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Nonfatal and Fatal Firearm-Related Injuries -- United States, 1993-1997

In 1997, 32,436 deaths resulted from firearm-related injuries, making such injuries the second leading cause of injury mortality in the United States after motor-vehicle-related incidents (1). Also in 1997, an estimated 64,207 persons sustained nonfatal firearm-related injuries and were treated in U.S. hospital emergency departments (EDs); approximately 40% required inpatient hospital care. National firearm-related injury and death rates peaked in 1993, then began to decline (2). This report presents national data from 1993 through 1997, which showed that the decline in nonfatal and fatal firearm-related injury rates was substantial and consistent by sex, race/ethnicity, age, and intent of injury.

A firearm-related injury was defined as a penetrating injury or gunshot wound from a weapon that uses a powder charge to fire a projectile (e.g., handguns, rifles, and shotguns). Data on nonfatal firearm-related injuries treated in U.S. hospital EDs were obtained from the National Electronic Injury Surveillance System (NEISS) of the U.S. Consumer Product Safety Commission. NEISS is a stratified probability sample of hospitals in the United States that have at least six beds and provide 24-hour emergency care (3). Each firearm-related injury treated in a NEISS hospital ED was assigned a sample weight; the weights were summed to provide national estimates of nonfatal injuries (3). In 1997, the number of participating NEISS hospitals increased from 91 to 101; therefore, for this analysis, national estimates of nonfatal injuries for prior years were statistically adjusted to account for the sampling frame update. Data on firearm-related deaths were obtained through death certificate data from CDC's National Center for Health Statistics (1), and population estimates were from the Bureau of the Census.

To examine trends in nonfatal firearm-related rates by intent of injury, sample weights for cases with unknown intent (i.e., 13.4% of nonfatal injuries during the 5-year period) were allocated to one of the three known categories--assault/legal intervention, intentionally self-inflicted, or unintentional injury. This allocation accounted for the quarterly variation in the percentage of weighted cases with unknown intent during the study period, ranging from 7.1% to 17.7%. Cases with unknown intent were allocated within each quarter based on the weighted distribution of cases with known intent for that quarter. Although the percentage of firearm-related deaths with unknown intent was minimal (i.e., 1.2% of deaths during the 5-year period), these cases also were allocated to maintain consistency.

National estimates of nonfatal firearm-related injuries, their standard errors, and 95% confidence intervals (CIs) for the percentage decline in rates were computed using SUDAAN software to account for the sample weights and the complex survey design of NEISS. For firearm-related deaths, standard errors of death rates were computed assuming deaths follow a Poisson probability distribution so that CIs for the percentage decline in rates accounted for random variation. Multiple linear regression was performed to test for quarterly trends over the 5-year period.

Overall, annual nonfatal and fatal firearm-related injury rates declined consistently from 1993 through 1997. The annual nonfatal rate decreased 40.8%, from 40.5 per 100,000 (95% CI=22.6-58.4) in 1993 to 24.0 per 100,000 (95% CI=13.8-34.1) in 1997 (Table 1). This decline was accompanied by a decrease of 21.1% in the annual death rate from 15.4 per 100,000 (95% CI=15.2-15.5) in 1993 to 12.1 per 100,000 (95% CI=12.0-12.3) in 1997 (Table 2).

The declines in nonfatal and fatal firearm-related injury rates generally were consistent across all population subgroups (Tables 1 and 2). The declines in nonfatal and fatal injury rates were similar for males (40.7% for nonfatal, 20.9% for fatal) and for females (42.1% for nonfatal, 23.2% for fatal). Declines in death rates for blacks and Hispanics were similar, and were both greater than the decline observed for non-Hispanic whites. For nonfatal injury rates, no consistent pattern was found in the estimated decline across age groups, but for fatal injury rates, age and percentage change were inversely related. With respect to intent, the declines in nonfatal injury rates were seen in assault-related, intentionally self-inflicted, and unintentional firearm-related injuries. However, the declines in homicide and unintentional injury death rates were approximately three times greater than that of the suicide rate.

