Approximately 5.8 million persons die from injuries each year, accounting for 10%
of all deaths worldwide (1). In the United States, 180,000 persons die each year from
injuries, making the category the country’s leading cause of death for those aged
1–44 years and the leading cause of years of potential life lost before age 65 years
(2). Injuries also result in 2.8 million hospitalizations and 29 million emergency
department visits each year in the United States. Motor vehicle crashes, falls, homicides,
suicides, domestic violence, child maltreatment, and other forms of intentional and
unintentional injury affect all strata of society, with widespread physical, mental,
and reproductive health consequences. Injuries and violence affect not only individuals,
but also families and communities, producing substantial economic and societal burdens
related to health-care costs, work loss, and disruption of education. The estimated
annual U.S. cost in medical expenses and lost productivity resulting from injuries
is $355 billion (2).
As is true in most areas of public health, to effectively prevent injuries, injury
and violence prevention strategies and interventions should be tested in real-world
settings. Real-world settings also can be fertile laboratories for generating new
interventions and prevention strategies. Community input to help identify and prioritize
problems for which interventions should be developed, propose interventional models,
and test, refine, and adapt interventions can help ensure relevance, feasibility,
acceptability, scalability, and sustainability.
Translating injury and violence prevention evidence into action in the United States
depends on coordination among federal, state, and local agencies, and partnerships
in the research and practice communities. In 2010, CDC published a compendium of 22
effective interventions from around the world aimed at prevention of falls among older
adults (3), then funded the translation of some of these strategies into programs
for specific communities and delivery systems. Three programs to prevent falls that
were highlighted in the compendium currently are being piloted in Colorado, New York,
and Oregon (3). The following two case studies on suicide and alcohol-impaired driving
are examples of using an evidence-based approach to injury and violence prevention
to improve public health policy and practice.
Case Study 1: Using Science to Guide Suicide Prevention Activities in Oregon
During the past 10 years, the U.S. suicide rate has increased approximately 10%, despite
greater recognition of the problem and expansion of antidepressant use (4). For every
suicide death, approximately 11 suicide attempts are made, and many other persons
have suicidal thoughts. One theorist has suggested that there are three key factors
leading to suicide: 1) “thwarted belongingness,” or feelings of alienation despite
trying to connect with others; 2) “perceived burdensomeness,” or feeling like a burden
to others; and 3) “the acquired ability to enact lethal self-injury,” or desensitization
to pain and death from repeated exposure. The last factor is supported by the observation
that the risk factor most strongly associated with dying by suicide is having attempted
suicide previously; a pattern of increasing lethality of attempts is observed among
some suicide decedents (5).
In 2010 in Oregon, a total of 685 deaths were attributed to suicide, more than in
2009 and more than the number of deaths attributed to motor vehicle crashes. Suicide
was the state’s eighth leading cause of death, and the rate of death by suicide among
men was almost four times the rate among women. The highest suicide death rates were
observed in men aged ≥75 years. To address the high suicide rate, the Public Health
Division of the Oregon Health Authority, along with other state agencies and representatives
from 13 communities throughout Oregon, created a suicide prevention plan for older
adults. Development of the plan was funded by CDC and the Substance Abuse and Mental
Health Services Administration.
Surveillance data from the National Violent Death Reporting System (NVDRS) was important
to development of the plan. NVDRS is a registry of deaths by suicide, homicide, legal
intervention, and undetermined intent that links data from multiple sources, including
death certificates, medical examiners, law enforcement, and crime laboratories. Through
NVDRS, public health practitioners and researchers have access to data regarding the
circumstances surrounding reported deaths that are not available from the National
Vital Statistics System. NVDRS has been in operation since 2002 and is currently implemented
in 18 states, including Oregon.
In 2009, NVDRS data for the 640 reported suicide deaths in Oregon indicated that 209
(33%) of the decedents had experienced a depressed mood, and 268 (42%) had disclosed
suicidal intent (Table). Persons aged 20–44 years were most likely to have disclosed
suicidal intent (50%), followed by those aged ≥65 years (40%), aged 45–64 years (38%),
and aged 10–24 years (37%).
Whereas substantial percentages of suicide decedents in younger age groups had experienced
alcohol or substance abuse (e.g., 34% of those aged 20–44 years) and relationship
problems (e.g., 48% of those aged 20–44 years and 36% of those aged 10–24 years),
chronic disease or declining health was more prevalent (68%) among suicide decedents
aged ≥65 years (Table). Additional findings exclusively regarding decedents aged ≥65
years (prevalences in other age groups were not assessed) indicated that 44% had lived
alone, and only 17% had visited a health-care provider in the 30 days before death,
suggesting a need for community intervention to reduce social isolation and use of
health-care encounters as intervention venues. The substantial prevalence of disclosed
suicidal intent also supported the idea that sensitizing health-care and social-service
providers to the possibility of disclosure and giving them guidance regarding how
to respond might be worthwhile interventions.
