Perspectives in Disease Prevention and Health Promotion Premature Mortality Due to Unintentional Injuries -- United States, 1983

As life expectancy has increased in the United States, the leading causes of death have shifted to those diseases occurring late in life, such as heart disease, cancer, and stroke. Mortality rates have long been used to measure the magnitude of these diseases and to determine resource allocation in public health. However, this traditional measure of mortality does not provide the information needed to compare the amount of premature mortality by cause of death. In 1950, an index was proposed that expressed deaths in terms of years of life lost (YLL) to complement conventional death rates (1). However, the YLL index was little used during the 1950s and 1960s. A 1965 study noted that injuries caused a significant loss of years of life and that the allocation of health resources must consider not only the number of deaths by cause but also by age (2). During the 1970s and early 1980s, the YLL index became an accepted tool for state and local health planners (3). In 1982, CDC began reporting years of potential life lost before age 65 years (YPLL) in Table V of the MMWR The YPLL index draws attention to potentially preventable mortality occurring early in life.

Unintentional injuries are the leading cause of YPLL. In 1984, they accounted for 2,308,000 YPLL, or about 19.6% of all YPLL (see Table V, page 365). Overall, unintentional injuries (E800-E949)* accounted for 2,277,000 YPLL in 1983, or about 19.4% of all YPLL. This report focuses on the 10 leading causes of YPLL due to unintentional injury for 1983, the last year for which complete data are available.

For this report, age- and cause-specific mortality data obtained from the National Center for Health Statistics (NCHS) were used to determine the number of deaths and to calculate the YPLL for each cause of unintentional injury death in the United States during 1983. Population estimates from the U.S. Bureau of the Census were used to calculate YPLL rates.

Among unintentional injuries, motor vehicle traffic crashes (E810-E819) are the leading cause of both YPLL and deaths (Figure 1). Among all other causes of death, motor vehicle traffic crashes rank only below malignant neoplasms and diseases of the heart for YPLL. The remaining 10 leading causes of YPLL from unintentional injuries, in order, are: drownings (E910), fire and flames (E890-E899), poisonings (E850-E869), falls (E880-E888), firearms (E922), choking on food or object (E911-E912), water transport (E830-E838), air transport (E840-E845), and motor vehicle nontraffic crashes (E820-E825).

The rank order of the cause-specific numbers of deaths is the same as that of YPLL, except for fire and flames (fourth instead of third) and water transport (ninth instead of eighth).

Crude YPLL rates per 100,000 population and average YPLL per death (equivalent to 65 minus the average age at death) vary by each of the 10 leading causes of unintentional injury YPLL and by the sex of the victim (Table 1). The variation by sex in the YPLL rates is measured in the YPLL rate ratios. Males have higher YPLL rates than females for each of the listed unintentional injury causes of death. The highest YPLL rate ratios for males compared with females are for deaths due to water transport and deaths due to firearms, whereas the lowest are for deaths due to fire and flames and deaths due to choking on food or object. Except for motor vehicle traffic crashes, poisonings, and falls, the average YPLL per death is higher for females than males. The highest average YPLL per death is for that associated with motor vehicle nontraffic crashes for females, and the lowest is for that associated with falls for females.

Both YPLL and mortality rates highlight the importance of injuries as a health problem among children. Annually, about 10,000 children aged 1-14 years die from injuries (4). Injuries account for more deaths among children than any disease. The six leading causes of unintentional injury death among children are: motor vehicles, drownings, fire and flames, choking on food or object, firearms, and falls (5). About 40% of motor vehicle deaths among children involved the child as a pedestrian (4). Considered as a separate cause of deaths among children, pedestrian death is the third leading cause of unintentional injury death after deaths among motor vehicle occupants and deaths due to drowning. Reported by Div of Injury Epidemiology and Control, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: Injury exacts an enormous toll in the United States, causing more than 140,000 deaths and over 3.5 million years of potential life lost per year (see Table V, page 365). Intentional injuries result from interpersonal or self-inflicted violence and include homicide, assaults, suicide and suicide attempts, child abuse, and rape. Unintentional injuries include those resulting from motor vehicle collisions, falls, fires, poisonings, and drownings. Injuries occur during work and include unintentional trauma (e.g., motor vehicle-related injuries, falls, and electrocutions) and intentional injuries. One in every three Americans suffers an injury each year, and 80,000 persons suffer permanent disabling injuries from brain or spinal cord trauma (6). Direct and indirect costs of injury are estimated at $75-$100 billion per year.

