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Recommended Framework for Presenting Injury Mortality Data

Summary

Injuries * are a substantial and preventable public health problem and account for approximately 6% of deaths in the United States. Many injury epidemiology and injury control programs depend on injury mortality and morbidity data aggregated by external cause of injury codes (E codes) for program planning and evaluation. This report provides a framework for the uniform tabulation and analysis of injury mortality data classified by the Ninth Revision of the International Classification of Diseases (ICD-9) (a subsequent report will address the application of this framework to injury morbidity data). Standard ICD-9 E-code groupings are presented in the form of a matrix and are depicted as mechanism by intent of injury. All cells in the matrix are mutually exclusive. Injury mortality data from the National Center for Health Statistics (NCHS) are presented in the matrix for 1993 to illustrate numbers of deaths within each cell. Justifications are given for assigning E codes to major categories and subcategories within the matrix.

The groupings of external causes presented in this framework were developed by CDC (National Center for Injury Prevention and Control {NCIPC} and NCHS) in collaboration with members of the American Public Health Association's Injury Control and Emergency Health Services Section (ICEHS). These groupings are intended to assist persons involved in planning and evaluating injury control programs at national, state, and local levels and are relevant for all persons who collect, code, analyze, and report injury data.

Public health researchers and other public health professionals are encouraged to adopt or adapt these groupings as a minimum framework for tabulating injury deaths and death rates. For historical continuity, vital statistics programs will continue to use tabulation standards based on both the guidelines of the World Health Organization and derivative lists developed by CDC (NCHS) for presentation of national mortality statistics. The proposed framework can be used to supplement these tabulation standards by providing more detailed presentations of injury deaths and death rates, which are useful for making policy decisions and planning injury prevention activities.

INTRODUCTION

Injuries * are a substantial and preventable public health problem. For example, in the United States in 1993, injuries accounted for 57% and 78% of all deaths among persons aged 1-34 and 15-24 years, respectively (1).

Many injury epidemiology and injury control programs depend on injury mortality and morbidity data aggregated by external cause of injury codes (E codes) for program planning and evaluation. Such data are relevant for all persons engaged in injury research, prevention, and control activities and for those who collect, code, analyze, and report data concerning injury.

External causes of injury and poisoning are a component of an internationally established classification system for mortality data -- the Manual of the International Statistical Classification of Diseases, Injuries, and Causes of Death, Ninth Revision (ICD-9) -- which was promulgated by the World Health Organization (WHO) (2). (A clinical modification of ICD-9, designated as ICD-9-CM {3}, is used for morbidity coding in the United States.) These external causes are classified into several hundred categories, each of which is designated by a four or five character code (E code), which begins with an "E" and is followed by a three- or four-digit number (e.g., E965). E codes range from E800.0 through E999.

The groupings of external causes presented in this framework were developed by CDC (National Center for Injury Prevention and Control {NCIPC} and National Center for Health Statistics {NCHS}) in collaboration with members of the American Public Health Association's Injury Control and Emergency Health Services Section (ICEHS). This minimum framework is presented in the form of a matrix, depicted as mechanism by intent of injury (e.g., poisoning-related {mechanism} suicide {intent}). The categories of external causes within the matrix are mutually exclusive. Presenting numbers of deaths in each category of the matrix provides useful information about the specific mechanism and intent of injury. In addition, by aggregating across categories, data can be summarized by using the marginal totals to describe injury deaths by either general mechanism or intent categories (e.g., deaths caused by poisoning or suicide). Certain E codes pertain to abnormal reactions and complications of medical care (E870.0-E879.9) and adverse effects of the therapeutic use of drugs (E930.0-E949.9). The proposed framework excludes these external cause groupings from the summary category of "all injuries" but includes them in the summary category of "all external causes."

In this report, recommended external cause groupings are described and used to define categories for a basic table of injury mortality data. Data are presented for 1993 to illustrate numbers of deaths within each cell; data from this year were used because they were the most current at the time the initial draft of this report was prepared. The rationale for each external cause grouping is discussed, with reference to its usefulness for program planning and in making general comparisons of injury mortality across international, national, state, and local jurisdictions.

CLASSIFYING EXTERNAL CAUSE OF INJURY DATA

Injury prevention and control activities in the United States have accelerated in the past decade. Since 1985, several documents have been published that highlight the importance of external cause of injury data in a) defining injury as a public health problem, b) identifying and characterizing risk factors, and c) developing effective prevention activities (4-9). These documents emphasize the need for health information specialists, injury researchers, and injury control practitioners to standardize the collection, processing, and tabulation of reliable and comparable injury data.

The ICD classification system and its external cause of injury codes facilitate aggregation of information regarding adverse health conditions. The universal adoption of this system by all members of WHO permits comparison of disease and injury problems among jurisdictions within one country and among several countries across time. The system originated as the International List of Causes of Deaths and was adopted in 1893 by the International Statistical Institute. The classification system has been revised approximately every 10 years since the beginning of the century. The early revisions of the system contained a chapter concerning "violent or accidental" deaths, which addressed external causes. As a result of the Sixth Revision Conference in 1948, the first undertaken by WHO, international agreement was reached about rules for assigning E codes to describe underlying cause of death. Trained coders now assign E codes drawing on cause-of-death information provided by coroners, medical examiners, and other medical-legal officers.

Under the ninth revision of the ICD, most E codes can be used to group the circumstances of an injury or poisoning along two dimensions: intent (i.e., manner) and mechanism of injury (i.e., cause of death). The classification by intent has the following groupings: accident (i.e., unintentional), suicide (i.e., intentionally self-inflicted), homicide (i.e., intentionally inflicted by another), and intent undetermined. Injuries associated with legal intervention and operations of war are classified separately. The classification by mechanism characterizes the external agents or particular activities that caused the injury (e.g., motor vehicle, firearm, submersion, fall, and poisoning). The intent of injury takes precedence in the classification, with mechanism of injury being coded within an intent category. For example, suicides and self-inflicted injuries (intent) by cutting and piercing instruments (mechanism) have their own category, which is coded as "E956," whereas suicides by poisoning are categorized as "E950-E952." Three fourths of the three- to four-digit E codes are assigned to accidents or unintentional injury (E800.0-E869.9, E880.0-E929.9), adverse effects of medical care (E870.0-E879.9), and adverse effects of the therapeutic use of drugs (E930.0-E949.9); the remaining codes include suicide (E950.0-E959.9), homicide (E960.0-E969), legal intervention (E970-E978), intent undetermined (E980.0-E989), and operations of war (E990.0-E999).

Persons in the field of injury control have given increasing attention to the mechanisms of injury, because evaluation research (10) indicates that "passive protection" through modification of consumer products and environments is most effective in reducing injury -- regardless of intent. However, the intent of injury also can be important when determining effective interventions that involve changes in human behavior (11). Standard external cause groupings that allow uniform aggregation of injury deaths by mechanism and intent are paramount for injury prevention activities. Such groupings can facilitate comparisons of injury mortality data across studies, jurisdictions, and populations; help to define and characterize injury mortality as a public health problem; and aid in determining target populations at high risk.

Within the framework of the WHO tabulation guidelines for mortality, NCHS has developed several aggregated lists for tabulating cause of death (1,12,13). In the NCHS lists, injury-related deaths are divided into four major categories: accidents and adverse effects (E800-E949) (with a subcategory for motor vehicle accidents {E810-E825} and all other accidents {E800-E807, E826-E949}); suicide (E950-E959); homicide and legal intervention (E960-E978); and all other external causes (E980-E999). These major categories have been useful for monitoring the 10 leading causes of death in the United States for 1993 (Table_1) (14). More specific injury detail is subsumed under these broad categories. The detailed mortality tabulation list shows each of the most detailed ICD categories that are used for cause-of-death coding and classification. The categories in the NCHS lists are organized initially by manner (intent) and then by mechanism. In this report, these categories are reorganized into the injury matrix. More detailed breakdowns of injury- and violence-related deaths are needed by injury researchers, epidemiologists, and public health practitioners and officials; more specific E-code groupings are needed to help define the role of other mechanisms of injuries (e.g., falls, drownings, poisonings, fires and flames, and firearms).

DEVELOPING THE MINIMUM FRAMEWORK FOR CLASSIFYING INJURY MORTALITY DATA

Until recently, public health researchers created their own groupings of external causes of injury for specific studies and reports, and no effort was made to standardize which external causes should be assigned to specified categories. This effort is now underway. The recommendations presented in this report have resulted from collaboration by persons involved in classification and coding, injury prevention and surveillance activities, and the provision of medical care to injured persons. During 1991-1992, CDC (NCIPC) collaborated with experts to assess various aspects and problems associated with assigning E codes and tabulating E-coded mortality and morbidity data. As a result of this assessment, standard E-code groupings for tabulating injury data were proposed. These proposed groupings were presented at the 1993 and 1994 annual meetings of the American Public Health Association's (APHA) Injury Control and Emergency Health Services Section (ICEHS), receiving the attention of health information specialists, injury researchers, and injury control practitioners

  • including staff from CDC (NCIPC and NCHS). A consensus was reached for supporting and continuing this project, and ICEHS was selected to serve as the organizational base for the project.

During Spring 1995, expert consultants prepared a draft report -- Recommendations for Standard E Code Groupings for Morbidity and Mortality Data Systems (Berenholz Consulting Associates, unpublished data, 1995) -- which included a proposed minimum framework for tabulating mortality and morbidity data by standard external-cause groupings. An accompanying document -- a proposed matrix for presenting E-coded data by mechanism and intent (CDC, unpublished data, 1995) also was prepared.

In Summer 1995, these two documents were circulated to a wide constituency, including the members of ICEHS and persons representing public health and professional organizations. Comments were received from numerous persons and organizations; feedback also was obtained from project officers of the Vital Statistics Cooperative Program, from members of the International Collaborative Effort on Injury Statistics, and as a result of further discussions at the annual APHA meeting in November 1996. All of these comments were used to refine E-code groupings presented in the matrix and to make final recommendations for the minimum framework for tabulating injury mortality data.

These recommendations are intended to encourage the use of the injury matrix (Table_2) for presenting injury mortality data at national, state, and local levels and for use in international comparisons. However, vital statistics programs at the national and state levels also will continue to use categories consistent with international requirements and historic presentations of deaths and death rates by cause of death. In addition, categories historically used for tabulations of NCHS mortality data in Vital Statistics of the United States (12-14) and Healthy People 2000: National Health Promotion and Disease Prevention Objectives (8) will be used to maintain comparability of data across time and among geographic areas. The groupings and matrix recommended in this report augment the traditional tabulation categories by shifting the emphasis from manner of death (e.g., homicide, suicide, and unintentional injury) to a combination of mechanism by intent of death. This change in emphasis illuminates important aspects of injury as a public health problem that may be more amenable to prevention. For example, NCHS prepared the Injury Chartbook in Health, United States, 1996-97, which incorporates the matrix approach as a method for describing and understanding major public health problems (15).

