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Emergency Department Surveillance for Weapon-Related Injuries -- Massachusetts, November 1993-April 1994

During 1992, a total of 37,776 firearm-related deaths occurred in the United States (1), and in 1991, firearm-related deaths were the leading or second leading cause of injury death in 15 states (2). Because of limitations in data, however, the epidemiology of nonfatal firearm- and other weapon-related injuries has not been well characterized. To improve characterization of these problems, in 1989, the Massachusetts Department of Public Health (MDPH) began a pilot project to develop the first emergency-department-based statewide Weapon-Related Injury Surveillance System (WRISS) in the United States (3). All 85 hospital emergency departments in Massachusetts (1990 population: 6,016,425) now participate in this system. This report summarizes results from the first 6 months of statewide reporting (November 1993-April 1994), including previously unavailable statewide morbidity data on gunshot and stabbing injuries.

Since 1927, physicians in Massachusetts have been required to report to law enforcement authorities all gunshot wounds (GSWs) and all violence-related sharp instrument wounds (SIWs). * GSWs are defined as "all injuries resulting from, or caused by, the discharge of a gun, pistol, BB gun, or other air rifle or firearm." Violence-related SIWs are defined as nonself-inflicted "wounds or injuries caused by a knife or sharp or pointed instrument if, in the physician's judgment, a criminal act was involved." Although the statute requires reporting by all physicians, WRISS is a voluntary reporting system that has been implemented only in hospital-based emergency departments. The goal of WRISS is to ascertain all reportable weapon-related injuries treated in an emergency department regardless of outcome. WRISS does not ascertain nonfatal injuries treated outside the emergency department or injuries declared fatal at the scene whose victims are taken directly to the state medical examiner's office.

To facilitate reporting to WRISS and minimize reporting burden for providers, the existing police reporting form was modified and variables were added to a new voluntary reporting portion of the form. Completed forms are sent periodically from hospitals to the MDPH and state law enforcement authorities. Variables in WRISS include demographics (age, race/ethnicity, sex, and community of residence), location of incident, injury characteristics (type of weapon and location of wound), suspected drug or alcohol use, and injury severity (treated and released, admitted to hospital, or died). Reports for GSWs include type of injury (nonself-inflicted violence related; unintentional; or self-inflicted), and reports for violence-related GSWs and SIWs include victim-offender relationship and precipitating circumstance. Based on periodic audits of records, reporting compliance is 70%-80% systemwide. Responses are unknown or missing for less than or equal to 25% of demographic variables, injury characteristics, and injury severity; 32%-68% of victim-offender relationships; and 26%-57% of precipitating circumstances.

During November 1993-April 1994, WRISS received reports of 1345 weapon-related injuries, including 451 GSWs and 894 SIWs. Based on these findings, estimated annual statewide rates were 15 GSWs per 100,000 residents and 30 violence-related SIWs per 100,000 residents. Of the 1345 injured persons, 1139 (85%) were male. The mean age was 27 years; 613 (46%) were aged 15-24 years, 396 (29%) were aged 25-34 years, and 267 (20%) were aged greater than or equal to 35 years. Persons with GSWs were more likely to be hospitalized (240 {53%}) than persons with SIWs (258 {29%}).

Although 37% of persons in Massachusetts reside in large communities (population greater than or equal to 50,000), 71% (300) of the GSW-related injuries occurred among persons who resided in large communities. Persons incurring GSWs in large communities were more likely than those in small communities to be aged less than 35 years (264 {88%} compared with 94 {76%}). In comparison, persons incurring SIWs in large communities were more likely than those in small communities to be aged greater than or equal to 35 years (158 {25%} compared with 39 {17%}). In large communities, most (68%) GSW injuries were violence related, while in small communities 30% were violence related and 40% were unintentional Table_1. Community size was not associated with victim-offender relationship or precipitating circumstances for either GSWs or SIWs. Among violence-related GSW incidents, when the victim-offender relationship was known, a higher proportion was associated with a stranger (28% in large communities and 22% in small communities) than with someone known by the victim (14% and 11%, respectively) while among SIW injuries, the offender was more likely to be known by the victim (34% and 39%) than to be a stranger (24% and 30%). For GSWs for which information on circumstance was known, argument or abuse was involved in 18% of incidents in large communities and 11% in small communities. Approximately half (46% in large communities and 52% in small communities) of incidents associated with SIWs involved argument or abuse.

