Social media has become a pervasive presence in everyday life, including among youths. In 2023, for the first time, CDC's nationally representative Youth Risk Behavior Survey included an item assessing U.S. high school students' frequency of social media use. Data from this survey were used to estimate the prevalence of frequent social media use (i.e., used social media at least several times a day) among high school students and associations between frequent social media use and experiences with bullying victimization, persistent feelings of sadness or hopelessness, and suicide risk. All prevalence estimates and measures of association used Taylor series linearization. Prevalence ratios were calculated using logistic regression with predicted marginals. Overall, 77.0% of students reported frequent social media use, with observed differences by sex, sexual identity, and racial and ethnic identity. Frequent social media use was associated with a higher prevalence of bullying victimization at school and electronically, persistent feelings of sadness or hopelessness, and some suicide risk among students (considering attempting suicide and having made a suicide plan), both overall and in stratified models. This analysis characterizes the potential harms of frequent social media use for adolescent health among a nationally representative sample of U.S. high school students. Findings might support multisectoral efforts to create safer digital environments for youths, including decision-making about social media policies, practices, and protections.

This is the third of three reports in the MMWR supplement that updates and expands CDC's guidance for assessing, investigating, and responding to suicide clusters based on current science and public health practice. The first report, Background and Rationale - CDC Guidance for Communities Assessing, Investigating, and Responding to Suicide Clusters, United States, 2024, describes an overview of suicide clusters, methods used to develop the supplement guidance, and intended use of the supplement reports. The second report, CDC Guidance for Community Assessment and Investigation of Suspected Suicide Clusters, United States, 2024, describes the potential methods, data sources, and analysis that communities can use to identify and confirm suspected suicide clusters and better understand the relevant issues. This report describes how local public health and community leaders can develop a response plan for suicide clusters. Specifically, the steps for responding to a suicide cluster include preparation, direct response, and action for prevention. These steps are not intended to be explicitly adopted but rather adapted into the local context, culture, capacity, circumstances, and needs for each suicide cluster.

To assist community leaders in public health, mental health, education, and other fields with developing a community response plan for suicide clusters or for situations that might develop into suicide clusters, in 1988, CDC published Recommendations for a Community Plan for the Prevention and Containment of Suicide Clusters (MMWR Suppl 1988;37[No. Suppl 6]:1-12). Since that time, the reporting and investigation of suicide cluster events has increased, and more is known about cluster risk factors, assessment, and identification. This supplement updates and expands CDC guidance for assessing, investigating, and responding to suicide clusters based on current science and public health practice. This report is the first of three in the MMWR supplement that describes an overview of suicide clusters, information about the other reports in this supplement, methods used to develop the supplement guidance, and the intended use of the supplement reports. The second report, CDC Guidance for Community Assessment and Investigation of Suspected Suicide Clusters - United States 2024, describes the potential methods, data sources and analysis that communities can use to identify and confirm suspected suicide clusters, and better understand the relevant issues. The final report, CDC Guidance for Community Response to Suicide Clusters - United States, 2024, describes how local public health and community leaders can develop a response plan for suicide clusters. The guidance in this supplement is intended as a conceptual framework that can be used by public health practitioners and state and local health departments to develop response plans for assessing and investigating suspected clusters that are tailored to the needs, resources, and cultural characteristics of their communities.

BACKGROUND: All data systems used for non-fatal injury surveillance and research have strengths and limitations that influence their utility in understanding non-fatal injury burden. The objective of this paper was to compare characteristics of major data systems that capture non-fatal injuries in the USA. METHODS: By applying specific inclusion criteria (eg, non-fatal and non-occupational) to well-referenced injury data systems, we created a list of commonly used non-fatal injury data systems for this study. Data system characteristics were compiled for 2018: institutional support, years of data available, access, format, sample, sampling method, injury definition/coding, geographical representation, demographic variables, timeliness (lag) and further considerations for analysis. RESULTS: Eighteen data systems ultimately fit the inclusion criteria. Most data systems were supported by a federal institution, produced national estimates and were available starting in 1999 or earlier. Data source and injury case coding varied between the data systems. Redesigns of sampling frameworks and the use of International Classification of Diseases, 9th Revision, Clinical Modification/International Classification of Diseases, 10th Revision, Clinical Modification coding for some data systems can make longitudinal analyses complicated for injury surveillance and research. Few data systems could produce state-level estimates. CONCLUSION: Thoughtful consideration of strengths and limitations should be exercised when selecting a data system to answer injury-related research questions. Comparisons between estimates of various data systems should be interpreted with caution, given fundamental system differences in purpose and population capture. This research provides the scientific community with an updated starting point to assist in matching the data system to surveillance and research questions and can improve the efficiency and quality of injury analyses.

