Perspectives in Disease Prevention and Health Promotion Progress Toward Achieving the National 1990 Objectives for Injury Prevention and Control

The nation's health objectives, established in 1979 (1), include goals for preventing and controlling injuries. Nine of these objectives address intentional and unintentional injuries and have helped to set the priorities for injury control. Work-related injuries and some aspects of intentional injury prevention are addressed in other reviews of the 1990 objectives. The nine injury control objectives are presented below along with a status report and a discussion of pertinent risk factors and indicators as well as strategies for progress.

By 1990, the motor vehicle fatality rate should be reduced to no greater than 18.0/100,000 population (baseline rate in 1978: 23.6/100,000).

Status: The 1984 rate was 19.6/100,000. This objective is projected to be met, despite increases of 9% in the population, 13% in licensed drivers, 19% in registered motor vehicles, and 21% in the total vehicle miles traveled (2). According to data from the National Highway Traffic Safety Administration (NHTSA), the mortality rate per miles driven decreased from 3.26 deaths per 100 million miles traveled in 1978 to 2.48 deaths per 100 million miles traveled in 1986 (2). Motor vehicle crashes in 1986 resulted in 46,056 deaths (2).

The reduction in alcohol-related fatalities from 1982 through 1986 was a major contributor to the decreases in motor fatalities and fatality rates. The proportion of driver fatalities that involved a blood alcohol concentration (BAC) greater than or equal to0.10 mg/dL decreased from 44% in 1982 to 39% in 1986. Among youthful drivers (20-24 years of age), the proportion of fatalities involving a BAC greater than or equal to0.10 mg/dL dropped from 40% in 1982 to 34% in 1986. Arrests for alcohol-impaired driving increased from about 0.5 million in 1978 to 1.7 million in 1986. The legal age for the purchase or public possession of alcoholic beverages is now 21 years in all but one state.

The increasing use of seat belts was another major contributor to declines in motor vehicle fatality rates (3). From 1978 to 1986, overall use of seat belts increased from under 13% to over 39% (4). Twenty-nine states and the District of Columbia have now adopted laws making the use of seat belts mandatory.

By 1990, the motor vehicle fatality rate for children under 15 should be reduced to no greater than 5.5/100,000 children (baseline rate in 1978: 9.0/100,000).

Status: The 1984 rate was 6.6/100,000. If the current rate of decline continues, this objective will be met by 1990. According to data from NHTSA, the 1986 fatality rate was 25% below the 1978 rate, and the number of deaths decreased from 4,209 in 1978 to 3,160 in 1986 (2). Use of child restraints increased 413%, from approximately 15% in 1979 to 77% in 1986 (3). In 1978, one state had a law mandating the use of safety belts for children, but, by 1986, all 50 states and the District of Columbia had child-restraint laws.

By 1990, the death rate from falls should be reduced to no more than 2.0/100,000 population (baseline rate in 1978: 6.2/100,000).

Status: The 1984 rate was 5.1/100,000. This objective is not expected to be met by 1990, although the trend in the number of fatalities due to falls has been and continues to be decreasing. However, this objective has been met for persons under 65 years of age, whose mortality rate from falls was 1.5/100,000 in 1984. The overall mortality rate from falls is affected by the disproportionately high rate among the elderly. In 1984, rates for the elderly ranged from 10.2/100,000 for 65- to 74-year-olds to 147.0/100,000 for persons 85 years of age and older. The downward trend of the overall crude fatality rate from falls may plateau or begin to rise as the proportion of the U.S. population aged 65 years or older increases. In addition, National Center for Health Statistics, CDC, mortality data may undercount fatalities from falls more than other fatalities. Because the fatal events that often follow hip fractures (e.g., pneumonia or pulmonary embolism) occur long after the fall, deaths may be misclassified (5,6).

Medical and behavioral factors that lead to falls include disorders of gait and balance and the use of certain prescription and nonprescription drugs (including alcohol). Environmental factors implicated as contributors to falls include items such as poor lighting and loose rugs. Survival after injury is greatly influenced by the immediate management of head trauma and hip fracture and by the subsequent prevention of venous thrombosis, pulmonary embolism, and disorders of gait and balance and the use of certain prescription and nonprescription drugs (including alcohol). Environmental factors implicated as contributors to falls include items such as poor lighting and loose rugs. Survival after injury is greatly influenced by the immediate management of head trauma and hip fracture and by the subsequent prevention of venous thrombosis, pulmonary embolism, and pneumonia.

Advances in knowledge about these factors and their roles in fall-related mortality could highlight opportunities to prevent falls and fatalities from falls. Focused prevention efforts, based on clearly defined priorities, can help coordinate the activities of many governmental and nongovernmental entities in addressing this problem.