Researchers and planners are encouraged to use the injury matrix when examining injury mortality data to more clearly depict the overall burden of cause-specific, injury-related fatalities. The new injury matrix is not intended to replace more specific or different groupings that are needed for special studies and projects. The applicability of the groupings in the matrix may differ for data presentations that address specific geographical regions, age groups, or mechanisms of injury and for targeted programs and research hypotheses. Access to unaggregated data is essential for persons undertaking more detailed statistical investigations. The goal of establishing both ICD-9 external cause groupings and the matrix is to enhance the usefulness of injury mortality data for current surveillance and prevention activities. A similar approach will be used to define a new standard external cause of injury grouping after ICD-10 coding is implemented in the United States.

USES OF MORTALITY DATA FOR INJURY PREVENTION

Using the matrix to tabulate injury data by external cause and intent of injury will provide essential information for assessing health outcomes (e.g., injury-related deaths) in relation to public-health-based injury prevention programs. The public health model addresses three sets of factors: host, agent, and environment, for which E-coded data provide important information. Successful injury prevention programs have either modified behavior (e.g., the wearing of seat belts and helmets {16}), addressed problems associated with hazardous agents (e.g., automobiles {17}, flammable children's nightwear {18}, packaging for drugs {19}, and home-care products {20}) or addressed environmental hazards (e.g., bridge abutments, road surfaces and shoulders {21}, and residential pools {22}). The most effective interventions have focused on passive protection, which is accomplished by changing agents and environments. Passive protection reduces the likelihood of injury, regardless of the behavior of those involved in an injury-related incident.

To be useful, E-coded mortality data must reflect accurate, specific information about the circumstances surrounding the injury-related incident that are recorded on the death certificate (23,24). The quality of these data can be improved by

  • encouraging greater specificity in reporting and avoiding the use of generalized codes (e.g., "fracture, cause unspecified," "unspecified accident," and "assault by unspecified means");

  • providing sufficient narrative detail in the item "how the injury occurred" on the death certificate to enhance the information in the cause-of-death section of the certificate (identifying when an agent {e.g., consumer product or type of motor vehicle} is involved in an injury and obtaining specific information about the agent and the injury scenario are particularly important, because that information is not routinely captured in the E code); and

  • educating medical certifiers about the usefulness of E-coded mortality data.

BASIC INJURY MORTALITY TABLES

The proposed minimum framework for tabulating injury mortality data (Table_2) depicts the E codes assigned to each cell within the mechanism-by-intent matrix. Two major recommendations vary from the traditional way NCHS tabulates data regarding injury deaths (Table_1). First, an "all injury" category has been defined, which includes all injury mechanisms in the matrix except abnormal reactions and complications of medical care and adverse effects from the therapeutic use of drugs. NCHS historically has tabulated "adverse effects" with "accidents," or unintentional injuries. However, these adverse effects traditionally have not been viewed as the responsibility of public health professionals in the field of injury prevention and control (25). The "all injury" category includes only injury mechanisms (or causes of death) that are considered pertinent to injury prevention and surveillance activities. Second, deaths by homicide and deaths caused by legal intervention are tabulated separately in the matrix table. Legal-intervention codes have been combined with operations-of-war codes to represent a separate column entitled "other" in the matrix. NCHS historically has reported homicides and deaths caused by legal intervention together. For comparison with mortality reports by NCHS (14), homicide and deaths from legal intervention can be combined.

The numbers of injury-related deaths and death rates in 1993, according to the E-code groupings in the matrix (Table_2) (1), provide an overview of the major causes of injury-related death by manner of death in the United States (Table_3). The "all injuries" category sums to 148,136 deaths with an additional 2,925 deaths caused by adverse effects of medical care and therapeutic use of drugs. These two distinct categories represent 151,061 deaths from "all external causes" of injury and poisoning.

IMPORTANCE OF NAMING CONVENTIONS

Specific naming conventions should be used to differentiate the proposed categories from the traditional injury tabulations of international, national, and state vital statistics data. For example, the proposed category of "Motor Vehicle Traffic" (E810-E819; E958.5; E988.5) differs from the traditional presentation of deaths under the heading "Motor Vehicle Accidents" (E810-E825) in that "Motor Vehicle Traffic" is restricted to deaths from motor vehicles occurring in traffic on public highways, including suicides and deaths from motor vehicles that are "intent undetermined." The traditional category "Motor Vehicle Accidents" includes these deaths and deaths from incidents involving motor vehicles being used in recreational or sporting activities off the highway. The proposed category also differs from the grouping "Motor Vehicle Traffic Accidents" (E810-E819) used in routine vital statistics tabulations, which includes only unintentional traffic-related deaths. The number of deaths in each of the three distinct groupings is similar, but not the same. Deaths from "Motor Vehicle Traffic" total 41,021, from "Motor Vehicle Accidents" 41,893, and from "Motor Vehicle Traffic Accidents" 40,899. Maintaining clear distinctions in naming conventions is essential to prevent confusion among persons who use the data. In any analyses of injury data, the appropriate E codes should be documented with the category name.

ACCOMMODATING A THIRD DIMENSION TO THE MATRIX TABLE

The display of data in the mechanism-by-intent table can be modified to accommodate a third dimension (e.g., age) (26). For example, the total number of injury deaths and death rates per 100,000 population for 1993 can be categorized according to the "intent-by-mechanism" categories and age of the decedent (Table_4) and (Table_5). Arranging the data in this manner indicates that 359 (78%) of the 462 homicides among children aged 10-14 years involved firearms (Table_4). For drowning among children aged 0-14 years, the intent of injury is predominantly unintentional. For deaths from poisoning among persons aged 25-44 years, intent of injury could not be determined for 1,327 (14%) of the total of 9,547 deaths.

JUSTIFICATION FOR E-CODE GROUPINGS, BY SELECTED EXTERNAL CAUSES OF INJURY IN THE MINIMUM FRAMEWORK

Five criteria were used to define the recommended E-code groupings, including a) consistency with ICD-9 coding conventions; b) extent to which data were needed for surveillance and prevention activities at the national, state, and local levels and for international comparisons; c) assurance that E codes assigned to groupings were mutually exclusive; d) frequency of deaths assigned within specific mechanism-by-intent-of-injury categories; and e) desire to accommodate injury morbidity data by using the same matrix. The following paragraphs contain justifications based on these criteria for each recommended E-code grouping in the minimum framework for presenting injury mortality data. The number of deaths reported in each cell of the matrix was assessed by using 1993 national injury mortality data from NCHS (1). The number of deaths reported in the following section is from this data set, unless otherwise specified.

Category: Cut/Pierce Number of Deaths: 3,854 E Codes: E920.0-.9, E956, E966, E974, E986

This category includes deaths caused by cutting and piercing instruments. E codes for unintentional deaths caused by cutting and piercing allow for some specification of the type of instruments or objects involved in the injury incident, including knives, swords, and daggers; power lawn mowers, power hand tools, and household appliances; and other specified and unspecified sharp objects. The codes for homicide and suicide do not permit identification of specific products. In 1993, only 3% of the cutting and piercing deaths were coded as unintentional. Thus, the specific cutting or piercing instrument used in 97% of deaths in this category cannot be identified by using E codes.

Category: Drowning Number of Deaths: 5,059 E Codes: E830.0-.9, E832.0-.9, E910.0-.9, E954, E964, E984

This category includes deaths from drowning and submersion with and without involvement of watercraft. In 1993, a total of 13% of unintentional drownings (583 deaths {E830.0-.9; E832.0-.9}) involved boats and other types of water transport. The remaining 87% {E910.0-.9} involved drowning in seas, rivers, pools, bathtubs, and other bodies of water where no watercraft was involved. Codes for drownings identified as suicide and homicide do not specify whether watercraft was involved.

Category: Falls Number of Deaths: 10,473 E Codes: E880.0-E886.9, E888, E957.0-.9, E968.1, E987.0-.9

This category includes deaths from falls associated with various mechanisms. Some of these E codes specify the type of fall involved. For example, within the unintentional falls category, there are E codes for falls involving steps or stairs (1,087 deaths {E880.0,.9}), ladders and scaffolds (301 deaths {E881.0,.1}), and other falls from one level to another (1,156 deaths {E884.0-.9} including 523 deaths from a chair or bed {E884.2}). Different interventions are required by different types of falls, but greater specificity can be provided by specific studies of deaths caused by falls. Of concern is the substantial number of cases (6,099 deaths {E888}) coded as "other and unspecified fall." The general code for "fracture, cause unspecified" (3,353 deaths {E887}) has been assigned to the "other" category rather than the falls category, because this E code is used for fractures when nothing is known about the cause. Greater attention to documenting the circumstances of injury is needed to reduce the substantial number of unspecified fall-related deaths and to provide more useful data for injury prevention activities.

For falls from high places, 621 deaths were coded as unintentional falls (509 deaths from a building or other structure {E882} and 112 deaths from a cliff {E884.1}), 605 suicides were coded as "jumping from high place" (E957.0-.9), 24 homicides were coded as "pushing from high place" (E968.1), and 56 deaths were coded as "falling from high place, intent undetermined" (E987.0-.9).

Determining where to assign codes for falls in, on, or from transport vehicles (e.g., boats, planes, and trains) was difficult. Although all falls could be clustered together, keeping them with transport groupings was determined to be more useful, so that prevention programs that focus on different modes of transport can account for falls.

Category: Fire/Burn Number of Deaths: 4,547 E Codes: E890.0-E899; E924.0-.9; E958.1,.2,.7; E961; E968.0,.3; E988.1,.2,.7

This category includes deaths from fire and flames and from hot objects and substances. It does not include burns from electric current, from exposure to radiation from infrared heaters and lamps or from ultraviolet light sources (e.g., sunburn), or from explosions of combustible material. Deaths from these mechanisms are excluded from this category because E codes do not distinguish between burns and other types of injury associated with these mechanisms. Subcategories are included for fire/flame and hot object/substance injuries. These two subcategories combined represent a substantial portion of injuries traditionally treated in burn units and addressed by prevention programs.

Subcategory: Fire/Flame Number of Deaths: 4,398 E Codes: E890.0-E899, E958.1, E968.0, E988.1

This subcategory identifies deaths caused by fire and flames, including those from smoke inhalation. Structural fires, primarily in private residences, are the major cause of fire- and flame-related deaths. Unintentional deaths from fire and flames mostly include fires in private dwellings (3,268 deaths {E890.0-.9}), fires in other structures (68 deaths {E891.0-.9}), and clothing ignition (157 deaths {E893.0-.9}). Four deaths coded to "explosion, burning of watercraft" (E837.0-.9) were grouped with other watercraft-related deaths in the "transport, other" category. As previously mentioned, other explosion-related deaths are not included in this category. Thus, this category is considered an undercount of all deaths caused by fire and flames (27).

Subcategory: Hot Objects/Substances Number of Deaths: 149 E Codes: E924.0-.9; E958.2,.7; E961; E968.3; E988.2,.7

This subcategory includes deaths caused by hot liquids and steam, caustics, and corrosives. These injuries rarely are fatal in the United States, but they account for a substantial number of emergency department visits and hospitalizations.

