The risk of injury is so great that most persons sustain a significant injury at some time during their lives.[1] Nevertheless, this widespread human damage too often is taken for granted, in the erroneous belief that injuries happen by chance and are the result of unpreventable “accidents.” In fact, many injuries are not “accidents,” or random, uncontrollable acts of fate; rather, most injuries are predictable and preventable.[2]

Issues and Trends

Injury Prevention

In 1997, 146,400 persons in the United States died from injuries due to a variety of causes such as motor vehicle crashes, firearms, poisonings, suffocations, falls, fires, and drownings. About 400 persons die from injuries each day, including 55 children and teenagers. One death out of every 17 in the United States results from injury.[3] Of these deaths, 63 percent are classified as unintentional and 34 percent as intentional.Unintentional injury deaths include approximately 42,000 resulting from motor vehicle crashes per year. In 1997, of approximately 50,000 intentional injury deaths, almost 31,000 were classified as suicide and nearly 20,000 as homicide.1 In 1997, injuries accounted for 20 percent more years of potential life lost (YPLL) than cancer did (1,990 per 100,000 compared to 1,500 per 100,000).[4]

For ages 1 through 44 years, deaths from injuries far surpass those from cancer—the overall leading natural cause of death at these ages—by about three to one. Injuries cause more than two out of five deaths (43 percent) of children aged 1 through 4 years and result in four times the number of deaths due to birth defects, the second leading cause of death for this age group. For ages 15 to 24 years, injury deaths exceed deaths from all other causes combined from ages 5 through 44 years. For ages 15 to 24 years, injuries are the cause of nearly four out of five deaths. After age 44 years, injuries account for fewer deaths than other health problems, such as heart disease, cancer, and stroke. However, despite the decrease in the proportion of deaths due to injury, the death rate from injuries is actually higher among older persons than among younger persons.

Injuries often are classified on the basis of events and behaviors that preceded them as well as the intent of the persons involved. For example, many injuries are preceded by alcohol consumption in amounts or circumstances that increase risk of injury.[5] Although the events leading to an intentional injury and an unintentional injury differ, the outcomes and extent of the injury are similar.

Unintentional Injury Prevention

More persons aged 1 to 34 years die as a result of unintentional injuries than any other cause of death. Across all ages, 92,353 persons died in 1997 as a result of unintentional injuries. Motor vehicle crashes account for approximately half the deaths from unintentional injuries; other unintentional injuries rank second, and falls rank third, followed by poisonings, suffocations, and drownings.[6]

Additional millions of persons are incapacitated by unintentional injuries, with many suffering lifelong disabilities. These events occur disproportionately among young and elderly persons. In 1995, 29 million persons visited emergency departments as a result of unintentional injuries.[7]

Although the greatest impact of injury is in human suffering and loss of life, the financial cost is staggering. Included in the costs associated with injuries are the costs of direct medical care and rehabilitation as well as lost income and productivity. By the late 1990s, injury costs were estimated at more than $441 billion annually, an increase of 42 percent over the 1980s.[8] As with other health problems, it costs far less to prevent injuries than to treat them.For example:

Several themes become evident when examining reports on injury prevention and control, including acute care, treatment, and rehabilitation. First, unintentional injury comprises a group of complex problems involving many different sectors of society. No single force working alone can accomplish everything needed to reduce the number of injuries. Improved outcomes require the combined efforts of many fields, including health, education, transportation, law, engineering, and safety sciences. Second, many of the factors that cause unintentional injuries are closely associated with violent and abusive behavior. Injury prevention and control addresses both unintentional and intentional injuries.

Violence and Abuse Prevention

Violence in the United States is pervasive and can change quality of life. Reports of children killing children in schools are shocking and cause parents to worry about the safety of their children at school. Reports of gang violence make persons fearful for their safety. Although suicide rates began decreasing in the mid-1990s, prior increases among youth aged 10 to 19 years and adults aged 65 years and older have raised concerns about the vulnerability of these population groups. Intimate partner violence and sexual assault threaten people in all walks of life.

