Emergency Department Visits for Firearm Injuries Before and During the COVID-19 Pandemic - United States, January 2019-December 2022

During the COVID-19 pandemic, the U.S. firearm homicide rate increased by nearly 35%, and the firearm suicide rate remained high during 2019-2020 (1). Provisional mortality data from the National Vital Statistics System indicate that rates continued to increase in 2021: the rates of firearm homicide and firearm suicide in 2021 were the highest recorded since 1993 and 1990, respectively (2). Firearm injuries treated in emergency departments (EDs), the primary setting for the immediate medical treatment of such injuries, gradually increased during 2018-2019 (3); however, more recent patterns of ED visits for firearm injuries, particularly during the COVID-19 pandemic, are unknown. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined changes in ED visits for initial firearm injury encounters during January 2019-December 2022, by year, patient sex, and age group. Increases in the overall weekly number of firearm injury ED visits were detected at certain periods during the COVID-19 pandemic. One such period during which there was a gradual increase was March 2020, which coincided with both the declaration of COVID-19 as a national emergency^† and a pronounced decrease in the total number of ED visits. Another increase in firearm injury ED visits occurred in late May 2020, concurrent with a period marked by public outcry related to social injustice and structural racism (4), changes in state-level COVID-19-specific prevention strategies,^§ decreased engagement in COVID-19 mitigation behaviors (5), and reported increases in some types of crime (4). Compared with 2019, the average number of weekly ED visits for firearm injury was 37% higher in 2020, 36% higher in 2021, and 20% higher in 2022. A comprehensive approach is needed to prevent and respond to firearm injuries in communities, including strategies that engage community and street outreach programs, implement hospital-based violence prevention programs, improve community physical environments, enhance secure storage of firearms, and strengthen social and economic supports.

Association of Recent Violence Encounters With Suicidal Ideation Among Adolescents With Depression

IMPORTANCE

Suicide prevention is an important component of depression management. Knowledge about depressed adolescents with increased risk for suicide can inform suicide prevention efforts.

OBJECTIVE

To describe the risk of documented suicidal ideation within a year following a diagnosis of depression and to examine how the risk of documented suicidal ideation differed by recent violence encounter status among adolescents with new depression diagnoses.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study in clinical settings including outpatient facilities, emergency departments, and hospitals. Using IBM's Explorys database containing electronic health records from 26 US health care networks, this study observed a cohort of adolescents with new depression diagnoses from 2017 to 2018 for up to 1 year. Data were analyzed from July 2020 to July 2021.

EXPOSURES

Recent violence encounter was defined by a diagnosis of child maltreatment (physical, sexual, or psychological abuse or neglect) or physical assault within 1 year before depression diagnosis.

MAIN OUTCOMES AND MEASURES

The main outcome was diagnosis of suicidal ideation within 1 year following depression diagnosis. Multivariable adjusted risk ratios of suicidal ideation were calculated for overall recent violence encounters and for individual forms of violence.

RESULTS

Among a total of 24 047 adolescents with depression, 16 106 (67.0%) were female and 13 437 (55.9%) were White. A total of 378 had experienceda violence (hereafter, encounter group) and 23 669 had not (hereafter, nonencounter group). Following the diagnosis of depression, 104 adolescents with any past-year violence encounter (27.5%) documented suicidal ideation within 1 year. In contrast, 3185 adolescents in the nonencounter group (13.5%) experienced thoughts of suicide following the diagnosis of depression. In multivariable analyses, those with any violence encounter had 1.7 times (95% CI 1.4-2.0) higher risk of documented suicidal ideation compared with those in the nonencounter group (P < .001). Among different forms of violence, sexual abuse (risk ratio, 2.1; 95% CI, 1.6-2.8) and physical assault (risk ratio, 1.7; 95% CI, 1.3-2.2) were associated with significantly increased risk of suicidal ideation.