Category: Firearms Number of Deaths: 39,595 E Codes: E922.0-.9, E955.0-.4, E965.0-.4, E970, E985.0-.4

This category includes all codes related to deaths from firearms, including unintentional, suicide, homicide, legal intervention, and undetermined intent. Firearms are a substantial cause of death across all manner/intent categories. Among all firearm-related deaths, 3.8% were coded as unintentional, 47.8% as suicide, 46.1% as homicide, 1.4% as undetermined, and 0.8% as legal intervention.

The category of deaths from firearms does not include deaths resulting from explosives. For homicide and suicide involving firearms, the fourth digit of the E code distinguishes firearms (.0-.4) from explosives (.5-.9). Intentional deaths (32 deaths {E955.5,.9, E965.5-.9}) and unintentional deaths (178 deaths {E923.0-.9} resulting from explosives are assigned to the "other specified and classifiable" category.

Although E codes permit differentiation among handguns, shotguns, hunting rifles, and military firearms, the type of firearm often is not reported. Currently, conclusions about the contribution of handguns or long guns to deaths cannot be drawn from NCHS mortality data, because most cases are coded as "other or unspecified firearm." The type of firearm was unspecified in 75% of firearm-related deaths in 1993. More specific data are needed to define the role of certain types of firearms in the injury incident (28).

The Department of Justice's Uniform Crime Reports database (29,30) provides information on firearms involved in homicides, but does not report on firearms involved in suicides or unintentional deaths from firearms. The Uniform Crime Reports database reported 24,530 murders for 1993. The type of weapon used was reported for 23,271 (94.9%) of these murders; 16,189 (70%) of these murders involved firearms, and 82% of firearm homicides involved a handgun. In contrast, NCHS mortality data (14) indicated 26,009 homicides and legal interventions in 1993, with 18,571 (71.4%) involving firearms. Of the 356 deaths (E970-E978) resulting from legal intervention, 318 deaths (89%) (E970) involved firearms.

Category: Machinery Number of Deaths: 999 E Codes: E919.0-.9

This category includes injuries associated with machinery used in various industrial and occupational activities. For example, 549 deaths were associated with agricultural machinery (E919.0), 40 deaths with mining machinery (E919.1), 133 deaths with lifting machinery (E919.2), and 104 deaths with earthmoving machinery (E919.7). Although this category does not account for a substantial percentage of deaths included in 1993 U.S. mortality data, it may figure more prominently in mortality data of specific states or other countries. This category also is important for analyzing occupational mortality data.

Category: Motor Vehicle Traffic Number of Deaths: 41,021 E Codes: E810.0-E819.9, E958.5, E988.5

This category differs from the traditional "Motor Vehicle Accident" category (E810-E825) and is designed to permit comparison of mortality data from NCHS's National Vital Statistics System (1) and the National Highway Traffic Safety Administration's (NHTSA) Fatality and Analysis Reporting System (FARS) (31,32). This category includes all deaths resulting from motor-vehicle-traffic injuries involving automobiles, vans, trucks, motorcycles, and other motorized cycles known or assumed to be traveling on public roads or highways. This category does not include E codes E820-E825, which refer to non-traffic and off-road deaths, but does include E codes E958.5 and E988.5, which refer to deaths judged to be suicide or intent undetermined. During the past decade, an average of 1,006 off-road deaths occurred per year, and an average of 44,813 deaths from motor-vehicle traffic occurred per year. Recently, an average of 100 motor-vehicle-related deaths per year have been coded as suicide or intent undetermined.

Five major subcategories identifying the deceased's involvement in the traffic-related incidents are recommended for inclusion in the minimum reporting framework. These subcategories are specified using the fourth digit of the E code, including a) occupant (24,586 deaths, E810-E819 {.0,.1 *}): vehicle occupant as driver or passenger; b) motorcyclist (1,927 deaths, E810-E819 {.2,.3}): as driver or passenger; c) pedal cyclist (789 deaths, E810-E819{.6}): whose death resulted from a collision between a pedal cycle (e.g., bicycle) and motor vehicle in traffic; d) pedestrian (5,978 deaths, E810-E819{.7}): whose death resulted from being hit by a motor vehicle on a public road or highway; and e) unspecified (7,583 deaths, E810-E819{.9}): a death where the deceased was coded as "unspecified person." Three fourth-digit codes (i.e., .4 -- "occupant of streetcar," .5 -- "rider of animal," and .8 -- "other specified person") are not separated because of the minimal numbers of deaths in these categories. However, because they are included in the overall "Motor Vehicle Traffic" category, the sum of these categories can be derived by subtraction.

In 1993 in the United States, 108 motor-vehicle-related deaths were coded as suicide, and 14 were coded as intent undetermined. No specific E code exists for homicide by motor vehicle in ICD-9 (although an E code for motor vehicle assaults {E968.5} has been added to the ICD-9-CM for coding injury morbidity data).

Presenting deaths resulting from motor-vehicle traffic in the basic mortality table will permit researchers and data analysts to bring greater specificity to tabulating the number of traffic-related deaths by using both FARS and NCHS mortality data (1). The ICD-9 system lacks generalized E codes for "motor vehicle occupant" and "motorcycle occupant." When it is unknown whether the deceased was the driver or passenger in a car or motorcycle, cause of death is coded with the fourth digit of the E code as "unspecified person." A total of 7,583 deaths (18.5% of all deaths from motor-vehicle traffic) in 1993 were coded as "unspecified person;" this substantial number of unspecified cases obscures the magnitude of occupant-related deaths. Because FARS uses police crash reports rather than death certificates, information obtained by using this system almost always specifies the involvement of the deceased. Thus, FARS data can be used to approximate the distribution of deaths reported as "unspecified persons" in the NCHS mortality data into motorcyclists and occupants of other motor vehicles.

NCHS and FARS national mortality data sets can be compared for persons who died from injuries caused by motor-vehicle traffic in 1993 (Table_6). For both NCHS and FARS data sets, the motor vehicle "occupant" category excludes persons on motor-cycles, whereas "motorcyclist" includes drivers and passengers on motorcycles. "Other" for the NCHS data set includes occupant of streetcar, rider of animal, other specified person, and cases coded as suicide or intent undetermined. "Other" for the FARS data set means "other non-occupant."

NCHS and FARS data sets also differ for other categories. The number for deaths caused by motor-vehicle traffic in the NCHS data set is 906 higher than that reported by FARS (Table_6). This difference primarily exists because FARS includes only those deaths that occur within 30 days of the incident, whereas the NCHS vital statistics system includes all deaths from motor-vehicle traffic. In addition, ICD-9 E-coding rules for motor-vehicle-related deaths instruct the coders to default to the "traffic" codes when information is insufficient. The number of pedestrians killed in traffic-related incidents is higher in the NCHS data set than in the FARS data set (Table_4). A substantial number of injured pedestrians are elderly; thus, they are less able to survive less severe injuries and more likely to die of complications of their injuries several weeks or months after the incident. Such persons would not meet the inclusion criteria for FARS.

The percentage distributions of deaths for NCHS and FARS data sets by motor-vehicle traffic subcategories are defined by the deceased's involvement in the incident (Table_6). NCHS and FARS data differ primarily in three categories: "occupant " (59.9% in NCHS versus 77.5% in FARS), "motorcyclist " (4.7% in NCHS versus 6.1% in FARS), and "unspecified" (18.5% in NCHS versus zero in FARS).

When only specified occupants and motorcyclists are considered in both data sets, the distribution between these two categories is almost identical (for "occupant," 92.73% in NCHS versus 92.71% in FARS) (Table_6). Thus, the "unspecified" deaths in the NCHS data set can be partitioned and distributed to the "occupant" and "motorcyclist" categories based on either FARS or NCHS data. The notable undercount of deaths of motor-vehicle occupants and motorcyclists that results from using NCHS mortality data can be adjusted upward by distributing the "unspecified" deaths (Box)(Table_1B).

Category: Pedal Cyclist, Other Number of Deaths: 116 E Codes: E800-E807 (.3), E820-E825 (.6), E826.1,.9

This category includes all deaths among pedal cyclists not involving motor-vehicle traffic incidents. It includes persons hit by a train (11 deaths {E800-E807 (.3)}) or by a motor vehicle while not in traffic (one death {E820-E825 (.3)}), hit by other means of transport (one death {E827-E829 (.1)}, and killed by a collision with another pedal cycle or by another mishap (97 deaths {E826.1,.9}). The total number of persons whose death can be attributed to pedal cyclist-related incidents can be computed by adding cases in the "Motor Vehicle Traffic: Pedal Cyclist" and "Pedal Cyclist, Other" categories.

This category is intended to include only deaths to pedal cycle riders, not all deaths involving a pedal cycle. The codes (E826.2-.8) that specify that the deceased was not the pedal cyclist or a pedestrian have been assigned to the "Transportation: Other" category. In 1993, this included one person, a "rider of an animal." Deaths coded as E826.9, where the person injured was "unspecified," were included in this category because of the high likelihood that the deceased was a pedal cyclist. In 1993, only six cases were coded as E826.9. However, better documentation about the role of the deceased in the pedal cycle incident is needed from the death investigation to minimize the number of unspecified deaths.

Category: Pedestrian, Other Number of Deaths: 941 E Codes: E800-E807 (.2), E820-E825 (.7), E826-E829 (.0)

This category includes codes for pedestrians hit by a train (533 deaths {E805.2}), a motor vehicle where the collision did not occur in traffic (i.e., on a public road or highway) (395 deaths {E820-E825 (.7)}), or another means of transportation (10 deaths {E826-E829 (.0)}). For the latter two categories, 374 of the 405 deaths were coded as "other motor-vehicle non-traffic accident involving collision with a moving object (pedestrian)" (E822.7). Many of these fatal incidents involved a person (often a child aged less than 5 years) hit by a motor vehicle while not on a public street, road, or highway. Common locations for such incidents include private driveways and parking lots. The total number of deaths of pedestrians can be obtained by adding the number of cases in the "Motor-Vehicle Traffic: Pedestrian" and "Pedestrian, Other" categories.

More than half of the deaths in the "Pedestrian, Other" category involve railway trains and not motor vehicles, to which most traditional pedestrian categories have referred. For persons concerned with monitoring railway-related deaths, deaths of pedestrians (536 deaths {E800-E807(.2)} should be considered along with all other railway-related deaths assigned to the "Transport, Other" category.