Overall, quarterly fatal and nonfatal firearm-related injury rates showed statistically significant downward trends over the 5-year period adjusting for seasonal changes (overall predicted percentage declines were 36.6% and 17.3% for nonfatal and fatal injury rates, respectively, from first quarter 1993 through fourth quarter 1997; pless than 0.01 for both). For males aged 15-24 years, quarterly assaultive firearm-related injury rates also declined significantly from 1993 through 1997 (Figure 1) (overall predicted percentage declines were 37.5% and 16.0% for nonfatal and fatal injury rates, respectively, from first quarter 1993 through fourth quarter 1997; pless than 0.01 for both). For males aged 15-24 years, the cyclical seasonal pattern was consistent for both fatal and nonfatal assaultive firearm-related injury rates (Figure 1), with the highest rates occurring during July, August, and September. These summer rates were significantly higher than rates during the other three quarters for fatal injuries (pless than 0.01) but not for nonfatal injuries (p=0.17).

Reported by: Office of Statistics and Programming and Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note:

The overall percentage decline in nonfatal and fatal firearm-related injury rates in the U.S. population from 1993 through 1997 is consistent with a 21% decrease in violent crime during the same time (4). Since 1950, unintentional fatal firearm-related injury rates have declined. NEISS data also suggest a decline since 1993 in the rate of nonfatal unintentional firearm-related injuries treated in hospital EDs. Most of these nonfatal injuries occurred among males aged 15-44 years, were self-inflicted, and were associated with hunting, target shooting, and routine gun handling (i.e., cleaning, loading, and unloading a gun) (5). Additional investigation should focus on factors that may have contributed to the decrease, such as gun safety courses and information campaigns, the proportion of the population that uses guns for recreational purposes, and legislation.

Numerous factors may have contributed to the decrease in both nonfatal and fatal assaultive firearm-related injury rates. Possible contributors include improvements in economic conditions; the aging of the population; the decline of the crack cocaine market; changes in legislation, sentencing guidelines, and law-enforcement practices; and improvements associated with violence prevention programs (6). However, the importance and relative contribution of each of these factors have not been determined, and the reasons are not known for the declines in firearm-related suicide and suicide attempt rates.

This analysis also indicates that using NEISS is an effective means for tracking national estimates of nonfatal firearm-related injuries. Quarterly nonfatal firearm-related injury rates based on NEISS data track closely with firearm-related death rates based on death-certificate data. For males aged 15-24 years, a known high-risk group for assaultive injury (2,3), both fatal and nonfatal quarterly assaultive firearm-related rates show cyclical seasonal trends over the 5-year study period, with the highest rates occurring during the summer months.

A limitation of NEISS is that it is not designed to provide data to examine trends at the state and local level. State and local data are needed for jurisdictions to design and evaluate firearm-related injury-prevention programs. CDC has collaborated with states and communities to design and implement successful firearm-related injury surveillance and data systems (7), which can serve as models for future efforts.

Although firearm-related injuries have declined substantially across all intent categories and population subgroups, recent school-related shootings, multiple shootings, and homicide-suicide incidents are reminders that firearm-related injuries remain a serious public health concern. Even with the significant declines in nonfatal and fatal firearm-related injury rates, approximately 96,000 persons in the United States sustained gunshot wounds in 1997. However, results from the Youth Risk Behavior Survey also indicate a decline in violence-related behavior among high school students, including a 25% decline in carrying guns on school property and a 9% decline in engaging in a physical fight on school grounds during this 5-year period (8 ). Prevention efforts should continue to design, implement, and evaluate public health, criminal justice, and education programs to further reduce firearm-related injuries in the United States.