Violence claims the lives of many of the Nation’s young persons and threatens the health and well-being of many persons of all ages in the United States. On an average day in America, 53 persons die from homicide, and a minimum of 18,000 persons survive interpersonal assaults, 84 persons complete suicide, and as many as 3,000 persons attempt suicide.[10] (See Focus Area 18. Mental Health and Mental Disorders.)

Youth continue to be involved as both perpetrators and victims of violence. Elderly persons, females, and children continue to be targets of both physical and sexual assaults, which are frequently perpetrated by individuals they know.Examples of general issues that impede the public health response to progress in this area include the lack of comparable data sources, lack of standardized definitions and definitional issues, lack of resources to establish adequately consistent tracking systems, and lack of resources to fund promising prevention programs.

Because national data systems will not be available in the first half of the decade for tracking progress, one subject of interest, maltreatment of elderly persons, is not addressed in this focus area’s objectives. The maltreatment of persons aged 60 years and older is a topic for research and data collection for the coming decade.

Disparities

While every person is at risk for injury, some groups appear to experience certain types of injuries more frequently. American Indians or Alaska Natives have disproportionately higher death rates from motor vehicle crashes, residential fires, and drownings. In addition, their death rates are about 1.75 times higher than the death rate for the overall U.S. population. Higher death rates from unintentional injury also occur among African Americans.1

Certain racial and ethnic groups experience more unintentional injuries and deaths than whites. Unintentional injuries are the second leading cause of death for American Indian males and the third leading cause of death for American Indian females. More than 1,000 American Indians die from injuries, and 10,000 more are hospitalized for injuries each year. The age-adjusted injury death rate for American Indians is three times higher than that of all other persons in the United States. Among American Indians, 46 percent of the YPLL is a result of injury, which is five times greater than the YPLL due to a next highest cause, heart disease (8 percent). Among the factors that contribute to these increased rates for American Indians are rural or isolated living, minimal emergency medical services, and great distances to sophisticated trauma care.[11]

African American, Hispanic, and American Indian children are at higher risk than white children for home fire deaths.[12] Adults aged 65 years and older are at increased risk of death from fire because they are more vulnerable to smoke inhalation and burns and are less likely to recover. Sense impairment (such as blindness or hearing loss) may prevent older adults from noticing a fire, and mobility impairment may prevent them from escaping its consequences. Older adults also are less likely to have learned fire safety behavior and prevention information, because they grew up at a time when little fire safety was taught in schools, and most current educational programs target children.

In every age group, drowning rates are almost two to four times greater for males than for females.[13] In 1997, the overall drowning rate for African Americans was 50 percent greater than that for whites; however, the rate was not higher for all age groups. For example, among children aged 1 through 4 years, the drowning rate for whites was slightly higher than the rate for African Americans. For children aged 5 to 19 years, African American children are twice as likely to drown as white children.[14]

Homicide victimization is especially high among African American and Hispanic youth. In 1995, African American males and females aged 15 to 24 years had homicide rates (74.4 per 100,000) that were more than twice the rate of their Hispanic counterparts (34.1 per 100,000) and nearly 14 times the rate of their white non-Hispanic counterparts (5.4 per 100,000).[15]

Trends in suicide among blacks aged 10 to 19 years in the United States during 1980–95 indicate that suicidal behavior among all youth has increased; however, rates for black youth have shown a greater increase.[16]

Although black youth historically have lower suicide rates than have whites, during 1980–95, the suicide rate for black youth aged 10 to 19 years increased from 2.1 to 4.5 per 100,000 population. As of 1995, suicide was the third leading cause of death among blacks aged 15 to 19 years.[17]

Opportunities

To reduce the number and severity of injuries, prevention activities must focus on the type of injury—drowning, fall, fire or burn, firearm, or motor vehicle.[18] For example, a nonfatal spinal cord injury produces the same outcome whether it was caused by an unintentional motor vehicle crash or an attempted suicide.