BACKGROUND: Unintentional injuries are the leading cause of death for children and youth aged 1-19 in the United States. The purpose of this report is to describe how unintentional injury death rates among children and youth aged 0-19 years have changed during 2010-2019. METHOD: CDC analyzed 2010-2019 data from the National Vital Statistics System (NVSS) to determine two-year average annual number and rate of unintentional injury deaths for children and youth aged 0-19 years by sex, age group, race/ethnicity, mechanism, county urbanization level, and state. RESULTS: From 2010-2011 to 2018-2019, unintentional injury death rates decreased 11% overall-representing over 1,100 fewer annual deaths. However, rates increased among some groups-including an increase in deaths due to suffocation among infants (20%) and increases in motor-vehicle traffic deaths among Black children (9%) and poisoning deaths among Black (37%) and Hispanic (50%) children. In 2018-2019, rates were higher for males than females (11.3 vs. 6.6 per 100,000 population), children aged < 1 and 15-19 years (31.9 and 16.8 per 100,000) than other age groups, among American Indian or Alaska Native (AIAN) and Blacks than Whites (19.4 and 12.4 vs. 9.0 per 100,000), motor-vehicle traffic (MVT) than other causes of injury (4.0 per 100,000), and rates increased as rurality increased (6.8 most urban [large central metro] vs. 17.8 most rural [non-core/non-metro] per 100,000). From 2010-2011 to 2018-2019, 49 states plus DC had stable or decreasing unintentional injury death rates; death rates increased only in California (8%)-driven by poisoning deaths. Conclusion and Practical Application: While the overall injury death rates improved, certain subgroups and their caregivers can benefit from focused prevention strategies, including infants and Black, Hispanic, and AIAN children. Focusing effective strategies to reduce suffocation, MVT, and poisoning deaths among those at disproportionate risk could further reduce unintentional injury deaths among children and youth in the next decade.

Beginning in March 2020, the COVID-19 pandemic and response, which included physical distancing and stay-at-home orders, disrupted daily life in the United States. Compared with the rate in 2019, a 31% increase in the proportion of mental health-related emergency department (ED) visits occurred among adolescents aged 12-17 years in 2020 (1). In June 2020, 25% of surveyed adults aged 18-24 years reported experiencing suicidal ideation related to the pandemic in the past 30 days (2). More recent patterns of ED visits for suspected suicide attempts among these age groups are unclear. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined trends in ED visits for suspected suicide attempts(†) during January 1, 2019-May 15, 2021, among persons aged 12-25 years, by sex, and at three distinct phases of the COVID-19 pandemic. Compared with the corresponding period in 2019, persons aged 12-25 years made fewer ED visits for suspected suicide attempts during March 29-April 25, 2020. However, by early May 2020, ED visit counts for suspected suicide attempts began increasing among adolescents aged 12-17 years, especially among girls. During July 26-August 22, 2020, the mean weekly number of ED visits for suspected suicide attempts among girls aged 12-17 years was 26.2% higher than during the same period a year earlier; during February 21-March 20, 2021, mean weekly ED visit counts for suspected suicide attempts were 50.6% higher among girls aged 12-17 years compared with the same period in 2019. Suicide prevention measures focused on young persons call for a comprehensive approach, that is adapted during times of infrastructure disruption, involving multisectoral partnerships (e.g., public health, mental health, schools, and families) and implementation of evidence-based strategies (3) that address the range of factors influencing suicide risk.

BACKGROUND: Drowning death rates in the African region are estimated to be the highest in the world. Data collection and surveillance for drowning in African countries are limited. We aimed to establish the availability of drowning data in multiple existing administrative data sources in Uganda and to describe the characteristics of drowning based on available data. METHODS: We conducted a retrospective descriptive study in 60 districts in Uganda using existing administrative records on drowning cases from January 2016 to June 2018 in district police offices, marine police detachments, fire/rescue brigade detachments, and the largest mortuary in those districts. Data were systematically deduplicated to determine and quantify unique drowning cases. RESULTS: A total of 1435 fatal and non-fatal drowning cases were recorded; 1009 (70%) in lakeside districts and 426 (30%) in non-lakeside districts. Of 1292 fatal cases, 1041 (81%) were identified in only one source. After deduplication, 1283 (89% of recorded cases; 1160 fatal, 123 non-fatal) unique drowning cases remained. Data completeness varied by source and variable. When demographic characteristics were known, fatal victims were predominantly male (n=876, 85%), and the average age was 24 years. In lakeside districts, 81% of fatal cases with a known activity at the time of drowning involved boating. CONCLUSION: Drowning cases are recorded in administrative sources in Uganda; however, opportunities to improve data coverage and completeness exist. An improved understanding of circumstances of drowning in both lakeside and non-lakeside districts in Uganda is required to plan drowning prevention strategies.