References

  1. Hoyert DL, Kochanek KD, Murphy SL. Deaths: final data for 1997. Mon Vital Stat Rep 1999;47(9).
  2. Cherry D, Annest JL, Mercy JA, Kresnow M, Pollock DA. Trends in nonfatal and fatal firearm-related injury rates in the United States, 1985-1995. Ann Emerg Med 1998;32:51-9.
  3. Annest JL, Mercy JA, Gibson DR, Ryan GW. National estimates of nonfatal firearm-related injuries: beyond the tip of the iceberg. JAMA 1995;273:1749-54.
  4. Rand M. Criminal victimization 1997: changes 1996-1997 with trends 1993-1997. Washington, DC: US Department of Justice, Bureau of Justice Statistics, December 1998.
  5. Sinauer N, Annest JL, Mercy JA. Unintentional, nonfatal firearm-related injuries: a preventable public health burden. JAMA 1996;275:1740-3.
  6. Moore MH, Tonry M. Youth violence in America. In: Tonry M, Moore MH, eds. Crime and justice: a review of the research. Vol 24. Chicago, Illinois: The University of Chicago Press, 1998:1-26.
  7. Ikeda RM, Mercy JA, Teret SP, eds. Firearm-related injury surveillance. Am J Prev Med 1998;15(3S).
  8. Brener ND, Simon TR, Krug EG, Lowry R. Recent trends in violence-related behaviors among high school students in the United States. JAMA 1999;282:440-6.


Table 1

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TABLE 1. National estimates and crude rates of nonfatal firearm-related injuries, overall and by selected populations -- United States, 1993-1997

 

Number*

Rate

Characteristic

1993

1994

1995

1996

1997

1993

1994

1995

1996

1997

% Change from 1993 to 1997

(95% CI)

Sex

                       

Male

92,375

79,904

75,766

61,903

57,004

73.4

62.8

58.9

47.7

43.5

-40.7%

( -77.3, -4.1)

Female

11,998

9,840

8,556

7,746

7,203

9.1

7.4

6.4

5.7

5.3

-42.1%

( -77.3, -6.8)

Unknown**

17

0

0

0

0

             

Race/Ethnicity

                       

White, non-Hispanic

24,951

23,889

22,827

18,787

17,016

13.0

12.4

11.8

9.7

8.7

-32.8%

( -67.2, 1.5)

Black

56,852

46,473

40,676

34,002

29,717

176.7

142.4

122.9

101.5

87.5

-50.5%

( -91.2, -9.7)

Hispanic

14,543

13,412

14,922

10,562

11,440

60.8

54.0

58.0

39.6

41.3

-32.1%

(-123.7, 59.6)

Other/Unknown**

8,044

5,970

5,897

6,298

6,034

             

Age (yrs)

                       

0-14

4,346

3,696

2,996

3,390

2,514

7.7

6.5

5.2

5.9

4.3

-43.5%

( -73.0, 14.0)

15-24

50,086

42,421

40,638

32,470

30,225

138.4

117.3

112.2

89.6

82.6

-40.3%

( -79.9, -0.7)

25-34

25,968

22,200

21,077

16,758

16,510

62.1

53.8

51.6

41.5

41.7

-32.8%

( -73.8, 8.1)

35-44

14,065

11,471

10,426

9,001

7,990

34.5

27.5

24.5

20.7

18.2

-47.3%

( -78.9, 15.8)

>=45

9,153

9,649

9,134

7,945

6,835

11.1

11.5

10.7

9.1

7.6

-31.3%

( -74.4, 11.8)

Unknown**

772

307

51

85

133

             

Intent of injury

                       

Assault/Legal intervention

76,491

68,491

62,206

48,331

47,453

29.7

26.3

23.7

18.2

17.7

-40.2%

( -82.4, 2.0)

Intentionally self-inflicted

6,514

6,302

5,669

4,849

3,699

2.5

2.4

2.2

1.8

1.4

-45.3%

( -85.9, -4.7)

Unintentional

21,385

14,951

16,447

16,469

13,055

8.3

5.7

6.3

6.2

4.9

-41.2%

( -65.0, -17.3)

Disposition at discharge from ED

                       

Hospitalized

51,298

44,497

38,658

31,894

27,393

19.9

17.1

14.7

12.0

10.2

-48.6%

( -92.4, -4.7)

Treated and released

47,559

40,349

40,341

33,229

31,628

18.5

15.5

15.4

12.5

11.8

-35.9%

( -67.5, -4.4)

Transferred

5,448

4,786

5,154

4,391

4,933

2.1

1.8

2.0

1.7

1.8

-12.8%

( -59.4, 33.8)

Unknown**

85

112

169

135

253

             
                         

Overall

104,390

89,744

84,322

69,649

64,207

40.5

34.5

32.1

26.3

24.0

-40.8%

( -77.0, -4.5)

