January 28, 1994 / Vol. 43 / No. 3 Deaths Resulting from Firearm- and Motor-Vehicle-Related Injuries — United States, 1968-1991 Abortion Surveillance: Preliminary Data — United States, 1991 Hantavirus Pulmonary Syndrome — United States, 1993 MORBIDITAYN D MORTALITY WEEKLY REPORT Effectiveness in Disease and Injury Prevention Deaths Resulting from Firearm- and Motor-Vehicle—Related Injuries — United States, 1968-1991 Injury is the leading cause of death for persons aged 1-44 years in the United States. More than half (55%) of all injury-related deaths are caused by motor vehicles and firearms (7). Although the number of deaths from motor-vehicle crashes has exceeded those from firearms, since 1968, differences in the number of deaths have declined: from 1968 through 1991, motor-vehicle-related deaths decreased by 21% (from 54,862 to 43,536) while firearm-related deaths increased by 60% (from 23,875 to 38,317) (7). Based on these trends, by the year 2003, the number of firearm- related deaths will surpass the number of motor-vehicle crashes, and firearms will become the leading cause of injury-related death (Figure 1). This report compares trends and patterns of deaths resulting from firearm- and motor-vehicle-related inju- ries in the United States from 1968 through 1991. Information about firearm- and motor-vehicle-related injury deaths was obtained from mortality data files maintained by CDC’s National Center for Health Statistics. Rates were calculated by using population estimates obtained from the U.S. Bureau of the Census. From 1968 through 1991, the number of firearm-related deaths exceeded the num- ber of motor-vehicle crash-related deaths every year in the District of Columbia and for 17 of the 24 years in Alaska. Before 1990, the number of firearm-related deaths exceeded that of motor-vehicle—-related deaths in any year in no more than two states and the District of Columbia. In 1990, however, the number of firearm-related deaths equaled or exceeded motor-vehicle-related deaths in five states (Alaska, Louisiana, Maryland, New York, and Texas) and the District of Columbia, and in 1991, in seven states (California, Louisiana, Maryland, Nevada, New York, Texas, and Virginia) and the District of Columbia. In addition, in 1991, the number of motor-vehicle—related deaths exceeded the number of firearm-related deaths by 10% or less in eight states (Alaska, Florida, Georgia, Illinois, Michigan, Missouri, North Carolina, and Vermont) (Table 1, Figure 2). In 1991, the ratio of firearm-related deaths to motor-vehicle-related deaths was highest for the District of Columbia (5.21:1) and lowest for Hawaii (0.41:1) (Table 1). U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES / Public Health Service 38 MMWR January 28, 1994 Firearm- and Motor-Vehicle-Related Injuries — Continued In 1991, the age-adjusted death rate from motor-vehicle crashes was highest for black males (26.2 per 100,000 population) and was nearly equal to that for white males (24.2 per 100,000), 2.5 times that for white females (10.4 per 100,000), and 3.0 times that for black females (8.7 per 100,000).* The age-adjusted death rate for firearms also was highest for black males (66.4 per 100,000) and was 3.2 times that for white males (20.7 per 100,000), 8.3 times that for black females (8.0 per 100,000), and 17.9 times that for white females (3.7 per 100,000). For both motor-vehicle— and firearm-related deaths, age-specific death rates were highest for persons aged 15-24 years (CDC, un- published data, 1991). Reported by: Div of Violence Prevention and Div of Unintentional Injury Prevention, National Center for Injury Prevention and Control; Office of Analysis and Epidemiology, National Center for Health Statistics, CDC. Editorial Note: The findings in this report indicate that, since 1968, the number of motor-vehicle-related deaths in the United States has decreased while the number of firearm-related deaths has increased, and by the year 2003 firearm-related deaths may become the leading cause of injury-related death. These trends may reflect differ- ences in the approaches to preventing motor-vehicle— and firearm-related injuries. In particular, reductions in the occurrence of motor-vehicle-related injuries have been *Data on other racial/ethnic groups are provided in a separate report (7). FIGURE 1. Observed and predicted firearm- and motor-vehicle—related injury deaths, by year — United States, 1968-2005* Observed Motor-Vehicle-Related Deaths (DTehaotuhss ands) Observed Firearm-Related Deaths Predicted Motor-Vehicle-Related Deaths Predicted Firearm-Related Deaths | Tf |a TT Ff 1 wget | we eS | .wee | . ww? 1 7 ve fe 1 ,. Se 1970 1975 1980 1985 1990 1995 2000 2005 Year *The lines are predicted numbers of deaths based on linear regression. Vol. 43 / No. 3 MMWR Firearm- and Motor-Vehicle-Related Injuries — Continued TABLE 1. Number, crude rates*, and ratios of firearm- and motor-vehicle—related deaths, by decedents’ state of residence — United States, 1991* Firearm-related deaths Motor-vehicle-related deaths State No. Rate No. Rate Ratio Alabama 928 22.7 1,225 30.0 0.76 Alaska 98 ; 102 17.9 0.96 Arizona 696 y 814 21.7 0.86 Arkansas 483 ? 639 26.9 0.76 California 5,064 ; 5,009 16.5 1.01 Colorado 429 ; 586 17.4 0.73 Connecticut 287 7 335 10.2 0.86 Delaware 53 8 106 15.6 0.50 District of Columbia 344 5 66 11.0 5.21 Florida 2,323 5 2,517 19.0 0.92 Georgia 8 1,466 22.1 0.94 Hawaii 0 140 12.3 0.41 Idaho 0 252 24.3 0.58 Illinois 6 1,667 14.4 0.94 Indiana TY9: 1,047 18.7 0.69 lowa NON6ON WATON50 3 18.0 0.48 Kansas 3. 8 440 17.6 0.78 Kentucky 6. 3 821 22.1 0.74 Louisiana 5. 9 869 20.4 1.27 Maine 0. 0 196 15.9 0.63 Maryland ==oo0fd)t 4. 6 708 14.6 1.00 Massachusetts 5. 1 614 10.2 0.50 Michigan - 6. 0 513 16.2 0.99 Minnesota 7. 9 598 13.5 0.59 Mississippi 23. 7 812 31.3 0.76 Missouri 18 3 ,023 19.8 0.92 Montana 17 8 181 22.4 0.80 Nebraska 10 6 300 18.8 0.56 Nevada 25 9 272 21.2 1.22 New Hampshire 7 5 153 13.8 0.54 New Jersey 5. 5 857 11.0 0.50 New Mexico 6 431 27.8 0.67 New York 9 2,226 . 1.13 North Carolina 8 1,407 K 0.90 North Dakota 71 98 0.46 Ohio 1,656 ; 0.78 Oklahoma 8 680 , 0.74 Oregon 6 500 : 0.73 Pennsylvania ooooaatdtd 9 1,723 , 0.76 Rhode island 5 93 0.59 South Carolina 4 897 0.69 South Dakota 7 146 0.51 Tennessee 3 1,161 0.86 Texas 5 3,229 1.15 Utah 1 269 0.80 Vermont 5 91 0.90 Virginia 7 965 1.02 Washington 0 768 “ ~HW—A AWDRDEDDO ANDDGSSDAA©N0. 7W2 West Virginia ~BoVNtwB~ D 2 431 : 0.68 Wisconsin HO3S MOANNTO NUA8N23D WO } 0.60 Wyoming -_ @ a 111 . 0.77 Total 38,317 15.2 43,536 . 0.88 *Crude death rates per 100,000; rates should not be compared between states because of differing age, sex, and race distributions. tThese data may differ from estimates of the National Highway Traffic Safety Administration’s Fatal Accident Reporting System because deaths occurring on both public and nonpublic roadways are included. Source: Mortality data tapes from CDC’s National Center for Health Statistics for number of deaths; U.S. Bureau of the Census for annual population estimates. 40 MMWR January 28, 1994 Firearm- and Motor-Vehicle-Related Injuries — Continued FIGURE 2. Comparison of firearm- and motor-vehicle—related deaths, by decedents’ state of residence — United States, 1991 Firearm-related deaths equaled or exceeded motor-vehicie-related deaths Motor-vehicle-related deaths exceeded firearm-related deaths by <10% Motor-vehicle-related deaths exceeded firearm-related deaths by >10% associated with the development of a set of comprehensive and science-based inter- ventions and policies (2); in contrast, there have been limited efforts to develop a systematic framework to reduce the incidence and impact of injuries associated with firearms. Elements of the multifaceted, science-based approach to reduce mortality from motor-vehicle crashes have included public information programs, promotion of be- havioral change, changes in legislation and regulations, and advances in engineering and technology. These strategies have resulted in safer vehicles (e.g., the addition of laminated windshields and interior padding), safer driving practices (e.g., reduced occurrence of alcohol-impaired driving and increased use of safety belts), safer travel environments (e.g., construction of safer highways and roads), and improved eme-- gency medical services. Key elements of the science-based approach have includea the establishment of a national data-collection system to routinely monitor motor- vehicle-related deaths, identification of modifiable risk factors, design and implemen- tation of preventive measures, and evaluation of the effectiveness of these measures. Since 1966, when the federal government identified highway safety as a major goal and subsequently established the National Highway Traffic Safety Administration to help reduce death and injury on the highway, the annual number of motor-vehicle- related deaths in the United States has decreased, even though the annual