Firearm Homicides and Suicides in Major Metropolitan Areas - United States, 2015-2016 and 2018-2019.

Firearm homicides and suicides represent an ongoing public health concern in the United States. During 2018-2019, a total of 28,372 firearm homicides (including 3,612 [13%] among youths and young adults aged 10-19 years [youths]) and 48,372 firearm suicides (including 2,463 [5%] among youths) occurred among U.S. residents (1). This report is the fourth in a series* that provides statistics on firearm homicides and suicides in major metropolitan areas. As with earlier reports, this report provides a special focus on youth violence, including suicide, recognizing the magnitude of the problem and the importance of early prevention efforts. Firearm homicide and suicide rates were calculated for the 50 most populous U.S. metropolitan statistical areas (MSAs)† for the periods 2015-2016 and 2018-2019, separated by a transition year (2017), using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. Following a period of decreased firearm homicide rates among persons of all ages after 2006-2007 in large metropolitan areas collectively and nationally, by 2015-2016 rates had returned to levels comparable to those observed a decade earlier and remained nearly unchanged as of 2018-2019. Firearm suicide rates among persons aged ≥10 years have continued to increase in large MSAs collectively as well as nationally. Although the youth firearm suicide rate remained much lower than the overall rate, the youth rate nationally also continued to increase, most notably outside of large MSAs. The findings in this report underscore a continued and urgent need for a comprehensive approach to prevention. This includes efforts to prevent firearm homicide and suicide in the first place and support individual persons and communities at increased risk, as well as lessening harms after firearm homicide and suicide have occurred.

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.

A descriptive exploration of the geographic and sociodemographic concentration of firearm homicide in the United States, 2004-2018.

This study examined the population-based incidence of firearm homicide in the United States to identify geographic concentrations and to determine whether such concentrations have changed over time. It further examined the simultaneous associations of urbanization, poverty, and ethnicity/race with firearm homicide incidence. Using county-level data from the National Vital Statistics System and the U.S. Census Bureau for the years 2004-2018, the findings show geographic patterns not commonly recognized, including several lengthy and continuous corridors with a high incidence of firearm homicide, traversing both metro and non-metro areas. While the data clearly show a strongly disproportionate concentration of firearm homicide incidence in a subset of the population defined by geography, they do not suggest increasing concentration over time. The study findings also generally indicate increasing firearm homicide incidence with increasing levels of surrounding poverty, a phenomenon observed for both metro and non-metro areas.

Traumatic Brain Injury-Related Deaths From Firearm Suicide: United States, 2008-2017.

Objectives. To document the increasing influence of firearm suicide on the incidence of traumatic brain injury (TBI)-related death in the United States.Methods. We used national vital statistics data from 2008 to 2017 to identify TBI-related deaths, overall and by cause, among US residents. National counts stratified by year, sex, and age group (to facilitate age adjustment) were merged with corresponding population estimates to calculate incidence rates.Results. During the 10-year period beginning in 2008, when it became the leading cause of TBI-related death in the United States, firearm suicide accounted for nearly half (48.3%) of the increase in the absolute incidence of TBI-related death when combining all injury categories showing absolute increases. Rates of TBI-related firearm suicide increased among both males and females.Conclusions. Safe storage of firearms among people at risk and training of health care providers and community members to identify and support people who may be thinking of suicide are part of a comprehensive public health approach to suicide prevention.Public Health Implications. States, communities, and health care systems can save lives by prioritizing comprehensive suicide prevention.

Deaths from Fall-Related Traumatic Brain Injury - United States, 2008-2017.

One in 10 U.S. residents aged ≥18 years reports falling each year (1). Among all age groups, falls can cause serious injury and are the second leading cause of traumatic brain injury (TBI)-related deaths (2). TBI is a head injury caused by a bump, blow, or jolt to the head or body or a penetrating head injury that results in disruption of normal brain function.* CDC estimated national and state-specific rates and trends for TBI-related deaths (TBI deaths) caused by unintentional falls (fall-related TBI deaths) among U.S. residents during 2008-2017, by selected decedent characteristics. The national age-adjusted rate of fall-related TBI deaths increased by 17% from 2008 to 2017. Rate trends at the national level increased significantly for nearly all decedent characteristics, with the most notable increases observed among persons living in noncore (i.e., most rural), nonmetropolitan counties and those aged ≥75 years. Analysis of state-specific rate trends determined that rates of fall-related TBI deaths increased significantly in 29 states over the 10-year study period. A fall can happen to anyone of any age, but falls are preventable. Health care providers and the public need to be aware of evidence-based strategies to prevent falls, given that rates of fall-related TBI deaths are increasing. Health care providers can educate patients on fall and TBI prevention, assess their risk for falls, and when needed, encourage participation in appropriate evidence-based fall prevention programs.†.

