Video Abstract

Video Abstract

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Firearm injury is a leading and preventable cause of death for youth in the United States. The Centers for Disease Control and Prevention web-based injury statistics query and reporting system was queried to examine changes in firearm injury mortality among youth aged 0 to 19 from 2001 to 2019. This includes assessment of overall mortality rates, mortality rates based on intent and race/ethnicity, and the proportion of deaths due to homicide, suicide, and unintentional shootings among different age groups. Regression analysis was used to identify significant differences in mortality rate over time between Black and White youth. Deaths due to firearm injury were compared with deaths due to motor vehicle traffic collisions. In 2019, firearm injuries surpassed motor vehicle collisions to become the leading cause of death for youth aged 0-19 years in the United States, after excluding deaths due to prematurity and congenital anomalies. Homicide is the most common intent across all age groups, but suicide represents a large proportion of firearm deaths in 10- to 19-year-old youth. In 2019, Black youth had a firearm mortality rate 4.3 times higher than that of White youth and a firearm homicide rate over 14 times higher than that of White youth. For each additional year after 2013, the mortality rate for Black youth increased by 0.55 deaths per 100 000 compared with White youth (time by race interaction effect P < .0001). These data indicate the growing burden of firearm injuries on child mortality and widening racial inequities with Black youth disproportionately affected by firearm violence. This public health crisis demands physician advocacy to reduce these preventable deaths among youth.

Firearm injury is a leading cause of death for youth in the United States.1  In 2016, firearm injury was the second leading cause of death for youth aged 1 to 19 in the United States behind motor vehicle collisions (MVC).1  Firearm deaths are preventable, and as clinicians and investigators develop evidence-based prevention strategies, it is critical to understand the current trends in the mortality data, with a particular focus on intent, differences by age group, and racial/ethnic inequities.

When youth are killed by firearms, these deaths are classified by intent categories, including unintentional (when a youth gains access to an unsecured firearm and unintentionally kills themselves or someone else), homicide, and suicide. Overall, ∼60% of youth deaths from firearm injuries are homicides, 35% are suicides, and 4% are unintentional firearm deaths.1 

Youth in the United States have a higher risk of dying by firearm injury compared with their peers in other countries.2  In 2015, the United States accounted for >90% of all high-income country firearm deaths among 0- to 14-year-old children.3  Minoritized racial and ethnic groups have been disproportionately affected by this public health crisis. Although firearm injury was the second leading cause of death for all youth in the United States in 2016, it was the leading cause of death for Black youth and has been since at least 2001.1  NonHispanic Black youth have a higher rate of firearm homicide when compared with their White, Hispanic, American Indian, and Asian American peers.4  Black youth have previously been shown to be 14 times more likely to die of firearm injury compared with their White peers.5  Alternatively, firearm suicide is more likely to impact the American Indian and White populations.4  There is no biological plausibility for these disparities, but rather they are a reflection of racist systems and policies that perpetuate inequities in violent injuries and death. Firearm injury is a significant driver of racial health inequities among US youth.

Updated epidemiologic data are needed to inform targeted implementation of evidence-based firearm injury prevention programs including secure storage counseling68  and hospital-based violence intervention programs (HVIPs).911 

In 2019, the Firearm Safety Among Children and Teens (FACTS) consortium developed a consensus-driven research agenda, which included understanding recent epidemiologic trends and how demographic factors, such as race and ethnicity, are associated with fatal firearm outcomes.12  To address this need, we examined the most recent available data to report updated youth firearm mortality rates and trends over time with a focus on intent by age group and racial/ethnic inequities.

Mortality data were derived from the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics’ (NCHS) web-based injury statistics query and reporting system (WISQARS). Mortality data available through WISQARS are based on death certificates from the national vital statistics system operated by the CDC’s NCHS. WISQARS provides death counts and death rates for the United States by age, race, Hispanic ethnicity, cause of death, injury intent, and injury mechanism. Data are from the MVC and firearm injury by intent (including homicide, suicide, and unintentional but excluding legal intervention and undetermined intent) causes of death from 2001 to 2019 (the most recent data available) for youth aged 0 to 19. MVC mortality rates are used as a comparator group because MVC has been the leading cause of death for youth in the United States for decades.1  Deaths due to prematurity and congenital anomalies were excluded.