CONCLUSIONS AND RELEVANCE

Among adolescents with depression, persons who experienced past-year violence encounters showed a higher rate of suicidal ideation than those who had not. These findings highlight the importance of identifying and accounting for past violence encounters when treating adolescents with depression to reduce risk of suicide. Public health approaches to prevent violence may help to avert morbidity associated with depression and suicidal ideation.

Development of a Machine Learning Model to Estimate US Firearm Homicides in Near Real Time

Importance

Firearm homicides are a major public health concern; lack of timely mortality data presents considerable challenges to effective response. Near real-time data sources offer potential for more timely estimation of firearm homicides.

Objective

To estimate near real-time burden of weekly and annual firearm homicides in the US.

Design, Setting, and Participants

In this prognostic study, anonymous, longitudinal time series data were obtained from multiple data sources, including Google and YouTube search trends related to firearms (2014-2019), emergency department visits for firearm injuries (National Syndromic Surveillance Program, 2014-2019), emergency medical service activations for firearm-related injuries (biospatial, 2014-2019), and National Domestic Violence Hotline contacts flagged with the keyword firearm (2016-2019). Data analysis was performed from September 2021 to September 2022.

Main Outcomes and Measures

Weekly estimates of US firearm homicides were calculated using a 2-phase pipeline, first fitting optimal machine learning models for each data stream and then combining the best individual models into a stacked ensemble model. Model accuracy was assessed by comparing predictions of firearm homicides in 2019 to actual firearm homicides identified by National Vital Statistics System death certificates. Results were also compared with a SARIMA (seasonal autoregressive integrated moving average) model, a common method to forecast injury mortality.

Results

Both individual and ensemble models yielded highly accurate estimates of firearm homicides. Individual models' mean error for weekly estimates of firearm homicides (root mean square error) varied from 24.95 for emergency department visits to 31.29 for SARIMA forecasting. Ensemble models combining data sources had lower weekly mean error and higher annual accuracy than individual data sources: the all-source ensemble model had a weekly root mean square error of 24.46 deaths and full-year accuracy of 99.74%, predicting the total number of firearm homicides in 2019 within 38 deaths for the entire year (compared with 95.48% accuracy and 652 deaths for the SARIMA model). The model decreased the time lag of reporting weekly firearm homicides from 7 to 8 months to approximately 6 weeks.

Conclusions and Relevance

In this prognostic study of diverse secondary data on machine learning, ensemble modeling produced accurate near real-time estimates of weekly and annual firearm homicides and substantially decreased data source time lags. Ensemble model forecasts can accelerate public health practitioners' and policy makers' ability to respond to unanticipated shifts in firearm homicides.

County-Level Social Vulnerability and Emergency Department Visits for Firearm Injuries - 10 U.S. Jurisdictions, January 1, 2018-December 31, 2021

At least 100,000 persons in the United States experience a fatal or nonfatal firearm injury each year.* CDC examined rates of firearm injury emergency department (ED) visits by community social vulnerability using data from CDC's Firearm Injury Surveillance Through Emergency Rooms (FASTER) program.^† ED visit data, shared with CDC's National Syndromic Surveillance Program (NSSP)^§ during 2018-2021, were analyzed for 647 counties in 10 FASTER-funded jurisdictions.^¶ County-level social vulnerability data were obtained from the 2018 Social Vulnerability Index (SVI).** Rates of ED visits for firearm injuries (number of firearm injury ED visits per 100,000 ED visits) were calculated across tertile levels of social vulnerability. Negative binomial regression models were used to estimate rate ratios (RRs) and associated 95% CIs comparing rates of ED visits across social vulnerability levels. During 2018-2021, compared with rates in counties with low overall social vulnerability, the firearm injury ED visit rate was 1.34 times as high in counties with medium social vulnerability and 1.80 times as high in counties with high social vulnerability. Similar patterns were observed for the SVI themes of socioeconomic status and housing type and transportation, but not for the themes of household composition and disability status or racial and ethnic minority status and language proficiency. More timely data^†† on firearm injury ED visits by social vulnerability can help identify communities disproportionately experiencing elevated firearm injury rates. States and communities can use the best available evidence to implement comprehensive prevention strategies that address inequities in the social and structural conditions that contribute to risk for violence, including creating protective community environments, strengthening economic supports, and intervening to reduce harms and prevent future risk (e.g., with hospital-based violence intervention programs) (1,2).