Effects of Poly-Victimization Before Age 18 on Health Outcomes in Young Kenyan Adults: Violence Against Children Survey.

Children's exposure to poly-victimization, which is the experience of multiple types of victimization, has been found to be associated with negative health outcomes and risk behaviors. We examined the collective effects of childhood sexual, physical, and emotional violence on selected self-reported health outcomes among young Kenyan females and males using the Violence Against Children Survey (VACS). Overall, 76.2% of females and 79.8% of males were victims of sexual, physical, or emotional violence prior to age 18, and one-third (32.9% and 34.5%, respectively) experienced two or more types of violence. Poly-victimization was significantly associated with current feelings of anxiety, depression, and suicidal thoughts in females and males, as well as self-reported fair or poor health in males (p < .05) as compared to those who experienced no violence. The study data demonstrate an urgent need to reduce all types of violence against children, as well develop appropriate strategies for its prevention.

Firearm Homicides and Suicides in Major Metropolitan Areas - United States, 2012-2013 and 2015-2016.

Firearm homicides and suicides represent a continuing public health concern in the United States. During 2015-2016, a total of 27,394 firearm homicides (including 3,224 [12%] among persons aged 10-19 years) and 44,955 firearm suicides (including 2,118 [5%] among persons aged 10-19 years) occurred among U.S. residents (1). This report updates an earlier report (2) that provided statistics on firearm homicides and suicides in major metropolitan areas during 2006-2007 and 2009-2010, and places continued emphasis on youths, in recognition of the importance of early prevention efforts. Firearm homicide and suicide rates were determined for the 50 most populous U.S. metropolitan statistical areas (MSAs)* during 2012-2013 and 2015-2016 using mortality data from the National Vital Statistics System (NVSS) and population data from the U.S. Census Bureau. In contrast to the earlier report, which indicated that firearm homicide rates among persons of all ages had been declining both nationally and in large MSAs overall, current findings show that rates have returned to levels comparable to those observed during 2006-2007. Consistent with the earlier report, these findings show that firearm suicide rates among persons aged ≥10 years have continued to increase, both nationally and in large MSAs overall. Although firearm suicide rates among youths remain notably lower than those among persons of all ages, youth rates have also increased both nationally and in large MSAs collectively. These findings can inform ongoing development and monitoring of strategies directed at reducing firearm-related violence.

Vital Signs: Trends in State Suicide Rates - United States, 1999-2016 and Circumstances Contributing to Suicide - 27 States, 2015.

INTRODUCTION: Suicide rates in the United States have risen nearly 30% since 1999, and mental health conditions are one of several factors contributing to suicide. Examining state-level trends in suicide and the multiple circumstances contributing to it can inform comprehensive state suicide prevention planning. METHODS: Trends in age-adjusted suicide rates among persons aged ≥10 years, by state and sex, across six consecutive 3-year periods (1999-2016), were assessed using data from the National Vital Statistics System for 50 states and the District of Columbia. Data from the National Violent Death Reporting System, covering 27 states in 2015, were used to examine contributing circumstances among decedents with and without known mental health conditions. RESULTS: During 1999-2016, suicide rates increased significantly in 44 states, with 25 states experiencing increases >30%. Rates increased significantly among males and females in 34 and 43 states, respectively. Fifty-four percent of decedents in 27 states in 2015 did not have a known mental health condition. Among decedents with available information, several circumstances were significantly more likely among those without known mental health conditions than among those with mental health conditions, including relationship problems/loss (45.1% versus 39.6%), life stressors (50.5% versus 47.2%), and recent/impending crises (32.9% versus 26.0%), but these circumstances were common across groups. CONCLUSIONS: Suicide rates increased significantly across most states during 1999-2016. Various circumstances contributed to suicides among persons with and without known mental health conditions. IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: States can use a comprehensive evidence-based public health approach to prevent suicide risk before it occurs, identify and support persons at risk, prevent reattempts, and help friends and family members in the aftermath of a suicide.