Firearm injury deaths are identified by using International Classification of Diseases, 10th Revision (ICD-10) underlying cause-of-death codes W32, W33, W34 (0.00,0.09,10,19) X72, X73, X74 (0.8,0.9), X93, X94, X95 (0.8,0.9), Y22, Y23, Y24 (0.8,0.9) Y35 (0.00-0.03, 0.09) Y36 (0.42,0.92) Y37 (0.42,0.43,0.92, Y38.4). MVC deaths include motor vehicle occupants, motorcyclists, pedestrians, and cyclists. MVC deaths are identified by using ICD-10 underlying cause-of-death codes V02–V04 (0.1, 0.9), V09.2, V12–V14 (0.3–0.9), V19 (0.4–0.6), V20–V28 (0.3–0.9), V29–V79 (0.4–0.9), V80 (0.3–0.5), V81.1, V82.1, V83–V86 (0.0–0.3), V87 (0.0–0.8), and V89.2.

To determine the relationship between all intent firearm mortality rate and traffic MVC mortality rate over time, the database was first queried for deaths due to all intent firearm injury and traffic MVC to report mortality rates (deaths per 100 000) for youth aged 0 to 19 (10 to 19 for suicide because of the rarity of suicide in youth <10 years old and neurodevelopmental concerns regarding the ability to determine intent in youth <10 years old) from 2001 to 2019. Firearm mortality rates by intent category were also reported over time from 2001 to 2019.

To determine the breakdown of intent of youth firearm deaths within age groups (0 to 4, 5 to 9, 10 to 14, and 15 to 19) proportion of deaths by intent was reported by age group.

To explore differences in mortality rate by race/ethnicity, all intent firearm injury mortality rate by race and ethnicity categories over time from 2001 to 2019 was determined. Race categories in WISQARS are reported as White, Black, American Indian, and Asian/Pacific Islander. Each of these race categories is divided into Hispanic or nonHispanic ethnicity. For the purposes of this study, all youth identified as Hispanic ethnicity were combined into one race/ethnicity category of Hispanic. Therefore, reported categories in this analysis are nonHispanic Black, nonHispanic White, nonHispanic American Indian, nonHispanic Asian/Pacific Islander, and Hispanic. In addition, mortality rates over time by race/ethnicity were determined for each firearm injury intent category (homicide, suicide, and unintentional injury). The suicide mortality rate was calculated among youth aged 10 to 19.

To evaluate time trend differences in firearm injury mortality rates between Black and White youth, a two-part linear regression analysis was performed for all intent, homicide, suicide, and unintentional firearm injury mortality rates. Separate models were run for the time periods before and after 2013. Covariates included in the model were race, year, and an interaction term between race and year, and the primary outcome of interest. American Indian, Hispanic, and Asian/Pacific Islander races/ethnicities were not included in the models given their small sample sizes.

In 2019, firearm injury surpassed MVCs to become the number one cause of death in children aged 0-19 years old, after excluding deaths due to prematurity and congenital anomalies (Figure 1). The firearm injury mortality rate in 2019 was 4.15 per 100 000 vs 3.99 per 100 000 for MVC. Firearm injury mortality has increased in the study period (from 3.63 in 2001 to 4.15 in 2019), whereas the MVC mortality rate has decreased (from 9.08 in 2001 to 3.99 in 2019) (Fig 1). The increase in firearm injury death is attributable to an increase over time in homicide (2.19 per 100 000 in 2001 vs 2.48 per 100 000 in 2019), and suicide (2.24 per 100 000 in 2001 vs 2.79 per 100 000 in 2019). From 2001 to 2019, unintentional firearm mortality rate decreased (0.22 per 100 000 in 2001 vs 0.14 per 100 000 in 2019).

