical examiner reports, and law enforcement reports allowing for a more comprehensive picture and targeted prevention efforts. The system currently operates in 40 states, the District of Columbia, and Puerto Rico; however, with additional funding from the Consolidated Appropriations Act of 2018, this surveillance system will fully expand to cover all 50 states. A number of analyses have been conducted using NVDRS data to compare suicide and homicide among women with men; however, only a handful of studies have been conducted among subgroups of women. The present study provides an overview of NVDRS while highlighting a few key analytic studies with implications for suicide and homicide prevention/intervention among women. Data from the 2014 NVDRS Surveillance Summary are also presented to emphasize the unique opportunity to use NVDRS data to study the characteristics of suicide and homicide among women. The summary includes data from 18 states that were collected statewide. This information can provide state and local public health experts with essential data on female suicide and homicide, not provided in other surveillance systems, to help shape prevention and intervention efforts.

Surveillance for Violent Deaths - National Violent Death Reporting System, 27 States, 2015.

PROBLEM/CONDITION: In 2015, approximately 62,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 27 U.S. states for 2015. Results are reported by sex, age group, race/ethnicity, location of injury, method of injury, circumstances of injury, and other selected characteristics. REPORTING PERIOD: 2015. DESCRIPTION OF SYSTEM: NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 27 states that collected statewide data for 2015 (Alaska, Arizona, Colorado, Connecticut, Georgia, Hawaii, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesota, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Vermont, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) into a single incident. RESULTS: For 2015, NVDRS captured 30,628 fatal incidents involving 31,415 deaths in the 27 states included in this report. The majority (65.1%) of deaths were suicides, followed by homicides (23.5%), deaths of undetermined intent (9.5%), legal intervention deaths (1.3%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1.0%). (The term "legal intervention" is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Demographic patterns varied by manner of death. Suicide rates were highest among males, non-Hispanic American Indian/Alaska Natives, non-Hispanic whites, adults aged 45-54 years, and men aged ≥75 years. The most common method of injury was a firearm. Suicides often were preceded by a mental health, intimate partner, substance abuse, or physical health problem, or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged <1 year and 20-34 years. Among males, non-Hispanic blacks accounted for the majority of homicides and had the highest rate of any racial/ethnic group. Homicides primarily involved a firearm, were precipitated by arguments and interpersonal conflicts, were related to intimate partner violence (particularly for females), or occurred in conjunction with another crime. When the relationship between a homicide victim and a suspected perpetrator was known, an acquaintance/friend or an intimate partner frequently was involved. Legal intervention death rates were highest among males and persons aged 20-54 years; rates among non-Hispanic black males were approximately double the rates of those among non-Hispanic white males. Precipitating circumstances for legal intervention deaths most frequently were an alleged criminal activity in progress, the victim reportedly using a weapon in the incident, a mental health or substance abuse problem (other than alcohol abuse), an argument or conflict, or a recent crisis (during the previous or upcoming 2 weeks). Unintentional firearm deaths were more frequent among males, non-Hispanic whites, and persons aged 10-24 years; these deaths most often occurred while the shooter was playing with a firearm and most often were precipitated by a person unintentionally pulling the trigger or mistakenly thinking the firearm was unloaded. Deaths of undetermined intent were more frequent among males, particularly non-Hispanic black and American Indian/Alaska Native males, and persons aged 30-54 years. Substance abuse, mental health problems, physical health problems, and a recent crisis were the most common circumstances preceding deaths of undetermined intent. In 2015, approximately 3,000 current or former military personnel died by suicide. The majority of these decedents were male, non-Hispanic white, and aged 45-74 years. Most suicides among military personnel involved a firearm and were precipitated by mental health, physical health, and intimate partner problems, as well as a recent crisis. INTERPRETATION: This report provides a detailed summary of data from NVDRS for 2015. The results indicate that deaths resulting from self-inflicted or interpersonal violence most frequently affect males and certain age groups and minority populations. Mental health problems, intimate partner problems, interpersonal conflicts, and general life stressors were primary precipitating events for multiple types of violent deaths, including suicides among current or former military personnel. PUBLIC HEALTH ACTION: NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Virginia VDRS data are used to help identify suicide risk factors among active duty service members, Oregon VDRS suicide data are used to coordinate information and activities across community agencies that support veterans and active duty service members, and Arizona VDRS data are used to develop recommendations for primary care providers who deliver care to veterans. The continued development and expansion of NVDRS to include all 50 states, U.S. territories, and the District of Columbia are essential to public health efforts to reduce deaths due to violence.