Trends in Suicide by Level of Urbanization - United States, 1999-2015.

Suicide is a major and continuing public health concern in the United States. During 1999-2015, approximately 600,000 U.S. residents died by suicide, with the highest annual rate occurring in 2015 (1). Annual county-level mortality data from the National Vital Statistics System (NVSS) and annual county-level population data from the U.S. Census Bureau were used to analyze suicide rate trends during 1999-2015, with special emphasis on comparing more urban and less urban areas. U.S. counties were grouped by level of urbanization using a six-level classification scheme. To evaluate rate trends, joinpoint regression methodology was applied to the time-series data for each level of urbanization. Suicide rates significantly increased over the study period for all county groupings and accelerated significantly in 2007-2008 for the medium metro, small metro, and non-metro groupings. Understanding suicide trends by urbanization level can help identify geographic areas of highest risk and focus prevention efforts. Communities can benefit from implementing policies, programs, and practices based on the best available evidence regarding suicide prevention and key risk factors. Many approaches are applicable regardless of urbanization level, whereas certain strategies might be particularly relevant in less urban areas affected by difficult economic conditions, limited access to helping services, and social isolation.

Increases in United States life expectancy through reductions in injury-related death.

BACKGROUND: During the previous century the average lifespan in the United States (US) increased by over 30 years, with much of this increase attributed to public health initiatives. This report examines further gains that might be achieved through reduced occurrence of injury-related death. METHODS: US life tables and injury death rate data were used to estimate potential increases in life expectancy assuming various reductions in the rate of fatal injuries. Corresponding numbers of deaths potentially averted annually were also estimated; unit (per death) medical and lifetime work loss costs were employed to estimate total costs potentially averted annually. RESULTS: Through elimination of injury as a cause of death, average US life expectancy at birth could be increased by approximately 1.5 years, with notable variations by sex, ethnicity, and race. More conservatively, average life expectancy at birth could be increased by 0.41 years assuming that the national injury death rate could be brought into line with the lowest state-specific rate. Under this more conservative but plausible assumption, an estimated 48,400 injury deaths and $61 billion in medical and work loss costs would be averted annually. CONCLUSIONS: Increases in life expectancy of the magnitude considered in this report are arguably attainable based on long-term historical reductions in the US injury death rate, as well as significant continuing reductions seen in other developed countries. Contemporary evidence-based interventions can play an important role in reducing injury-related deaths, such as those due to drug overdoses and older adult falls, as well as suicides.

Notes from the Field: Pediatric Emergency Department Visits for Buprenorphine/Naloxone Ingestion - United States, 2008-2015.

Expanding access to office-based medication-assisted treatment with buprenorphine/naloxone for opioid dependence is a key part of the national strategy to address the opioid abuse epidemic (1). However, as buprenorphine/naloxone prescribing increased, emergency department (ED) visits and hospitalizations for unsupervised ingestions by young children began to increase, with buprenorphine/naloxone ingestions becoming the most common cause of hospitalization for medication ingestions by young children during 2010-2011 (2). Buprenorphine ingestions might be asymptomatic or can cause drowsiness, vomiting, or respiratory depression, which if untreated can result in death (3). Buprenorphine/naloxone was available only as tablets in multidose child-resistant bottles (Suboxone) until late 2010, when film strips packaged in unit-dose, child-resistant pouches were introduced. In 2013, tablets became available in unit-dose packaging (Zubsolv). Because unit-dose, child-resistant packaging encloses each dose until opened, it might limit unintended ingestions by young children compared with traditional child-resistant bottles that must be resecured after every use (4). This study compared ED visits for pediatric buprenorphine/naloxone ingestions before and after these product packaging/formulation changes.