Estimating Weekly National Opioid Overdose Deaths in Near Real Time Using Multiple Proxy Data Sources

IMPORTANCE

Opioid overdose is a leading public health problem in the United States; however, national data on overdose deaths are delayed by several months or more.

OBJECTIVES

To build and validate a statistical model for estimating national opioid overdose deaths in near real time.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, signals from 5 overdose-related, proxy data sources encompassing health, law enforcement, and online data from 2014 to 2019 in the US were combined using a LASSO (least absolute shrinkage and selection operator) regression model, and weekly predictions of opioid overdose deaths were made for 2018 and 2019 to validate model performance. Results were also compared with those from a baseline SARIMA (seasonal autoregressive integrated moving average) model, one of the most used approaches to forecasting injury mortality.

EXPOSURES

Time series data from 2014 to 2019 on emergency department visits for opioid overdose from the National Syndromic Surveillance Program, data on the volume of heroin and synthetic opioids circulating in illicit markets via the National Forensic Laboratory Information System, data on the search volume for heroin and synthetic opioids on Google, and data on post volume on heroin and synthetic opioids on Twitter and Reddit were used to train and validate prediction models of opioid overdose deaths.

MAIN OUTCOMES AND MEASURES

Model-based predictions of weekly opioid overdose deaths in the United States were made for 2018 and 2019 and compared with actual observed opioid overdose deaths from the National Vital Statistics System.

RESULTS

Statistical models using the 5 real-time proxy data sources estimated the national opioid overdose death rate for 2018 and 2019 with an error of 1.01% and -1.05%, respectively. When considering the accuracy of weekly predictions, the machine learning-based approach possessed a mean error in its weekly estimates (root mean squared error) of 60.3 overdose deaths for 2018 (compared with 310.2 overdose deaths for the SARIMA model) and 67.2 overdose deaths for 2019 (compared with 83.3 overdose deaths for the SARIMA model).

CONCLUSIONS AND RELEVANCE

Results of this serial cross-sectional study suggest that proxy administrative data sources can be used to estimate national opioid overdose mortality trends to provide a more timely understanding of this public health problem.

Vital Signs: Changes in Firearm Homicide and Suicide Rates - United States, 2019-2020

INTRODUCTION

The majority of homicides (79%) and suicides (53%) in the United States involved a firearm in 2020. High firearm homicide and suicide rates and corresponding inequities by race and ethnicity and poverty level represent important public health concerns. This study examined changes in firearm homicide and firearm suicide rates coinciding with the emergence of the COVID-19 pandemic in 2020.

METHODS

National vital statistics and population data were integrated with urbanization and poverty measures at the county level. Population-based firearm homicide and suicide rates were examined by age, sex, race and ethnicity, geographic area, level of urbanization, and level of poverty.

RESULTS

From 2019 to 2020, the overall firearm homicide rate increased 34.6%, from 4.6 to 6.1 per 100,000 persons. The largest increases occurred among non-Hispanic Black or African American males aged 10-44 years and non-Hispanic American Indian or Alaska Native (AI/AN) males aged 25-44 years. Rates of firearm homicide were lowest and increased least at the lowest poverty level and were higher and showed larger increases at higher poverty levels. The overall firearm suicide rate remained relatively unchanged from 2019 to 2020 (7.9 to 8.1); however, in some populations, including AI/AN males aged 10-44 years, rates did increase.

CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

During the COVID-19 pandemic, the firearm homicide rate in the United States reached its highest level since 1994, with substantial increases among several population subgroups. These increases have widened disparities in rates by race and ethnicity and poverty level. Several increases in firearm suicide rates were also observed. Implementation of comprehensive strategies employing proven approaches that address underlying economic, physical, and social conditions contributing to the risks for violence and suicide is urgently needed to reduce these rates and disparities.

Interpersonal Violence Victimization Among High School Students - Youth Risk Behavior Survey, United States, 2019

Adolescent interpersonal violence victimization is an adverse childhood experience and a serious public health problem for youths, their families, and communities. Violence victimization includes dating violence, sexual violence, and bullying. Youth Risk Behavior Survey data for 2019 were used to examine physical and sexual dating violence; sexual violence by anyone; and bullying victimization, whether on school property or electronic, of U.S. high school students by sex, race/ethnicity, and sexual identity. In addition, this report explores frequency of dating violence and frequency of sexual violence among students who reported these forms of victimization and presents composites of dating violence and bullying. Findings reveal that 8.2% of students reported physical dating violence; 8.2% reported sexual dating violence; 10.8% reported sexual violence by anyone, of which 50% of cases were by a perpetrator other than a dating partner; 19.5% reported bullying on school property; and 15.7% reported electronic bullying victimization during the previous 12 months. Approximately one in eight students reported any dating violence, and one in four reported any bullying victimization. Female students; lesbian, gay, and bisexual students; and students not sure of their sexual identity reported the highest prevalence estimates across all five violence victimization types, any and both forms of dating violence, and any bullying victimization. Non-Hispanic white students reported the highest prevalence of bullying victimization. Among students experiencing physical or sexual dating violence or sexual violence by anyone, the most common frequency reported was one time during the previous year; higher frequency was more prevalent among male students compared with female students. These findings provide a contextual understanding of the prevalence of interpersonal violence of U.S. high school students, highlighting those with highest prevalence. Findings can be used by public health professionals to guide prevention efforts with youths in schools and communities.

Prevalence and Correlates of Receiving Medical Advice to Increase Physical Activity in U.S. Adults: National Health and Nutrition Examination Survey 2013-2016

INTRODUCTION

National objectives recommend healthcare professionals provide physical activity advice. This study examined health and demographic characteristics associated with receipt of medical advice to increase physical activity among U.S. health care-utilizing adults and differences in associations by age group.

METHODS

Analyses included 8,410 health care-utilizing adults aged ≥20 years from the 2013-2016 National Health and Nutrition Examination Surveys (analyzed in 2018). Logistic regression was used to examine associations between receipt of medical advice to increase physical activity in the past year and measured health conditions, reported health behaviors, and demographic characteristics. Models were stratified by age group (20-39, 40-59, and ≥60 years).

RESULTS

Physical activity medical advice was received by 42.9% (95% CI=40.8, 44.9) of adults overall. By age group, 32.7% of younger adults, 46.7% of middle-aged adults, and 48.9% of older adults received advice. Among all adults and across all age groups, receipt of advice was higher among adults with chronic health conditions: obesity (63.0%, 95% CI=60.3, 65.7), hypertension (56.5%, 95%=CI 53.8, 59.2), diabetes (69.8%, 95% CI=66.5, 72.8), hypercholesterolemia (55.6%, 95% CI=52.3, 59.0), and low high-density lipoprotein cholesterol (53.8%, 95% CI=50.1, 57.4). Among all adults, those with obesity, hypertension, and diabetes had significantly greater odds of receipt of advice after adjustment. Stronger associations between diabetes and hypercholesterolemia and receiving physical activity advice were observed among younger adults.

CONCLUSIONS

Receipt of physical activity medical advice was highest among adults with specific chronic health conditions, and this pattern was stronger among younger adults with diabetes and hypercholesterolemia. However, most health care-utilizing adults did not receive physical activity medical advice.