Introduction: National estimates for nonfatal self-directed violence (SDV) presenting at EDs are calculated from the National Electronic Injury Surveillance System – All Injury Program (NEISS–AIP). In 2005, the Centers for Disease Control and Prevention and Consumer Product Safety Commission added several questions on patient characteristics and event circumstances for all intentional, nonfatal SDV captured in NEISS–AIP. In this study, we evaluated these additional questions along with the parent NEISS–AIP, which together is referred to as NEISS–AIP SDV for study purposes. Methods: We used a mixed methods design to evaluate the NEISS–AIP SDV as a surveillance system through an assessment of key system attributes. We reviewed data entry forms, the coding manual, and training materials to understand how the system functions. To identify strengths and weaknesses, we interviewed multiple key informants. Finally, we analyzed the NEISS–AIP SDV data from 2018—the most recent data year available—to assess data quality by examining the completeness of variables. Results: National estimates of SDV are calculated from NEISS–AIP SDV. Quality control activities suggest more than 99% of the cause and intent variables were coded consistently with the open text field that captures the medical chart narrative. Many SDV variables have open-ended response options, making them difficult to efficiently analyze. Conclusions: NEISS–AIP SDV provides the opportunity to describe systematically collected risk factors and characteristics associated with nonfatal SDV that are not regularly available through other data sources. With some modifications to data fields and yearly analysis of the additional SDV questions, NEISS–AIP SDV can be a valuable tool for informing suicide prevention. Practical Applications: NEISS-AIP may consider updating the SDV questions and responses and analyzing SDV data on a regular basis. Findings from analyses of the SDV data may lead to improvements in ED care.

Introduction: The volume of new data that is created each year relevant to injury and violence prevention continues to grow. Furthermore, the variety and complexity of the types of useful data has also progressed beyond traditional, structured data. In order to more effectively advance injury research and prevention efforts, the adoption of data science tools, methods, and techniques, such as natural language processing and machine learning, by the field of injury and violence prevention is imperative. Method: The Centers for Disease Control and Prevention's (CDC) National Center for Injury Prevention and Control has conducted numerous data science pilot projects and recently developed a Data Science Strategy. This strategy includes goals on expanding the availability of more timely data systems, improving rapid identification of health threats and responses, increasing access to accurate health information and preventing misinformation, improving data linkages, expanding data visualization efforts, and increasing efficiency of analytic and scientific processes for injury and violence, among others. Results: To achieve these goals, CDC is expanding its data science capacity in the areas of internal workforce, partnerships, and information technology infrastructure. Practical Application: These efforts will expand the use of data science approaches to improve how CDC and the field address ongoing injury and violence priorities and challenges.

In this ecological study, we attempt to quantify the extent to which differences in homicide and suicide death rates between three countries, and among states/provinces within those countries, may be explained by differences in their social, economic, and structural characteristics. We examine the relationship between state/province level measures of societal risk factors and state/province level rates of violent death (homicide and suicide) across Australia, Canada, and the United States. Census and mortality data from each of these three countries were used. Rates of societal level characteristics were assessed and included residential instability, self-employment, income inequality, gender economic inequity, economic stress, alcohol outlet density, and employment opportunities). Residential instability, self-employment, and income inequality were associated with rates of both homicide and suicide and gender economic inequity was associated with rates of suicide only. This study opens lines of inquiry around what contributes to the overall burden of violence-related injuries in societies and provides preliminary findings on potential societal characteristics that are associated with differences in injury and violence rates across populations.

Although the proportion of anemia amenable to change varies by population, the World Health Organization (WHO) criteria used to describe the public health severity of anemia are based on population prevalences. We describe the importance of measuring iron and other etiologic indicators to better understand what proportion of anemia could be responsive to interventions. We discuss the necessity of measuring inflammation to interpret iron biomarkers and documenting anemia of inflammation. Finally, we suggest assessing nonmodifiable genetic blood disorders associated with anemia. Using aggregated results from the Global Burden of Disease 2016, we compare population prevalence of anemia with years lived with disability (YLD) estimates, and the relative contributions of mild, moderate, and severe anemia to YLD. Anemia prevalences correlated with YLD and the relative proportion of moderate or severe anemia increased with anemia prevalence. However, individual-level survey data revealed irregular patterns between anemia prevalence, the prevalence of moderate or severe anemia, and the prevalence of iron deficiency anemia (IDA). We conclude that although the WHO population prevalence criteria used to describe the public health severity of anemia are important for policymaking, etiologic-specific metrics that take into account IDA and other causes will be necessary for effective anemia control policies.