By 1990, the home injury fatality rate for children under 15 years of age should be no greater than 5.0/100,000 children (baseline rate in 1978: 6.0/100,000).

Status: The 1984 rate was 4.9/100,000. This objective has already been achieved. For nearly 50 years, home injury deaths and mortality rates for children under 15 years of age have steadily declined. In 1984, almost 40% of the injury deaths involving children under 5 years of age occurred in the home. The home injury fatality rate is highest for children under 1 year of age; however, the rate for this age group declined from 14.7/100,000 in 1979 to 11.9/100,000 in 1984.

The causes of home injury deaths include fires, drowning, suffocation, falls, firearms, and poisoning. Since 1978, home injury deaths have decreased in every category except poisoning. Deaths in that category increased from a rate of 0.12/100,000 population in 1978 to 0.15/100,000 in 1984. For children under 1 year of age, suffocation is now the most prevalent cause of death, whereas, for children 10 to 14 years of age, deaths are most often due to fires and unintentional firearm injuries.

By 1990, the death rate from drowning should be reduced to no more than 1.5/100,000 persons (baseline rate in 1978: 3.2/100,000).

Status: The 1984 rate was 2.3/100,000. This objective is not expected to be met by 1990. During the last decade, boating activities, which have increased greatly, have exposed more people to the risk of drowning. Nonetheless, boating-related drownings declined from 1,242 to 944 between 1978 and 1984, and the rate decreased from 0.6/100,000 to 0.4/100,000 population, nearly a 29% reduction in the rate of such fatalities. Alcohol use by boat operators is increasingly recognized as contributing to boating fatalities (7). From 1978 to 1984, nonboating drownings decreased from 5,784 to 4,444, and the rate of such drownings decreased nearly 27%, from 2.6/100,000 to 1.9/100,000. Despite improved safety in residential swimming pools and spas, approximately 300 children under 5 years of age drown each year in this setting (8).

By 1990, residential fire deaths should be reduced to no more than 4,500 per year (baseline deaths in 1978: 5,401).

Status: The number of deaths in 1984 was 4,466. This objective was reached in 1984. The overall annual mortality rate due to residential fires decreased 21%, from 2.4/100,000 persons in 1978 to 1.9 in 1984. For males, the mortality rate due to residential fires decreased 20%, from 3.0/100,000 in 1978 to 2.4/100,000 in 1984. For females, the rate decreased 26%, from 1.9/100,000 in 1978 to 1.4/100,000 in 1984.

Mortality rates due to residential fires differ markedly for blacks and whites. In 1984, the rate among blacks was 4.8/100,000; it was 1.5/100,000 among whites. By region, the mortality rate due to residential fires was highest in the South and lowest in the West. By age group, it was highest for persons 65 years of age or older (4.6/100,000) and second highest for children under 5 years of age (4.1/100,000).

Cigarette smoking and alcohol use are important contributors to residential fires (9). Cigarettes are involved in half of all deaths caused by residential fires. Typically, these fires occur late at night when people fall asleep while smoking in bed. About 40% of the victims of residential fires who have been studied have had blood alcohol concentrations greater than or equal to0.1 mg/dL. Alcohol use probably contributes to the occurrence of fires and also impairs the escape of intoxicated individuals.

Smoke detectors halve the risk of death in residential fires (10). Thus, the increased ownership of smoke detectors (from 5% in 1970 to 75% in 1985) has probably helped reduce the rate of residential fire deaths. Public education efforts have heightened awareness of the safety value of detectors; the cost of detectors has substantially decreased; and there are more laws requiring smoke detectors in homes. Blacks and the elderly are less likely than other groups to own smoke detectors (11).

By 1990, the number of unintentional deaths from firearms should be held to no more than 1,700 (baseline cases in 1978: 1,806).

Status: The number of deaths in 1984 was 1,668. This objective has already been met. Despite this success, 287 (17%) of these 1,668 unintentional deaths from firearms occurred among children under 15 years of age; 34 occurred among children under 5; and 253, among children 5-14. Unintentional firearm injuries have the greatest impact on young males, minorities, and rural residents. About half of these fatalities occur at home.

Firearms rank second, behind motor vehicles, as the most important cause of injury mortality (12). In 1984, firearms accounted for 31,361 deaths (1,688 unintentional injuries, 17,113 suicides, 11,825 homicides, 253 legal interventions, and 482 of undetermined intent). Each year, there are about 15 firearm-related deaths for every 100,000 individuals. By comparison, there are 20 motor vehicle fatalities per 100,000.