number of vehicle-miles traveled has increased 114% (3). Vol. 43 / No. 3 MMWR 41 Firearm- and Motor-Vehicle-Related Injuries — Continued Based on the effectiveness of efforts to reduce motor-vehicle-related deaths, a multifaceted approach to reduce firearm-related injuries should include at least three elements. First, changes in behavior may be fostered by campaigns to educate and inform persons about the risks and benefits of firearm possession and the safe use and storage of firearms. Second, legislative efforts may be directed toward preventing access to or acquisition of firearms by specific groups that should not possess fire- arms (e.g., felons and children) and toward regulating the storage, transport, and use of firearms. Third, technologic changes could be used to modify firearms and ammu- nition to render them less lethal (e.g., a requirement for childproof safety devices [i.e., trigger locks] and loading indicators) (4 ). A multifaceted effort to prevent firearm-related injuries should emphasize the need to inform the public about the risks and benefits of access to firearms in a manner similar to the approach used to inform the public about the benefits of wearing safety belts and the dangers of drunk driving. For example, the public should be informed about recent findings indicating that the presence of a gun in a household is associ- ated with an approximately fivefold increase in the risk of suicide and threefold increase in the risk of homicide for household residents (5,6 ). Such efforts also should convey the appropriate interpretations of epidemiologic patterns in firearm-related injuries. For example, the findings in this report indicate that rates of firearm-related deaths were substantially higher for black males than for white males—a pattern underscoring the disproportionate impact of firearm homicides on blacks. However, race is not known to be a risk factor for homicide victimization; instead, race-specific variations in the incidence of firearm-related deaths probably reflect differences in other factors (e.g., poverty) that increase a person’s risk for becoming a victim of homicide (7). Elements of the science-based approach used to prevent injuries associated with motor-vehicle crashes also should be applied to prevent firearm-related injuries. These elements should include establishment of a national firearm injury surveillance system to enable systematic collection of data about fatal and nonfatal firearm-related injuries and about the patterns of firearm ownership and use, and continued efforts to define more precisely the risks and benefits of gun ownership and the modifiable fac- tors that increase the risk of death and injury from firearms. In addition, despite the implementation of a variety of approaches to the prevention of firearm-related injuries and death, efforts to evaluate these approaches have been limited (8-10 ) and under- score the need for continued assessment of the effectiveness of such intervention strategies. Because highway safety has been a national priority since 1966, an estimated 250,000 motor-vehicle-related deaths have been averted. Despite this progress, ef- forts to reduce the burden of motor-vehicle-related injuries and fatalities must be sustained. In addition, adoption of a similar multifaceted, science-based approach should assist in decreasing the public health impact and societal! burden of injuries resulting from use of firearms. References 1. Fingerhut LA, Jones C, Makuc D. Firearm and motor vehicle injury mortality—variation by state and race and ethnicity: United States, 1990-1991. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1994. (Advance data from vital and health statistics; no. 242). 42 MMWR January 28, 1994 Firearm- and Motor-Vehicle-Related Injuries — Continued 2. CDC/National Highway Traffic Safety Administration. Position papers from the Third National Injury Control Conference: setting the national agenda for injury control in the 1990s. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, 1992. . National Highway Traffic Safety Administration. Fatal Accident Reporting System, 1991: a review of information on fatal traffic crashes in the United States. Washington, DC: US De- partment of Transportation, National Highway Traffic Safety Administration, 1993. . US Genera! Accounting Office. Accidental shootings: many deaths and injuries caused by firearms could be prevented—report to the Chairman, Subcommittee on Antitrust, Monop- olies, and Business Rights, Committee on the Judiciary, House of Representatives. Washington, DC: US General Accounting Office, 1991; report no. GAO/PEMD-91-9. . Kellermann AL, Rivara FP, Somes G, et al. Suicide in the home in relation to gun ownership. N Engl J Med 1992;327:467-72. . Kellermann AL, Rivara FP, Rushforth NB, et al. Gun ownership as a risk factor for homicide in the home. N Engl J Med 1993;329:1084-91. . Reiss AJ, Roth JA, eds. Understanding and preventing violence. Washington, DC: National Academy Press, 1993. . Rossman D, Paul F, Pierce GL, McDevitt J, Bowers W. Massachusetts’ mandatory minimum sentence gun law: enforcement, prosecution, and defense impact. Crim Law Bull 1980;61:150- 63. . McDowall D, Loftin C, Wiersema B. Acomparative study of the preventive effects of mandatory sentencing laws for gun crimes. J Criminal Law and Criminology 1992;83:378-94. . Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med 1991;325:1615-20. Current Trends Abortion Surveillance: Preliminary Data — United States, 1991 For 1991, CDC received data about legal induced abortions from 52 reporting areas (the 50 states, New York City, and the District of Columbia). This report presents pre- liminary data for 1991. In 1991, 1,388,937 legal induced abortions were reported to CDC (Table 1), a de- crease of 2.8% from the number reported in 1990 (7), and the number of live births decreased by 1.2%. As a result, the national abortion ratio declined from 345 legal induced abortions per 1000 live births in 1990 to 339 per 1000 in 1991. The national abortion rate (the number of legal induced abortions per 1000 women aged 15- 44 years) remained stable at 24. As in previous years, 92% of women who had a legal induced abortion were residents of the state in which the procedure was performed. Most women who obtained legal induced abortions in 1991 were aged <25 years, white, and unmarried (Table 1). When compared with women who obtained abortions in 1990, a slightly lower proportion of women who had abortions in 1991 had had no previously live-born infants (49.2% versus 47.5%, respectively). Curettage (suction and sharp) remained the primary abortion procedure (approximately 99% of all such procedures). As in previous years, more than half (52%) of legal induced abortions were performed during the first 8 weeks of gestation and approximately 89% during the first 12 weeks. Reported by: Statistics and Computer Resources Br, Div of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Editorial Note: The number of legal induced abortions performed in the United States has remained relatively stable since 1980, varying each year by 5% or less. In 1991, the Vol. 43 / No. 3 MMWR Abortion Surveillance — Continued TABLE 1. Reported number of legal induced abortions, abortion ratios,* abortion rates,t and characteristics of women who obtained legal induced abortions — United States, selected years, 1972-1991 Year Characteristic 1972 1976 1980 1985 1988 1989 1990 19918 Reported no. legal induced abortions 586,760 988,267 1,297,606 1,328,570 1,371,285 1,396,658 1,429,577 1,388,937 Abortion ratio 180 312 359 354 352 346 345 339 Abortion rate 13 21 25 24 24 24 24 Percentage distribution! Residence in-state Out-of-state Age (yrs) <19 20-24 225 Race White All others Marital status Married Unmarried No. live births** 24 Type of procedure Curettage Suction Sharp Intrauterine instiflation Other Weeks of gestation 8 9-10 11-12 13-15 16-20 221 *Per 1000 live births. tPer 1000 women aged 15-44 years. 5Preliminary data. fExcludes unknown values. Percentage distributions are based on data from all areas reporting a given characteristic. **For 1972 and 1976, data indicate number of living children. ttincludes hysterotomy and hysterectomy. 44 MMWR January 28, 1994 Abortion Surveillance — Continued FIGURE 1. Fertility rate* and abortion ratio' and rate’, by year — United States, 1972-1991 500 80 4 | Fertility Rate ' seeee " eae 50 4 “ Abortion Ratio = 4 > 40 4 4 + 200 304 Abortion Rate 20: a 100 104 “4 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 Year *Live births per 1000 women aged 15-44 years. *Number of legal induced abortions per 1000 live births. 