The drug epidemic in the United States continues to evolve. The drug overdose death rate has rapidly increased among women (1,2), although within this demographic group, the increase in overdose death risk is not uniform. From 1999 to 2010, the largest percentage changes in the rates of overall drug overdose deaths were among women in the age groups 45-54 years and 55-64 years (1); however, this finding does not take into account trends in specific drugs or consider changes in age group distributions in drug-specific overdose death rates. To target prevention strategies to address the epidemic among women in these age groups, CDC examined overdose death rates among women aged 30-64 years during 1999-2017, overall and by drug subcategories (antidepressants, benzodiazepines, cocaine, heroin, prescription opioids, and synthetic opioids, excluding methadone). Age distribution changes in drug-specific overdose death rates were calculated. Among women aged 30-64 years, the unadjusted drug overdose death rate increased 260%, from 6.7 deaths per 100,000 population (4,314 total drug overdose deaths) in 1999 to 24.3 (18,110) in 2017. The number and rate of deaths involving antidepressants, benzodiazepines, cocaine, heroin, and synthetic opioids each increased during this period. Prescription opioid-related deaths increased between 1999 and 2017 among women aged 30-64 years, with the largest increases among those aged 55-64 years. Interventions to address the rise in drug overdose deaths include implementing the CDC Guideline for Prescribing Opioids for Chronic Pain (3), reviewing records of controlled substance prescribing (e.g., prescription drug monitoring programs, health insurance programs), and developing capacity of drug use disorder treatments and linkage to care, especially for middle-aged women with drug use disorders.

OBJECTIVES: Both the National Vital Statistics System (NVSS) and the Fatality Analysis Reporting System (FARS) can be used to examine motor vehicle crash (MVC) deaths. These 2 data systems operate independently, using different methods to collect and code information about the type of vehicle (e.g., car, truck, bus) and road user (e.g., occupant, motorcyclist, pedestrian) involved in an MVC. A substantial proportion of MVC deaths in NVSS are coded as "unspecified" road user, which reduces the utility of the NVSS data for describing burden and identifying prevention measures. This study aimed to describe characteristics of unspecified road user deaths in NVSS to further our understanding of how these groups may be similar to occupant road user deaths. METHODS: Using data from 1999 to 2015, we compared NVSS and FARS MVC death counts by road user type, overall and by age group, gender, and year. In addition, we examined factors associated with the categorization of an MVC death as unspecified road user such as state of residence of decedent, type of medical death investigation system, and place of death. RESULTS: The number of MVC occupant deaths in NVSS was smaller than that in FARS in each year and the number of unspecified road user deaths in NVSS was greater than that in FARS. The sum of the number of occupant and unspecified road user deaths in NVSS, however, was approximately equal to the number of FARS occupant deaths. Age group and gender distributions were roughly equivalent for NVSS and FARS occupants and NVSS unspecified road users. Within NVSS, the number of MVC deaths listed as unspecified road user varied across states and over time. Other categories of road users (motorcyclists, pedal cyclists, and pedestrians) were consistent when comparing NVSS and FARS. CONCLUSIONS: Our findings suggest that the unspecified road user MVC deaths in NVSS look similar to those of MVC occupants according to selected characteristics. Additional study is needed to identify documentation and reporting challenges in individual states and over time and to identify opportunities for improvement in the coding of road user type in NVSS.

INTRODUCTION: Each year from 1999 through 2015, residential fires caused between 2,000 and 3,000 deaths in the U.S., totaling approximately 45,000 deaths during this period. A disproportionate number of such deaths are attributable to smoking in the home. This study examines national trends in residential fire death rates, overall and smoking-related, and their relationship to adult cigarette smoking prevalence, over this same period. METHODS: Summary data characterizing annual U.S. residential fire deaths and annual prevalence of adult cigarette smoking for the years 1999-2015, drawn from the National Vital Statistics System, the National Fire Protection Association, and the National Health Interview Survey were used to relate trends in overall and smoking-related rates of residential fire death to changes in adult cigarette smoking prevalence. RESULTS: Statistically significant downward trends were identified for both the rate of residential fire death (an average annual decrease of 2.2% - 2.6%) and the rate of residential fire death attributed to smoking (an average annual decrease of 3.5%). The decreasing rate of residential fire death was strongly correlated with a gradually declining year-to-year prevalence of adult cigarette smoking (r=0.83), as was the decreasing rate of residential fire death attributed to smoking (r=0.80). CONCLUSIONS AND PRACTICAL APPLICATIONS: Decreasing U.S. residential fire death rates, both overall and smoking-related, coincided with a declining prevalence of adult cigarette smoking during 1999-2015. These findings further support tobacco control efforts and fire prevention strategies that include promotion of smoke-free homes. While the general health benefits of refraining from smoking are widely accepted, injury prevention represents a potential benefit that is less recognized.

BACKGROUND: Non-fatal self-inflicted (SI) injuries may be underidentified in administrative medical data sources. OBJECTIVE: Compare patients with SI versus undetermined intent (UI) injuries according to patient characteristics, incidence of subsequent SI injury and risk factors for subsequent SI injury. METHODS: Truven Health MarketScan was used to identify patients' (aged 10-64) first SI or UI injury in 2015 (index injury). Patient characteristics and subsequent SI within 1 year were assessed. A logistic regression model examined factors associated with subsequent SI. RESULTS: Among analysed patients (n=44 806; 36% SI, 64% UI), a higher proportion of patients with SI index injury were female, had preceding comorbidities (eg, depression), Medicaid (vs commercial insurance), treatment in an ambulance or hospital and cut/pierce or poisoning injuries compared with patients with UI index injury. Just 1% of patients with UI had subsequent SI</=1 year vs 16% of patients with SI. Among patients with UI index injury, incidence of and risk factors for subsequent SI injury were similar across assessed age groups (10-24 years, 25-44 years, 45-64 years). Severe injuries (eg, treated in emergency department), cut/pierce or poisoning injuries, mental health and substance use disorder comorbidities and Medicaid (among adult patients) were risk factors for subsequent SI among patients with UI index injuries. CONCLUSIONS: Regardless of circumstances that influence clinicians' SI vs UI coding decisions, information on incidence of and risk factors for subsequent SI can help to inform clinical treatment decisions when SI injury is suspected as well as provide evidence to support the development and implementation of self-harm prevention activities.