FIGURE 1

Firearm injury and motor vehicle collision mortality among youth aged 0–19 from 2001–2019. Data are derived from the CDC and NCHS. Data are from the overall motor vehicle traffic and firearm causes of injury related deaths by intent from 2001 to 2019, as compiled by NCHS Vital Statistics System for numbers of deaths. The Bureau of Census was referenced for population estimates. Accessed at https://www.cdc.gov/injury/wisqars/index.html. All Intent = all firearm deaths (homicide, suicide, and unintentional); Homicide, firearm homicide deaths; MVC, motor vehicle traffic collision; Suicide, firearm suicide deaths; Unintentional, unintentional firearm deaths. Suicide mortality rate calculated per 100 000 youth aged 10 to 19.

FIGURE 1

Firearm injury and motor vehicle collision mortality among youth aged 0–19 from 2001–2019. Data are derived from the CDC and NCHS. Data are from the overall motor vehicle traffic and firearm causes of injury related deaths by intent from 2001 to 2019, as compiled by NCHS Vital Statistics System for numbers of deaths. The Bureau of Census was referenced for population estimates. Accessed at https://www.cdc.gov/injury/wisqars/index.html. All Intent = all firearm deaths (homicide, suicide, and unintentional); Homicide, firearm homicide deaths; MVC, motor vehicle traffic collision; Suicide, firearm suicide deaths; Unintentional, unintentional firearm deaths. Suicide mortality rate calculated per 100 000 youth aged 10 to 19.

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When analyzing the intent of firearm death by age group, unintentional injury represents a large proportion of deaths among youth aged 0 to 4 and the proportion decreases as youth get older, at least one-third of firearm deaths are due to suicide in ages 10 to 14 and 15 to 19, although homicide injury is the most prevalent across all ages from 0 to 19 (Fig 2).

FIGURE 2

Firearm injury deaths by age group and intent among youth aged 0–19 from 2001–2019. Data are derived from CDC and NCHS. Data are from the overall firearm causes of injury related deaths from age 0 to 19 by intent from 2001 to 2019, as compiled by NCHS Vital Statistics System for numbers of deaths. The Bureau of Census was referenced for population estimates. Accessed at https://www.cdc.gov/injury/wisqars/index.html.

FIGURE 2

Firearm injury deaths by age group and intent among youth aged 0–19 from 2001–2019. Data are derived from CDC and NCHS. Data are from the overall firearm causes of injury related deaths from age 0 to 19 by intent from 2001 to 2019, as compiled by NCHS Vital Statistics System for numbers of deaths. The Bureau of Census was referenced for population estimates. Accessed at https://www.cdc.gov/injury/wisqars/index.html.

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There are significant widening racial inequities in firearm injuries among youth. From 2001 to 2019, the average annual firearm mortality rate among Black youth was 9.9 per 100 000, whereas the average among White youth was 2.3 per 100 000 (Fig 3a). In a linear regression analysis of all intent firearm injury mortality rates before 2013, there was no significant time trend difference between Black and White youth (time by race interaction effect P = .685). In a separate model, it was found that, for each additional year after 2013, the mortality rate among Black youth increased by 0.55 deaths per 100 000 youth compared with White youth (time by race interaction effect P < .0001).

FIGURE 3

Firearm injury mortality among youth aged 0–19 by race/ethnicity from 2001–2019. Data are derived from CDC and NCHS. Data are from firearm all intent causes of injury related deaths from age 0 to 19 from 2001 to 2019, as compiled by NCHS Vital Statistics System for numbers of deaths. The Bureau of Census was referenced for population estimates. Accessed at https://www.cdc.gov/injury/wisqars/index.html. Race and Ethnicity is reported in categories made available in WISQARS. All youth identified as Hispanic ethnicity were combined into one category regardless of race. Suicide mortality rate calculated per 100 000 youth aged 10 to 19. A, All intent firearm injury mortality among youth aged 0 to 19 by race/ethnicity from 2001 to 2019. B, Firearm homicide mortality among youth aged 0 to 19 by race/ethnicity from 2001 to 2019. C, Firearm suicide mortality among youth aged 10 to 19 by race/ethnicity from 2001 to 2019. D, Unintentional firearm mortality among youth aged 0 to 19 by race/ethnicity from 2001 to 2019.