The Oregon Older Adult Suicide Prevention Plan (6) has helped raise awareness about
the risk for suicide among older persons. Suicide prevention interventions have been
integrated into other services provided to older adults and also have been included
in broader agency discussions about promoting healthy aging. As one result, Oregon’s
state health department has collaborated with Oregon Health and Sciences University
to develop a web-based training program for primary-care providers on recognition
and management of suicide risks among older adults.
Case Study 2: From Evidence to Policy in Alcohol-Impaired Driving
In 2011, alcohol-impaired driving resulted in almost 10,000 traffic deaths in the
United States, accounting for one third of all traffic-related deaths (7), approximately
27 deaths per day. An analysis of data from 2010 found that alcohol-related traffic
deaths cost $65 billion for that year alone (8). A conservative estimate is that one
in 10 persons in the United States will be involved in an alcohol-related crash in
their lifetime. Blood alcohol content (BAC), the measure of alcohol in a person’s
bloodstream as detected by blood, breath, or urine testing, has been found to have
a direct and dose-response effect on driving performance (9).
In 1939, Indiana became the first state to implement a presumptive BAC limit for impaired
driving of 0.15% for drivers. By the 1950s, many other states followed, setting their
BAC limit at 0.15% at the recommendation of the American Medical Association. By the
1960s, states began lowering their BAC limit from 0.15% to 0.10%, as scientific evidence
mounted regarding the relationship between driver BAC and fatal crashes. In 1980,
Utah became the first state to lower its limit to 0.08%. By 1992, the National Highway
Traffic Safety Administration had proposed that all states adopt 0.08% BAC laws, and
in 1998, a legislative proposal was introduced in Congress that would have required
states to enact and enforce 0.08% BAC laws or face cuts in highway funding (10). That
proposal failed and, instead, grants were offered to states that lowered their BAC
limits to 0.08%; however, only three states did so.
In the 1990s, only four published studies had demonstrated the effectiveness of 0.08%
BAC laws in reducing traffic fatalities. In 1999, a Government Accountability Office
report concluded that the evidence did not conclusively establish that 0.08% BAC laws,
by themselves, resulted in reductions in the number and severity of traffic crashes
(11).
Subsequently, CDC and the Community Preventive Services Task Force began a systematic
review of the effectiveness of 0.08% BAC laws (12). The results of nine studies that
met the quality criteria set by the task force demonstrated a median 7% decline in
fatalities in states with 0.08% BAC laws. It was estimated that if all states had
0.08% BAC laws, 400–600 lives could be saved annually. The task force concluded that
0.08% BAC laws were effective in reducing alcohol-related traffic fatalities and recommended
enactment of these laws based on strong evidence (13). Shortly afterward, a bill was
approved and subsequently signed into law on October 23, 2000, that included cuts
in highway funds for states without 0.08% BAC laws, based in part on the available
scientific evidence demonstrating lives could be saved. By 2004, all U.S. states had
enacted 0.08% BAC legislation (14). However, the impact on reducing fatalities was
not realized until several years later. Self-reported episodes of drinking and driving
declined from 161 million in 2006 to 112 million in 2010, and death rates from alcohol-impaired
driving have shown similar declines, with steep reductions since 2005 (7).
Additional work is needed to further reduce the incidence of fatalities related to
alcohol-impaired driving in the United States, including supporting and promoting
other interventions such as use of ignition interlocks and sobriety checkpoints, enforcement
of primary seatbelt laws and reduction of binge drinking (15), and assessing the evidence
of the impact on traffic fatalities in the United States by lowering the BAC limits
even further, to 0.05%, which is already the legal limit in nearly half of all countries
(16,17).
The Future of Injury and Violence Prevention
Most events resulting in injury, death, or disability are predictable, and therefore
preventable. An important contemporary challenge in injury prevention is the need
to make the best use of technologies that can prevent injuries at the personal and
population level, while mitigating hazards resulting from technological advances (e.g.,
distracted driving).
Expanded use of the Internet and social media can provide platforms to disseminate
evidence-based injury prevention information. Evaluation research and community-based
studies are needed to assess the effects of such communications on progress toward
the ultimate goals of preventing injuries and deaths.
Community prevention efforts can attain maximum impact by recognizing that injury
and violence prevention are core components of public health. Injury prevention practice
can inform research, much like research informs clinical practice, and the growth
and education of the next generation of practitioners and researchers needs to be
ensured through training (18). Injury prevention efforts should be visible, with their
value documented to ensure accountability and increase impact in communities. Innovative
solutions to injury problems should be pursued, and opportunities to link clinical
medicine and public health should be fostered (19). As the U.S. population becomes
older and more ethnically diverse, the additional challenges of language, access to
health-care information, and limited public health resources for injury and violence
prevention will grow more pronounced.
Reported by
Linda C. Degutis, DrPH, Office of the Director; David A. Sleet, PhD, Div of Unintentional
Injury, National Center for Injury Prevention and Control, CDC. Melvin Kohn, MD, Oregon
Public Health Div. Georges Benjamin, MD, American Public Health Assoc. Nicole Cohen,
MD, John Iskander, MD, Office of the Director, CDC.
Corresponding contributor:
David A. Sleet, dsleet@cdc.gov, 779-488-4699.