Injuries and violence among young people have a substantial emotional, physical, and economic toll on society. Understanding the epidemiology of this public health problem can guide prevention efforts, help identify and reduce risk factors, and promote protective factors. We examined fatal and nonfatal unintentional injuries, injuries intentionally inflicted by other (i.e., assaults and homicides) among children ages 0-19, and intentionally self-inflicted injuries (i.e., self-harm and suicides) among children ages 10-19. We accessed deaths (1999-2015) and visits to emergency departments (2001-2015) for these age groups through the Centers for Disease Control and Prevention's (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS), and examined trends and differences by age, sex, race/ethnicity, rural/urban status, and injury mechanism. Almost 13,000 children and adolescents age 0-19 years died in 2015 from injury and violence compared to over 17,000 in 1999. While the overall number of deaths has decreased over time, there were increases in death rates among certain age groups for some categories of unintentional injury and for suicides. The leading causes of injury varied by age group. Our results indicate that efforts to reduce injuries to children and adolescents should consider cause, intent, age, sex, race, and regional factors to assure that prevention resources are directed at those at greatest risk.

Motorcyclists account for 23% of global road traffic deaths and over half of fatalities in countries where motorcycles are the dominant means of transport. Wearing a helmet can reduce the risk of head injury by as much as 69% and death by 42%; however, both child and adult helmet use are low in many countries where motorcycles are a primary mode of transportation. In response to the need to increase helmet use by all drivers and their passengers, the Global Helmet Vaccine Initiative (GHVI) was established to increase helmet use in three countries where a substantial portion of road users are motorcyclists and where helmet use is low. The GHVI approach includes five strategies to increase helmet use: targeted programs, helmet access, public awareness, institutional policies, and monitoring and evaluation. The application of GHVI to Vietnam, Cambodia, and Uganda resulted in four key lessons learned. First, motorcyclists are more likely to wear helmets when helmet use is mandated and enforced. Second, programs targeted to at-risk motorcyclists, such as child passengers, combined with improved awareness among the broader population, can result in greater public support needed to encourage action by decision-makers. Third, for broad population-level change, using multiple strategies in tandem can be more effective than using a single strategy alone. Lastly, the successful expansion of GHVI into Cambodia and Uganda has been hindered by the lack of helmet accessibility and affordability, a core component contributing to its success in Vietnam. This paper will review the development of the GHVI five-pillar approach in Vietnam, subsequent efforts to implement the model in Cambodia and Uganda, and lessons learned from these applications to protect motorcycle drivers and their adult and child passengers from injury.

PROBLEM/CONDITION: Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies. REPORTING PERIOD: Illicit drug use and drug use disorders during 2003-2014, and drug overdose deaths during 1999-2015. DESCRIPTION OF DATA: The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers' camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40-X44, X60-X64, X85, and Y10-Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC's National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan). RESULTS: Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003-2005 to 2012-2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12-17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003-2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2). INTERPRETATION: Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012-2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern. PUBLIC HEALTH ACTIONS: Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC's guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates.

BACKGROUND: During the previous century the average lifespan in the United States (US) increased by over 30 years, with much of this increase attributed to public health initiatives. This report examines further gains that might be achieved through reduced occurrence of injury-related death. METHODS: US life tables and injury death rate data were used to estimate potential increases in life expectancy assuming various reductions in the rate of fatal injuries. Corresponding numbers of deaths potentially averted annually were also estimated; unit (per death) medical and lifetime work loss costs were employed to estimate total costs potentially averted annually. RESULTS: Through elimination of injury as a cause of death, average US life expectancy at birth could be increased by approximately 1.5 years, with notable variations by sex, ethnicity, and race. More conservatively, average life expectancy at birth could be increased by 0.41 years assuming that the national injury death rate could be brought into line with the lowest state-specific rate. Under this more conservative but plausible assumption, an estimated 48,400 injury deaths and $61 billion in medical and work loss costs would be averted annually. CONCLUSIONS: Increases in life expectancy of the magnitude considered in this report are arguably attainable based on long-term historical reductions in the US injury death rate, as well as significant continuing reductions seen in other developed countries. Contemporary evidence-based interventions can play an important role in reducing injury-related deaths, such as those due to drug overdoses and older adult falls, as well as suicides.