By 1990, the rate of suicide among people 15 to 24 years of age should be below 11.0/100,000 population (baseline rate in 1978: 12.1/100,000).

Status: The 1984 rate was 12.2/100,000. This is the only injury control objective for which the rate is not declining. Although the youth suicide rate did not change significantly between 1978 and 1984, the 1978 rate was nearly 200% above the 1950 rate (13). This increase had been steady and consistent from the mid-1950s until 1977, when it reached a peak of 13.6/100,000. The rate leveled out at 12.1 in 1978. The rates for persons 15-19 years of age increased from 7.9 to 9.0 between 1978 and 1984. During that period, the rate for persons 20-24 years of age decreased slightly, from 16.5 to 15.6.

White males 20-24 years of age have the highest youth suicide rate. The rate for this age group is almost twice the rate for white males aged 15-19. The male-to- female ratio of youth suicide rates is approximately 5:1. Firearms are the most common method of suicide for both males and females 15-24 years of age; the increase in firearm suicides accounted for most of the increase in the youth suicide rate over the past 30 years.

A number of risk factors have been suggested to be associated with youth suicide (14), including serious psychiatric problems; a previous suicide attempt; a family history of suicide; abnormally low levels of 5-hydroxyindoleacetic acid, an important neurotransmitter; widowed or divorced marital status; substance abuse; exposure to suicide directly, through knowing the victim, or indirectly, through the media; and the presence of firearms in the home.

Various preventive approaches have been advocated, but their effectiveness is not known (14). These approaches include 1) teaching youths to identify and understand feelings to help them cope with the types of problems that can lead to suicide, 2) early identification of youths at high risk of committing suicide and their referral for treatment, 3) school-based screening programs, 4) crisis centers and hotlines, 5) improved training of health-care professionals in treating conditions that can lead to suicide; and 6) restriction of access to the lethal means of suicide.

By 1990, the death rate from homicide among black males ages 15 to 24 should be reduced to below 60.0/100,000 (baseline rate in 1978: 70.7/100,000).

Status: The 1984 rate was 61.5/100,000. Among black males 15-24 years of age, more lives are lost from homicide than from any other cause. During the period 1970-1984, 31,920 homicide victims were black males 15-24 years of age. In general, both the numbers and rates of homicide for this group were highest during the early 1970s and gradually declined to a 15-year low in 1984. The 1984 rate of 61.5/100,000 represents a 13% decrease from the 1978 index year rate of 70.7.

Most (61%) homicides among black males 15-24 years of age occurred in the context of an argument or other nonfelony circumstance. More than half of the victims (53%) were killed by persons they knew; 20% were killed by strangers; and, for the remainder, the victim-assailant relationship was undetermined. More than 75% of the young black victims were killed with firearms; 19% were killed with cutting or piercing instruments; 3%, with a bludgeoning instrument; and 2%, with other weapons. The homicide rate for black males 15-24 years of age is twice as high in metropolitan counties as in nonmetropolitan counties.

Promising local community efforts to develop and implement homicide prevention programs have involved the collaboration of health, criminal justice, social service agencies, and many other entities. Other approaches to intervention include decreasing the acceptance of behaviors that promote violence; developing strategies to reduce firearm-associated injuries; teaching nonviolent conflict-resolution skills; and improving the recognition, management, and treatment of victims of violence. These interventions must be evaluated for their ability to decrease injuries and deaths, their benefits and costs, and their social acceptability.

Young black males should continue to be a focus for prevention efforts, but the problem of homicide among other blacks and other minorities should also be addressed (15). In addition, future efforts should address the tremendous morbidity associated with nonfatal interpersonal violence. Reported by: Office of Disease Prevention and Health Promotion, Public Health Svc, Dept of Health and Human Svcs. Div of Injury Epidemiology and Control, Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: Since 1979, when the health status objectives for nonoccupational injuries were selected, injury fatality rates have declined (Figure 1) (16). A broad range of federal agencies* participated in the 1987 injury progress review to identify areas of success and failure and to highlight areas for future efforts. Each federal agency represented many different constituencies within and outside government, including state and local agencies and private entities.

In 1985, the National Academy of Sciences (NAS) provided a major impetus to expand injury control activities by reviewing the nation's injury control needs (17), as requested by Congress. Responding to the NAS recommendations, Congress appropriated $10 million in 1986 and again in 1987 for a pilot program to create a center for injury control at CDC and to expand support for injury prevention research. CDC created the Center for Environmental Health and Injury Control (CEHIC) by bring ing together its units that work on both intentional and unintentional injuries (18). CEHIC is charged with 1) establishing surveillance systems and conducting and fostering prevention programs, 2) improving and expanding professional education and training, 3) collecting and analyzing data, and 4) serving as the lead federal agency in injury research and prevention.