Category: Transport, Other Number of Deaths: 1,829 E Codes: E800-E807(.0,.1,.8,.9), E820-E825(.0-.5, .8,.9), E826.2-.8, E827-E829(.2-.9), E831.0-.9, E833.0-E845.9

This category includes deaths associated with various other means of transportation: railway (123 deaths {E800-E807 (.0,.1,.8,.9)}), off-road and other motor vehicles not in traffic (592 deaths {E820-E825 (.0-.5, .8-.9)}), other surface transport (74 deaths {E827-829(.2-.9)}), water (180 deaths {E831.0-.9, E833.0-E838.9}, and aircraft (859 deaths {E840.0-844.9}). Some specific circumstances associated with these means of transport (e.g., streetcars and horse-and-carriages) have been assigned to other categories. For example, drowning associated with boats was assigned to "Drowning/Submersion," and pedal cyclists and pedestrians hit by trains (536 pedestrians and 11 pedal cyclists) were assigned to "Pedal Cyclists, Other" and "Pedestrian, Other," respectively.

Category: Natural/Environmental Factors Number of Deaths: 1,559 E Codes: E900.0-E909, E928.0-.2, E958.3, E988.3

This category combines several distinct factors. The number of deaths in this category varies substantially, depending on the extent of adverse environmental conditions. In 1993, a total of 299 deaths were caused by excessive heat (E900.0-.9), 641 deaths were caused by excessive cold (E901.0-.9), 123 deaths were caused by hunger (E904.1), and 106 deaths resulted from excessive exposure to weather conditions {E904.3}. In addition, 96 deaths were associated with cataclysmic storms (e.g., tornados, floods, and hurricanes) (E908), and 17 deaths were associated with cataclysmic land movement (e.g., earthquakes, land slides, avalanches, and tidal waves) (E909). Deaths caused by bites and stings also are included as a subcategory.

Subcategory: Bites and Stings Number of Deaths: 89 E Codes: E905.0-.6,.9; E906.0-.4,.9

This subcategory includes deaths from bites and stings of venomous and nonvenomous insects and other animals. For example, 39 deaths resulted from stings from hornets, wasps, and bees (E905.3), and 20 deaths were caused by dog bites (E906.0). Although these injuries rarely are fatal, they result in a substantial number of visits to hospital emergency departments.

Category: Overexertion Number of Deaths: 19 E Code: E927

This category contains injuries that rarely are fatal (19 deaths in 1993). However, many persons with injuries caused by overexertion are either treated in emergency departments, hospitalized, or both.

Category: Poisoning Number of Deaths: 15,770 E Codes: E850.0-E869.9, E950.0-E952.9, E962.0-.9, E972, E980.0-E982.9

The proposed basic matrix aggregates all codes referring to poisoning without differentiating among specific agents. However, E codes exist for specific agents. Drugs and other medicinal substances accounted for 78% and gases accounted for 18% of all deaths resulting from poisoning. Among the 12,133 deaths attributed to drugs and other medicinal substances (E850.0-E858.9, E950.0-.5, E962.0, E980.0-.5), 14% (1,742 deaths) were coded as intent undetermined (E980.0-.5). The other deaths involving drugs were distributed as follows: 7,382 deaths were coded as unintentional (E850.0-E858.9), 2,975 deaths as suicide (E950.0-.5), and 34 deaths as homicide (E962.0). Among deaths involving gases, 646 deaths were coded as unintentional (E868.0-E869.9), 2,092 deaths were coded as suicide (E951.0-E952.9), and 107 deaths were coded as intent undetermined (E981.0-E982.9). Other substances involved in unintentional poisoning were alcohol (337 deaths {E860.0-.9}); disinfectants, cleansers, paints, and lubricants (70 deaths {E861.0-E862.9}); insecticides, herbicides, fungicides, and fumigants (16 deaths {E863.0-.9}); corrosives and caustics (13 deaths {E864.0-.4}); and food (five deaths {E865.0-.9}). The category for poisoning does not include the 201 deaths resulting from "drugs, medicinal, and biological substances causing adverse effects in therapeutic use (E930.0-E949.9)," which are assigned to the "Adverse Effects" category.

Category: Struck By/Against Number of Deaths: 1,273 E Codes: E916-E917.9, E960.0, E968.2, E973, E975

This category includes injuries resulting from being struck by or striking against objects or persons. Although E codes exist for unintentional injury and assault, self-inflicted or "intent undetermined" deaths have no specific E codes. The E codes for unintentional injuries specify being struck accidentally by a falling object (714 deaths {E916}) and striking against or being struck accidentally by objects or persons (187 deaths {E917.0-.9}), including 42 deaths coded as being associated with sports {E917.0}. The E codes for homicide include being struck by a blunt or thrown object (279 deaths {E968.2}) and injuries sustained in an unarmed fight or brawl (89 deaths {E960.0}).

Consideration was given to including E codes associated with intentionally jumping or lying before a moving object (278 deaths {E958.0}), assuming that the damage results from being struck by the moving object. However, this code was not included because it is used primarily for suicide attempts caused by a person stepping in front of moving transport (e.g., trains, subways, and cars). These E codes have been assigned to the "Other Specified and Classifiable" category.

Category: Suffocation Number of Deaths: 9,835 E Codes: E911-E913.9, E953.0-.9, E963, E983.0-.9

This category represents two major ways in which suffocation causes deaths: a) by the inhalation or ingestion of food or other objects that block respiration and b) by other mechanical means that hinder breathing (e.g., plastic bag over nose or mouth, suffocation by bedding, and unintentional or intentional hanging or strangulation). Food and other objects blocking respiration accounted for 3,160 deaths (E911-E912), or 76% of the unintentional deaths resulting from suffocation. Eighty-four percent of the suffocation-related suicides (3,886 deaths {E953.0}) were caused by hanging.

Category: Other Specified and Classifiable Number of Deaths: 2,353 E Codes: see (Table_3)

This category contains the codes for causes of injury death that are not assigned to specific categories within the matrix. For unintentional injury, this category includes mechanisms such as foreign body entering orifice (22 deaths {E915}); caught accidentally in or between objects (91 deaths {E918}); explosions (227 deaths {E921.0-.9, E923.0-.9}); and electric current (548 deaths {E925.0-.9}). This category also contains codes for the late effects of specific unintentional injury, including motor vehicle (385 deaths {E929.0}), other transport (11 deaths {E929.1}), poisoning (12 deaths {E929.2}), falls (272 deaths {E929.3}), fire (two deaths {E929.4}), and natural and environmental factors (15 deaths {E929.5}). These deaths were placed in this grouping to separate them from the acute events and because there were no comparable late-effects E codes for specific mechanisms of intentional injury.

For suicide, 278 deaths were associated with a person intentionally jumping in front of a moving object (E958.0), as distinguished from a "fall" or "struck by/against." For homicide, this category includes rape (six deaths {E960.1}), child battering (311 deaths {E967.0-.9}), explosives (18 deaths {E965.5-.9}), and criminal neglect (28 deaths {E968.4}). For other causes of violence, 30 deaths were associated with legal execution {E978}).

Category: Other Specified, Not Elsewhere Classifiable Number of Deaths: 1,449 E Codes: see (Table_3)

This category contains codes for mechanisms of injury that have been reported on the death certificate but for which no specified E codes exist. The largest contributor to this category is "assault by other specified means" (932 deaths {E968.8}). This category contains other late-effects codes, including other specific unintentional injury (90 deaths {E929.8}), self-inflicted (43 deaths {E959}), assault (161 deaths {E969}), and injuries of undetermined intent (26 deaths {E989}).

Category: Unspecified Number of Deaths: 7,444 E Codes: see (Table_3)

This category contains codes to accommodate cases where the mechanisms are not reported on the death certificate. In some instances, categorizing a death as "unspecified" is appropriate. The largest contributors to this category are "fracture, cause unspecified" (3,353 deaths {E887}), "unspecified accidents" (2,477 deaths {E928.9}), "late effects of unspecified accidents" (233 deaths {E929.9}), and "assault by unspecified means" (1,056 deaths {E968.9}). Persons who provide data (e.g., coroners and medical examiners) should strive to be more specific in reporting causes of death and injury.

Category: Adverse Effects Number of Deaths: 2,925 E Codes: E870-E879, E930.0-E949.9

This category includes a series of codes clustered under "misadventures to patients during surgical and medical care" (418 deaths {E870.0-E876.9}), "surgical and medical procedures as the cause of abnormal reaction of patient or later complication, without mention of misadventure at the time of procedure" (2,306 deaths {E878.0-E879.9}), and "drugs and medicinal and biological substances causing adverse effects in therapeutic use" (201 deaths {E930.0-E949.9}). Adverse effects are separated from other external causes of injury and are not included in the calculation of injury deaths and death rates.

CONCLUSIONS

Public health professionals and researchers are encouraged to adopt the recommended framework for presenting injury mortality data to supplement the traditional tabulations of vital statistics mortality data. This framework can provide the basis for comparison of national and state injury-mortality statistics for use in identifying external causes of injury death needing priority public health attention in jurisdictions. The process of developing the recommended framework has involved the participation of federal, state, private, and professional organizations. Future efforts, using a similar process, will be directed to refine the framework, to develop recommendations for presenting injury-morbidity data, and to prepare for the transition involved in implementing and presenting mortality and morbidity data using the tenth revision of the International Classification of Diseases' (ICD-10) and the ICD-10 Clinical Modifications' external causes of injury and poisoning codes. Acknowledgements

We thank Dr. Joe Sniezek and Mr. Hank Weiss for their expert consultation and for early contributions in this effort to develop a framework for presenting injury data, Ms. Helen Jakimenko for her helpful clerical support, and Ms. Rachel Wilson for her editorial expertise in preparing the final version of this report for publication.

References

  1. Department of Health and Human Services. Public use data tape: 1993 -- detail mortality file. Hyattsville, MD: National Center for Health Statistics, 1995.

  2. World Health Organization. Manual of the international statistical classification of diseases, injuries, and causes of death, based on the recommendations of the Ninth Revision Conference, 1975. Geneva: World Health Organization, 1977.

  3. US Department of Health and Human Services, Public Health Service, Health Care Financing Administration. International classification of diseases, 9th revision, clinical modification, sixth revision. October 1, 1996.

  4. National Academy of Sciences. Injury in America. Washington, DC: National Academy Press, 1985.

  5. National Academy of Sciences. Injury control. Washington, DC: National Academy Press, 1988.

  6. Rice DP, MacKenzie EJ. Cost of injury in the United States: a report to Congress. San Francisco: Institute for Health and Aging, University of California and Injury Prevention Center, The Johns Hopkins University, 1989.

  7. National Committee for Injury Prevention and Control. Injury prevention: meeting the challenge. New York: Oxford University Press, 1989.

  8. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives: full report, with commentary. Washington, DC: US Government Printing Office, 1991; DHHS publication no. (PHS)91-50212.

  9. Injury control in the 1990s: a national plan for action -- a report to the second World Conference on Injury Control, May, 1993.

  10. Christoffel T, Teret SP. Protecting the public: legal issues in injury prevention. New York, NY: Oxford University Press, 1993;173-210.

  11. Mercy JA, Potter LB. Combining analysis and action to solve the problem of youth violence. In: Powell KE, Hawkins DF, eds. Youth violence prevention: descriptions and baseline data from 13 evaluation projects. Am J Prev Med 1996(suppl. 12):1-2.