OBJECTIVES: The aim of this study was to highlight the differences in injury rates between populations through a descriptive epidemiological study of population-level trends in injury mortality for the high-income countries of Australia, Canada and the United States. METHODS: Mortality data were available for the US from 2000 to 2014, and for Canada and Australia from 2000 to 2012. Injury causes were defined using the International Classification of Diseases, Tenth Revision external cause codes, and were grouped into major causes. Rates were direct-method age-adjusted using the US 2000 projected population as the standard age distribution. RESULTS: US motor vehicle injury mortality rates declined from 2000 to 2014 but remained markedly higher than those of Australia or Canada. In all three countries, fall injury mortality rates increased from 2000 to 2014. US homicide mortality rates declined, but remained higher than those of Australia and Canada. While the US had the lowest suicide rate in 2000, it increased by 24% during 2000-2014, and by 2012 was about 14% higher than that in Australia and Canada. The poisoning mortality rate in the US increased dramatically from 2000 to 2014. CONCLUSION: Results show marked differences and striking similarities in injury mortality between the countries and within countries over time. The observed trends differed by injury cause category. The substantial differences in injury rates between similarly resourced populations raises important questions about the role of societal-level factors as underlying causes of the differential distribution of injury in our communities.

Introduction: The Centers for Disease Control and Prevention (CDC) developed the Web-based Injury Statistics Query and Reporting System (WISQARSTM) to meet the data needs of injury practitioners. In 2015, CDC completed a Portfolio Review of this system to inform its future development. Methods: Evaluation questions addressed utilization, technology and innovation, data sources, and tools and training. Data were collected through environmental scans, a review of peer-reviewed and grey literature, a web search, and stakeholder interviews. Results: Review findings led to specific recommendations for each evaluation question. Response: CDC reviewed each recommendation and initiated several enhancements that will improve the ability of injury prevention practitioners to leverage these data, better make sense of query results, and incorporate findings and key messages into prevention practices.

BACKGROUND: The complexity of current injury-related health issues demands the usage of diverse and massive data sets for comprehensive analyses, and application of novel methods to communicate data effectively to the public health community, decision-makers and the public. Recent advances in information visualisation, availability of new visual analytic methods and tools, and progress on information technology provide an opportunity for shaping the next generation of injury surveillance. OBJECTIVE: To introduce data visualisation conceptual bases, and propose a visual analytic and visualisation platform in public health surveillance for injury prevention and control. METHODS: The paper introduces data visualisation conceptual bases, describes a visual analytic and visualisation platform, and presents two real-world case studies illustrating their application in public health surveillance for injury prevention and control. RESULTS: Application of visual analytic and visualisation platform is presented as solution for improved access to heterogeneous data sources, enhance data exploration and analysis, communicate data effectively, and support decision-making. CONCLUSIONS: Applications of data visualisation concepts and visual analytic platform could play a key role to shape the next generation of injury surveillance. Visual analytic and visualisation platform could improve data use, the analytic capacity, and ability to effectively communicate findings and key messages. The public health surveillance community is encouraged to identify opportunities to develop and expand its use in injury prevention and control.

OBJECTIVE: This paper analyses helmet use before and after implementing Helmets for Kids, a school-based helmet distribution and road safety programme in Cambodia. METHODS: Nine intervention schools (with a total of 6721 students) and four control schools (with a total of 3031 students) were selected using purposive sampling to target schools where students were at high risk of road traffic injury. Eligible schools included those where at least 50% of students commute to school on bicycles or motorcycles, were located on a national road (high traffic density), had few or no street signs nearby, were located in an area with a history of crash injuries and were in a province where other Cambodia Helmet Vaccine Initiative activities occur. Programme's effectiveness at each school was measured through preintervention and postintervention roadside helmet observations of students as they arrived or left school. Research assistants conducted observations 1-2 weeks preintervention, 1-2 weeks postintervention, 10-12 weeks postintervention and at the end of the school year (3-4 months postintervention). RESULTS: In intervention schools, observed student helmet use increased from an average of 0.46% at 1-2 weeks preintervention to an average of 87.9% at 1-2 weeks postintervention, 83.5% at 10-12 weeks postintervention and 86.5% at 3-4 months postintervention, coinciding with the end of the school year. Increased helmet use was observed in children commuting on bicycle or motorcycle, which showed similar patterns of helmet use. Helmet use remained between 0.35% and 0.70% in control schools throughout the study period. CONCLUSIONS: School-based helmet use programmes that combine helmet provision and road safety education might increase helmet use among children.