FIGURE 3

Firearm injury mortality among youth aged 0–19 by race/ethnicity from 2001–2019. Data are derived from CDC and NCHS. Data are from firearm all intent causes of injury related deaths from age 0 to 19 from 2001 to 2019, as compiled by NCHS Vital Statistics System for numbers of deaths. The Bureau of Census was referenced for population estimates. Accessed at https://www.cdc.gov/injury/wisqars/index.html. Race and Ethnicity is reported in categories made available in WISQARS. All youth identified as Hispanic ethnicity were combined into one category regardless of race. Suicide mortality rate calculated per 100 000 youth aged 10 to 19. A, All intent firearm injury mortality among youth aged 0 to 19 by race/ethnicity from 2001 to 2019. B, Firearm homicide mortality among youth aged 0 to 19 by race/ethnicity from 2001 to 2019. C, Firearm suicide mortality among youth aged 10 to 19 by race/ethnicity from 2001 to 2019. D, Unintentional firearm mortality among youth aged 0 to 19 by race/ethnicity from 2001 to 2019.

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From 2001 to 2019, the average annual firearm homicide mortality rate among Black youth was 8.68 per 100 000, whereas the average among White youth was 0.62 per 100 000. In 2019, specifically, 10.32 per 100 000 Black youth were killed by firearm homicide, compared with 0.72 per 100 000 White youth (Fig 3b). In a linear regression analysis of firearm homicide injury mortality rates before 2013, there was no significant time trend difference between Black and White youth (time by race interaction effect P = .427). In a separate model, it was found that, for each additional year after 2013, the mortality rate among Black youth increased by 0.49 deaths per 100 000 youth compared with White youth (time by race interaction effect P < .0001).

NonHispanic White children have experienced an increase in firearm suicide mortality with a rate of 2.74 per 100 000 in 2001 and reaching a rate of 3.69 per 100 000 in 2019 (Fig 3c). In a linear regression analysis of firearm suicide injury mortality rates, there was no significant time trend difference between Black and White youth before or after 2013 (time by race interaction effect before 2013 P = .3337, after 2013 P = .0548).

The overall rate of unintentional firearm death has decreased from 0.58 to 0.25 per 100 000 from 2001 to 2019, although Black youth have a >3 times higher rate of unintentional firearm deaths compared with White and Hispanic youth (Fig 3d). In a linear regression analysis of firearm unintentional injury mortality rates before 2013, there was no significant time trend difference between Black and White youth (time by race interaction effect P = .456). In a separate model, it was found that, for each additional year after 2013, the mortality rate among Black youth increased by 0.03 deaths per 100 000 youth compared with White youth (time by race interaction effect P = .0008). (Fig 3d)

For intent-specific analysis by race, estimates among the nonHispanic American Indian and Asian/Pacific Islander populations can be unstable because of low case counts. For this reason, American Indian and Asian/Pacific Islander data were not included in the intent-specific graphs.

After excluding deaths due to prematurity and congenital anomalies, firearm injury became the leading cause of death for youth in the United States in 2019, surpassing MVCs. From 2001 to 2019, there has been a 14% increase in the firearm injury mortality rate among youth in the United States, whereas there has been a 66% reduction in the MVC mortality rate. Public health approaches that have proven successful in reducing MVC mortality, including public education campaigns, industry safety standards, and legislative advocacy, must be used to reduce firearm deaths among youth.