  12. National Center for Health Statistics. Vital statistics, ICD-9 underlying cause-of-death lists for tabulating mortality statistics. NCHS instruction manual; part 9. Hyattsville, Maryland: Public Health Service, 1979.

  13. Gardner P, Rosenberg HM, Wilson RW. Leading causes of death by age, sex, race, and Hispanic origin: United States, 1992. National Center for Health Statistics. Vital Health Stat 1996;20.

  14. Gardner P, Hudson BL. Advance report of final mortality statistics, 1993. Monthly vital statistics report. Hyattsville, MD: National Center for Health Statistics, 1996;44(suppl.).

  15. Fingerhut LA, Warner M. Injury chartbook. In: Health, United States, 1996-97. Hyattsville, MD: National Center for Health Statistics, 1997.

  16. National Highway Traffic Safety Administration. Report to Congress: benefits of safety belts and motorcycle helmets, based on data from the Crash Outcome Data Evaluation System (CODES). Washington, DC: Department of Transportation, 1996; DOT HS 808347.

  17. Robertson LS. Automobile safety regulations and death reductions in the United States. Am J Public Health 1981;71:818-22.

  18. McLoughlin E, Clarke N, Stahl K, Crawford JD. One pediatric burn unit's experience with sleep-wear related injuries. Pediatrics 1977;60:405-9.

  19. Rodgers GB. The safety effects of child resistant packaging for oral prescription drugs: two decades of experience. JAMA 1996;275:1661-5.

  20. Howes DR. An evaluation of the effectiveness of child-resistant packaging. Washington, DC: Consumer Product Safety Commission, 1978.

  21. Kraus JF, Anderson CL, Arzemanian S, Salatka M, Hemyari P, Sun G. Epidemiological aspects of fatal and severe injury urban freeway crashes. Accident Analysis and Prevention 1993;25:229-39.

  22. Pearn JH, Wong RY, Brown J, Ching YC, Bart R Jr., Hammar S. Drowning and near-drowning involving children: a five year total population study from the city and county of Honolulu. Am J Public Health 1979;69:450-4.

  23. Dijkhuis H, Zwerling C, Parish G, Bennett T, Kemper HC. Medical examiner data in injury surveillance: a comparison with death certificates. Am J Epidemiol 1994;139:637-43.

  24. Moyer LA, Boyle CA, Pollock DA. Validity of death certificates for injury-related causes of death. Am J Epidemiol 1989;130:1024-32.

  25. Smith GS, Langlois JA, Buechner JS. Methodological issues in using hospital discharge data to determine the incidence of hospitalized injuries. Am J Epidemiol 1991;134:1146-58.

  26. Fingerhut LA, Annest JL, Baker SP, Kochanek KD, McLoughlin E. Injury mortality among children and teenagers in the United States, 1993. Injury Prevention 1996;2:93-4.

  27. Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends, and data sources. J Burn Care Rehabil 1996;17:95-108.

  28. Wintemute GJ. The relationship between firearm design and firearm violence: handguns in the 1990s. JAMA 1996;275:1749-53.

  29. Federal Bureau of Investigation. Uniform Crime Reports: crime in the United States. Washington, DC: US Department of Justice, 1994.

  30. Rokaw WM, Mercy JA, Smith JC. Comparing death certificate data with FBI crime reporting statistics on U.S. homicides. Public Health Rep 1990;105:447-55.

  31. National Highway Traffic Safety Administration. Traffic safety facts 1993: a compilation of motor vehicle crash data from the Fatal Accident Reporting System and the General Estimates System. Washington, DC: US Department of Transportation, October 1994.

  32. Fife D. Matching fatal accident reporting system cases with National Center for Health Statistics motor vehicle deaths. Accid Anal Prev 1989;21:79-83.

* The term "injury" in this report includes a) unintentional injuries, suicides, and homicides and b) injuries from undetermined intent, legal intervention (i.e., law enforcement), and operations of war. The term does not include adverse effects of both medical care and therapeutic use of drugs. Although persons involved in the field of injury control prefer the term "unintentional injury" rather than the word "accident," the latter is used in the Ninth Revision of the International Classification of Diseases (ICD-9) External Causes of Injury and Poisoning System. Thus, "accident" is used in this report when referring to specific ICD-9 terminology.

* This notation implies that the decimal in brackets should be applied to each individual three-digit E code in the grouping.


Table_1
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TABLE 1. Number of deaths and death rates per 100,000 population for 10 leading causes of death -- United States, 1993
========================================================================================================================================
Ranking   Causes                                                        ICD-9 Codes                  No. of deaths             Rate *
----------------------------------------------------------------------------------------------------------------------------------------
1         Diseases of the heart                                         390-398,402,404-429                743,460             284.4
2         Malignant neoplasms                                           140-208                            529,904             205.6
3         Cerebrovascular diseases                                      430-438                            150,108              58.2
4         Chronic obstructive pulmonary diseases                        490-496                            101,077              39.2
5         Accidents and adverse effects                                 E800-E949                           90,523              35.1
            Motor vehicle accidents                                     E810-E825                           41,893              16.3
            All other accidents and   adverse effects                   E800-E807 E826-E949                 48,630              18.9
6         Pneumonia and influenza                                       480-487                             82,820              32.1
7         Diabetes mellitus                                             250                                 53,894              20.9
8         Human immunodeficiency virus infection (HIV)                  042-044+                            37,267              14.5
9         Suicide                                                       E950-E959                           31,102              12.1
10        Homicide and legal intervention                               E960-E978                           26,009              10.1
          All other causes                                              Residual                           422,389             163.9
          Total                                                                                          2,268,553             880.0
----------------------------------------------------------------------------------------------------------------------------------------
NOTE: The bolded categories denote the major external cause of death categories historically used to summarize injury-related deaths by
the National Center for Health Statistics (NCHS) in annual U.S. mortality reports.

* Calculated as the crude death rate. The 1993 U.S. resident population used to calculate crude death rates was 257,783,004 (U.S.
  Bureau of the Census).
+ Beginning in 1987, NCHS introduced categories 042-044 for classifying and coding HIV infec-tion. These categories are not part of
  the Ninth Revision International Classification of Diseases.

Source: Department of Health and Human Services. Public use data tape: 1993_detail mortality file. Hyattsville, MD: National Center
for Health Statistics, 1996.
========================================================================================================================================

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Table_2
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TABLE 2. Proposed matrix table with assignment of E codes for injury mortality data
======================================================================================================================================================================================================================================================
                                                                                                                                             Manner/intent
                                            ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Mechanism/cause                             Unintentional                                                                            Suicide                Homicide                            Undetermined        Other *
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cut/pierce                                  E920.0-.9                                                                                E956                   E966                                E986                E974
Drowning/submersion                         E830.0-.9,E832.0-.9,E910.0-.9                                                            E954                   E964                                E984                --
Fall                                        E880.0-E886.9,E888                                                                       E957.0-.9              E968.1                              E987.0-.9           --
Fire/burn                                   E890.0-E899,E924.0-.9                                                                    E958.1,.2,.7           E961; E968.0,.3                     E988.1,.2,.7        --
  Fire/flame                                E890.0-E899                                                                              E958.1                 E968.0                              E988.1              --
  Hot object/substance                      E924.0-.9                                                                                E958.2,.7              E961,E968.3                         E988.2,.7           --
Firearm                                     E922.0-.9                                                                                E955.0-.4              E965.0-.4                           E985.0-.4           E970
Machinery                                   E919 .0-.9                                                                               --                     --                                  --                  --
MV traffic +                                E810-E819 (.0-.9 &)                                                                      E958.5                 --                                  E988.5              --
  Occupant                                  E810-E819 (.0,.1)                                                                        --                     --                                  --                  --
  Motorcyclist                              E810-E819 (.2,.3)                                                                        --                     --                                  --                  --
Pedal cyclist                               E810-E819 (.6)                                                                           --                     --                                  --                  --
Pedestrian                                  E810-E819 (.7)                                                                           --                     --                                  --                  --
Unspecified                                 E810-E819 (.9)                                                                           --                     --                                  --                  --
Pedal cyclist,other                         E800-E807 (.3); E820-E825 (.6); E826.1,.9; E827-E829 (.1)                                --                     --                                  --                  --
Pedestrian,other                            E800-E807 (.2),E820-E825 (.7),E826-E829 (.0)                                             --                     --                                  --                  --
Transport,other                             E800-E807 (.0,.1,.8,.9),E820-E825 (.0-.5,.8,.9),E826.2-.8,E827-E829 (.2-.9),E831.0-      E958.6                 --                                  E988.6              --
                                            .9,E833.0-E845.9
Natural/environmental                       E900.0-E909,E928.0-.2                                                                    E958.3                 --                                  E988.3              --
Bites and stings                            E905.0-.6,.9; E906.0-.4,.9                                                               --                     --                                  --                  --
Overexertion                                E927                                                                                     --                     --                                  --                  --
Poisoning                                   E850.0-E869.9                                                                            E950.0-E952.9          E962.0-.9                           E980.0-E982.9       E972
Struck by,against                           E916-E917.9                                                                              --                     E960.0,E968.2                       --                  E973,E975
Suffocation                                 E911-E913.9                                                                              E953.0-.9              E963                                E983.0-.9           --
Other specified,classifiable                E846-E848,E914-E915,E918,E921.0-.9,E923.0-.9,E925.0-E926.9,E929.0-.5                     E955.5,.9; E958.0,.4   E960.1,E965.5-.9,E967.0-.9,E968.4   E985.5; E988.0,.4   E971,E978,E990-E994,E996,E997.0-.2
Other specified,not elsewhere classifiable  E928.8,E929.8                                                                            E958.8,E959            E968.8,E969                         E988.8,E989         E977,E995,E997.8,E998,E999
Unspecified                                 E887,E928.9,E929.9                                                                       E958.9                 E968.9                              E988.9              E976,E997.9
All injury @                                E800-E869,E880-E929                                                                      E950-E959               E960-E969                          E980-E989           E970-E978,E990-E999
Adverse effects                             --                                                                                       --                     --                                  --                  E870-E879,E930.0-E949.9
Medical care **                             --                                                                                       --                     --                                  --                  E870-E879
Drugs ++                                    --                                                                                       --                     --                                  --                  E930.0-E949.9
All external causes                         --                                                                                       --                     --                                  --                  E800-E999
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NOTE: "--" represents categories in which no E codes are assigned.