The annualized crude rate for GSW injuries was 27 per 100,000 persons in large communities, compared with seven per 100,000 persons in small communities; however, the difference was greatest for violence-related GSWs Table_2. Of the 451 GSWs, 60 (13%) were associated with BB guns and other nonpowder guns; of these, 45 (75%) occurred in small communities. In addition, BB guns and other nonpowder guns accounted for 19 (42%) of all reported weapon-related injuries to children aged less than 15 years. Most (36 {60%}) BB gun injuries were unintentional, and 13 (22%) were violence related; the remaining injuries were self-inflicted or of unknown intent.

Of the 894 SIWs, 636 (71%) occurred among persons in large communities (annualized crude rate: 57 per 100,000 residents), and 225 (25%) occurred in small communities (12 per 100,000 residents); information on community of residence was missing or unknown for 33 (4%). Most (734 {82%} of 894) injured persons were male, and the mean age was 28 years. Reported by: V Ozonoff, C Barber, B Hume, L Jannelli, M Schuster, H McLaughlin, Massachusetts Dept of Public Health. Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note

Editorial Note: National injury-control priorities include reductions in intentional, unintentional, and self-inflicted firearm injuries (4). Surveillance for weapon-related injuries -- which involves the systematic collection of data about both fatal and nonfatal injuries -- is an essential component in the development of a science-based approach to preventing these injuries and can assist in efforts to provide public education, develop legislation to reduce risks for weapon-related injuries, identify groups and communities at highest risk for such injuries, and evaluate prevention initiatives (5).

In Massachusetts, findings from WRISS routinely have been disseminated throughout the state to violence-prevention groups, hospitals, and policymakers through newsletters, presentations, and staff training. These data have been used by hospitals to obtain funding for victim services programs, design violence-prevention educational materials, and train postgraduate medical staff. WRISS data also were used by an adolescent violence-prevention coalition to select neighborhoods for a teen mentoring program and by a community coalition in Boston in planning a gun buy-back initiative and related public education efforts. In addition, data have been requested by mayors and city councils and cited by the governor in a newspaper editorial addressing gun access.

Analysis of the statewide findings in Massachusetts indicates important variations in injury patterns that cannot be discerned based only on findings from localities. For example, the types of weapons and related injuries differed substantially between small and large communities. In addition, this emergency-department-based system enabled recognition of the magnitude of childhood injuries associated with BB guns. Although BB guns and other nonpowder guns are an important cause of injury among children (6), data about these injuries are not otherwise available because the injuries rarely cause death or result in hospital admission.

The MDPH is using WRISS data to establish an enhanced firearm surveillance system by linking it with mortality and hospital discharge data to estimate weapon-related injury costs, identifying potential risk factors through interviews with victims of unintentional GSWs, and interviewing violence-related GSW victims to assess data validity and provide additional information on victim-offender relationships and precipitating circumstances. In addition, WRISS data will be used for a new MDPH initiative to develop statewide surveillance for violence against women; data on victim-offender relationship and precipitating circumstance will be particularly important for that project.

The development of WRISS in Massachusetts has established the feasibility and utility of a statewide, emergency-department-based surveillance system for weapon-related injury. In addition, this system may provide guidance in developing surveillance systems in other states. In Massachusetts, implementation of a voluntary, emergency-department-based system for reporting to MDPH was facilitated by the pre-existing police reporting requirement. At least 40 other states (7) have mandatory reporting requirements for GSWs that could be used in developing and implementing surveillance systems similar to WRISS.


  1. NCHS. Vital statistics mortality data, underlying cause-of-death detail, 1992 {Machine-readable public-use data tape}. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994.

  2. Fingerhut LA, Jones C, Makuc DM. Firearm and motor vehicle injury mortality -- variations by state, race, and ethnicity: United States, 1990-91. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994. (Advance data no. 242).