Understanding injuries allows for development and implementation of effective prevention interventions. Some interventions can reduce injuries from both unintentional and violence-related episodes. For instance, efforts to promote proper storage of firearms in homes can help reduce the risk of assaultive, intentional self-inflicted, and unintentional shootings in the home.[19] Higher taxes on alcoholic beverages are associated with lower death rates from motor vehicle crashes and lower rates for some categories of violent crime, including rape.[20], [21]

Many injuries and injury-related deaths occur in some population groups (such as younger children from birth to age 4 years) where the intentionality of the injury is unknown and requires more detailed investigation. As these cases are examined, interventions can be developed to address ways injuries occur—for instance, unintentional poisonings in children or hangings among teenagers—that are emerging in society as growing public health concerns.

Poverty, discrimination, lack of education, and lack of employment opportunities are important risk factors for violence and must be addressed as part of any comprehensive solution to the epidemic of violence. Strategies for reducing violence should begin early in life, before violent beliefs and behavioral patterns can be adopted.

Many potentially effective culturally and linguistically competent intervention strategies for violence prevention exist, such as parent training, mentoring, home visitation, and education.[22] Evaluation of ongoing programs is a major component to help identify effective approaches for violence prevention. The public health approach to violence prevention is multidisciplinary, encouraging experts from scientific disciplines, organizations, and communities to work together to find solutions to violence in the Nation.

Many school-aged children suffer disabling and fatal injuries each year. As educational programs for school children are developed and proven effective in preventing injuries, these programs should be included in quality health education curricula at the appropriate grade level. Education should aim at reducing risks of injury directly and at preparing children to be knowledgeable adults. (See Focus Area 7. Educational and Community-Based Programs.)

A total of 45 objectives addressed injury prevention in Healthy People 2000. Twenty-six objectives were specific for unintentional injuries, and 19 objectives were specific for violence prevention. By the end of the decade, targets had been met for 11 objectives. Unintentional injury objectives showing achievement were unintentional injury hospitalizations, residential fire deaths, nonfatal head injuries, spinal cord injuries, nonfatal poisonings, and pedestrian deaths. Violence prevention objectives that met their targets were homicide, suicide, weapon carrying by adolescents, conflict resolution in schools, and child death review systems.

Progress was made for 13 objectives. Much of the progress made in unintentional injury objectives was with motor vehicle fatalities and use of vehicle occupant restraints. Those unintentional injury objectives showing progress were unintentional injury deaths, motor vehicle deaths, motor vehicle crash deaths, motor vehicle occupant protection systems, helmet use by motorcyclists and bicyclists, safety belt use laws, alcohol-related motor vehicle deaths, and drownings. Violence prevention objectives showing progress were firearm-related deaths, partner abuse, rape and attempted rape, physical fighting among adolescents aged 14 to 17 years, and the number of States with firearm storage laws.

There were six objectives with no progress or movement away from the Healthy People 2000 targets. In unintentional injury, the hospitalization rate for hip fractures remains above baseline levels, indicating no progress toward the year 2000 target. Data from five violence prevention objectives also show movement away from the year 2000 target. Those objectives relate to child abuse and neglect, assault injuries, suicide attempts among adolescents aged 14 to 17 years, battered women turned away from shelters, and suicide prevention protocols in jails.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Goal: Reduce injuries, disabilities, and deaths due to unintentional injuries and violence.

Injury Prevention

Baseline: 60.6 hospitalizations for nonfatal head injuries per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Total Population, 1998	Hospitalizations for Nonfatal Head Injuries
TOTAL	60.6
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	58.4
White	46.0

Hispanic or Latino	DSU
Not Hispanic or Latino	DSU
Black or African American	DSU
White	DSU
Gender
Female	42.8
Male	77.9
Education level
Less than high school	DNC
High school graduate	DNC
At least some college	DNC
Select populations
Males aged 15 to 24 years (not age adjusted)	117.6
Persons aged 75 years and older (not age adjusted)	174.9

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Baseline: 4.5 hospitalizations for nonfatal spinal cord injuries per 100,000 population occurred in 1998 (age adjusted to the year 2000 standard population).

Target setting method: 46 percent improvement. (Better than the best will be used when data are available.)