*  Includes legal intervention (E970- E978) and operations of war (E990-E999).
+  Three fourth- digit codes (. 4--" occupant of streetcar," .5--"  rider of animal," and .8--" other specified person") are not separated because of
   the minimal number of deaths in these categories. However, because they are included in the overall "Motor Vehicle Traffic" category, the sum of
   these categories can be derived by subtraction.
&  This parenthetical notation implies that the decimal should be applied to each individual three- digit E code in the grouping.
@  Adverse effects have been excluded from the "all injury" category but are included in the "all external causes" category.
** Includes a) adverse effects to patients during surgical and medical care and b) surgical and medical procedures as the cause of abnormal reactions
   or later complications without mention of negative events at the time of procedure.
++ drugs and medicinal and biological substances causing adverse effects when used therapeutically.
======================================================================================================================================================================================================================================================

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Table_3
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TABLE 3. Number of deaths and crude death rate * per 100,000 population, by mechanism- by-intent categories -- United States, 1993
===============================================================================================================================================================================

                                                                                             Manner/intent
                                                     ---------------------------------------------------------------------------------------------------
                                                     Unintentional          Suicide              Homicide               Undetermined        Other +            Total
                                                     --------------     ----------------     ----------------          -------------     -------------    ---------------------
Mechanism/cause                                        No.     Rate        No.     Rate         No.     Rate            No.     Rate      No.     Rate       No.       Rate
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Cut/pierce                                             108     0.04        537      0.2       3,204      1.2              5       -- &     --       --     3,854        1.5
Drowning                                             4,390      1.7        355      0.1          52     0.02            262      0.1       --       --     5,059        2.0
Falls                                                9,788      3.8        605      0.2          24     0.01             56     0.02       --       --    10,473        4.1
Fire/burn                                            4,030      1.6        188      0.1         227      0.1            102     0.04       --       --     4,547        1.8
  Fire/flame                                         3,900      1.5        187      0.1         214      0.1             97     0.04       --       --     4,398        1.7
  Hot object/   substance                              130      0.1          1       -- &        13       -- &            5       -- &     --       --       149        0.1
Firearm                                              1,521      0.6     18,940      7.3      18,253      7.1            563      0.2      318      0.1    39,595       15.4
Machinery                                              999      0.4         --       --          --       --             --       --       --       --       999        0.4
MV traffic@                                         40,899     15.9        108     0.04          --       --             14       -- &     --       --    41,021       15.9
  Occupant                                          24,586      9.5         --       --          --       --             --       --       --       --    24,586        9.5
  Motorcyclist                                       1,927      0.7         --       --          --       --             --       --       --       --     1,927        0.7
  Pedal cyclist                                        789      0.3         --       --          --       --             --       --       --       --       789        0.3
  Pedestrian                                         5,978      2.3         --       --          --       --             --       --       --       --     5,978        2.3
  Unspecified                                        7,583      2.9         --       --          --       --             --       --       --       --     7,583        2.9
Pedal cyclist, other                                   116     0.04         --       --          --       --             --       --       --       --       116       0.04
Pedestrian, other                                      941      0.4         --       --          --       --             --       --       --       --       941        0.4
Transport, other                                     1,829      0.7         --       --          --       --             --       --       --       --     1,829        0.7
Natural/ environmental                               1,544      0.6          8       -- &        --       --              7       -- &     --       --     1,559        0.6
    Bites/stings                                        89     0.03         --       --          --       --             --       --       --       --        89       0.03
Overexertion                                            19       -- &       --       --          --       --             --       --       --       --        19         --
Poisoning                                            8,537      3.3      5,271      2.0          59     0.02          1,903      0.7       --       --    15,770        6.1
Struck by, against                                     901      0.3         --       --         368      0.1             --       --        4       -- &   1,273        0.5
Suffocation                                          4,178      1.6      4,627      1.8         954      0.4             76     0.03                       9,835        3.8
Other specified and classifiable                     1,626      0.6        308      0.1         363      0.1             25     0.01       31     0.01     2,353        0.9
Other specified, not elsewhere classifiable            109       -- &      117     0.05       1,093      0.4            121     0.05        9       -- &   1,449        0.6
Unspecified                                          6,063      2.4         38     0.01       1,056      0.4            285      0.1        2       -- &   7,444        2.9
All injury                                          87,598     34.0     31,102     12.1      25,653     10.0          3,419      1.3      364      0.1   148,136       57.5
Adverse effects                                         --       --         --       --          --       --             --       --       --       --     2,925        1.1
  Medical care                                          --       --         --       --          --       --             --       --       --       --     2,724        1.1
  Drugs                                                 --       --         --       --          --       --             --       --       --       --       201        0.1
All external causes                                     --       --         --       --          --       --             --       --       --       --   151,061       58.6
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NOTE: Cells contain "--" when no applicable deaths have occurred with the respective ICD-9 E codes.
* Rates are given to two decimal places when the rate is <=0.05.
+ Includes legal intervention (E970-E978) and operations of war (E990-E999).
& The crude death rate would have been based on <20 deaths.
@ Three fourth-digit codes (.4--"occupant of streetcar," .5--"rider of animal," and .8--"other specified person") are not separated because of
  the minimal number of deaths in these categories. However, because they are included in the overall "Motor Vehicle Traffic" category, the sum of these
  categories can be derived by subtraction.

Sources: Department of Health and Human Services. Public use data tape: 1993_detail mortality file. Hyattsville, MD: National Center for Health Statistics, 1996.

         US Bureau of Census. U.S. population estimates by age, sex, race, and Hispanic origin: Census file RESPO793, 1995.
===============================================================================================================================================================================

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Table_4
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TABLE 4. Number of injury deaths according to intent and mechanism of injury, by age -- United States, 1993 -- Continued
================================================================================================================================================================================================
                                                                                                                Age of decedent (yrs)
                                                                        ------------------------------------------------------------------------------------------------------------------------
Intent and mechanism                                     All ages *       <1 1-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65-74 75-84>=85
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All injuries +
Cut/pierce                                                   3,854         3      18      23       42      261      449    1,137       856       393       263      229       128          38
Drowning                                                     5,059        87     580     196      244      440      451      918       739       427       320      309       204          93
Fall                                                        10,473        12      70      24       33      137      190      550       727       665       793    1,338     2,703       3,226
Fire/burn                                                    4,547       134     640     246      101      111      173      490       514       406       360      516       517         328
Firearm                                                     39,595        14     102     141      700    4,794    6,410    9,391     6,526     3,932     2,616    2,509     1,900         526
Machinery                                                      999         0      24      11       15       25       58      146       161       138       157      146        94          24
Motor-vehicle traffic                                       41,021       183     756     838    1,048    4,893    5,485    8,055     5,988     3,731     2,841    3,057     3,129         984
Pedal cyclist,other                                            116         0       5       9       12        7        7       18        20        13         9       10         3           2
Pedestrian,other                                               941         6     119      30       22       69       83      178       158        82        68       53        44          23
Transport,other                                              1,829         4      25      32       63      104      149      423       379       276       180      102        71           2
Natural/enironmental                                         1,559        25      34      17       21       36       45      131       174       174       182      229       280         202
Overexertion                                                    19         0       0       0        0        0        1        2         3         2         4        2         3           2
Poisoning                                                   15,770        38      73      35       51      363      815    3,837     5,710     2,355     1,002      727       496         256
Struck by/against                                            1,273         7      47      28       27       42       84      230       275       193       122      133        62          23
Suffocation                                                  9,835       414     220      74      191      467      729    1,704     1,386       816       663      929     1,185       1,040
Other specified,classifiable                                 2,353       172     177      29       41       99      174      433       410       273       161      125       138         118
Other specified,not elsewhere classifiable                   1,449        28      46      26       23       67      125      308       314       184       107       97        70          50
Unspecified                                                  7,444       142     129      34       35      115      158      440       497       416       453      788     1,719       2,499
  Total                                                    148,136     1,269   3,065   1,793    2,669   12,030   15,586   28,391    24,837    14,476    10,301   11,299    12,746       9,454
Unintentional
Cut/pierce                                                     108         0       4       7        0        2        9       16        21        14        11       11         9           4
Drowning                                                     4,390        77     556     192      239      422      397      778       608       356       264      235       154          73
Fall                                                         9,788        12      67      24       28      105      139      389       593       576       722    1,293     2,638       3,199
Fire/burn                                                    4,030       121     600     224       91       91      141      400       420       340       309      478       495         315
Firearm                                                      1,521         0      30      38      137      321      274      255       193       113       158       52        37          13
Machinery                                                      999         0      24      11       15       25       58      146       161       138       157      146        94          24
Motor-vehicle traffic                                       40,899       183     756     838    1,046    4,876    5,470    8,030     5,957     3,719     2,834    3,051     3,124         982
Pedal cyclist,other                                            116         0       5       9       12        7        7       18        20        13         9       10         3           2
Pedestrian,other                                               941         6     119      30       22       69       83      178       158        82        68       53        44          23
Transport,other                                              1,829         4      25      32       63      104      149      423       379       276       180      102        71          20
Natural/environmental                                        1,544        24      34      17       21       35       45      130       173       171       179      228       277         202
Overexertion                                                    19         0       0       0        0        0        1        2         3         2         4        2         3           2
Poisoning                                                    8,537        20      59      22       27      148      386    2,268     3,412     1,143       384      279       238         145
Struck by/against                                              901         3      41      28       23       22       55      153       185       140        90      103        42          16
Suffocation                                                  4,178       371     183      53       65       62       77      215       270       271       315      559       857         876
Other specified,classifiable                                 1,626         9      26      18       32       76      133      317       303       230       125      110       132         114
Other specified,not elsewhere classifiable                     109         0       5      12        9        5        7       19        21         4         5        6         7           9
Unspecified                                                  6,063        34      28      21       20       50       72      185       236       237       347      706     1,659       2,467
  Total                                                     87,598       864   2,562   1,576    1,850    6,420    7,503   13,922    13,113     7,825     6,061    7,424     9,884       8,486
Suicide
Cut/pierce                                                     537        NA      NA       0        1        7       19      109       116        86        69       79        38          13
Drowning                                                       355        NA      NA       0        1        7       24       55        65        44        38       62        40          17
Fall                                                           605        NA      NA       0        5       28       44      141       123        77        64       38        59          24
Fire/burn                                                      188        NA      NA       0        2       12       13       37        47        34        19       19         4           1
Firearm                                                     18,940        NA      NA       1      186    1,273    1,940    3,611     3,194     2,433     1,997    2,104     1,714         483
Motor-vehicle traffic                                          108        NA      NA       0        2       16       13       20        28        11         6        5         5           2
Natural/environmental                                            8        NA      NA       0        0        0        0        1         1         1         3        1         0           0
Poisoning                                                    5,271        NA      NA       1       22      178      331      985     1,536       966       520      394       238          99
Suffocation                                                  4,627        NA      NA       3       92      340      532    1,232       929       466       298      316       278         134
Other specified,classifiable                                   308        NA      NA       1        4       15       34       92        83        32        29       12         5           1
Other specified,not elsewhere classifiable                     117        NA      NA       0        0        7       12       18        39        14         9        7         7           4
Unspecified                                                     38        NA      NA       0        0        1        3        6         9         4         9        3         2           0
  Total                                                     31,102        NA      NA       6      315    1,884    2,965    6,307     6,170     4,168     3,061    3,040     2,390         778
Homicide
Cut/pierce                                                   3,204         3      13      16       41      252      420    1,011       719       292       182      139        81          21
Drowning                                                        52         6      13       2        1        5        6       10         3         3         2        1         0           0
Fall                                                            24         0       3       0        0        1        1        6         2         5         1        2         3           0
Fire/burn                                                      227        10      34      17        6        7        9       39        32        24        18       11        12           8
Firearm                                                     18,253        14      71      99      359    3,082    4,023    5,295     2,990     1,302       527      319       120          26
Poisoning                                                       59         8       9       8        1        2        2        7        12         1         7        1         0           1
Struck by/against                                              368         4       6       0        4       20       29       77        87        53        32       30        19           7
Suffocation                                                    954        31      34      17       18       58      115      245       178        74        48       53        49          28
Other specified,classifiable                                   363       163     151      10        4        6        3        7         5         2         4        2         1           3
Other specified,not elsewhere classifiable                   1,093        20      38      14       13       51       94      256       235       146        83       64        49          26
Unspecified                                                  1,056        85      92      11       15       56       74      210       187       120        65       64        43          19
  Total                                                     25,653       344     464     194      462    3,540    4,776    7,163     4,450     2,022       969      686       377         139
Undetermined
Cut/pierce                                                       5         0       1       0        0        0        1        1         0         1         1        0         0           0
Drowning                                                       262         4      11       2        3        6       24       75        63        24        16       11        10           3
Fall                                                            56         0       0       0        0        3        6       14         9         7         6        5         3           3
Fire/burn                                                      102         3       6       5        2        1       10       14        15         8        14        8         6           4
Firearm                                                        563         0       1       3       18       82      101      129        77        59        29       29        28           4
Motor-vehicle traffic                                           14         0       0       0        0        1        2        5         3         1         1        1         0           0
Natural/environmental                                            7         1       0       0        0        1        0        0         0         2         0        0         3           0
Poisoning                                                    1,903        10       5       4        1       35       96      577       750       245        91       53        20          11
Suffocation                                                     76        12       3       1       16        7        5       12         9         5         2        1         1           2
Other specified,classifiable                                    25         0       0       0        1        2        4        5         8         4         0        1         0           0
Other specified,not elsewhere classifiable                     121         8       3       0        1        4       12       14        19        19        10       13         7          11
Unspecified                                                    285        23       9       2        0        8        9       38        64        55        32       15        15          13
  Total                                                      3,419        61      39      17       42      150      270      884     1,017       430       202      137        93          51
Other &
Firearm                                                        318         0       0       0        0       36       72      101        72        25         5        5         1           0
Struck by/against                                                4         0       0       0        0        0        0        0         3         0         0        0         1           0
Other specified,classifiable                                    31         0       0       0        0        0        0       12        11         5         3        0         0           0
Other specified,not elsewhere classifiable                       9         0       0       0        0        0        0        1         0         1         0        7         0           0
Unspecified                                                      2         0       0       0        0        0        0        1         1         0         0        0         0           0
  Total                                                        364         0       0       0        0       36       72      115        87        31         8       12         2           0
Adverse effects
Medical care                                                 2,724        34      26      23       16       14       15       75       115       186       321      663       753         483
Drugs                                                          201         0       2       0        1        3       11       25        27        18        23       38        28          25
  Total                                                      2,925        34      28      23       17       17       26      100       142       204       344      701       781         508
All external causes                                        151,061     1,303   3,093   1,816    2,686   12,047   15,612   28,491    24,979    14,680    10,645   12,000    13,527       9,962
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
* Includes deaths from injuries in which the age of the decedent was unknown.
+ Excludes all abnormal reactions and complications of medical care and adverse effects of the therapeutic use of drugs.
& Includes legal intervention (E970-E978) and operations of war (E990-E999).