Firearm injuries are subdivided into 3 primary intent categories: homicide, suicide, and unintentional. Consistent with previous literature, intent category distribution varies by age. The majority of youth firearm deaths for all age groups are due to homicide. The proportion of deaths due to unintentional injury decreases as youth get older, although suicide is a significant driver of firearm mortality in youth aged 10 to 19. Although youth <10 years of age were not included in our suicide mortality rate calculation, it is important to note that screening for suicidality should be considered in 8- to 9-year-old youth to allow for early intervention.13  These data contrast with adult firearm mortality data, in which the majority of firearm deaths are due to suicide.14 

These data reveal significant racial inequities in youth firearm mortality. Black youth carry a disproportionate burden of overall firearm deaths and firearm homicide deaths. There are widening racial inequities in all-intent, homicide, and unintentional mortality rates with rates among Black youth increasing at a faster rate than among White youth since 2013. There is no plausible biological explanation for these inequities. Centuries of racist policies have led to a multitude of racial inequities in child health,15  and firearm violence is a significant contributor. Any solutions to reduce youth firearm mortality must take this into account, as any increase in youth firearm mortality will only contribute to further racial health inequities among youth in the United States. Similarly, any effective strategy to reduce youth firearm deaths will help to address these inequities.

The firearm suicide mortality rate has increased in all reported racial/ethnic groups. The overall increase over time in all reported racial/ethnic groups underscores the importance of suicide prevention interventions in any comprehensive strategy to decrease the burden of firearm mortality among youth in the United States. Additionally, the racial/ethnic demographics suggest targeted interventions to decrease firearm suicide risk among high-risk youth in the United States, including both American Indian youth and White youth, are likely needed.

Although the overall rate of unintentional firearm injuries among youth has decreased from 2001 to 2019, these deaths consistently represent ∼5% of the overall firearm youth deaths in the United States. Many of these deaths could be prevented through the implementation of secure firearm storage in the home (storing guns locked, unloaded, and separate from ammunition). This is an area in which pediatricians can act immediately to reduce the burden of firearm injury among youth by providing secure storage counseling at every patient encounter.

A comprehensive public health approach to reducing the burden of firearm injuries and deaths among US youth must include a combination of public education, clinical interventions, and legislative advocacy.16  Much can be learned from the successful reduction in MVC mortality. Our study demonstrates a 66% reduction in MVC mortality among youth aged 0 to 19 from 2001 to 2019. The rapid decline in MVC deaths among youth has largely been attributed to the mandated use of age- and size-appropriate child restraints (car seats, booster seats, seat belts)1719  in addition to other policies.20,21  Although the interventions used to address MVC deaths are different from those which are needed to address firearm deaths, the same tenets of public health apply, including a combination of research, public education, community-based initiatives, industry safety standards and accountability, governmental coordination, investment, and legislation.

Previous studies have identified a lack of education around firearm injury prevention in undergraduate, graduate, and continuing medical education.22  McKay et al recently addressed this with the development and implementation of a pediatric resident workshop on firearm safety counseling, which demonstrated residents completing the workshop were more likely to report counseling on firearm safety.23  Part of the medical education on pediatric firearm injuries must include clarification around legal prohibitions to discussing firearm storage with patients. There are currently no restrictions on a physician’s legal right to discuss firearm ownership and storage with patients.24,25 

Secure Storage Counseling

More than 13 million children in the United States live in homes with firearms, and 4.6 million of those children reside in homes where guns are improperly stored (ie loaded and unlocked).26  Firearm access in the home increases the risk of unintentional shootings and firearm suicide.27  Nearly 90% of all child-involved unintentional shootings take place in the home.28  Additionally, 90% of guns used in youth suicide are from the child’s home or the home of a friend or relative.29  Access to unsecured firearms also facilitates city gun violence as evidence suggests some youth obtain the weapons they carry from their own home.30  Responsible storage (storing guns locked, unloaded, and separate from ammunition) decreases risk for unintentional shootings by 78% and firearm suicide by up to 85%.6 