Total Population, 1998	Hospitalizations for Nonfatal Spinal Cord Injuries
TOTAL	4.5
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	DSU
White	3.4

Hispanic or Latino	DSU
Not Hispanic or Latino	DSU
Black or African American	DSU
White	DSU
Gender
Female	DSU
Male	7.6
Education level
Less than high school	DNC
High school graduate	DNC
At least some college	DNC

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

The physical and emotional toll associated with head and spinal cord injuries can be significant for the survivors and their families. Persons with existing disabilities from head and spinal cord injuries are at high risk for further secondary disabilities. Prevention efforts should target motor vehicle crashes, falls, firearm injury, diving, and water safety.

Among pedalcyclists killed, most died from head injuries. Similarly, the common cause of death among motorcyclists is catastrophic head injury. Death rates from head injuries have been shown to be twice as high among cyclists in States lacking helmet laws or having laws that apply only to young riders, compared with States where laws apply to all riders.

Falls account for 87 percent of all fractures among adults aged 65 years and older and are the second leading cause of both spinal cord injury and brain injury for this age group.[23], [24] Falls also cause the majority of deaths and severe injuries from head trauma among children under age 14 years. Falls account for 90 percent of the most severe playground-related injuries treated in hospital emergency departments (mostly head injuries and fractures) and one-third of reported fatalities. Head injuries are involved in about 75 percent of all reported fall-related deaths associated with playground equipment.

Many diving-related incidents also result in spinal cord injury. Diving-related injury first becomes an issue during adolescence. Injuries to males outnumber injuries to females. Diving injuries account for one of eight spinal cord injuries, with half of those injuries resulting in quadriplegia.[25]

Baseline: 11.3 deaths per 100,000 population were related to firearm injuries in 1998 (age adjusted to the year 2000 standard population).

Total Population, 1998	Firearm-Related Deaths
TOTAL	11.3
Race and ethnicity
American Indian or Alaska Native	11.3
Asian or Pacific Islander	4.2
Asian	DNC
Native Hawaiian and other Pacific Islander	DNC
Black or African American	20.3
White	10.0

Hispanic or Latino	9.7
Cuban	11.0
Mexican	9.8
Puerto Rican	8.4
Not Hispanic or Latino	11.3
Black or African American	21.0
White	9.6
Gender
Female	3.3
Male	20.1
Education level (aged 25 to 64 years)
Less than high school	21.4
High school graduate	17.7
At least some college	7.0
Select firearm-related deaths
Homicides	4.3
Suicides	6.5
Unintentional deaths	0.5

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Baseline: 19 percent of the population lived in homes with loaded and unlocked firearms in 1998 (age adjusted to the year 2000 standard population).

Total Population, 1998	Loaded, Unlocked Firearms in Home
TOTAL	19
Race and ethnicity
American Indian or Alaska Native	25
Asian or Pacific Islander	DSU
Asian	DSU
Native Hawaiian and other Pacific Islander	DSU
Black or African American	28
White	18

Hispanic or Latino	17
Not Hispanic or Latino	19
Black or African American	28
White	18
Gender
Female	16
Male	21
Education level (aged 25 years and older)
Less than high school	22
High school graduate	17
At least some college	21

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.
Note: Age adjusted to the year 2000 standard population.

Baseline: 24.0 nonfatal firearm-related injuries per 100,000 population occurred in 1997.

Data source: National Electronic Injury Surveillance System (NEISS), Consumer Product Safety Commission (CPSC).

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Total Population, 1997	Nonfatal Firearm-Related Injuries
TOTAL	24.0
Race and ethnicity
American Indian or Alaska Native	DSU
Asian or Pacific Islander	DSU
Asian	DSU
Native Hawaiian and other Pacific Islander	DSU
Black or African American	DNA
White	DNA

Hispanic or Latino	39.0
Not Hispanic or Latino	DNA
Black or African American	92.0
White	8.7
Gender
Female	5.3
Male	43.5
Education level
Less than high school	DNC
High school graduate	DNC
At least some college	DNC
Select populations
Males aged 15 to 24 years	143.8

The United States has the highest rates of lethal childhood violence than every other industrialized country.[26] The increase in the total homicide rate from 1979 through 1993 resulted solely from increases in firearm-related homicides.[27] Fatalities, however, are only part of the problem. For each of the 32,436 persons killed by a gunshot wound in the United States in 1997, approximately 2 more were treated for nonfatal wounds in hospital emergency departments.[28]

Potential data source: Inter-Agency Council on Child Abuse and Neglect (ICAN) National Database, FBI Uniform Crime Report, U.S. Department of Justice.