5Number of legal induced abortions per 1000 women aged 15-44 years. national ratio of abortions to live births was again lower than for any year since 1977, indicating that a greater proportion of pregnancies ended in a live birth (Figure 1) (2). The national abortion rate has fluctuated minimally since 1980 (Figure 1). Although the national fertility rate (live births per 1000 women of reproductive age) was slightiy lower in 1991 than in 1990, it was higher than the rate for any other year since 1972 (3). The total number of legal induced abortions was available for all 52 reporting areas. However, approximately 27% of abortions were reported from states that do not have centralized reporting; these areas could provide no information on the characteristics of women obtaining abortions. Because the number of states that report such infor- mation varies annually, temporal comparisons should be made with caution. Abortion and birth statistics both are essential to provide estimates of pregnancy rates. In addition, abortion and pregnancy rates can be used to evaluate the effective- ness of family planning programs and programs to prevent unintended pregnancy. The use of such information for these purposes is constrained, however, because of limitations in the completeness of reporting by states of the number and charac- teristics of women who have legal induced abortions. References 1. CDC. Abortion surveillance: preliminary data—United States, 1990. MMWR 1992;41:936-8. 2. CDC. Abortion surveillance, 1977. Atlanta: US Department of Health and Human Services, Pub- lic Health Service, 1979. 3. NCHS. Advance report of final natality statistics, 1990. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, CDC, 1993. (Monthly vital statistics report; vol 41, no. 9, suppl). Vol. 43 / No. 3 Emerging Infectious Diseases Hantavirus Pulmonary Syndrome — United States, 1993 In June 1993, a newly recognized hantavirus was identified as the etiologic agent of an outbreak of severe respiratory illness (hantavirus pulmonary syndrome [HPS)]) in the southwestern United States (7-3). Since this problem was recognized, sporadic cases have been identified from a wide geographic area in the western United States (2). This report summarizes the epidemiologic characteristics of HPS cases reported to CDC from May 1 through December 31, 1993. Through December 31, 53 persons with illnesses meeting the surveillance case definition of HPS (2) have been reported to CDC. Patients’ ages have ranged from 12 years to 69 years (median age: 31 years), and 32 (60%) were aged 20-39 years; 30 (57%) were male. Twenty-six (49%) were American Indians; 22 (42%), non-Hispanic whites; four (8%), Hispanic; and one (2%), non-Hispanic black. Thirty-two (60%) pa- tients died; persons with fatal cases and persons with nonfatal cases were similar in age, sex, and race (Table 1). Cases have occurred in residents of 14 states (Figure 1). Of the 34 (64%) persons who were residents of Arizona, Colorado, or New Mexico, illness occurred in 25 (74%) during April-July 1993 and in one before 1993 (Figure 2). In comparison, of 19 cases reported from other states, five (26%) had onset of illness during April-July 1993, and seven (37%) had onset before 1993. All patients either lived in rural areas or had vis- ited rural areas during the 6 weeks before onset of illness. The etiology of HPS was initially identified by serology, polymerase chain reaction (PCR), and immunohistochemistry (2). Additional cloning and sequencing of virus ri- bonucleic acid (RNA) from human autopsy tissues indicated that all three of the RNA segments of this new virus were unlike those of any known hantavirus; the new hantavirus is most closely related to the Prospect Hill strain of hantavirus (4,5 ). TABLE 1. Characteristics of 53 persons reported with hantavirus pulmonary syndrome, by outcome — United States, May-December, 1993 Deaths Characteristic Total No. (%) Relative risk (95% Ci*) Age (yrs) <20 7 (57) Referent 20-29 14 (50) 0.9 (0.4—2.0) 30-39 18 (78) 1.4 (0.8-2.7) >40 14 (50) 0.9 (0.4-2.0) Sex Female 23 13 (57) Referent Male 30 19 (63) 1.1 (0.7-1.8) Race American Indian 26 15 (58) Referent Othert 27 17 (63) 1.1 (0.7-1.7) *Confidence interval. tNon-Hispanic white, Hispanic, and non-Hispanic black. 46 MMWR January 28, 1994 Hantavirus Pulmonary Syndrome — Continued FIGURE 1. Number of reported confirmed cases of hantavirus pulmonary syndrome — United States, 1993 FIGURE 2. Number of confirmed cases of hantavirus pulmonary syndrome, by month and year of onset and by state — July 1990-December 1993* [_] Residents of Arizona, Colorado, or New Mexico B Residents of Other States JFMAMJ JASON oa. ae 1993 Month/Year of Onset *Does not include one case from 1980 reported in California.