Source: Department of Health and Human Services. Public use data tape: 1993--detail mortality file. Hyattsville, MD: National Center for Health
Statistics, 1996.
================================================================================================================================================================================================

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Table_5
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TABLE 5. Injury death rates* per 100,000 population according to intent and mechanism, by age -- United States, 1993
=======================================================================================================================================================================================
                                                        Age of decedent (yrs)
Intent and mechanism                        All ages +                     <1     1-4    5-9   10-14   15-19    20-24    25-34    35-44   45-54    55-64   65-74   75-84        >=85
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
All injuries &
Cut/pierce                                        1.5                      -- @    --    0.1     0.2     1.5      2.4      2.7      2.1     1.4      1.3     1.2     1.2         1.1
Drowning                                          2.0                     2.2     3.7    1.1     1.3     2.5      2.4      2.2      1.8     1.5      1.5     1.7     1.9         2.7
Fall                                              4.1                      --     0.4    0.1     0.2     0.8      1.0      1.3      1.8     2.3      3.8     7.2    25.2        94.5
Fire/burn                                         1.8                     3.4     4.1    1.3     0.5     0.6      0.9      1.2      1.3     1.4      1.7     2.8     4.8         9.6
Firearm                                          15.4                      --     0.6    0.8     3.8    27.8     34.2     22.4     16.0    13.7     12.5    13.5    17.7        15.4
Machinery                                         0.4                      --     0.2     --      --     0.1      0.3      0.3      0.4     0.5      0.8     0.8     0.9         0.7
Motor-vehicle traffic                            15.9                     4.7     4.8    4.5     5.7    28.3     29.2     19.2     14.7    13.0     13.6    16.4    29.2        28.8
Pedal cyclist, other                              0.04                     --      --     --      --      --       --       --     0.05      --       --      --      --          --
Pedestrian, other                                 0.4                      --     0.8    0.2     0.1     0.4      0.4      0.4      0.4     0.3      0.3     0.3     0.4         0.7
Transport, other                                  0.7                      --     0.2    0.2     0.3     0.6      0.8      1.0      0.9     1.0      0.9     0.5     0.7         0.6
Natural/environmental                             0.6                     0.6     0.2     --     0.1     0.2      0.2      0.3      0.4     0.6      0.9     1.2     2.6         5.9
Overexertion                                       --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Poisoning                                         6.1                     1.0     0.5    0.2     0.3     2.1      4.3      9.2     14.0     8.2      4.8     3.9     4.6         7.5
Struck by/against                                 0.5                      --     0.3    0.2     0.1     0.2      0.4      0.5      0.7     0.7      0.6     0.7     0.6         0.7
Suffocation                                       3.8                    10.6     1.4    0.4     1.0     2.7      3.9      4.1      3.4     2.8      3.2     5.0    11.1        30.5
Other specified, classifiable                     0.9                     4.4     1.1    0.2     0.2     0.6      0.9      1.0      1.0     1.0      0.8     0.7     1.3         3.5
Other specified, not elsewhere classifiable       0.6                     0.7     0.3    0.1     0.1     0.4      0.7      0.7      0.8     0.6      0.5     0.5     0.7         1.5
Unspecified                                       2.9                     3.6     0.8    0.2     0.2     0.7      0.8      1.1      1.2     1.5      2.2     4.2    16.0        73.2

 Total                                            57.5                   32.4    19.4    9.7    14.4    69.7     83.1     67.8     60.9    50.5     49.2    60.6   118.9       277.0

Unintentional
Cut/pierce                                        0.04                     --      --     --      --      --       --       --     0.05      --       --      --      --          --
Drowning                                          1.7                     2.0     3.5    1.0     1.3     2.4      2.1      1.9      1.5     1.2      1.3     1.3     1.4         2.1
Fall                                              3.8                      --     0.4    0.1     0.2     0.6      0.7      0.9      1.5     2.0      3.5     6.9    24.6        93.7
Fire/burn                                         1.6                     3.1     3.8    1.2     0.5     0.5      0.8      1.0      1.0     1.2      1.5     2.6     4.6         9.2
Firearm                                           0.6                      --     0.2    0.2     0.7     1.9      1.5      0.6      0.5     0.4      0.3     0.3     0.3          --
Machinery                                         0.4                      --     0.2     --      --     0.1      0.3      0.3      0.4     0.5      0.8     0.8     0.9         0.7
Motor-vehicle traffic                            15.9                     4.7     4.8    4.5     5.6    28.2     29.2     19.2     14.6    13.0     13.5    16.4    29.1        28.8
Pedal cyclist, other                              0.04                     --      --     --      --      --       --       --     0.05      --       --      --      --          --
Pedestrian, other                                 0.4                      --     0.8    0.2     0.1     0.4      0.4      0.4      0.4     0.3      0.3     0.3     0.4         0.7
Transport, other                                  0.7                      --      --    0.2     0.3     0.6      0.8      1.0      0.9     1.0      0.9     0.5     0.7          --
Natural/environmental                             0.6                     0.6     0.2     --     0.1     0.2      0.2      0.3      0.4     0.6      0.9     1.2     2.6         5.9
Overexertion                                       --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Poisoning                                         3.3                     0.5     0.4    0.1     0.1     0.9      2.1      5.4      8.4     4.0      1.8     1.5     2.2         4.2
Struck by/against                                 0.3                      --     0.3    0.2     0.1     0.1      0.3      0.4      0.5     0.5      0.4     0.6     0.4          --
Suffocation                                       1.6                     9.5     1.2    0.3     0.4     0.4      0.4      0.5      0.7     0.9      1.5     3.0     8.0        25.7
Other specified, classifiable                     0.6                      --     0.2     --     0.2     0.4      0.7      0.8      0.7     0.8      0.6     0.6     1.2         3.3
Other specified, not elsewhere classifiabl        0.04                     --      --     --      --      --       --       --      0.1      --       --      --      --          --
Unspecified                                       2.4                     0.9     0.2    0.1     0.1     0.3      0.4      0.4      0.6     0.8      1.7     3.8    15.5        72.3

  Total                                           34.0                   22.1    16.2    8.5    10.0    37.2     40.0     33.2     32.2    27.3     29.0    31.8    92.2       248.6

Suicide
Cut/pierce                                        0.2                      NA      NA     --      --      --       --      0.3      0.3     0.3      0.3     0.4     0.4          --
Drowning                                          0.1                      NA      NA     --      --      --      0.1      0.1      0.2     0.2      0.2     0.3     0.4          --
Fall                                              0.2                      NA      NA     --      --     0.2      0.2      0.3      0.3     0.3      0.3     0.2     0.6         0.7
Fire/burn                                         0.1                      NA      NA     --      --      --       --      0.1      0.1     0.1       --      --      --          --
Firearm                                           7.3                      NA      NA     --      --     7.4     10.3      8.6      7.8     8.5      9.5    11.3    16.0        14.2
Motor-vehicle traffic                             0.04                     NA      NA     --      --      --       --     0.05      0.1      --       --      --      --          --
Natural/environmental                              --                      NA      NA     --      --      --       --       --       --      --       --      --      --          --
Poisoning                                         2.0                      NA      NA     --     0.1     1.0      1.8      2.4      3.8     3.4      2.5     2.1     2.2         2.9
Suffocation                                       1.8                      NA      NA     --     0.5     2.0      2.8      2.9      2.3     1.6      1.4     1.7     2.6         3.9
Other specified, classifiable                     0.1                      NA      NA     --      --      --      0.2      0.2      0.2     0.1      0.1      --      --          --
Other specified, not elsewhere classifiable       0.05                     --      --     --      --      --       --       --      0.1      --       --      --      --          --
Unspecified                                       0.01                     --      --     --      --      --       --       --       --      --       --      --      --          --