Barkin et al demonstrated that brief physician counseling, combined with the provision of a cable gun lock, is effective at increasing safe storage of home firearms.31  Results of other secure storage counseling interventions have been variable and there remains a lot to learn regarding ideal messengers, messaging, and setting.7  The American Academy of Pediatrics recommends that pediatricians routinely screen for access to firearms and counsel about risk reduction.16  The majority of health care providers agree that they should provide firearm counseling but report barriers to doing so including lack of time, inadequate training, and low self-efficacy.32  As demonstrated by Gastineau et al, an improvement in pediatric secure storage counseling is possible.33  In this study, the evidence-informed, American Academy of Pediatrics–aligned Be SMART for Kids program was used to increase rates of firearm screening and secure storage counseling from 3% to >75%.34 

Hospital-Based Violence Intervention Programs (HVIPs)

HVIPs are comprehensive programs integrated into hospitals and trauma centers that provide wrap-around services to youth and young adult victims of violence to address the underlying risk factors for violence and promote improved outcomes after injury. Through long-term intensive case management, mentorship, and support utilizing both hospital and community services (such as services for mental health, substance abuse, gang interruption, housing, education, employment, and creative outlets), HVIPs are demonstrated to improve utilization of supportive services, reduce violence recidivism, reduce involvement in the criminal justice system, and be cost-saving.911  These programs are supported and endorsed by multiple surgical and medical societies as a key public health strategy to support victims and reduce violence.35 

Healthcare providers can contribute to a reduction in pediatric firearm injury and death by engaging with community organizations that are working to support youth who have experienced violence or who are at risk for future violence. Physicians are credible messengers for public health initiatives like secure storage counseling and suicide prevention.

There are evidence-based legislative approaches to reducing pediatric firearm mortality,36  including laws that expand background checks to include all gun sales37  and secure storage laws that require firearms to be stored securely when not in use.3840  In addition to advocating for these evidence-based policies, pediatric healthcare providers may also consider advocating for research funding in proportion to the burden of morbidity and mortality of firearm injuries. Relative to its mortality rate, firearm violence received 1.6% of the predicted research funding with a resultant 4.6% of the predicted publication volume from 2004 to 2015.41 

There are several limitations to this study. This analysis is limited to deaths by firearm injury and does not consider the epidemiology of nonfatal firearm injuries. Data are not yet available from the CDC to understand the impact of the coronavirus disease 2019 (COVID-19) pandemic on the epidemiology of firearm injuries among youth. Gastineau et al used Pediatric Health Information Systems data to determine that, although overall pediatric hospitalization rates decreased during the first 6 months of the pandemic, pediatric hospitalizations for firearm injuries increased significantly compared with previous years.42  Although ICD-10 coding for firearm injury intent has previously been suggested to be unreliable,43,44  utilizing death certificate data, as the WISQARS database does, is much more accurate. Misclassification of intent is still possible. Reporting by race/ethnicity is limited by the categories available in the database. All Hispanic ethnicity deaths were combined regardless of race, making it more difficult to draw conclusions about specific subgroups of Hispanic youth. Similarly, it is difficult to draw conclusions for patients identifying as mixed race.

Firearm injury has become the leading cause of death for youth in the United States, and firearm injuries remain a significant driver of racial health inequities. Evidence-based solutions exist, and pediatric healthcare providers are poised to contribute meaningfully to a comprehensive public health approach to reducing these preventable deaths.

Dr Andrews conceptualized and designed the study, carried out the analyses, drafted the initial manuscript and reviewed and revised the manuscript; Mr Killings and Drs Gastineau and Oddo conceptualized and designed the study, carried out the analyses, reviewed and revised the manuscript; Dr Hink conceptualized and designed the study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • CDC

    Centers for Disease Control and Prevention

  •  
  • HVIPs

    Hospital-Based Violence Intervention Programs

  •  
  • MVC

    motor vehicle collision

  •  
  • NCHS

    National Center for Health Statistics

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Competing Interests

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.