* Estimated number of nonfatal injuries treated in U.S. hospital emergency departments (EDs) based on data from CDC’s Firearm Injury Surveillance Study using National Electronic Injury Surveillance System; rates were calculated using postcensal population estimates from the Bureau of the Census. The unweighted sample sizes of weighted cases used to calculate annual national estimates and rates were 3491 for 1993; 2860 for 1994; 2639 for 1995; 2231 for 1996; and 2181 for 1997. The unweighted sample size of weighted cases used to calculate national estimates and rates within subgroups (excluding unknowns) ranged from 74 for transferred at ED discharge in 1994 to 3099 for males in 1993.
† Per 100,000 population.
Confidence interval; statistically significant at the 0.05 level if the confidence interval does not include zero.
Estimate has a coefficient of variation >= 30% and, therefore, may be unstable.
** Rates, percentage change, CIs, and coefficients of variation were not computed.


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Figure 1

Figure 1
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Table 2

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TABLE 2. Numbers and crude rates of fatal firearm-related injuries, overall and by selected populations -- United States, 1993-1997

 

Number*

Rate

Characteristic

1993

1994

1995

1996

1997

1993

1994

1995

1996

1997

% Change from 1993 to 1997

(95% CI)

Sex

                       

Male

33,711

33,021

30,724

29,183

27,756

26.8

25.9

23.9

22.5

21.2

-20.9%

(-22.1, -19.6)

Female

5,884

5,484

5,233

4,857

4,680

4.5

4.1

3.9

3.6

3.4

-23.2%

(-26.1, -20.2)

Race/Ethnicity

                       

White, non-Hispanic

21,960

21,549

20,764

20,004

19,507

11.6

11.3

10.9

10.5

10.2

-12.5%

(-14.2, -10.8)

Black

11,763

11,223

9,643

9,175

8,389

36.6

34.4

29.1

27.4

24.7

-32.4%

(-34.3, -30.5)

Hispanic

4,300

4,302

4,108

3,561

3,246

18.0

17.4

16.0

13.4

11.8

-34.8%

(-37.7, -31.7)

Other/Unknown**

1,572

1,431

1,442

1,300

1,294

             

Age (yrs)

                       

0-14

957

872

853

693

630

1.7

1.5

1.5

1.2

1.1

-35.7%

(-41.8, -28.9)

15-24

11,204

11,056

9,778

8,766

8,173

31.0

30.6

27.0

24.2

22.3

-27.8%

(-29.8, -25.7)

25-34

9,391

9,074

8,225

7,403

7,045

22.4

22.0

20.1

18.3

17.8

-20.8%

(-23.2, -18.3)

35-44

6,526

6,519

6,120

6,064

5,802

16.0

15.6

14.4

14.0

13.2

-17.5%

(-20.4, -14.6)

>=45

11,483

10,954

10,951

11,086

10,759

13.9

13.0

12.8

12.7

12.0

-13.8%

(-16.0, -11.5)

Unknown**

34

30

30

28

27

             

Intent/Manner of death

                       

Homicide/Legal intervention

18,839

18,110

16,010

14,503

13,677

7.3

7.0

6.1

5.5

5.1

-30.1%

(-31.6, -28.5)

Suicide

19,213

19,021

18,708

18,389

17,767

7.5

7.3

7.1

6.9

6.6

-10.9%

(-12.7, -9.1)

Unintentional

1,543

1,374

1,239

1,148

992

0.6

0.5

0.5

0.4

0.4

-38.1%

(-42.8, -32.9)

                         

Overall

39,595

38,505

35,957

34,040

32,436

15.4

14.8

13.7

12.8

12.1

-21.1%

(-22.2, -19.9)

* Number of fatal injuries from CDC’s National Vital Statistics System; rates were calculated using postcensal population estimate from the Bureau of the Census.
† Per 100,000 population.
Confidence interval; statistically significant at the 0.05 level if the confidence interval does not include zero.
Number of fatalities and death rates do not include data from Oklahoma because Hispanic origin was not recorded on state death certificates from 1993 through 1996.
** Rates, percentage change, and CIs were not computed.


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