Death resulting from injury is one of the most profound public health issues facing children in the United States today. In 1997, nearly 19,000 children aged 19 years and under were victims of injury—33 percent from violence and 67 percent from unintentional injury.[29]

In examination of these trends in childhood injury-related cause of death, information has typically come from one of several sources (vital statistics, protective service records, and the FBI Uniform Crime Report), each with specific limitations. In response to the increasing trend of violence against children and the lack of a comprehensive data source on violent childhood deaths, the Child Fatality Review Team (CFRT) process was developed in 1978 in California.

The goal of the CFRTs is the prevention of childhood fatalities. Their responsibility is to review so-called “suspicious” or “preventable” childhood fatalities. Minimal or core standards for CFRTs must include representatives from criminal justice, health, and social services. After integrating information from multiple sources, review teams strive to determine if the cause and manner of death were recorded accurately and to suggest prevention initiatives for all relevant agencies. Simply reviewing fatalities is not helpful unless recommendations for prevention also are included and plans are made for periodic followup to ensure that recommendations are being acted on.

Focusing on children aged 14 years and under will include most “unexplained” childhood deaths and is considered a more reasonable goal to achieve. However, States should continue to improve their CFRT systems. Teams with adequate resources are encouraged to extend their review to all causes of death for all children aged 18 years and under as their ultimate goal. CFRTs also should include culturally appropriate members.

Baseline: 348.4 nonfatal poisonings per 100,000 population occurred in 1997 (age adjusted to the year 2000 standard population).

Data source: National Hospital Ambulatory Medical Care Survey (NHAMCS), CDC, NCHS.

Number	Objective Short Title
Injury Prevention
15-1	Nonfatal head injuries
15-2	Nonfatal spinal cord injuries
15-3	Firearm-related deaths
15-4	Proper firearm storage in homes
15-5	Nonfatal firearm-related injuries
15-6	Child fatality review
15-7	Nonfatal poisonings
15-8	Deaths from poisoning
15-9	Deaths from suffocation
15-10	Emergency department surveillance systems
15-11	Hospital discharge surveillance systems
15-12	Emergency department visits
Unintentional Injury Prevention
15-13	Deaths from unintentional injuries
15-14	Nonfatal unintentional injuries
15-15	Deaths from motor vehicle crashes
15-16	Pedestrian deaths
15-17	Nonfatal motor vehicle injuries
15-18	Nonfatal pedestrian injuries
15-19	Safety belts
15-20	Child restraints
15-21	Motorcycle helmet use
15-22	Graduated driver licensing
15-23	Bicycle helmet use
15-24	Bicycle helmet laws
15-25	Residential fire deaths
15-26	Functioning smoke alarms in residences
15-27	Deaths from falls
15-28	Hip fractures
15-29	Drownings
15-30	Dog bite injuries
15-31	Injury protection in school sports
Violence and Abuse Prevention
15-32	Homicides
15-33	Maltreatment and maltreatment fatalities of children
15-34	Physical assault by intimate partners
15-35	Rape or attempted rape
15-36	Sexual assault other than rape
15-37	Physical assaults
15-38	Physical fighting among adolescents
15-39	Weapon carrying by adolescents on school property


15-2.		Reduce hospitalization for nonfatal spinal cord injuries.


15-4.		Reduce the proportion of persons living in homes with firearms that are loaded and unlocked.


15-6.		(Developmental) Extend State-level child fatality review of deaths due to external causes for children aged 14 years and under.


15-7.		Reduce nonfatal poisonings.