Racial and Ethnic Differences in Homicides of Adult Women and the Role of Intimate Partner Violence - United States, 2003-2014.

Homicide is one of the leading causes of death for women aged ≤44 years.* In 2015, homicide caused the death of 3,519 girls and women in the United States. Rates of female homicide vary by race/ethnicity (1), and nearly half of victims are killed by a current or former male intimate partner (2). To inform homicide and intimate partner violence (IPV) prevention efforts, CDC analyzed homicide data from the National Violent Death Reporting System (NVDRS) among 10,018 women aged ≥18 years in 18 states during 2003-2014. The frequency of homicide by race/ethnicity and precipitating circumstances of homicides associated with and without IPV were examined. Non-Hispanic black and American Indian/Alaska Native women experienced the highest rates of homicide (4.4 and 4.3 per 100,000 population, respectively). Over half of all homicides (55.3%) were IPV-related; 11.2% of victims of IPV-related homicide experienced some form of violence in the month preceding their deaths, and argument and jealousy were common precipitating circumstances. Targeted IPV prevention programs for populations at disproportionate risk and enhanced access to intervention services for persons experiencing IPV are needed to reduce homicides among women.

Managing the Personal Side of Health Care among Patients with HIV/AIDS.

The study describes the HIV care providers' sociodemographic and medical practice characteristics and the health care services offered to patients during medical care encounters in Houston/Harris County, Texas. We used data from the pilot cycle of the Centers for Disease Control and Prevention Medical Monitoring Project Provider Survey conducted in June to September 2009. The average age and HIV care experience of the providers were 46.7 and 11.7 years, respectively, and they provided care to an average of 113 patients monthly. The average proportion of HIV-infected patients seen per month by race/ethnicity was 43.3% for blacks, 28.5% for whites, 26.6% for Hispanics, 1.3% for Asians, and 0.6% for other races. A total of 67% of providers offered HIV testing to all patients 13 to 64 years of age. Most HIV care providers (73.9%) reported that patients in their practices sought HIV care only after experiencing symptoms. Understanding the HIV care delivery system from providers' perspectives may help enhance support services, patients' ongoing care and retention, leading to improved health outcomes.

Occupational Homicides of Law Enforcement Officers, 2003-2013: Data From the National Violent Death Reporting System.

INTRODUCTION: Law enforcement officers (LEOs) in the U.S. are at an increased risk for homicide. The purpose of this study is to describe the characteristics of homicides of LEOs in 17 U.S. states participating in the National Violent Death Reporting System. This active surveillance system uses data from death certificates, coroner/medical examiner reports, and law enforcement reports. METHODS: This study used quantitative and qualitative methods to analyze National Violent Death Reporting System data for 2003-2013. Deaths of LEOs feloniously killed in the line of duty were selected for analysis. LEO homicides and the circumstances preceding or occurring during the incident were characterized. Analyses were conducted October 2015-June 2016. RESULTS: A total of 128 officer homicides from 121 incidents were identified. Most (93.7%) LEO victims were male, 60.9% were aged 30-49 years (average age, 40.9 years). Approximately 21.9% of LEOs were killed during an ambush, and 19.5% were killed during traffic stops or pursuits. Of the 14.1% of LEOs killed responding to domestic disturbances, most disturbances were intimate partner violence related. More than half (57.0%) of homicides were precipitated by another crime, and of these, 71.2% involved crimes in progress. Most suspects were male. Ninety-one percent of homicides of LEOs were committed with a firearm. CONCLUSIONS: This information is critical to help describe encounter situations faced by LEOs. The results of this study can be used to help educate and train LEOs on hazards, inform prevention efforts designed to promote LEO safety, and prevent homicide among this population.

Surveillance for Violent Deaths - National Violent Death Reporting System, 17 States, 2013.