BACKGROUND: Although working smoke alarms halve deaths in residential fires, many households do not keep alarms operational. We tested whether theory-based education increases alarm operability. METHODS: Randomised multiarm trial, with a single arm randomly selected for use each day, in low-income neighbourhoods in Maryland, USA. Intervention arms: (1) Full Education combining a health belief module with a social-cognitive theory module that provided hands-on practice installing alarm batteries and using the alarm's hush button; (2) Hands-on Practice social-cognitive module supplemented by typical fire department education; (3) Current Norm receiving typical fire department education only. Four hundred and thirty-six homes recruited through churches or by knocking on doors in 2005-2008. Follow-up visits checked alarm operability in 370 homes (85%) 1-3.5 years after installation. Main outcome measures: number of homes with working alarms defined as alarms with working batteries or hard-wired and number of working alarms per home. Regressions controlled for alarm status preintervention; demographics and beliefs about fire risks and alarm effectiveness. RESULTS: Homes in the Full Education and Practice arms were more likely to have a functioning smoke alarm at follow-up (OR=2.77, 95% CI 1.09 to 7.03) and had an average of 0.32 more working alarms per home (95% CI 0.09 to 0.56). Working alarms per home rose 16%. Full Education and Practice had similar effectiveness (p=0.97 on both outcome measures). CONCLUSIONS: Without exceeding typical fire department installation time, installers can achieve greater smoke alarm operability. Hands-on practice is key. Two years after installation, for every three homes that received hands-on practice, one had an additional working alarm. TRIAL REGISTRATION NUMBER: http://www.clinicaltrials.gov number NCT00139126.

Motorcycle fatalities are increasing at an alarming rate in many South-East Asian countries, including Cambodia. Through brief face-to-face roadside interviews in Phnom Penh and four other Cambodian provinces, this article assesses Cambodian motorcyclists' attitudes, behaviours and beliefs related to motorcycle helmets. Out of 1016 motorcyclists interviewed, 50% were drivers, 40% were older passengers and 10% were child passengers. More drivers (50%) reported consistently wearing helmets, compared with older passengers (14%). Saving their life in the event of a crash was the impetus for drivers and older passengers to wear a helmet (96% and 98%, respectively). The top barriers to helmet use were: (1) 'depends on where I drive,' (2) 'I forget' and (3) 'inconvenient' or 'uncomfortable'. These descriptive findings were instrumental in shaping the Cambodian Helmet Vaccine Initiative passenger campaign to reduce the motorcycle-related injuries and fatalities to support the United Nations Decade of Action for Road Safety.

INTRODUCTION: Road traffic injuries (RTIs) are a major cause of both morbidity and mortality globally. Relative to countries with similar economic patterns both within and outside of South-East Asia, Cambodia's road traffic fatality rate is high, with motorcyclists accounting for more than half of all fatalities as a result of head injuries. Despite the initiation of national motorcycle helmet legislation for Cambodian drivers in 2009, helmet use among both drivers and passengers remains low. METHODS: This study adopted a two-pronged approach to assess the current status of and knowledge, attitudes, and practices (KAPs) towards helmet use among drivers and passengers in five provinces in Cambodia. The objective was to better understand helmet use over a two year period since the introduction of the 2009 legislation. Researchers conducted both (1) direct observation of daytime and nighttime helmet use (January 2011-January 2013) and (2) roadside KAP interviews with motorcyclists (November 2010-November 2012). RESULTS: The observed helmet rate across all study sites was 33% during nighttime and 48% during daytime, with proportions up to ten times higher among drivers compared with passengers. Self-reported helmet use was higher than observed use. Within the past 30 days, 60% of respondents reported that they "always" wore a helmet when they were drivers while only 24% reported they "always" wore a helmet as a passenger. Reported barriers for use among drivers included: "driving route", "forgetfulness", and "inconvenience/discomfort." CONCLUSION: Despite awareness of the protective value of helmets, motorcycle helmet use rates remain low in Cambodia. Many misconceptions remain in Cambodia regarding helmet use, including that they are unnecessary for short distance or at low speeds. These serve as an important barrier to helmet use, which, if dispelled and coupled with visible and regular enforcement, may significantly reduce the number of motorcycle-related injuries and fatalities.

ABSTRACT Objective: Worldwide, 1.24 million deaths and 20-50 million road crash injuries occur annually, with a disproportionate burden on low and middle-income countries. Facing continued growth in motorized vehicles, Cambodia has begun to address road safety, including the creation of a nationwide road crash surveillance system, the Road Crash and Victim Information System (RCVIS). This study evaluates RCVIS to understand whether road crash injuries are being monitored efficiently and effectively and to identify areas for improvement. METHODS: We used the CDC Guidelines for Evaluating Public Health Surveillance Systems as an evaluation framework. To assess system attributes, we conducted in-person interviews with Cambodian road safety stakeholders, including representatives from the Ministries of Health and Interior, and reviewed RCVIS annual reports and system-operation documents. Characteristics assessed include usefulness, flexibility, acceptability, sensitivity, representativeness, data quality, and timeliness. RESULTS: The Cambodian government uses RCVIS data extensively for road safety planning purposes. RCVIS participation varies by type of data source, with 100% of police districts and 65% of hospitals reporting in 2010. Representativeness over time is a limitation-between 2007 and 2008, the number of reporting hospitals decreased from 65 to 42. From 2007 to 2010, the number of non-fatal injuries reported to RCVIS decreased by 35%, despite rapid growth in vehicle registrations. The system is timely, with annual reports disseminated within 10 months to more than 250 stakeholders. CONCLUSION: RCVIS provides a strong foundation for the surveillance of road crash injuries and fatalities in Cambodia. Differences in participation by data source and reduced hospital participation over time affect data representativeness and may indicate issues with acceptability. Recommendations include working with hospitals to standardize reporting procedures and to increase awareness about the usefulness of the data they collect.

