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Firearm-Associated Deaths and Hospitalizations -- California, 1995-1996

During 1995-1996, 27% of recorded injury-related deaths in California involved firearms (California Department of Health Services [CDHS], unpublished data, 1995-1996). In 1996, CDHS began passive surveillance of "severe" firearm-related injuries (i.e., resulting in death or hospitalization) with resources provided by the California Wellness Foundation (1). To characterize firearm-related injuries in California, CDHS analyzed death records and hospital discharge records for 1995 and 1996 (the most recent years for which population data are available to calculate rates). This report summarizes the results of the analysis, which indicate that most of the 21,985 firearm-related injuries and deaths resulted from assault.

CDHS compiles state death records annually from death certificates submitted by each county's medical examiner or coroner, who investigates all firearm-related deaths. Patient discharge information from all nonfederal hospitals in California is reported to the Office of Statewide Health Planning and Development, which makes these data available for analysis. Data analyzed were for California residents for whom a firearm-related injury* was listed as the underlying cause of death or external cause of injury resulting in hospitalization. Discharge records of patients who died in a hospital were excluded, and transfers or other subsequent hospitalizations were eliminated to avoid counting cases twice.

During 1995 and 1996, gunshots resulted in 8832 deaths and 13,153 nonfatal injuries resulting in hospitalization. Most firearm-related deaths resulted from assaults (4847 [55%]) and self-inflicted gunshots (3619 [41%]). Most hospitalizations resulted from assaults (10,495 [80%]) and unintentional firearm-related injuries (1769 [13%]). Lethality of firearm-related injuries varied by intent (assaultive, self-inflicted, or unintentional). Of all firearm-related injuries, 90% of self-inflicted gunshot wounds resulted in death compared with 32% of assaultive and 10% of unintentional injuries.

Assaultive and self-inflicted injuries accounted for 8466 (96%) firearm-related injury deaths and 10,915 (83%) nonfatal injuries resulting in hospitalization in California during 1995-1996 (Table 1); 7389 (87%) deaths and 9858 (90%) hospitalizations occurred among males. Although more whites than persons of any other racial/ethnic group died from firearm-related injuries, the death rate was highest for blacks (34.6 per 100,000 population), followed by Hispanics (15.2), whites (10.6), and Asians/Pacific Islanders (6.2). For whites, most firearm-related fatalities were suicides. The suicide rate for whites (8.1) was more than double the suicide rate for blacks, the next highest group. For nonfatal firearm-related injuries resulting in hospitalization, both number and rates were lower for whites (number: 1657; rate: 4.8) than for blacks (3143; 69.4) and Hispanics (5321; 28.9). Asians/Pacific Islanders had the fewest hospitalizations (473) but the third highest hospitalization rate (7.0).

Total firearm-related injury deaths and hospitalizations were substantially higher among adolescents and young adults (ages 15-24 years) than among persons in older age groups. Among older persons, the rate of fatal firearm-related assault decreased but the rate for suicide increased. Among persons aged 35-44 years and older, suicide was the most frequently reported manner of fatal firearm-related injuries; 919 firearm-related suicides occurred among persons aged greater than or equal to 65 years compared with 73 firearm-related homicides and four unintentional firearm-related injury deaths.

Reported by: RB Trent, PhD, JC Van Court, MPH, AN Kim, MS, Epidemiology and Prevention for Injury Control Br, California Dept of Health Svcs. Div of Violence Prevention, National Center for Injury Prevention and Control, CDC.

Editorial Note:

The findings in this report demonstrate differences in fatal and nonfatal firearm-related injuries in California by focusing on the lethality of gunshots. Fatal and nonfatal firearm-related injury patterns are different, particularly among self-inflicted and unintentional injuries. During 1992-1993, data from the National Electronic Injury Surveillance System and vital statistics data indicated that the ratio of fatal firearm-related injuries to nonfatal injuries (including emergency department outpatients) was approximately 1:2.6 (2); in California, the ratio was 1:1.3. Analyses limited only to deaths or to hospitalizations give incomplete pictures of the problem. For example, only 10% of unintentional firearm-related injuries resulted in death, but 90% of self-inflicted firearm-related injuries resulted in death.

Some of the assaultive firearm-related injuries included in this report may have been inflicted in self-defense. The International Classification of Diseases, Ninth Revision, does not classify assaultive injuries as legally justifiable or unjustifiable. However, the California Department of Justice Supplemental Homicide Reports for 1995 and 1996 indicate that 2% of firearm-related homicides committed by persons other than peace officers were considered justifiable.