The 1990 objectives for injury control originally addressed only unintentional injuries, but this more comprehensive review addresses homicide and suicide and reflects the philosophy behind CDC's reorganization and the mandate from NAS and Congress. Thus, this review covers aspects of both intentional and unintentional injuries. Other 1990 objectives related to intentional injury will be addressed in a future report on the control of stress and violent behavior.

Achieving the 1990 objectives in injury control and developing new objectives for the year 2000 will require the coordinated efforts of federal, state, and local agencies from health and other sectors; academic institutions; professional associations; and private entities. Injury control for the balance of the 1980s and into the next decade will focus on:

1. Establishing and improving injury surveillance systems to permit accurate, timely characterization of injury problems at national, state, and local levels.

2. Expanding injury control research focused on the 1990 objectives and other priorities and applying the findings to injury control programs.

3. Developing rigorous approaches to the evaluation of injury control methods, implementing and evaluating selected demonstration programs for injury control, and disseminating the findings.

4. Implementing effective injury control programs focused on priority problems of the locale; mobilizing the assistance of public, industrial, and private institutions; and coordinating the efforts of public agencies.

References

1. Public Health Service. The 1990 health objectives for the nation: a midcourse review. Washington, DC: US Department of Health and Human Services, Public Health Service, 1986.

2. National Highway Traffic Safety Administration. Fatal accident reporting system 1985: a review of information on fatal accidents in the U.S. in 1985. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1987; DOT publication no. (HS)807-071.

3. National Highway Traffic Safety Administration. Restraint system usage in the traffic population, 1986 annual report. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1987; DOT publication no. (HS)802-0800.

4. Goryl ME. Restraint system usage in the traffic population. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration, 1986; DOT publication no. (HS)806-987.

5. Baker SP, O'Neill B, Karpf RS. The injury fact book. Lexington, Massachusetts: Lexington Books, 1984:113.

6. Radebaugh TS, Hadley E, Suzman R, eds. Symposium on falls in the elderly: biologic and behavioral aspects. In: Clinics in geriatric medicine. Philadelphia: WB Saunders, 1985. (Vol 1, no 3).

7. National Research Council. Proceedings of the workshop on alcohol-related accidents in recreational boating. Washington, DC: Transportation Research Board, National Research Council, 1986.

8. US Consumer Product Safety Commission, National Spa and Pool Institute. National Pool and Spa Safety Conference (Report). Washington, DC: US Consumer Product Safety Commission, National Spa and Pool Institute, 1985.

9. Karter MJ Jr. Patterns of fire deaths among the elderly and children in the home. Fire J 1986;Mar:19-22.

10. McLoughlin E, Marchone M, Hanger L, German PS, Baker SP. Smoke detector legislation: its effect on owner-occupied homes. Am J Public Health 1985;75:858-62.

11. Hall JR. A decade of detectors: measuring the effect. Fire J 1985;79:37-78.

12. Jagger J, Dietz PE. Death and injury by firearms: who cares? JAMA 1986;255:3143-4.

13. Centers for Disease Control. Youth suicide in the United States, 1970-1980. Atlanta: US Department of Health and Human Services, Public Health Service, 1986.

14. Eddy DM, Wolpert RL, Rosenberg ML. Estimating the effectiveness of interventions to prevent youth suicide. Medical Care 1987;25(12):S57-S65.

15. US Department of Health and Human Services. Report of the Secretary's Task Force on Black and Minority Health. Washington, DC: US Department of Health and Human Services, Public Health Service, 1986.

16. Centers for Disease Control. CDC surveillance summaries. MMWR 1987;37(suppl SS-1) (in press).

17. Committee on Trauma Research, Commission on Life Sciences, National Research Council, Institute of Medicine. Injury in America: a continuing public health problem. Washington, DC: National Academy Press, 1985.

18. Division of Injury Epidemiology and Control, Center for Environmental Health, Centers for Disease Control. 1986 annual report. Atlanta: US Department of Health and Human Services, Public Health Service, 1987. America: a continuing public health problem. Washington, DC: National Academy Press, 1985.

19. Division of Injury Epidemiology and Control, Center for Environmental Health, Centers for Disease Control. 1986 annual report. Atlanta: US Department of Health and Human Services, Public Health Service, 1987.

*Participants represented the National Highway Traffic Safety Administration, National Institute on Aging, U.S. Consumer Product Safety Commission, U.S. Fire Administration, Health Resources and Services Administration, National Institute for Mental Health, and the Centers for Disease Control.

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