  3. Ozonoff VV, Barber CW, Spivak H, Hume B, Jannelli L, Scott NJ. Weapon-related injury surveillance in the emergency department. Am J Public Health 1994;84:2024-5.

  4. CDC/National Highway Traffic Safety Administration. Position papers from the Third National Injury Control Conference: setting the national agenda for injury control in the 1990s. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992.

  5. CDC. Deaths resulting from firearm- and motor-vehicle-related injuries -- United States, 1968-91. MMWR 1994;43:37-42.

  6. Christoffel T, Christoffel K. Nonpowder firearm injuries: whose job is it to protect children? Am J Public Health 1987;77:735-8.

  7. Lee RK, Waxweiler RJ, Dobbins JG, Paschetag T. Incidence rates of firearm injuries in Galveston, Texas, 1979-1981. Am J Epidemiol 1991;134:511-21.

* Mass. Gen. L. ch. 112, *** 12A (1986).

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TABLE 1. Number and percentage of gunshot wounds and sharp instrument
wounds reported by emergency departments, by type of injury and size of
victim's community of residence * -- Weapon-Related Injury Surveillance
System, Massachusetts, November 1, 1993-April 30, 1994
                                    Large communities    Small communities
                                    -----------------    -----------------
Injury                               No.        (%)       No.        (%)
Gunshot Wounds +
  Violence-related                   204       ( 68)       37       ( 30)
    Victim-offender relationship
      Offender known to victim        26       ( 14)        4       ( 11)
      Stranger-to-stranger            57       ( 28)        8       ( 22)
      Missing/Unknown                121       ( 59)       25       ( 68)
      Argument/Abuse                  37       ( 18)        4       ( 11)
      Other crime-related             40       ( 20)        5       ( 14)
      Other                           25       ( 12)        7       ( 19)
      Missing/Unknown                102       ( 50)       21       ( 57)
  Suspected violence-related          28       (  9)        9       (  7)
  Unintentional                       25       (  8)       50       ( 40)
  Self-inflicted                       7       (  2)       14       ( 11)
  Missing/Unknown                     36       ( 12)       14       ( 11)
  Total                              300       (100)      124       (100)

Sharp instrument wounds &
  Violence-related                   549       ( 86)      186       ( 83)
    Victim-offender relationship
      Offender known to victim       190       ( 34)       71       ( 39)
      Stranger-to-stranger           130       ( 24)       56       ( 30)
      Missing/Unknown                229       ( 42)       59       ( 32)
      Argument/Abuse                 253       ( 46)       97       ( 52)
      Other crime-related             83       ( 15)       29       ( 16)
      Other                           35       (  6)       11       (  6)
      Missing/Unknown                178       ( 32)       49       ( 26)
  Suspected violence-related          87       ( 14)       39       ( 17)
  Total                              636       (100)      225       (100)
* Large communities=populations >=50,000; small communities=populations
+ Excludes 27 reports in which victim's community was missing/unknown.
& Excludes 33 reports in which victim's community was missing/unknown.

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TABLE 2. Number of reported weapon-related injuries and estimated annual
incidence rates *, by size of victim's community of residence + --
Weapon-Related Injury Surveillance System, Massachusetts, November 1,
1993-April 30, 1994
                                 Large          Small        Large/Small
                              communities    communities     communities
                              -----------    -----------     ------------
Injury                        No.   Rate     No.    Rate      Rate ratio
Gunshot wounds
    and suspected
    violence-related          232   21.0      46     2.0        10.5
  Unintentional                25    2.0      50     3.0         0.7
  Self-inflicted                7    1.0      14     1.0         1.0
  Total &                     300   27.0     124     7.0         3.9

Sharp instrument wounds **
    and suspected
    violence-related          636   57.0     225    12.0         4.7
 * Per 100,000 persons.
 + Large communities=populations >=50,000; small communities=populations
 & Excludes 27 reports in which victim's community was missing/unknown.
 @ Includes injuries of unknown intent.
** Excludes 33 reports in which victim's community was missing/unknown.

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