PROBLEM/CONDITION: In 2013, more than 57,000 persons died in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 17 U.S. states for 2013. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics. REPORTING PERIOD COVERED: 2013. DESCRIPTION OF SYSTEM: NVDRS collects data from participating states regarding violent deaths obtained from death certificates, coroner/medical examiner reports, law enforcement reports, and secondary sources (e.g., child fatality review team data, supplemental homicide reports, hospital data, and crime laboratory data). This report includes data from 17 states that collected statewide data for 2013 (Alaska, Colorado, Georgia, Kentucky, Maryland, Massachusetts, North Carolina, New Jersey, New Mexico, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Utah, Virginia, and Wisconsin). NVDRS collates documents for each death and links deaths that are related (e.g., multiple homicides, a homicide followed by a suicide, or multiple suicides) from a single incident. RESULTS: For 2013, a total of 18,765 fatal incidents involving 19,251 deaths were captured by NVDRS in the 17 states included in this report. The majority (66.2%) of deaths were suicides, followed by homicides (23.2%), deaths of undetermined intent (8.8%), deaths involving legal intervention (1.2%) (i.e., deaths caused by law enforcement and other persons with legal authority to use deadly force, excluding legal executions), and unintentional firearm deaths (<1%). (The term legal intervention is a classification incorporated into the International Classification of Diseases, Tenth Revision [ICD-10] and does not denote the lawfulness or legality of the circumstances surrounding a death caused by law enforcement.) Suicides occurred at higher rates among males, non-Hispanic whites, American Indian/Alaska Natives, persons aged 45-64 years, and males aged ≥75 years. Suicides were preceded primarily by a mental health, intimate partner, or physical health problem or a crisis during the previous or upcoming 2 weeks. Homicide rates were higher among males and persons aged 15-44 years; rates were highest among non-Hispanic black males. Homicides primarily were precipitated by arguments and interpersonal conflicts, occurrence in conjunction with another crime, or were related to intimate partner violence (particularly for females). A known relationship between a homicide victim and a suspected perpetrator was most likely either that of an acquaintance or friend or an intimate partner. Legal intervention death rates were highest among males and persons aged 20-24 years and 30-34 years; rates were highest among non-Hispanic black males. Precipitating factors for the majority of legal intervention deaths were another crime, a mental health problem, or a recent crisis. Deaths of undetermined intent occurred at the highest rates among males and persons aged <1 year and 45-54 years. Substance abuse and mental or physical health problems were the most common circumstances preceding deaths of undetermined intent. Unintentional firearm death rates were higher among males, non-Hispanic whites, and persons aged persons aged 15-19 and 55-64 years; these deaths were most often precipitated by a person unintentionally pulling the trigger while playing with a firearm or while hunting. INTERPRETATION: This report provides a detailed summary of data from NVDRS for 2013. The results indicate that violent deaths resulting from self-inflicted or interpersonal violence disproportionately affected persons aged <65 years, males, and certain minority populations. For homicides and suicides, intimate partner problems, interpersonal conflicts, mental health problems, and recent crises were primary precipitating factors. PUBLIC HEALTH ACTION: NVDRS data are used to monitor the occurrence of violence-related fatal injuries and assist public health authorities in the development, implementation, and evaluation of programs and policies to reduce and prevent violent deaths. For example, Utah Violent Death Reporting System (VDRS) data were used to develop policies that support children of intimate partner homicide victims, Colorado VDRS data to develop a web-based suicide prevention program targeting middle-aged men, and Rhode Island VDRS data to help guide suicide prevention efforts at workplaces. The continued development and expansion of NVDRS to include all U.S. states, territories, and the District of Columbia are essential to public health efforts to reduce the impact of violence.

The National Violent Death Reporting System: overview and future directions.

OBJECTIVE: To describe the National Violent Death Reporting System (NVDRS). This is a surveillance system for monitoring the occurrence of homicides, suicides, unintentional firearm deaths, deaths of undetermined intent, and deaths from legal intervention (excluding legal executions) in the US. DESIGN: This report provides information about the history, scope, data variables, processes, utility, limitations, and future directions of the NVDRS. RESULTS: The NVDRS currently operates in 32 states, with the goal of future expansion to all 50 states, the District of Columbia, and US territories. The system uses existing primary data sources (death certificates, coroner/medical examiner reports, and law enforcement reports), and links them together to provide a comprehensive picture of the circumstances surrounding violent deaths. CONCLUSIONS: This report provides an overview of the NVDRS including a description of the system, discussion of its expanded capability, the use of new technologies as the system has evolved, how the data are being used for violence prevention efforts, and future directions.

Screening for Cervical Cancer and Sexually Transmitted Diseases Among HIV-Infected Women.