The use of YPLL has become a mainstay in the evaluation of the impact of injuries on public health. Although YPLL is a valuable index in analyzing various causes of injury mortality, this report also includes YPLL rates, YPLL rate ratios, and average YPLL per death. The use of YPLL rates allows comparison of YLL between different populations. For each of the 10 leading causes of unintentional injury YPLL, males have a higher rate of YPLL than females. These higher rates in males may reflect a greater involvement in hazardous activities, in use of alcohol (4), and in risk-taking behavior. However, the use of average YPLL per death shows that, among those who die from unintentional injuries, females, on average, are dying at a younger age than males for each of the 10 leading causes of unintentional injury YPLL, except for motor vehicle traffic crashes, poisonings, and falls. Persons are dying from drownings, motor vehicle nontraffic crashes, and firearms at a younger age, on average, than from the other leading causes of unintentional injury YPLL.

When injuries are studied epidemiologically, many opportunities for prevention may become evident. What is known about host, agent, and environment can be translated into programmatically sound interventions that reduce injury morbidity and mortality. A project of the Carter Center of Emory University entitled, "Closing the Gap," examined the impact of the injury problem and its potential reduction by applying existing scientific and technical knowledge (7). The Carter Center estimates that, by applying broad-based mixed strategies, motor vehicle-related fatalities and injuries could be reduced by about 75% (8). About 23,000 deaths per year result from unintentional injuries that occur in the home (8). The Carter Center estimates that targeted interventions could reduce home injuries by about 50% (8). Appropriately targeted interventions also could reduce by about 25% all fatal and serious injuries in which alcohol is an important factor (8).

Past and current research and surveillance efforts have identified many prevention strategies to be applied and evaluated, and a growing number of state and local public health agencies and other organizations are now in the process of meeting this challenge. State agencies, in particular, can assume several responsibilities in injury prevention, including: (1) coordinating their activities with local agencies, academic institutions, and private entities; (2) conducting injury surveillance; (3) developing intervention plans with other involved groups; (4) providing information to the public; and (5) providing technical advice on legislative proposals needed to support injury-control efforts.

References

1. Haenszel W. A standardized rate for mortality defined in units of lost years of life. Am J Public Health 1950;40:17-26.

2. Stickle G. What priority, human life? Am J Public Health 1965;55:1692-8.

3. Perloff JD, LeBailly SA, Kletke PR, Budetti PP, Connelly JP. Premature death in the United States: years of life lost and health priorities. J\Pub Health Policy 1984;5:167-184.

4. Baker SP, O'Neill B, Karpf RS. The injury fact book. Lexington, Massachusetts: Lexington Books, 1984:20.

5. National Safety Council. Accident facts, 1985. Chicago: National Safety Council, 1985.

6. Institute of Medicine and National Research Council. Injury in America. Washington, D.C.: National Academy Press, 1985.

7. Foege WH, Amler RW, White CC. Closing the gap. Report of the Carter Center health policy consultation. JAMA 1985;254:1355-8.

8. Smith GS. Measuring the gap for unintentional injuries: the Carter Center health policy project. Public Health Rep 1985;100:565-8. *Based on The International Classification of Diseases, 9th Revision, Supplementary Classification of External Cause of Injury. Includes those not related to water transport.

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