Pediatric Firearm Injury Mortality Epidemiology

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).

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).

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).

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)^17–19  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 

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 

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.^9–11  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.^38–40  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.

CDC

Centers for Disease Control and Prevention

HVIPs

Hospital-Based Violence Intervention Programs

MVC

motor vehicle collision

NCHS

National Center for Health Statistics