  Total                                          12.1                      NA      NA     --     1.7    10.9     15.8     15.1     15.1    14.5     14.6    16.3    22.3        22.8

Homicide
Cut/pierce                                        1.2                      --      --     --     0.2     1.5      2.2      2.4      1.8     1.0      0.9     0.7     0.8         0.6
Drowning                                          0.02                     --      --     --      --      --       --       --       --      --       --      --      --          --
Fall                                              0.01                     --      --     --      --      --       --       --       --      --       --      --      --          --
Fire/burn                                         0.1                      --     0.2     --      --      --       --      0.1      0.1     0.1       --      --      --          --
Firearm                                           7.1                      --     0.5    0.5     1.9    17.8     21.4     12.6      7.3     4.5      2.5     1.7     1.1         0.8
Poisoning                                         0.02                     --      --     --      --      --       --       --       --      --       --      --      --          --
Struck by/against                                 0.1                      --      --     --      --     0.1      0.2      0.2      0.2     0.2      0.2     0.2      --          --
Suffocation                                       0.4                     0.8     0.2     --      --     0.3      0.6      0.6      0.4     0.3      0.2     0.3     0.5         0.8
Other specified, classifiable                     0.1                     4.2     1.0     --      --      --       --       --       --      --       --      --      --          --
Other specified, not elsewhere classifiable       0.4                     0.5     0.2     --      --     0.1      0.5      0.6      0.6     0.5      0.4     0.3     0.5         0.8
Unspecified                                       0.4                     2.2     0.6     --      --     0.1      0.4      0.5      0.5     0.4      0.3     0.3     0.4          --

Total                                            10.0                     8.8     2.9    1.0     2.5    20.5     25.5     17.1     10.9     7.1      4.6     3.7     3.5         4.1

Undetermined
Cut/pierce                                         --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Drowning                                          0.1                      --      --     --      --      --      0.1      0.2      0.2     0.1       --      --      --          --
Fall                                              0.02                     --      --     --      --      --       --       --       --      --       --      --      --          --
Fire/burn                                         0.04                     --      --     --      --      --       --       --       --      --       --      --      --          --
Firearm                                           0.2                      --      --     --      --     0.5      0.5      0.3      0.2     0.2      0.1     0.2     0.3          --
Motor-vehicle traffic                              --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Natural/environmental                              --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Poisoning                                         0.7                      --      --     --      --     0.2      0.5      1.4      1.8     0.9      0.4     0.3     0.2          --
Suffocation                                       0.03                     --      --     --      --      --       --       --       --      --       --      --      --          --
Other specified, classifiable                     0.01                     --      --     --      --      --       --       --       --      --       --      --      --          --
Other specified, not elsewhere classifiable       0.05                     --      --     --      --      --       --       --       --      --       --      --      --          --
Unspecified                                       0.1                     0.6      --     --      --      --       --      0.1      0.2     0.2      0.2      --      --          --

Total                                             1.3                     1.6     0.2     --     0.2     0.9      1.4      2.1      2.5     1.5      1.0     0.7     0.9         1.5

Other**
Firearm                                           0.1                      --      --     --      --     0.2      0.4      0.2      0.2     0.1       --      --      --          --
Struck by/against                                  --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Other specified, classifiable                     0.01                     --      --     --      --      --       --       --       --      --       --      --      --          --
Other specified, not elsewhere classifiable        --                      --      --     --      --      --       --       --       --      --       --      --      --          --
Unspecified                                        --                      --      --     --      --      --       --       --       --      --       --      --      --          --

Total                                             0.1                      --      --     --      --     0.2      0.4      0.3      0.2     0.1       --      --      --          --

Adverse effects
Medical care                                      1.1                     0.9     0.2    0.1      --      --       --      0.2      0.3     0.6      1.5     3.6     7.0        14.2
Drugs                                             0.1                      --      --     --      --      --       --      0.1      0.1      --      0.1     0.2     0.3         0.7

Total                                             1.1                     0.9     0.2    0.1      --      --      0.1      0.2      0.3     0.7      1.6     3.8     7.3        14.9

All external causes                              58.6                    33.3    19.6    9.8    14.5    69.8     83.2     68.0     61.2    51.2     50.9    64.4   126.2       291.9
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
*  Death rates given are crude death rates.
+  Includes deaths from injuries in which the age of the decedent was unknown.
&  Excludes all abnormal reactions and complications of medical care and adverse effects of the therapeutic use of drugs.
@  Cells contain "--" when the crude death rate would have been based on <20 deaths. Rates are given in two decimal places when the rate was <=0.05.
** Includes legal intervention (E970-E978) and operations of war (E990-E999).

NA = not applicable.

Sources: Department of Health and Human Services. Public use data tape: 1993--detail mortality file. Hyattsville, MD: National Center for Health
         Statistics, 1996.

         US Bureau of Census. U. S. population estimates by age, sex, race, and Hispanic origin: 1993. Census file RESPO793, 1995.
=======================================================================================================================================================================================

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Table_6
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TABLE 6. Number and percentage of deaths from injuries associated with motor-vehicle traffic -- National Center for Health Statistics (NCHS) vital
statistics system and the National Highway Traffic Safety Administration's Fatality and Analysis Reporting System (FARS), United States, 1993
========================================================================================================================================================
                                      Occupant             Motorcyclist         Pedal cyclist          Pedestrian      Other            Unspecified
                                  --------------        ---------------         -------------      --------------    ----------        --------------
                    Total no.         No.      %            No.     %             No.     %           No.      %     No.     %           No.       %
--------------------------------------------------------------------------------------------------------------------------------------------------------
NCHS                   41,021      24,586   59.9          1,927   4.7             789   1.9         5,978   14.6     158   0.4         7,583    18.5
FARS                   40,150      31,125   77.5          2,449   6.1             816   2.0         5,649   14.1     111   0.3             0       0
MNCHS-FARS                871      -6,539                  -522                   -27                 329             47               7,583
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sources: NCHS. Department of Health and Human Services. Public use data tape: 1993 -- detail mortality file. Hyattsville, MD: National Center for
         Health Statistics, 1996.

         National Highway Traffic Safety Administration. Traffic safety facts 1993: a compilation of motor vehicle crash data from the Fatality and
         Analysis Reporting System (FARS) and the General Estimates System. Washington, DC: US Department of Transportation, October 1994.
========================================================================================================================================================

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Table_1B
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=======================================================================
BOX. Method of adjusting for an undercount of deaths of
motor-vehicle occupants and motorcyclists

     Multiply the number of "unspecified" deaths in the NCHS data set
(n=7,583) by the proportions drawn from FARS or NCHS (7,583 x
92.71%=7,030 for occupants; 7,583 x 7.29%=553 for motorcyclists)
and add that to the NCHS number (7,030 + 24,586 = 31,616 for
occupants; 553 + 1,927=2,480 for motorcyclists). This method
results in an overestimate of 491 occupants and 31 motorcyclists
when compared with FARS, but it is more accurate than the 6,539
and 522 undercount for NCHS versus FARS, respectively, by not
accounting for the "unspecified" cases. This overestimate is
expected, because the NCHS data set is more comprehensive.

     When presenting NCHS data concerning deaths from motor-vehicle
traffic for age-specific groups, the "unspecified" deaths can be
distributed based on the distribution of deaths in the NCHS
mortality data for each respective age-specific group. For
instance, "unspecified" deaths were distributed across the
occupant and motorcyclist categories based on the age-specific
distributions of deaths where the injured person was specified in
the 1993 NCHS mortality data file (1). The results suggest that in
1993, the traffic-related death rate among motor-vehicle occupants
was higher for persons aged 15 24 years and for those aged less
than or equal to 75 years than for persons in other age groups
((ºTable_7º)). The death rate among motorcyclists was highest among
persons aged 20 24 years ((ºTable_7º)). If other demographic variables
(e.g., sex and race) are used, the distribution of the number of
deaths should be specified within subgroups (e.g., sex- and
race-specific).
=======================================================================



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Table_7
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TABLE 7. Number of deaths and crude death rates per 100,000 population for unintentional motor vehicle (MV) traffic-related incidents, by person
injured and age -- United States, 1993
===============================================================================================================================================================
                                                                                       Age of decedent (yrs)
                                                    -----------------------------------------------------------------------------------------------------------
Mechanism               All ages *                   <1   1-4    5-9   10-14   15-19   20-24    25-34   35-44   45-54   55-64    65-74   75-84        >=85
---------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                            Number
                                                    -----------------------------------------------------------------------------------------------------------
MV traffic +             40,899                     183   756    838   1,046   4,876   5,470    8,030   5,957   3,719   2,834    3,051   3,124         982
Occupant&                31,618                     172   449    430     600   4,261   4,442    6,169   4,391   2,842   2,220    2,428   2,467         739
Motorcyclist &            2,478                       0     1      6      39     244     612      748     498     197      70       35      24           4
Pedal cyclist, other        789                       0    12     94     157      89      51      130     101      53      40       42      12           7
Pedestrian, other         5,978                      11   291    308     248     276     359      980     964     624     499      543     619         232
---------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                             Rate
                                                    -----------------------------------------------------------------------------------------------------------
MV traffic +               15.9                     4.7   4.8    4.5     5.6    28.2    29.2     19.2    14.6    13.0    13.5     16.4    29.1        28.8
Occupant&                  12.3                     4.4   2.8    2.3     3.2    24.7    23.7     14.7    10.8     9.9    10.6     13.0    23.0        21.6
Motorcyclist&               1.0                      -- @  --     --     0.2     1.4     3.3      1.8     1.2     0.7     0.3      0.2     0.2          --
Pedal cyclist, other        0.3                      --    --    0.5     0.8     0.5     0.3      0.3     0.2     0.2     0.2      0.2      --          --
Pedestrian, other           2.3                      --   1.8    1.7     1.3     1.6     1.9      2.3     2.4     2.2     2.4      2.9     5.8         6.8
---------------------------------------------------------------------------------------------------------------------------------------------------------------
* Includes deaths from injuries in which the age of the decedent was unknown.
+ Includes other specified persons.
& Includes deaths where the injured person was "unspecified." These deaths were distributed into occupant and motorcyclist subcategories based on the
  proportion of deaths in these subcategories by age group in the 1993 National Center for Health Statistics (NCHS) mortality data file.
@ Rates are unreliable because they are based on <20 deaths.

Sources: NCHS. Department of Health and Human Services. Public use data tape: 199 -- detail mortality file. Hyattsville, MD: National Center for
         Health Statistics, 1996.

         US Bureau of Census. U. S. population estimates by age, sex, race, and Hispanic origin: 1993. Census file RESPO793, 1995.
===============================================================================================================================================================

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