BACKGROUND: Norovirus (NoV) transmission may be impacted by changes in symptom intensity. Sudden onset of vomiting, which may cause an initial period of hyper-infectiousness, often marks the beginning of symptoms. This is often followed by: a 1-3 day period of milder symptoms, environmental contamination following vomiting, and post-symptomatic shedding that may result in transmission at progressively lower rates. Existing models have not included time-varying infectiousness, though representing these features could add utility to models of NoV transmission. METHODS: We address this by comparing the fit of three models (Models 1-3) of NoV infection to household transmission data from a 2009 point-source outbreak of GII.12 norovirus in North Carolina. Model 1 is an SEIR compartmental model, modified to allow Gamma-distributed sojourn times in the latent and infectious classes, where symptomatic cases are uniformly infectious over time. Model 2 assumes infectiousness decays exponentially as a function of time since onset, while Model 3 is discontinuous, with a spike concentrating 50% of transmissibility at onset. We use Bayesian data augmentation techniques to estimate transmission parameters for each model, and compare their goodness of fit using qualitative and quantitative model comparison. We also assess the robustness of our findings to asymptomatic infections. RESULTS: We find that Model 3 (initial spike in shedding) best explains the household transmission data, using both quantitative and qualitative model comparisons. We also show that these results are robust to the presence of asymptomatic infections. CONCLUSIONS: Explicitly representing explosive NoV infectiousness at onset should be considered when developing models and interventions to interrupt and prevent outbreaks of norovirus in the community. The methods presented here are generally applicable to the transmission of pathogens that exhibit large variation in transmissibility over an infection.

BACKGROUND: From 1992 to 1999, an average of more than 18,000 unintentional home injury deaths occurred in the U.S. annually. PURPOSE: The objective of this study was to provide current prevalence estimates of fatal unintentional injury in the home. METHODS: Data from the 2000-2008 National Vital Statistics System were used in 2011 to calculate average annual rates for unintentional home injury deaths for the U.S. overall, and by mechanism of injury, gender, and age group. RESULTS: From 2000 to 2008, there was an annual average of 30,569 unintentional injury deaths occurring in the home environment in the U.S. (10.3 deaths per 100,000). Poisonings (4.5 per 100,000) and falls (3.5 per 100,000) were the leading causes of home injury deaths. Men/boys had higher rates of home injury death than women/girls (12.7 vs 8.2 per 100,000), and older adults (≥80 years) had higher rates than other age groups. Home injury deaths and rates increased significantly from 2000 to 2008. CONCLUSIONS: More than 30,000 people die annually in the U.S. from unintentional injuries at home, with the trend rising since the year 2000. The overall rise is due in large part to the dramatic increase in deaths due to poisonings, and to a lesser degree falls at home. Unintentional home injuries are both predictable and preventable. Through a multifaceted approach combining behavioral change, adequate supervision of children, installation and maintenance of safety devices, and adherence to building codes, safety regulations and legislation, home injuries can be reduced.

BACKGROUND: One third of adults aged ≥65 years fall annually, and women are more likely than men to be treated for fall injuries in hospitals and emergency departments. PURPOSE: The aim of this study was to examine how men and women differed in seeking medical care for falls and in the information about falls they received from healthcare providers. METHODS: This study, undertaken in 2010, analyzed population-based data from the 2005 Medicare Current Beneficiary Survey (MBCS), the most recent data available in 2010 from this survey. A sample of 12,052 community-dwelling Medicare beneficiaries aged ≥65 years was used to examine male-female differences among 2794 who reported falling in the previous year, sought medical care for falls and/or discussed fall prevention with a healthcare provider. Multivariable logistic regression analyses were conducted to determine the factors associated with falling for men and women. P-values ≤0.05 were considered significant. RESULTS: Nationally, an estimated seven million Medicare beneficiaries (22%) fell in the previous year. Among those who fell, significantly more women than men talked with a healthcare provider about falls and also discussed fall prevention (31.2% [95% CI=28.8%, 33.6%] vs 24.3% [95% CI=21.6%, 27.0%]). For both genders, falls were most strongly associated with two or more limitations in activities of daily living and often feeling sad or depressed. CONCLUSIONS: Women were significantly more likely than men to report falls, seek medical care, and/or discuss falls and fall prevention with a healthcare provider. Providers should consider asking all older patients about previous falls, especially older male patients who are least likely to seek medical attention or discuss falls with their doctors.