BACKGROUND: Women living with HIV infection are at higher risk for cervical cancer, an AIDS-defining diagnosis. We examined the prevalence of cervical cancer and sexually transmitted disease (STD) screening among human immunodeficiency virus (HIV)-infected women and factors associated with the receipt of Papanicolaou (Pap) tests. METHODS: We did a cross-sectional analysis of weighted data from a sample of HIV-infected adults receiving outpatient medical care. We used matched interview (report of Pap test) and medical record data (STD screenings) from HIV-infected women. We performed logistic regression to compute adjusted prevalence ratios and 95% confidence intervals for the association between demographic, behavioral, and clinical factors and receipt of Pap tests among HIV-infected women. RESULTS: Data were available for 2,270 women, who represent 112,894 HIV-infected women; 62% were African American, 17% were Hispanic/Latina, and 18% were white. Most (78%) reported having a Pap test in the past year. Among sexually active women (n = 1234), 20% reported sex without condoms, 27% were screened for gonorrhea, and 29% were screened for chlamydia. Being screened for STDs was less likely among women who did not have a Pap test in the past year (adjusted prevalence ratios 0.82, 95% confidence interval 0.77-0.87). Women who were ≥50 years of age and reported income above federal poverty level, no sexual activity, depression, no HIV care from an obstetrician/gynecologist, and no documented STD tests, were less likely to report a Pap test (p < 0.05). CONCLUSIONS: Screening for cervical cancer and STDs among HIV-infected women is suboptimal. Clinical visits for Pap tests are an important opportunity for HIV-infected sexually active women to also receive STD screenings and counseling regarding condoms.

Behavioral and clinical characteristics of persons receiving medical care for HIV infection - Medical Monitoring Project, United States, 2009.

PROBLEM: As of December 31, 2009, an estimated 864,748 persons were living with human immunodeficiency virus (HIV) infection in the 50 U.S. states, the District of Columbia, and six U.S.-dependent areas. Whereas HIV surveillance programs in the United States collect information about persons with a diagnosis of HIV infection, supplemental surveillance systems collect in-depth information about the behavioral and clinical characteristics of persons receiving outpatient medical care for HIV infection. These data are needed to reduce HIV-related morbidity and mortality and HIV transmission. REPORTING PERIOD COVERED: Data were collected during June 2009-May 2010 for patients receiving medical care at least once during January-April 2009. DESCRIPTION OF THE SYSTEM: The Medical Monitoring Project (MMP) is an ongoing surveillance system that assesses behaviors and clinical characteristics of HIV-infected persons who have received outpatient medical care. For the 2009 data collection cycle, participants must have been aged ≥18 years and have received medical care during January-April 2009 at sampled facilities that provide HIV medical care within participating MMP project areas. Behavioral and selected clinical data were collected using an in-person interview, and most clinical data were collected using medical record abstraction. A total of 23 project areas in 16 states and Puerto Rico were funded to collect data during the 2009 data collection cycle. The data were weighted for probability of selection and nonresponse to be representative of adults receiving outpatient medical care for HIV infection in the United States and Puerto Rico. Prevalence estimates are presented as weighted percentages. The period of reference is the 12 months before the patient interview unless otherwise noted. RESULTS: The patients in MMP represent 421,186 adults who received outpatient medical care for HIV infection in the United States and Puerto Rico during January-April 2009. Of adults who received medical care for HIV infection, an estimated 71.2% were male, 27.2% were female, and 1.6% were transgender. An estimated 41.4% were black or African American, 34.6% were white, and 19.1% were Hispanic or Latino. The largest proportion (23.1%) were aged 45-49 years. Most patients (81.1%) had medical coverage; 40.3% had Medicaid, 30.6% had private health insurance, and 25.7% had Medicare. An estimated 69.6% of patients had three or more documented CD4+ T-lymphocyte cell (CD4+) or HIV viral load tests. Most patients (88.7%) were prescribed antiretroviral therapy (ART), and 71.6% had a documented viral load that was undetectable or ≤200 copies/mL at their most recent test. Among sexually active patients, 55.0% had documentation in the medical record of being tested for syphilis, 23.2% for gonorrhea, and 23.9% for chlamydia. Noninjection drugs were used for nonmedical purposes by an estimated 27.1% of patients, whereas injection drugs were used for nonmedical purposes by 2.1% of patients. Overall, 12.9% of patients engaged in unprotected sex with a partner of negative or unknown HIV status. Unmet supportive service needs were prevalent, with an estimated 22.8% in need of dental care and 12.0% in need of public benefits, including Social Security Income or Social Security Disability Insurance. Fewer than half of patients (44.8%) reported receiving HIV and sexually transmitted disease prevention counseling from a health-care provider. INTERPRETATION: The findings in this report indicate that most adults living with HIV who received medical care in 2009 were taking ART, had CD4+ and HIV viral load testing at regular intervals, and had health insurance or other coverage. However, some patients did not receive clinical services and treatment in accordance with guidelines. Some patients engaged in behaviors, such as unprotected sex, that increase the risk for transmitting HIV to sex partners, and some used noninjection or injection drugs or both. PUBLIC HEALTH ACTIONS: Local and state health departments and federal agencies can use MMP data for program planning to determine allocation of services and resources, guide prevention planning, assess unmet medical and supportive service needs, inform health-care providers, and help focus intervention programs and health policies at the local, state, and national levels.