Network influences on the development and implementation of active transportation policies in six U.S. cities

Many communities have prioritized policy and built environment changes to promote active transportation (AT). However, limited information exists on the partnerships and processes necessary to develop and implement such policy and environmental changes, particularly among organizations in non-health sectors. Within the transportation sector, metropolitan planning organizations (MPOs) are increasingly recognized as organizations that can support AT policies. This study examined inter-organizational relationships among MPOs and their partners working to advance AT policies in six U.S. cities. In fall 2015, an average of 22 organizations in each city participated in an online survey about partnerships with MPOs and other organizations developing and implementing AT policies. Measures included organizational characteristics and relational attributes including: level of AT policy collaboration, information transmission, resource sharing, and perceived decisional power. Descriptive network analysis and exponential random graph modeling were used to examine organizational attributes and relational predictors associated with inter-organizational collaboration in each network. MPOs served as collaborative intermediaries, connecting other organizations around AT policies, in half of the cities examined. Organizations in each city were more likely to collaborate around AT policies when partners communicated at least quarterly. In half of the cities, the probability of AT policy collaboration was higher when two agencies exchanged resources and when organizations had perceived decisional authority. Network analysis helped identify factors likely to improve partnerships around AT policies. Results may contribute to best practices for collaboration among researchers, practitioners, policymakers, and advocates across diverse sectors seeking to promote population-level physical activity.

Trends in active transportation and associations with cardiovascular disease risk factors among U.S. adults, 2007-2016

Active transportation (AT), or walking or bicycling for transportation, represents one way individuals can achieve recommended physical activity (PA) levels. This study describes AT prevalence and temporal trends, and examines associations between AT levels and measured CVD risk factors (hypertension, hypercholesterolemia, low high-density [HDL] cholesterol, diabetes, and obesity) among U.S. adults. National Health and Nutrition Examination Survey (NHANES) 2007-2016 data (analyzed in 2017) were used to conduct overall trend analyses of reported AT in a typical week [none (0-9 min/week); low (10-149 min/week); or high (≥150 min/week)]. Logistic regression was used to examine associations between AT level and each CVD risk factor from NHANES 2011-2016 (n = 13,943). Covariates included age, sex, race/Hispanic origin, education, income, smoking, survey cycle, non-transportation PA, and urbanization level. U.S. adults who engaged in high AT levels increased from 13.1% in 2007-2008 to 17.9% in 2011-2012, and then decreased to 10.6% in 2015-2016 (p for quadratic trend = 0.004). Over the same period, the quadratic trend for low AT was not significant. During 2011-2016, 14.3% of adults engaged in high AT, 11.4% in low AT, and 74.4% in no AT. High AT levels were associated with decreased odds of each CVD risk factor assessed, compared to no AT. Low AT (versus no AT) was associated with decreased odds of hypertension (aOR = 0.77, 95% CI 0.64, 0.91) and diabetes (aOR = 0.68, 95% CI 0.54, 0.85). AT prevalence among adults has fluctuated from 2007 to 2016. Despite favorable associations between AT and CVD risk factors, most U.S. adults do not engage in any AT.

Prevalence of Low High-density Lipoprotein Cholesterol Among Adults, by Physical Activity: United States, 2011-2014

Data from the National Health and Nutrition Examination Survey •The prevalence of low high-density lipoprotein (HDL) cholesterol was significantly higher among adults who did not meet recommended physical activity guidelines (21.0%) than adults who met the guidelines (17.7%). •Low HDL cholesterol prevalence differed significantly for both men and women by adherence to physical activity guidelines. •Prevalence of low HDL cholesterol declined as age increased for both those who did and did not meet the physical activity guidelines. •Non-Hispanic white and non-Hispanic black adults who did not meet the physical activity guidelines had a higher prevalence than those who met the guidelines. •Low HDL cholesterol prevalence declined with increasing education level regardless of adherence to physical activity guidelines. Regular physical activity can improve cholesterol levels among adults, including increasing high-density lipoprotein (HDL) cholesterol (1). HDL cholesterol is known as "good" cholesterol because high levels can reduce cardiovascular disease risk (2). The 2008 Physical Activity Guidelines for Americans recommend that adults engage in 150 minutes or more of moderate-intensity aerobic activity per week, 75 minutes of vigorous-intensity aerobic activity per week, or an equivalent combination (3). Adherence to these guidelines is expected to decrease the prevalence of low HDL cholesterol levels (4-8). This report presents national data for 2011-2014 on low HDL cholesterol prevalence among U.S. adults aged 20 and over, by whether they met these guidelines.