Statistical air quality predictions for public health surveillance: evaluation and generation of county level metrics of PM2.5 for the environmental public health tracking network.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) developed county level metrics for the Environmental Public Health Tracking Network (Tracking Network) to characterize potential population exposure to airborne particles with an aerodynamic diameter of 2.5 µm or less (PM(2.5)). These metrics are based on Federal Reference Method (FRM) air monitor data in the Environmental Protection Agency (EPA) Air Quality System (AQS); however, monitor data are limited in space and time. In order to understand air quality in all areas and on days without monitor data, the CDC collaborated with the EPA in the development of hierarchical Bayesian (HB) based predictions of PM(2.5) concentrations. This paper describes the generation and evaluation of HB-based county level estimates of PM(2.5). METHODS: We used three geo-imputation approaches to convert grid-level predictions to county level estimates. We used Pearson (r) and Kendall Tau-B (τ) correlation coefficients to assess the consistency of the relationship, and examined the direct differences (by county) between HB-based estimates and AQS-based concentrations at the daily level. We further compared the annual averages using Tukey mean-difference plots. RESULTS: During the year 2005, fewer than 20% of the counties in the conterminous United States (U.S.) had PM(2.5) monitoring and 32% of the conterminous U.S. population resided in counties with no AQS monitors. County level estimates resulting from population-weighted centroid containment approach were correlated more strongly with monitor-based concentrations (r = 0.9; τ = 0.8) than were estimates from other geo-imputation approaches. The median daily difference was -0.2 µg/m(3) with an interquartile range (IQR) of 1.9 µg/m(3) and the median relative daily difference was -2.2% with an IQR of 17.2%. Under-prediction was more prevalent at higher concentrations and for counties in the western U.S. CONCLUSIONS: While the relationship between county level HB-based estimates and AQS-based concentrations is generally good, there are clear variations in the strength of this relationship for different regions of the U.S. and at various concentrations of PM(2.5). This evaluation suggests that population-weighted county centroid containment method is an appropriate geo-imputation approach, and using the HB-based PM(2.5) estimates to augment gaps in AQS data provides a more spatially and temporally consistent basis for calculating the metrics deployed on the Tracking Network.

Characteristics of fatal abusive head trauma among children in the USA: 2003-2007: an application of the CDC operational case definition to national vital statistics data.

OBJECTIVE: In March of 2008, an expert panel was convened at the Centers for Disease Control and Prevention to develop code-based case definitions for abusive head trauma (AHT) in children under 5 years of age based on the International Classification of Diseases, 10th Revision (ICD-10) nature and cause of injury codes. This study presents the operational case definition and applies it to US death data. METHODS: National Center for Health Statistics National Vital Statistics System data on multiple cause-of-death from 2003 to 2007 were examined. RESULTS: Inspection of records with at least one ICD-10 injury/disease code and at least one ICD-10 cause code from the AHT case definition resulted in the identification of 780 fatal AHT cases, with 699 classified as definite/presumptive AHT and 81 classified as probable AHT. The fatal AHT rate was highest among children age <1 year with a peak in incidence that occurred at 1-2 months of age. Fatal AHT incidence rates were higher for men than women and were higher for non-Hispanic African-Americans compared to other racial/ethnic groups. Fatal AHT incidence was relatively constant across seasons. CONCLUSIONS: This report demonstrates that the definition can help to identify population subgroups at higher risk for AHT defined by year and month of death, age, sex and race/ethnicity. This type of definition may be useful for various epidemiological applications including research and surveillance. These activities can in turn inform further development of prevention activities, including educating parents about the dangers of shaking and strategies for managing infant crying.

Assessing Female Suicide From a Health Equity Viewpoint, U.S. 2004-2018.

INTRODUCTION: Geographic and urbanization differences in female suicide trends across the U.S. necessitates suicide prevention efforts on the basis of geographic variations. The purpose of this study was to assess female suicide rates by mechanism within Census divisions and by urbanicity to help inform geographically tailored approaches for suicide prevention strategies. METHODS: Data from 2004 to 2018 were obtained from the National Vital Statistics System (analyzed in 2021). Annual counts of female suicides were tabulated for firearm, suffocation, and drug poisoning and stratified by the U.S. Census division and urbanicity. Age-adjusted rates were calculated to describe female suicide incidence by geographic areas and urbanicity. Data were analyzed annually and by 5-year timeframes. Trends in annual female suicide rates by mechanism for 3 urbanization levels were identified using Joinpoint Regression. Annual percent change estimates were calculated for age-adjusted female suicide rates between 2004 and 2018. RESULTS: Female suicide rates by mechanism were not homogeneous within Census divisions or by urbanization levels. Suicide rates by mechanism across Census divisions within the same urbanization level varied (range=3.38-11.15 [per 100,000 person per year]). From 2014 to 2018 in large metropolitan areas in the northern divisions, rates for suffocation were higher than for firearms and drug poisoning. During the same period, in all urbanization levels in southern divisions, rates for firearms were higher than for suffocation and drug poisoning. CONCLUSIONS: Female suicide mechanisms vary by urbanization level, and this variation differs by region. These results could inform female suicide prevention strategies on the basis of mechanism, urbanization, and geographic region.