The findings in this report are subject to at least two limitations. First, the CDHS does not have statewide information on firearm-related injuries treated in emergency departments or outpatient settings. Injury reports from emergency departments will become mandatory in California on January 1, 2002**. Analyses of these reports will improve understanding of the incidence, cost, and nature of firearm-related injuries in California. Second, this analysis excluded federal hospitals and non-California residents.

Few researchers have compared nonfatal and fatal firearm-related injuries (2-4). With assistance from CDC, systems permitting surveillance of both fatal and nonfatal firearm-related injuries have been developed in Colorado, Massachusetts, Missouri, New York City, Oklahoma, Washington, and Wisconsin (5). Other states and localities also conduct firearm injury surveillance (6).

Analyses such as the one described in this report can guide firearm-related injury prevention efforts by identifying populations at high risk for such injuries (e.g., blacks at risk for fatal and nonfatal firearm-related assault). These data also can contribute to analytic studies on costs associated with firearm-related injuries, evaluation of interventions and new laws, and assessment of firearm use in relation to other factors (e.g., alcohol use and domestic violence). One example would be to estimate the cost and health-care applications of firearm-related injuries by including persons who died after hospitalization in an analysis of hospital discharge data.


  1. Kim AN, Trent RB. Firearm-related injury surveillance in California. Am J Prev Med 1998;15(3S):31-7.
  2. 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.
  3. 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.
  4. Kellermann AL, Rivara FP, Lee RK, et al. Injuries due to firearms in three cities. N Engl J Med 1996;335:1438-44.
  5. Mercy JA, Ikeda R, Powell KE. Firearm-related injury surveillance: an overview of progress and the challenges ahead. Am J Prev Med 1998;15(3S):6-16.
  6. Hayes R, LeBrun E, Christoffel KK. Missing in action: health agencies lack critical data needed for firearm injury prevention. Chicago, Illinois: Handgun Epidemic Lowering Plan Network, Children's Memorial Medical Center, February 1999.

* International Classification of Diseases, Ninth Revision (for death certificate data), and International Classification of Diseases, Ninth Revision, Clinical Modification (for hospital discharge data), codes E965.0-E965.4 (assault), E955.0-E955.4 (self-inflicted), E922 (unintentional), E970 (legal intervention), and E985.0-E985.4 (undetermined).

** California, Health and Safety Code amendments, 1997-1998, chapter 735, statutes of 1998.

Table 1

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TABLE 1. Rate* and total number of assaultive and self-inflicted firearm-related fatal and nonfatal injuries resulting in
hospitalization+, by sex, race/ethnicity, and age of victim - California, 1995-1996
                                       Fatal injuries                             Nonfatal injuries
                          -----------------------------------------  ----------------------------------------------
                                                          Total                                          Total
                          Assault   Self-inflicted     ------------  Assault     Self-inflicted      --------------
Characteristic              rate         rate          Rate     No.    rate           rate           Rate       No.
  Male                      13.2          9.7          22.9   7,389    29.5           1.0            30.5     9,858
  Female                    1.8           1.5           3.3   1,077    3.0            0.3             3.3     1,057

  White                     2.4           8.1          10.6   3,621    4.0            0.8             4.8     1,657
  Hispanic                  12.5          2.6          15.2   2,797    28.3           0.5            28.9     5,321
  Black                     30.6          4.0          34.6   1,567    68.8           0.6            69.4     3,143
  Asian/Pacific Islander    4.0           2.1           6.2     420    6.9             &              7.0       473
  Other/Unknown              -             -              -      61     -              -                -       321

Age (yrs)
   0-14                     0.9           0.2           1.2     178    2.5             &              2.6       396
  15-24                     24.8          5.6          30.3   2,567    68.8           1.1            69.9     5,917
  25-34                     13.6          5.8          19.4   2,102    23.5           0.9            24.5     2,648
  35-44                     5.9           6.0          11.9   1,272    11.2           0.9            12.0     1,285
  45-54                     4.1           6.9          11.1     824    4.8            0.7             5.4       406
  55-64                     2.4           8.9          11.4     531    2.8            0.6             3.4       158
   >=65                     1.1          13.3          14.3     992    0.9            0.6             1.5       105

Total                       7.5           5.6          13.1   8,466    16.3           0.7            16.9    10,915
* Per 100,000 population.
+ International Classification of Diseases, Ninth Revision (for fatal injuries), and International Classification of Diseases, Ninth Revision,
  Clinical Modification (for nonfatal injuries), codes E965.0- E965.4 (assault) and E955.0- E955.4 (self-inflicted).
& Rates not calculated for <20 cases.
@ Denominator data are unavailable to calculate rates.

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