Governors' priorities for public health and chronic disease prevention: a qualitative analysis of State of the State addresses

Governors use State of the State speeches to publicly outline state status, progress, and policy priorities. The purpose of this study was to qualitatively analyze the public health content of State of the State addresses from 2009 to 2013. Speech transcripts were collected and uploaded into NVivo10. Speeches were coded using a priori, general thematic codes followed by detailed sub-coding of public health text. Data was organized by emergent thematic patterns. From 2009 to 2013, 48 governors presented 72 speeches with public health messages. Framing current public health problems and outlining strategies were two of the three main themes that emerged. Problems were often framed using data or emphasizing economic costs. Governors outlined prevention strategies on tobacco, nutrition, or physical activity through increased funding, policies, or partnerships. Speech content provides information on priorities and trends and can be used to inform advocacy efforts. Future research should link these priorities to outcomes of legislation.

Correlates of walking for transportation and use of public transportation among adults in St Louis, Missouri, 2012

INTRODUCTION

Attributes of the built environment can influence active transportation, including use of public transportation. However, the relationship between perceptions of the built environment and use of public transportation deserves further attention. The objectives of this study were 1) to assess the relationship between personal characteristics and public transportation use with meeting national recommendations for moderate physical activity through walking for transportation and 2) to examine associations between personal and perceived environmental factors and frequency of public transportation use.

METHODS

In 2012, we administered a mail-based survey to 772 adults in St Louis, Missouri, to assess perceptions of the built environment, physical activity, and transportation behaviors. The abbreviated International Physical Activity Questionnaire was used to assess walking for transportation and use of public transportation. The Neighborhood Environment Walkability Scale was used to examine perceptions of the built environment. Associations were assessed by using multinomial logistic regression.

RESULTS

People who used public transportation at least once in the previous week were more likely to meet moderate physical activity recommendations by walking for transportation. Age and employment were significantly associated with public transportation use. Perceptions of high traffic speed and high crime were negatively associated with public transportation use.

CONCLUSION

Our results were consistent with previous research suggesting that public transportation use is related to walking for transportation. More importantly, our study suggests that perceptions of traffic speed and crime are related to frequency of public transportation use. Future interventions to encourage public transportation use should consider policy and planning decisions that reduce traffic speed and improve safety.

Development and evaluation of a web-based training program for oral health care providers on secondary prevention of eating disorders

Although oral health care providers (OHP) are key in the secondary prevention of eating disorders (ED), the majority are not engaged in assessment, referral, and case management. This innovative pilot project developed and evaluated a web-based training program for dental and dental hygiene students and providers on the secondary prevention of ED. The intervention combined didactic and skill-based objectives to train OHP on ED and its oral health effects, OHP roles, skills in identifying the oral signs of ED, communication, treatment, and referral. Using a convenience sample of OHP (n=66), a pre-/post-test evaluated short-term outcomes and user satisfaction. Results revealed statistically significant improvements in self-efficacy (p<.001); knowledge of oral manifestations from restrictive behaviors (p<.001) and purging behaviors (p<.001); knowledge of oral treatment options (p<.001); and attitudes towards the secondary prevention of ED (p<.001). Most participants strongly agreed or agreed that the program provided more information (89 percent) and resources (89 percent) about the secondary prevention of ED than were currently available; 91 percent strongly agreed or agreed that they would access this program for information regarding the secondary prevention of ED. This pilot project provides unique training in the clinical evaluation, patient approach, referral, and oral treatment that takes a multidisciplinary approach to address ED.