Medication use leading to emergency department visits for adverse drug events in older adults.

BACKGROUND: The Beers criteria identify inappropriate use of medications in older adults. The number of and risk for adverse events from these medications are unknown. OBJECTIVE: To estimate the number of and risk for emergency department visits for adverse events involving Beers criteria medications compared with other medications. DESIGN: Nationally representative, public health surveillance of adverse drug events and a cross-sectional survey of outpatient medical visits. SETTING: National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance System, 2004-2005; National Ambulatory Medical Care Survey, 2004; and National Hospital Ambulatory Medical Care Survey, 2004. PARTICIPANTS: Persons 65 years of age or older seeking emergency department and outpatient care. MEASUREMENTS: Estimated number of and risks for emergency department visits for adverse drug events involving Beers criteria medications and other medications. RESULTS: Among U.S. patients 65 years of age or older, an estimated 177,504 emergency department visits (95% CI, 100,155 to 254,854 visits) for adverse drug events occurred both years. An estimated 3.6% (CI, 2.8% to 4.5%) of these visits were for adverse events medications considered to be always potentially inappropriate, according to the Beers criteria, and 33.3% (CI, 27.8% to 38.7%) of visits were for adverse events from 3 other medications (warfarin [17.3%], insulin [13.0%], and digoxin [3.2%]). Accounting for outpatient prescription frequency, the risk for emergency department visits for adverse events due to these 3 medications was 35 times (CI, 9.6 to 61) greater than that for medications considered to be always potentially inappropriate. LIMITATION: Adverse events were identified only in emergency departments. CONCLUSION: Compared with other medications, Beers criteria medications caused low numbers of and few risks for emergency department visits for adverse events. Performance measures and interventions targeting warfarin, insulin, and digoxin use could prevent more emergency department visits for adverse events.

Decreasing residential fire death rates and the association with the prevalence of adult cigarette smoking - United States, 1999-2015.

INTRODUCTION: Each year from 1999 through 2015, residential fires caused between 2,000 and 3,000 deaths in the U.S., totaling approximately 45,000 deaths during this period. A disproportionate number of such deaths are attributable to smoking in the home. This study examines national trends in residential fire death rates, overall and smoking-related, and their relationship to adult cigarette smoking prevalence, over this same period. METHODS: Summary data characterizing annual U.S. residential fire deaths and annual prevalence of adult cigarette smoking for the years 1999-2015, drawn from the National Vital Statistics System, the National Fire Protection Association, and the National Health Interview Survey were used to relate trends in overall and smoking-related rates of residential fire death to changes in adult cigarette smoking prevalence. RESULTS: Statistically significant downward trends were identified for both the rate of residential fire death (an average annual decrease of 2.2% - 2.6%) and the rate of residential fire death attributed to smoking (an average annual decrease of 3.5%). The decreasing rate of residential fire death was strongly correlated with a gradually declining year-to-year prevalence of adult cigarette smoking (r = 0.83), as was the decreasing rate of residential fire death attributed to smoking (r = 0.80). CONCLUSIONS AND PRACTICAL APPLICATIONS: Decreasing U.S. residential fire death rates, both overall and smoking-related, coincided with a declining prevalence of adult cigarette smoking during 1999-2015. These findings further support tobacco control efforts and fire prevention strategies that include promotion of smoke-free homes. While the general health benefits of refraining from smoking are widely accepted, injury prevention represents a potential benefit that is less recognized.

Applying the compound Poisson process model to the reporting of injury-related mortality rates.

Injury-related mortality rate estimates are often analyzed under the assumption that case counts follow a Poisson distribution. Certain types of injury incidents occasionally involve multiple fatalities, however, resulting in dependencies between cases that are not reflected in the simple Poisson model and which can affect even basic statistical analyses. This paper explores the compound Poisson process model as an alternative, emphasizing adjustments to some commonly used interval estimators for population-based rates and rate ratios. The adjusted estimators involve relatively simple closed-form computations, which in the absence of multiple-case incidents reduce to familiar estimators based on the simpler Poisson model. Summary data from the National Violent Death Reporting System are referenced in several examples demonstrating application of the proposed methodology.